NEUROLOGICAL 
JectUres <iik! 
By H. C. WOOD, M. D., 
Clinical Professor of Nervous Diseases in the University of Pennsylvania. ADDRESS IN MENTAL DISORDERS. 
HORATIO C. WOOD, M. D., LL. D. 
Clinical Professor of Diseases of the Nervous System in the Hospital of the 
University of Pennsylvania, etc 
When primeval man by means of his split flints had so subdued the oppos- 
ing forces of nature that he had leisure to things other than the immediate sup- 
plying of his wants, his attention was, no doubt, most painfully arrested by the 
torments of sickness. In that hour was born that science, which in the lapse 
of ages has developed, until now it constitutes the vast mass of discovered fact, 
established deduction and bold speculation which we know as the science of 
medicine. At first, the outward manifestations which were called symptoms 
attracted the observer. Ages probably passed by before these symptoms were 
in the consciousness of the race associated into well-defined groups. Then the 
underlying causes began to besought out. Morbid processes were investigated, 
and so step by step the study progressed until at present, pathology has so far 
been perfected that most disease-processes are understood, and when we speak 
of typhoid fever or any other equally well-known affection we refer not to a 
group of symptoms but to a definite disease-process. In mental medicine the 
pathological problems are so recondite that hitherto they have in great part 
baffled investigation ; it is indeed an open question how far we shall ever be 
able to apprehend the minute structural changes which are connected with 
morbid mental action ; there are problems in the settlement of which our finest 
microscopes are mere blundering, useless tools. To our utmost study the 
human spermatozoa are nothing but irregular, transparent specks of protoplasm 
not to be distinguished one from the other. Yet the records of past generations 
are written in those formless particles, and in them also are enfolded the poten- 
tialities of future successions of men. From one shall come forth a demon, 
from the other a saviour of the race. Who shall solve the riddle of their con- 
struction ? Helpless and hopeless are we. Almost hopeless is it that we shall 
ever understand the infinitely delicate changes which take place in the complex 
protoplasm of nerve cells, and be able to see the waves of emotional and mental 
excitement or paralysis which sweep over the individual, or to recognize the 
alterations in nervous protoplasm gone mad. Or our so-called mental diseases 
arc simple groups of symptoms, Which may, for aught we know, in different 
cases arise from essentially different pathological processes. In one individual 
suffering from paralytic dementia the depression fif melancholy clouds the life, 
whilst another man with apparently the same brain lesion revels in the wild 
exaltation of the mania of grandeur. 
For the purposes of discussion, we must, at the present stage of our know- 
ledge of insanity, give names to certain symptom-groups, but for the purpose of 
clear thinking it is essential for us to remember that these symptom-groups are 
not diseases, but associated symptoms which may in different cases depend on 
essentially different causes. Is a melancholia which is produced by impacted 
fseces and relieved almost at once bv tin: clearing,.out .of the rectum (American 2 
WOOD, ADDRESS IN MENTAD DISORDERS. 
Journ. of Insanity, XDII, p. 264), the same disease as a melancholia depending 
upon hidden and irremovable causes in the nerve centres ? It is odd that 
alienists of wide culture and ability have hot disagreements in regard to the 
diagnosis of a case. Thus in a review of Professor Seguin’s Opera Minora, 
Dr. Kiernan, of Chicago, exclaims of a case reported by Seguin as a maniac, 
“ whatever the psychosis might have been it certainly was not mania.” If 
mania were a distinct disease it is hardly likely that a neurologist of the exper- 
ience and culture of Dr. Seguin would not be able to recognize it. If mania 
be not a distinct disease, but a mere set of symptoms, surely the vehement 
assertion made by Kiernan is little less than an absurdity. The truth is that 
the thought of modern alienology is pervaded by the fallacy that our symptom- 
groups are diseases. 
Symptomatology in any department of medicine is a study of the first im- 
portance, but in mental medicine it at present almost bounds our horizon. To 
the study of this symptomatology men are urged not only by the needs of the 
insane but also by the necessities of the sane. 
If there be one thought more than another which ought not to be forgotten, 
it is that the human mind diseased is the human mind still. The coming on of 
insanity marks not the appearance of a new entity or a new force. The old 
entity or the old force simply goes astray. It is the failure to grasp this clearly 
which has lead many a lawyer to say to the expert ; ‘‘You crazy doctors 
believe that everybody is insane,” and has occasionally betrayed the unwary 
alienist into acknowledging that this assertion is true. I say distinctly that it 
is not true. Sanity is the condition of the great bulk of mankind, but the 
impulse, the mood, the failure of judgment, the lack of coherent thought—the 
various symptoms which constitute the chaos of disturbed intellection find their 
counterparts, or rather their germs, in every healthy mind. So long as these 
impulses, moods, etc., can be dominated by the will of the individual, just so 
long are they simply the weaknesses of humanity ; but when the will of the 
individual is powerless before them, then is that individual insane. The pas- 
sage from one state to the other may be so gradual that only to omniscience is 
it possible to say when the line between sanity and insanity, responsibility and 
irresponsibility is crossed. 
Insanity so terribly affects the relations of men that it very frequently is 
the centre of the legal battles whose arena is our courts. Not rarely the keen- 
est and most thoroughly trained intellect is baffled in attempting to decide how 
far responsibility should attach to the alleged criminal, or how far the original 
will of the individual has entered into the instrument which purports to be his 
last will and testament. When this is remembered, how utterly absurd appears 
to be our system for deciding the mental condition—a system which we have 
inherited from the times of oppression and of violence. Twelve men, perchance 
honest, of a certainty, many of them uneducated and probably all of them 
ignorant even of the ordinary principles of medicine or of mental action ; one 
judge, learned in the law, and bound in the iron hoops of legal prejudice and 
legal methods of thought, unacquainted with the science of medicine, and may- WOOD, ADDRESS IN MENTAL DISORDERS, 
3 
hap with the laws of mental action ; two lawyers, sharp, trained in every device 
for brow-beating and baffling witnesses and in every crafty method of hiding 
the truth and of misleading the ignorant, contending one with the other ; 
experts, chosen without guarantee of their knowledge of the subject, hired 
by one side or the other, possibly dishonest, certainly liable to have their 
view of the case affected by the glass through which they have looked at it. 
This is the machinery which in theory is to per petuate justice, but which 
in truth in a large proportion, if not the majority of cases, works out the 
wrong. With such a system and such a method is it a wonder that the 
decisions of our courts in questions of insanity are a laughing stock among 
those who know ? Is it a wonder that the sane man is so often judged in- 
sane, while the lunatic almost as often has the stamp of sanity put upon his 
untoward acts ? 
Is it a wonder that those who have seen much of this so-called justice grow 
cynical and look upon legal procedures as farces which, alas, but too often end 
in tragedies ? Not many years since two law}rers of eminence came into my 
office and laid a certain case before me, desiring that I should go upon 
the stand and declare that their client was sane. After listening to their state- 
ments, I said, “ This man is absolutely insane, and you cannot find on the two 
continents an individual who is at once honest and capable who will not give 
you an opinion similar to mine. There is no room for doubt in the case. If, 
however, you want to win, all that you must do is to call in no experts, declare 
that you do so because doctors and experts ax~e fools ; browbeat and confuse, as 
much as lies in your power, the expert witnesses on the other side and then 
appeal to the jury that this American citizen shall not be deprived of the rights 
for which the immortal Washington, Adams, and Jefferson contended, and for 
which heroes innumerable have fought and died.” They took my advice. 
The witnesses were confused, the jury was dazzled by the eloquent appeals. 
The judge made a charge which the newspapers of the day lauded to the skies, 
but which seemed to me veritable foolishness, and the man was declared sane. 
Shortly afterwards, in the wreck of his intellectual power, he had still sense 
enough to perceive that in order to protect himself from himself the restraints 
of an insane asylum were essential, and I believe that he is still a voluntary 
inmate of such an institution. 
To the truculent barons that gathered around King John at Runnymede, 
personal liberty seemed the one point for whose preservation all law should 
exist. But times, although not laws, have changed, and to day the danger to 
the State is not that personal liberty shall be restrained, but that it shall degen- 
erate into license. The spirit of the barons still lives in our legislation and in 
our public opinion in regard to insanity. Pamphlets, newspapers, lunacy 
commission reports, all portray the hardships of depriving the lunatic of his 
freedom and men grow eloeuent concerning the danger lest sane men shall be 
shut up in asylums. The medical profession seems to be in the eyes of the 
public an avaricious monster lending itself for gold to any nefarious design. 
Daws have for their basis the idea that men and women are for criminal purposes 4 
WOOD, ADDRESS IN MENTAR DISORDERS. 
habitnally incarcerated in asylums. The fear of this is, however, to my think- 
ing but a survival of mediaeval feelings and mediaeval possibilities. It is now 
nearly twenty years since I began to study insanity as a specialty, and I have 
never yet known a case in which a person was improperly placed in an asylum, 
though I have known cases in which persons whom I believe to be Innatics 
have been set free by lunacy commisions. More than this, I have had personal 
knowledge of almost every kind of prejudice as the result of the failure of the 
law to give protection from the lunatic. I have known the prisoner whose 
craziness should have been recognized, allowed in his cell weapon and 
opportunity for dashing out without cause the brains of an unsuspect- 
ing keeper—an almost raving lunatic suffered to pour sulphuric acid 
upon his victim—a mother permitted to cut the throat of her own off- 
spring and to die by her own hand ; a father scarcely stopped by neighbors 
in time to prevent the final completion of rape upon his daughter—another 
father allowed to blow out the brains of the helpless little child kneel- 
ing before him in an agony of prayer for life. I might extend the cata- 
logue, but I forbear, Waste of property, dishonor, death by murder and 
suicide—these constitute a long line of perpetually repeated tragedies which 
might and which ought to have been prevented by early recognition of the 
mental condition and sequestration of the insane criminal. On the one side 
the lunatic himself and his insane victims call aloud for protection from the 
wild, beast-like fury of the maddened brain. On the other is the bug-bear of 
personal freedom. Ret, however, a crime be committed, and here, at least in 
Pennsylvania, that law which has made protection so difficult cries for blood, 
although punishment has very little deterring effect upon the insane, and the 
only protection which is afforded to the community by hanging the insane 
murderer is a protection from his individual acts. A dead lunatic is certainly 
a harmless lunatic. The Pennsylvania law is wise in that it does give the 
judge the right to perpetual!}'- incarcerate the lunatic who has once been 
acquitted on account of his lunacy. But the general workings of the modern 
law is shown in the case of B. recorded in a recent number of the American 
Journal of Insanity. This man was a moral imbecile driven by a furious im- 
pulse and kill, whose greatest pleasure was to tie up horses in the 
woods and gradually whittle them to death, to mutilate living cats, torture 
chickens, break the legs and tear to pieces, whilst living, small birds, and who, 
when opportunity offered, reached the very heaven of his joy by assaulting, 
torturing, killing human beings. When twelve years old he took his toddling 
brother into the woods and nearly flogged him to death. He attempted to 
strangle a younger brother and to smother his infant sister; had stabbed various 
people, essayed to suffocate a harmless imbecile and to choke another inmate of 
the asylum, and committed at least two criminal assaults on women, the last 
during an escape from the asylum. Tried for this last offense in spite of the 
efforts of alienists, the patient was convicted and condemned to six months’ 
imprisonment. His conviction of course was tantamount to a legal declaration 
of sanity, and the judge in sentencing the prisoner told him that at the end of WOOD, ADDRESS IN MENTAL DISORDERS. 
5 
the three months he would be a free man. 
The problems growing out of the relation of insanity to crime are exceed- 
ingly difficult, and I do not propose to-day to say more about them except to 
express my conviction that the present system of trial would be improved by 
the presence of an alienist upon the bench as an associate judge, or by the 
reference of the question of insanity in criminal, as well as in civil cases, to a 
commission, whose report might probably be subject to review by the judge. 
Possibly the public opinion which at present demands the hanging of 
insane people is not so far wrong as some of us think, but certainly there can be 
no question as to the evils which have resulted from the systems of civil insane 
commissions. As proof of this I shall cite two recent cases which I believe 
have not been before published, and in which I have been personally concerned. 
The first case is that of Dr. Martin Weaver, an elderly gentleman living at 
Germantown. The petition asking that Dr. Martin Weaver, should be declared 
a lunatic was filed by his nephew, but the circumstances were such that the 
pecuniary interests of his daughter, Miss Weaver, were chiefly involved in the 
declaration that her father was a lunatic. 
Twelve witnesses in all, including the party who served the notices were 
examined on behalf of the petitioner, and but two or three of these witnesses 
testified to any knowledge of the alleged lunatic during the three years prece- 
ding the inquisition. On the other hand, twenty-two witnesses testified in the 
most positive manner as to the sanity of Dr. Martin Weaver covering a period 
from his boyhood to his present advanced age of eighty-one years. The 
following well-known physicians affirmed without qualification the undoubted 
mental capacity of Dr. Weaver, after they had made a personal examination of 
him : Dr. D. Hayes Agnew, Dr. Thomas G. Morton, Dr. John B. Chapin of the 
Pennsylvania Hospital for the Insane, Dr. John C. Hall of the Friend’s Insane 
Asylum, Dr. Henry M. Wetherill of the Pennsylvania Hospital for the Insane, 
Dr. Charles K. Mills, and Dr. J. R. Landis, the family physician of Dr. Martin 
Weaver for the past six consecutive years. Further, no less than eight well- 
known lawyers testified from personal knowledge as to the entire ability of Dr. 
Martin Weaver and his capacity to manage his own business. Not a single 
physician or expert on insanity was called to testify that Dr. Martin Weaver 
was insane. Nevertheless, the jury decided Dr. Martin Weaver to be insane in 
the face of the strongest protest from the commissioner, who was acting as judge 
in the case. The court of common pleas after hearing the whole case, set aside 
the report of the jury as contrary to the evidence, but when the matter was 
carried to the Supreme Court of Pennsylvania, it was then decided that the 
common pleas court had not the power to set aside the verdict, which still 
stands. I have myself, in two long interviews, studied the mental condition of 
Dr. Weaver, and although he is de jure a lunatic, he is de facto sane. 
Living near by to Dr. Martin Weaver was an adult imbecile man, whose 
father died after a long period of chronic lunacy. Miss Bessie Weaver, the 
same woman who was involved in the previous suit, was married to this young 
man in the city of Camden, and suit was afterwards brought in order to have 6 
WOOD, ADDRESS IN MENTAL, DISORDERS. 
the marriage set aside on the plea of the imbecility of the man, who was after- 
wards examined by Dr. Chase, of the Norristown Asylum, and myself, and we 
pronounced him without hesitation an imbecile of a low grade. Without going 
into the details of our examination, it suffices for the present to state that I 
questioned him to discover whether the marriage had been consummated or not, 
but did not succeed in making him clearly understand what I meant, although 
I judge that there had been no consummation of the marriage. Although he 
had been sent to school until he was twenty-two or twenty-three years of age, 
he was unable to give change for a dollar without counting on his fingers, and 
in no way could he completely give the change for a two dollar bill. He was 
without doubt a harmless, docile imbecile, yielding like putty to any one that 
he would come in contact with, yet the jury was divided, about half of them 
declaring that he was able not only to take care of himself, but- his inherited 
estates, which amounted to some hundreds of thousands of dollars. In the 
absence of any agreement he remained in the eyes of the law sane, and I am 
informed that this case was settled by the payment of a large sum to Miss 
Weaver never to come near the imbecile. I understand Miss W. has a very 
high opinion of our legal methods. 
The law of Pennsylvania provides two methods of declaring a patient 
insane by civil process. Thus one act requires that on statement in writing of 
any respectable person that a certain person is insane, and that the welfare of 
himself or of others requires his restraint, it shall be the duty of the judge to 
appoint immediately a commission which shall inquire into and report the facts 
of the case. This commission shall be composed of three persons, one of whom 
at least shall be a physician, and another a lawyer. In their inquisition they 
shall hear such evidence as may touch the merits of the case, as well as the party 
complained of or his counsel. If in their opinion it is a suitable case for conviction 
the judge shall issue his warrant for such disposition of the insane person as 
will secure the object of the measure. According to the second act, upon the 
application in writing of a relation by blood or marriage, or of a person interested 
in the estate, a commission empowering one or more persons as commissioners 
may be issued by the court of common pleas by virtue of which the sheriff is 
required to summon such number of persons, not less than six nor more than 
twelve upon this inquest, as the circumstances of the case may seem to them to 
require. When this inquisition after examination has declared the person a 
lunatic the aggrieved person may traverse the decision, provided such traverse 
be fulfilled within three months after the declaration of the inquisition. The 
power of traverse consists of a trial before a jury in the court of common pleas 
to determine whether the mind of the alleged lunatic be deranged to such an 
extent as to disqualify him from conducting himself with perfect safety to him- 
self and others, disposing his own affairs and discharging his relative duty. 
It so happens that I have never seen practiced the method of declaring a 
person insane by means of a commission of three persons as directed by the 
act here first spoken of, and its use must be very rare; the second plan being 
almost universally pursued probably because the law directly affirms that under WOOD, ADDRESS IN MENTAL DISORDERS. 
7 
it the estates as well as the person of the insane man pass into the hands of the 
trustees. This second method is practically a jury trial and possesses all the 
inherent faults of such a trial. It is hardly necessary to recall attention to 
these faults. They may be summed up as existing in the expensiveness of the 
method, and the absolute impossibility of obtaining just decisions in regard to 
intricate scientific questions, amid the ignorance and prejudice of twelve men 
drawn almost invariably from the lower walks of life and under the influence 
of trained minds trying to mislead. “Of course he ought to be confined in 
the asylum,” says the lawyer with a sneer, he pays them forty dollars a 
week, and the opinion of the juryman sets as plaster-of-Paris sets in the mould 
of the sculptor. 
All the legislation that would be required to make the laws of Pennsyl- 
vania in regard to the civil side of insanity worthy of some respect, would be 
to abolish the second method of declaring people insane, and to require that 
the decision should be allowed to rest with a commission consisting of three 
persons, one of whom shall be a lawyer, one a doctor, and one a general man 
of business. I believe myself that the decision of such a commission should 
be finally subject only to review by a bench of judges who, under restrictions, 
with which it is not necessary to here occupy time in discussion, should have 
the power to overrule it. In insanity cases I would do away entirely with the 
habeas corpus and its accompanying jury trial. Owing, however, to its close 
connection with political liberties in the past, the jury is still a fetich, which is 
worshipped probably by the bulk of the legal profession and the majority of 
the American public. It remains, however, a feudal relic utterly unsuited for 
many of the emergencies and complex relations of modern life. There is even 
a widespread belief that the man has a constitutional right to a jury trial. It 
is hardly necessary to say that this is not correct, that the constitution simply 
guarantees that the man shall not be deprived of his liberties without due pro- 
cess of law. What this process of law shall be is left to the legislature. 
Perhaps, however, I am all wrong in thinking that the term administra- 
tion of justice, applied to the process of the law, ought to be considered any- 
thing more than an euphemism. Wiser, no doubt, was the dictum of a very 
famous lawyer which I heard publicly quoted by Mr. George Biddle with ap- 
proval. According to this dictum the law does not exist for the purpose of 
preventing men from cutting one anothers throats. That in regard to insanity, 
law in America is not always successful, even in the latter aspect, is shown b}' 
a case of which I have cognizance, in which a jury acquitted a man of homi- 
cide on the ground of instantaneous irresistible impulse, although the murderer 
had armed himself, and traveled nearly one hundred miles with the apparent inten- 
tion of killing his wife’s paramour. This case is only one of many that might 
be cited as an illustration of the fact that the results of a jury trial depend 
much more upon the sympathies of the jury than upon the justice of the 
cause. 
I insist that not only for the purpose of justice, but for the purpose of 
control, the Pennsylvania law in regard to insanity still needs modification, a 8 
WOOD, SYMPTOMATOLOGY, OF INSANITY, 
modification which to my thinking ought to be easy of accomplishment, 
because it would consist chiefly in the abrogation of an old law, which in spirit 
is discordant with the recent act. Let at least in all civil cases the question of 
sanity or insanity of an individual be decided by a properly constituted com- 
mission, and it may happen in coming decades that justice shall invade even 
the province of the criminal law. Is it not fitting for this association to move in 
this matter, and would it not be well to appoint a committee who should have 
power to represent this body ? I therefore offer this resolution: 
Be it resolved that the President be directed to appoint a committee of 
members who shall confer with the State Committee of Lunacy, and if in the 
concurrent opinion of the committee changes are advisable in our laws relating 
to lunacy, shall have power to represent this body in obtaining such legislation. 
THOUGHTS CONCERNING THE SYMPTOMATOLOGY 
OF INSANITY. 
Bv H. C. Wood, M. D., LL. D., 
Professor of Therapeutics, and Clinical Professor of Nervous Diseases, University 
of Pennsylvania. 
In an address which I had the honor to make last June before the State 
Medical Society of Pennsylvania upon the subject of Insanity, I considered in 
some detail the following points : First, that the so-called different insanities 
are not diseases, but groups of symptoms. Second, that insanity is a condition 
which is developed out of sanity, often gradually, and that all the symptoms 
of insanity exist in embryo in the sane mind. Third, the difficulty in many 
cases as to deciding in regard to the sanity or insanity of the individual and the 
absolute uncertainty of our ordinary legal methods of procedure. It has occurred 
to me that possibly some further illustrations of the above thoughts, or 
rather some considerations growing out of the above thoughts might not be 
lacking in interest to the readers of this magazine. 
One great difficulty in obtaining proper laws in regard to insanity, is the 
ignorance and prejudice and consequent incorrect thinking of the legal profes- 
sion and of the general public upon the subject. In this country public 
opinion is all powerful and in the final event everything must yield to 
it. In matters like insanity, the opinion of the laity is slowly affected 
by knowledge which filters down through the medical profession. Am I 
wrong in thinking that the profession itself has been somewhat at fault in 
this matter? The compressed course studies which is all the American 
student, in the absence of much needed legislation, will tolerate, affords WOOD, SYMPTOMATOLOGY OF INSANITY. 
9 
no time for instruction in mental medicine. Cases of insanity as they arise are 
almost of necessity referred to the specialist, and so it comes to pass that the 
general medical practitioner often is little acquainted with the minute details or 
even the general principles of the subject. But it is the general practitioner to 
whom the family first appeals in cases of mental disease as well as of physical 
sickness, and not only may the health of the unfortunate victim of mental 
disease be imperilled, but even the lives of those about him may be brought into 
danger through the failure of the physician to understand the first mutter- 
ings of the coming tempest. Possibly, therefore, it is excusable if I here call 
attention to certain symptoms of insanity and to certain relations between 
mental power and mental integrity, in remarks which may seem to some trite. 
The various manifestations of abnormal mental action may be grouped 
under two heads. First, emotional; second, intellectual aberrations. The 
study of the normal life of man seems to me sufficient to convince any one that 
it is possible for a disordered condition of the emotions to exist, which shall 
completely overpower the individual and lead him to commit acts, the wrong 
of which is intellectually recognized by him, but which his will is powerless 
to prevent. The drift of modern science is to show that there is in the brain a 
more or less complete differentiation of function, and it is most probable that 
one set of nerve cells is connected with emotion, and another set with intellec- 
tual thought, so that the excitation of one set of cells produces an explosion of 
nerve force taking the form which we know as anger, and the excitation of 
another set of cells causes a paroxysm of fear or love, whilst the result of the 
action of still another set of cells is the development of ideas. If' an influence 
so affects the intellectual cells of the brain to-day as to pervert their function, 
intellectual insanity results. To-morrow, the same influence transferred to the 
emotional cells may cause an emotional insanity. The correctness of this a 
priori reasoning is most abundantly confirmed by the facts of every day life. 
When Jarndyce built the Growlery, into which he could retreat as soon as the 
cold wind from the North Sea turned sour in his bosom the milk of human 
kindness, he gave substantial recognition to the fact that the weather acts 
upon our nervous systems, and through our nervous systems upon our thoughts. 
The method in which this impression is made is very mysterious, but that the 
impression is made is undeniable. We are all familiar with the researches of 
the West Point professor of physics, who had the misfortune to lose an arm 
during the rebellion, and subsequently to suffer from neuralgia of the stump. 
Kvery north-east storm produced a paroxysm of pain ; the electrical conditions, 
the amount of moisture, forces and directions of the wind, the percentage of 
ozone, all the known characteristics of the storm disturbance were studied by 
this learned physicist, but no relation could be made out between them and 
the pain. It was, however, distinctly proven that the period of maximum pain 
or the pain centre travelled regularly about twenty-four hours in front of the 
storm centre, so that it was possible for a circular storm to sweep past and 
involve the neuralgic victim in its pain circuit, without any apparent distur- 
bance of the weather. WOOD, SYMPTOMATOLOGY OF INSANITY. 
The same mysterious atmospheric influence which in one individual 
produces sensory disturbance which we call pain, causes in a differently consti- 
tuted person an emotional disturbance which we call depression of spirits. By 
no direct effort of the will can the individual stop the pain, no more by a direct 
effort of the will can he stop the nervous depression. If the pain be not too 
severe by appropriate measures he can alleviate it, and if the depression be not 
too deep, by appropriate measures he can relieve it also, but when the condi- 
tions are too unfavorable it is not possible to prevent the nerve storm. All that 
the will of the individual can do is to rise superior to the pain or to the 
depression. 
Emotional depression deepens into the profoundest melancholia by a 
gradation as insensible as that by which the most perfect beach slopes into the 
deep ocean, and who shall say where the waves beat up over the individual’s 
power of control ? Where is the dividing line between the state in which the 
man is master of the mood and that in which the mood is master of the man ? 
At such point, wherever it be, lies the line between sanity and insanity, between 
responsibility and irresponsibility. 
In cases of intense moodiness, as in other instances in which the line of 
insanity is being approached, the position of physician may be one of serious 
embarrassment. In severe depression there is always some danger of 
suicide, although the intellectual faculties of the patient may not be at all 
unhinged. If suicide or homicide under these circumstances be committed, 
we have in the act reasonable proof that the mood has triumphed over 
the intellect, and that therefore the patient has become insane. It may well 
happen, however, that this momentary insanity should take the form of a sudden 
impulse; the position of the patient being comparable to that of a person 
on the seashore in water reaching to the neck, when the sudden wave goes 
over the head and momentarily engulfs the individual. It is the duty of the 
physician in all these cases, carefully to warn the friends of the patient, and 
even when this is done, occasionally a suicide or homicide will be committed, 
which could have been prevented by the previous sequestration of the individual. 
When the delusions of persecution manifest themselves in a melancholic patient, 
even though these delusions be imperfect and temporary, now appearing and 
now disappearing, the situation is a very grave one, and the physician who 
does not advise the placing of the patient in such positions as to be perpetually 
watched, incurs the gravest responsibility. 
A very curious attribute of humanity which has enormous effect upon 
human action, is the influence which is exerted by the surroundings of a man 
upon his personality. Sudden impulse may be produced by external circum- 
stances. A very common example is the impulse, which bids a man, standing 
on the verge of some great height, jump headlong—an impulse which is un- 
doubtedly occasionally obeyed and has produced not a few unpremeditated sui- 
cides. I suppose my own experience is not different from the common. Some- 
times standing on the platform of a station, seeing the great light of the loco- 
motive mysteriously moving down upon me through the darkness, only by a WOOD, SYMPTOMATOLOGY OF INSANITY 
distinct effort of the will have I been able to restrain myself from throwing 
myself under its wheels. This sudden impulsive motive is not confined to the 
human race. Any one who has ever hunted deer by the fire-jack in the 
night, must have witnessed or known of the animal being drawn to his own 
destruction by the mysterious influence of the brilliant light shining out of the 
darkness. If it be said that this is mere curiosity on the part of the deer, such 
explanation is not to be found in the throes of the bird, charmed by the basilisk 
eyes of the black snake, violently fluttering against its own will into the open 
jaws of destruction. Of similar character is the influence which spreads from 
person to person, uniting masses in one common impulse—an influence to which 
the name of sympathy has been given, but which is evidently of the same 
nature as that which bids a man throw himself headlong from the height. 
The orator knows full well the power of this impulse and how, when the audi- 
ence is scattered over a large room, the finest flights of eloquence fall without 
effect, but when man stands close to man, an apparently causeless power seems 
to gather itself and spread from bench to bench. It is this reverberating power 
of impulse which constitutes at once the weakness and danger of a mob. Let 
the heart of one be filled with rage, it overflows and spreads until men and 
women alike become full of the reckless cruelty of the wild beast, but if the 
panic comes into the breast of one, it too spreads with force and the mob melts, 
it may be before the steady discipline of a few policemen. 
There are undoubtedly certain morbid conditions of the human nervous 
system, in which the slightest external circumstance provokes overpowering 
impulses or in which, indeed, these impulses seem to be purely subjective and 
arise spontaneously within the individual. As an instance of an apparently 
purely subjective impulse, I may cite the case of a man long under my care, 
with a distinct history of hereditary insanity, but in whom the only evidence of 
mental unsoundness I could find, was an impulse to assault by-standers. Once, 
upon returning home, I found this man sitting in my office with pale face, 
haggard eyes and every expression of great excitement. He greeted me with, 
“ Doctor, Doctor, I nearly did it! I nearly did it! ” It appeared that he had spent 
forty-eight hours without intermission in a vortex of excitement, and suddenly 
the impulse to kill had come on with such power, that only by fleeing to my 
office was he able to save himself. 
That the impulse which seems to originate spontaneously in the nervous 
system, often, if not always, is awakened by some external suggestion, 
is illustrated by the case of a moral imbecile, reported in the American Journal 
of Insanity, who was dominated by a furious impulse to torture and kill, whose 
greatest pleasure was to tie up horses in the woods and gradually whittle them 
to death, to mutilate living cats, torture chickens, break the legs and tear to 
pieces whilst living, small birds, and who, when opportunity offered, reached 
the very heaven of his joy by torturing and killing human beings : 
when twelve years old, he took his toddling brother into the woods and nearly 
flogged him to death : he attempted to strangle a younger brother and to 
smother his infant sister, stabbed various people, essayed to suffocate a harm- 12 
WOOD, SYMPTOMATOLOGY OP INSANITY. 
less imbecile and to choke another inmate of the asylum, and committed at 
least two criminal assaults on women. 
Mr. B, sometimes passed through weeks and months of good behavior, but 
at any time the sight of blood would arouse the sleeping devil in him, he 
would become extremely pale and agitated, although seemingly quiet and list- 
less, but unless closely watched, would in the next few hours, gratify his lust 
for torture and death. That the gratification of the impulse gave him pleasure 
is certain; thus, once when surprised just after he had cut a cat’s throat with a 
piece of barrel hoop and was covered with blood, he appeared to be in an 
ecstacy of happiness, although very pale and weak. In some cases, the carry- 
ing out of the impulse gives to the doer pain rather than pleasure, although he 
is powerless to control his act. Thus, a gentleman whose life was ruined by 
impulses to do bizarre actions, said to me, ‘ ‘ Doctor, the sensation is 
like that when I try to hold my breath, just as in such case, the time comes 
when my will must yield to the impulse to breathe, so must I do these odd 
actions, which my nervous system demands. ’ ’ 
In those cases in which there are habitually powerful impulses without 
other indication of mental unsoundness, the physician who is consulted is 
placed in an embarrassing position. He may believe that there is the gravest 
danger of a crime being committed, but he cannot give a certificate of insanity. 
So long as the impulses are controlled in the patient, the latter is not 
insane, but so soon as the impulses control the patient he is insane : the danger 
is that insanity and the crime may be simultaneous. In such cases it seems to me 
that the first duty of the physician is, if possible, to persuade the person 
affected, either to put himself as a voluntary patient in some retreat, or to take 
himself out absolutely away from his present surroundings into circumstances 
which will not call forth the impulses, and which will guard him against the 
effects of these impulses, if they become overpowering. Especially in such 
cases, is it the physician’s duty to warn the friends of the patient of the situa- 
tion. When, as in my own practice, the patient has come simply to the 
office, perchance given a false name and carefully hidden his immediate connec- 
tions from the consultant, a plain unvarnished statement of the case to the 
patient himself, is about all that the physician can do, and it ought to relieve 
him from moral and legal responsibility. 
So far as the medico-legal relations of over-powering impulses are con- 
cerned, we must recognize that at this point, science has outstripped 
the possibilities of practical legislation. Whether courts will allow it or 
not, it is certainly a fact that these impulses do arise, are uncontrollable by the 
individual, are a form of insanity and do relieve from moral responsibility. 
I am not myself at all sure, however, that the law ought to recognize the doc- 
trine of instantaneous impulse. To allow such doctrine to have weight in a 
court room, would be to afford a shelter to every criminal, and it is perhaps 
better that an insane man occasionally be hung, than that murder be pro- 
tected. 
The symptom which is usually considered to be absolutely pathognomonic of WOOD, SYMPTOMATOLOGY OP INSANITY. 
13 
insanity, is that which is known by the name of delusions. By Spitzka insane 
delusion is defined as a false belief, out of which the subject cannot be reasoned 
by adequate methods for the time being. It is evident, however, that this 
definition is too wide, as there are perfectly sane persons who hold faulty or 
false beliefs, out of which they cannot be reasoned. Thus, either the Christian 
or the Mussulman under such a definition is a victim of an insane delusion. To 
meet the necessities of the case, the definition must be so modified as to read “A 
faulty belief concerning a subject capable of physical demonstration, out of 
which the person cannot be reasoned. ” It is important to remember too, that an 
idea or belief may be true, and yet may be insanely held and be in fact a delu- 
sion. As the prescribed limits of this article are too restricted for the develop- 
ment of this thought, I must refer any one interested to page 428 of my book 
on ‘ ‘Nervous Diseases. ’ ’ Suffice it for the present to call attention to the fact that 
the essential thing in the delusion is not the falsity or the truth of the belief, 
but the condition of the mind, which holds the delusion i. c., a condition in 
which the mind is incapable of receiving, weighing and acquiescing in 
evidence. 
To discuss all the important features of insane delusions, would carry me 
far beyond the proper limits of the present article, but there are some points 
to which I would briefly call attention. A delusion may develope suddenly, 
but often it grows gradually. At first it is a thought, then a suspicion, then a 
conviction and finally a delusion so firmly fixed that nothing can loosen its 
hold upon the mind of the now insane man. As illustrating this, I may men- 
tion a case which I met with at my clinic at the University Hospital. A man, 
after malarial fever, began to have suspicions in regard to the chastity of his 
wife. For a time he kept these to himself, but finally, he accused her of infidel- 
ity. After this had continued for some weeks, he presented himself with his 
wife at my clinic, saying to me, “ I think my wife goes with other men. She 
thinks lam crazy, and we have agreed to leave the question to you.” Five 
minutes conversation demonstrated that the belief was a partially crystallized 
delusion, and when his case was carefully explained to him, with a voice of 
authority, he said he now understood it, and was glad to hear it, and that it 
gave him power to brace himself against the delusion, ending with the asser- 
tion that he believed “ he had a good woman.” 
As the delusion comes, so it may go. I have seen an absolute fixed delusion, 
which had been held with unwavering faith for fifteen years, disappear in a night, 
and I have in other cases, traced the gradual weakening of the delusion as it 
slipped day by day from its hold upon the mind. Some very able alienists at- 
tach much importance in the classification of disease, as to whether a delusion 
is systematized or unsystematised; a systematized delusion being one which the 
patient defends by reasoning, an unsystematized delusion, one which the patient 
simply holds without defence. If, for instance, Mr. Jones affirms that he 
knows his soul is lost, because upon a certain day he committed the unpardon- 
able sin and because the birds say there is such a sin, which is the particular 
one he did, then Mr. Jones has a thoroughly systematized delusion. If, how- 14 
WOOD, SYMPTOMATOLOGY OF INSANITY. 
ever, Mr. A. simply says that his soul is lost, never attempting to defend it 
logically or give reasons for it, then he has an unsystematized delusion. As is 
very frequently the case in medicine, this distinction which in the black and white 
of print appears so clear and readily recognized, is, when invested with flesh 
and blood, as impalpable as the ghost of Hamlet, There can be no doubt that 
certain individuals have delusions, which they reason about to the fullest ex- 
tent, and which are, therefore, thoroughly systematized, and also, that other 
patients suffer from absolutely unsystematized delusions ; but I must insist that 
every grade is to be found in nature, between the most thoroughly systema- 
tized and the most thoroughly unsystematized delusion, and that any separating 
of diseases founded upon the difference between systematic and unsystematic 
delusions is artificial; justified only by the fact that the classification of in- 
sanity in our present state of knowledge must be symptomatological, and there- 
fore artificial. 
In the completely systematized delusion, the patient not only reasons from 
his delusion, but reasons in defence of it. A common form of partially system- 
atized delusion, is one in which the patient reasons from his delusion, but 
does not reason in defence of it. As illustrating this, I may mention a case of a 
gentleman, whom I visited at one of our insane asylums along with a relative who 
was a little careless in his dress. The delusion of the patient was, that every 
person has his double who could not be distinguished from the man himself. 
This delusion he did not defend, merely asserting the existence of doubles as 
a fact, but he continually reasoned from it and about it. He said to the rela- 
tive, “Are you Mr. or are you his double?” The relative asserted 
that he was the insane man’s brother-in-law, and gave an account of certain 
events which happened when the two were camping alone in the wilderness, evi- 
dently much to the surprise of the insane man who finally said, ‘ ‘ You look 
like my brother-in-law, you know things that nobody but my brother-in-law 
knows, but—no, no, you are not my brother-in-law, because,” taking hold 
of the brother-in-law’s somewhat ragged vest, “my brother-in-law never 
wore a vest like that, you must be hisdouble.” It has been said that those 
cases which appear to be half way between the unsystematized and system- 
atized delusion are only apparently so, and that the individual reasons very 
feebly or not at all concerning the delusion, simply because in health his rea- 
soning faculties are very feeble. I cannot, however, acknowledge that this is the 
case. The uneducated person of little logical endowment, when defending the 
systematized delusion, undoubtedly defends it with less skill and tenacity than 
does he who has been an educated logician, but this does not explain the 
gradations between systematized and unsystematized delusions to be met with 
in almost any large insane asylum. 
To attempt to describe the various forms and varieties of delusion, would 
be to essay a treatise, but it seems right to say a word here in regard to one 
class of delusions, especially since such delusions are frequently present, when 
the general mental powers of the individual are still well preserved, and when 
it may be impossible to convince a court or jury that the subject is insane. WOOD, SYMPTOMATOLOGY OF INSANITY. 
15 
although in truth, he is not only a lunatic, but also a dangerous one. I refer to 
the so called delusions of persecution ; delusional conditions in which the sub- 
ject believes that he is made the object of persecution. Voices of reproach, or 
of hatred, or of derision are heard by him in the night watches as well as in 
the day time, conspiracies are formed against his person or his good name, by- 
standers are seeking to do him harm, spirits are oppressing him, and so in a 
multitude of forms the unfortunate man is, in his own belief, a victim of the 
hate, the ill will, or the envy of others. The danger in these cases is that the 
sense of persecution may lead a person to the refuge of suicide, or more frequently 
to counterplotting, or to assaults. He who hears voices in the air may revenge 
himself upon those who happen to be near him and whom he believes to be the 
source of those voices. She who is bewitched may, as did a woman not long 
since, arm herself and travel half across the continent to take the life of a doc- 
tor with whom she had had no intercourse for years, but whom she believed 
was projecting evil spirits upon her. He who believes that his manhood is 
being taken away may, as did an unfortunate prisoner, beat out the 
brains of the man whom he believes is conspiring to his ruin ; or as in 
three cases which I have seen this spring, serious injury may result from un- 
toward attempts at escape. Thus a man coming from Mauch Chunk, where 
he had done a day’s work, thought that he saw three men looking at him and 
talking at him, leaped from the car and was crippled. Another gentleman, an 
Episcopal clergyman of good standing, jumped from an express train to avoid a 
fancied assault and broke his knee cap. A third man, going from Boston, 
watching everybody and believing that the voices are everywhere about him, 
notices four men playing at cards, and as one slaps down his card and cries vio- 
lently, “Hit him hard, I have got him,” sees in his disordered vision a 
pistol drawn, leaps in terror from the cars and ever after shows his elbow, shat- 
tered by the fall, as proof that he had no delusion, but was shot. Probably in 
not one of these cases would it have been possible to have convinced a jury 
that the man was really insane before he made the fatal jump. Of all forms of 
insanity without distinct homicidal impulses, that which is characterized by the 
existence of delusions of persecution is probably the most dangerous to the 
individual and to those about him. 
The close relations between sanity and insanity are illustrated by the fact 
that the insane mind may be capable of performing useful mental labor, and 
may even originate much that is of value to humanity. The records of genius 
and of great works achieved, show how perilously near intellectual power may 
lie to intellectual ruin and how often great works, especially great works of the 
imagination, are the outcomes of an unbalanced or even of disordered mind.- 
Genius or the power of creative thought is not insanity and may exist 
in a well balanced intellect; but undoubtedly, genius is often an outshoot from 
an insane stock, and with equal certainty may we affirm that some men have 
accomplished great things, because one mental function was in them so over- 
developed that the whole mental structure was perpetually in danger of top- 
pling over. Of all English prose works of fiction, I hold Bunyan’s Pilgrim’s 16 
WOOD, SYMPTOMATOLOGY OF INSANITY. 
Progress ro be one of the greatest, because it is the most read and most powerful 
in its influence upon the race. No one who is familiar with the history of Bunyan’s 
life can gainsay the statement, that for a long time he suffered from monomania 
with delusions, and probably, in the gloom of his prison cell, his immortal 
dream was to him much more than a dream, it was a verity. Of modern nov- 
elists, Victor Hugo, the greatest, illustrates well the close relationship between 
insanity and genius. His uncle and his brother both died insane, one of his 
daughters is now, and has been for many years living in an insane asylum, and 
with the London Medical Times, I think we all may agree in asserting that 
some of his finest passages could only have been conceived by a diseased imag- 
ination, and are indelibly stamped with madness. 
Space is wanting to do more than call attention to the overwhelming egot- 
ism of Byron; to the agonies of mental depression, which overshadowed the 
life of Cowper; to the hereditary madness, which led to the orgies of insane 
cruelty in so many of the world’s ablest despots, whether among the ancient 
Romans or in the more recent Russian dynasties of Rurik and of Romanoff; to 
the hallucinations which caused Swedenborg to affirm that the hand of Christ 
‘ ‘ squeezed my hand hard, ’ ’ and Luther to declare that the devil came into his 
cell, stamped through his cloister and drove him from his bed ; to the glorious 
visions which inspired Joan d’ Arc with a faith almost divine and an energy 
irresistible ; to the direct communication with God which enabled the son of 
Abdallah to link together millions in a confederacy of religious belief against 
which Christianity has as yet beaten in vain. If it were permissible these and 
many other historic biographies might be detailed to show how the most won- 
drous of all instruments, the human brain, may yield its finest work when it is 
itself distorted and deformed by the inheritance of the insane taint, even, per- 
chance on the verge of hopeless ruin. Reprinted from the 
University Medicae Magazine. 
April, 1889. 
ORIGINAL ARTICLES. 
TWO CASES OF LATERAL OR HOMONYMOUS HEMI- 
ANOPSIA ; TREPHINING IN ONE CASE. DEATH 
AND AUTOPSY. 
H. C. Wood, M.D., 88-D., 
Professor of Therapeutics, and Clinical Professor of Diseases of the Nervous System 
in the University of Pennsylvania. 
Becture I.—Delivered at the University Hospital, February 1, 1889. 
Gentlemen : I have placed on the board before you, the field of vision 
of the two cases beside me. You will notice in each instance that the patient 
is suffering from that form of hemianopsia which is known as lateral or homony- 
mous hemianopsia ; i. e., that in each eye the vision is lost in corresponding 
halves of the two retinas ; the left half of each retina, or the right half of each 
retina, as the case may be, being paralyzed. You will also see that there is a 
great contraction of the field of vision in the halves of the retinas which are 
still, to some extent, functionally active. This contraction is, I believe, the re- 
sult of the alterations of the optic nerve, due to the condition known as choked 
disk, and is, therefore, a secondary phenomenon not directly due to the primary 
lesion. 
In approaching the study of these cases, I shall first call your attention to 
lateral or homonymous hemianopsia as a symptom which enables us to locate 
a brain lesion, and which is therefore spoken of in modern parlance as a “local- 
izing symptom.” 
The diagram which I show, is an old one, but that makes it no less service- 
able in the explanation of the symptoms under consideration. The posterior por- 
tion of the diagram, BOD and BOS, represents the extreme ends of the occipital 2 
WOOD, DATERAD or homonymous hemianopsia. 
lobes. That marked CU is the cuneus. From the cuneus, you will see, pass 
forward conducting fibres to the region marked PO C, which represents the 
primary optic centres including the corpora quadrigemina, corpora geniculata, etc. 
From this region run forward the optic nerves to the optic chiasm where there 
is a decussation of fibres. The decussating fibres do not intermingle, but 
remain as separate bands, the left hand nerve supplying the left side of each 
retina, and the right hand nerve the right side of each retina. 
Fig. i. 
Any interference with the functional activity of the optic apparatus produces 
a corresponding interference with vision, but };rou will see at once that in order 
for the blindness to be localized in corresponding halves of the two retinas, the 
lesion must be posterior to the optic chiasm so as to interfere with the function 
of the optic nerve before it splits into its two divisions. We know, therefore, 
that in each of the two patients before us there is some lesion affecting the optic 
apparatus posterior to the chiasm. 
The next point in our progressive diagnosis of the cases is to determine 
whether the lesion which produces the hemianopsia is situated posterior to the pri- 
mary optic centres, or wEether it is in those centres or in the nerve trunks between 
them and the chiasm. We are enabled to decide this by the study of the move- 
ments of the pupils. As you know, the pupils are the subject of many reflexes. 
In the performance of these reflex acts are concerned—as afferent, impulse-to-the- 
centre-canying nerves, the optic nerves, and the general sensitive nerves of the 
body—as nerve centres, the primary optic centre—and as efferent nerves the ocu- 
lar-motor nerves and their companion antagonists the sympathetic nerves. If a le- wood, lateral or homonymous hemianopsia. 
3 
sion be posterior to the primary optic centres in the optic tract it will produce hemia- 
nopsia, which is not accompanied with disturbance of the reflexes because it is en- 
tirely behind the reflex ocular apparatus. If the lesion, however, be either in the 
optic nerve or in the primary optic centres, the reflexes will suffer as much as 
the vision. A tumor which presses upon the optic nerve posterior to the chiasm, 
as at T2, in the diagram, so as to produce a lateral or homonymous hemianopsia, 
will so interfere with the reflexes as to give rise to the optic symptom first pointed 
out by Wernicke, and known as “ hemiopic pupillary reaction,” or, sometimes, 
Wernicke’s pupillary reflex. In such an eye, a beam of light thrown 
upon the blind side of the retina fails to produce contraction of the pupil be- 
cause the impulse it generates in the retina cannot reach the reflex centre, it 
being stopped at T2 by the pressure of the tumor ; but when thrown upon the 
opposite, or functionally active side of the retina, the light causes normal con- 
tractions. 
A careful study of the reflexes in each of these cases has been made both by 
myself and Dr. de Schweinitz, and we have concluded that in each case the 
pupillary reflexes must be considered to be preserved, although the damage from 
the secondary alteration of the optic nerve, i. e., from the alteration of the 
choked disk, has been such that the reflexes are in each case sluggish. 
In the second case that I have here to-day—Mr. M.—a very curious condi- 
tion of the reflexes is present, the exact meaning of which I am at a loss to 
understand. His pupils are abnormally large, and when a beam of bright 
light is thrown into them they contract slowly, but in a moment dilate again 
and then contract, and so oscillate backward and forward until they finally 
settle down into a condition in which the pupil is not so large as it has 
been, but is not nearly so small as the normal eye should be under such an 
amount of light. This condition of the pupil is technically termed hippus. I 
may say here that Dr. de Schweinitz has made a very protracted study of each 
case to determine the existence of anything like the hemiopic reaction, but no 
sign of its presence could be found. I think, therefore, that we must conclude 
that each of our patients has a lesion affecting the optic tracts, i. e., situated 
posterior to the primary optic centres. 
The physiologist Munk was, I believe, the first to point out as the results 
of experiments, that the seat of conscious visual perception in the dog is situ- 
ated in the posterior portion of the occipital lobes. His general results have 
been abundantly confirmed, especially by Eerrier and Horsley. The exact posi- 
tion in the occipital lobes of the visual perception has been the source of some 
controversy. Attention has been especially directed to the angular gyrus and 
to that region in the posterior portion of the brain known as the cuneus. Ter- 
rier destroyed in a monkey both angular gyri and obtained blindness, which, 
although for a time complete, in the course of a few days passed away. He 
removed the region of the cuneus without the destruction of the sight. In one 
experiment, he destroyed both occipital lobes and then the left angular gyrus, 
and after twenty-four hours vision was apparently normal ; but in the second 
experiment unilateral destruction of the angular gyrus and of the occipital lobe 
caused permanent hemianopsia. In the studies of Horsley and Schafer, destruc- 4 
WOOD, LATERAL or homonymous hemianopsia. 
tion of the angular gyri and occipital lobe in the monkey caused permanent 
hemianopsia, so that I think we must conclude that those cases of Ferrier, in 
which the sight returned after the destruction of both of these centres, the cause 
of the return of sight was that the alleged destruction of the centres was only 
partial. 
When both occipital lobes were removed by Horsley and Schafer there was 
a complete but temporary blindness, and it would seem, therefore, that in the 
lower animals both the angular gyri and the occipital lobes are concerned in the 
visual perception, and that when one is destroyed the other is enabled to take 
on its function. It does not follow, however, that in man, the functions of the 
two centres are identical; from the lowest to the highest animal there is a pro- 
gressive differentiation of cerebral centres, and it seems to me that we must of 
necessity expect to find that this differentiation has proceeded much further in 
the complicated brain of the man than in the comparatively simple cerebrum of 
the monkey. Undoubtedly tiimors in the region of the angular gyrus have 
produced homonymous hemianopsia in man, but as was pointed out by.Seguin, 
the conducting fibres passing from the occipital centres to the primary optic cen- 
tres go directly under the angular gyrus, and are, therefore, liable to be pressed 
upon by tumors growing in this region. What light we have indicates that the 
angular gyrus is connected with the visual perception, but connected only so far 
as that visual perception is there converted into thought. 
You will remember, no doubt, that we have two conditions occasionally 
occurring, one known as mind blindness, the other as word blindness. Mind 
blindness is the condition in which the patient sees objects, but is unable to con- 
nect them with the past so as to recognize their nature. He sees his father or his 
mother, his horse or his dog, but the perceived image fails to bring with it any 
conscious recognition of its nature. In word blindness, the subject sees the 
word, but the word brings no thought or no image or no meaning to his intel- 
lect. Macewen, in a very famous case, had, as the only localizing symptom, 
mind blindness, and boldly cutting down upon the angular gyrus removed the 
compression from it and restored the power of conscious recognition to his 
patient. In a case which recently died under the care of Prof. Osier, the brain 
of which I had the pleasure of seeing, the primary symptom was mind blindness, 
and the lesion involved the region of the angular gyrus. I think, therefore, 
that at present when in any case of hemianopsia there is not and has not been 
any mind or word blindness, the probabilities are that it is the posterior occipital 
centres which are at fault. 
The exact point in the posterior occipital portions of the brain in which the 
visual centre resides is still a matter of controversy. My own belief is that these 
centres either vary in different individuals, or are more wide-spread out than 
some clinicians would allow. It appears to be certain that the cuneus is especi- 
ally the centre of vision, for Haab, Huguenin, Fere, and Seguin have all described 
cases in which homonymous hemianopsia was present before death, and in which 
the lesion was confined to the cuneus. On the other hand Berger and Noth- 
nagel have reported cases in which the lesion producing hemianopsia was re- 
stricted to the superior occipital convolution. WOOD, LATERAL OR HOMONYMOUS HEMIANOPSIA. 
5 
In each of the cases before us, there is homonymous or lateral hemianopsia, 
without mind blindness either in the past or present, and without disturbance 
of the pupillary reflexes ; and I think, therefore, that we must conclude that in 
each case the lesion affects the occipital lobes in their posterior portions, and is 
probably located so as to influence the cuneus, or possibly the superior occipital 
convolution. Although thus far our two cases seem similar, here the symptoms 
become divergent. 
I ask the man to place his right forefinger on his nose, and he does so with 
certainty and promptness. I ask him to perform the same movement with the 
left forefinger. You at once notice the difference, the uncertainty and hesita- 
tion with which he moves the finger, and at last places it not upon his nose, 
but upon his cheek. There is nearly as much muscular power in the left arm 
as in the right, but the man has not the same control over the muscles of the 
left arm as he has over those of the right. If he undertakes to button his cloth- 
ing with his left hand, he is scarcely able to do it. He is unable to pick up any 
small objects with the left hand. There is a loss of coordination rather than of 
strength in the left arm. By loss of coordination we mean the loss of power of 
directing movements, i. e., loss of the ability to control the action of antagonistic 
muscles so as to make the part go in the desired direction. If the flexors con- 
tract a little too much, the nervous mechanism causes a contraction of the exten- 
sors so as to adjust the action of the muscles, or mayhap relaxes the flexors so 
that the part is moved in the direction that we wish. It might be thought a 
simple act to put the finger on the nose, but it is the result of a very compli- 
cated mechanism. An important part, the starting place of that mechanism, is 
the so-called muscular sense, a sense which is half unperceived by ourselves, 
but which enables the regulating nerve centre to tell exactly where the muscle 
is, and how it is contracting. When I put forth my arm, I have no perception 
of the contraction of any muscle in that arm. Ido not estimate how far the 
biceps or the triceps is contracting, but without conscious perception, the lower 
nerve centre knows what the biceps is doing and how its antagonistic is acting, 
and regulates by means of that perception the movements of the muscles. 
Constant impulses must stream up from the contracting muscle giving to the 
brain knowledge of how much it is contracting. To this the term muscular 
sense is applied. 
Let me examine the case of A. B. before you. 
The muscular sense comes into the field of conscious perception under cer- 
tain circumstances. If you take up a body, especially if your muscles have been 
well trained, you can tell very nearly how much that weighs. That the 
power of recognizing weights is not due to the pressure on the skin, is shown by 
the fact that if the hand be placed on a solid body, and the weight laid upon it, 
we are unable to estimate the weight. In estimating the weight of a body, the 
hand is moved up and down, and the weight of the body is measured by the 
amount of force put out to lift. It is under these circumstances that the so- 
called muscular sense, which ordinarily does not reach up to the centres of 
perception, becomes consciously recognized. 
We have seen that this man has not the power to move the muscles of the 6 
WOOD, lateral or homonymous hemianopsia. 
left arm as he desires to do. Is this due to want of control or to loss of the mus- 
cular sense ? Is it that he cannot make the muscles contract when he wills it, 
or is it because the lower nervous system does not know where the muscle is ? 
Let us now test him with weights. With the right hand he gives us the cor- 
rect weights when I place a one- and then a two-pound weight in his hand. 
With the left hand he says that a four-pound weight is about two pounds, and 
that a one-pound weight is about an ounce. We have repeated this test with 
weights a number of times with the same result. With the right hand, except 
with very light weights, he almost invariably gives the correct weight, but with 
the left hand he rarely comes within fifty per cent, of the correct weight. We 
must conclude, therefore, that there is a distinct loss of muscular sense, and that 
the want of coordination depends upon the inability of the brain centres to deter- 
mine what movements the muscles are making. 
The next point is with reference to common sensibility. There is slight 
loss of sensibility to the sesthesiometer in the left hand as compared with the 
right, but this varies from day to day. When I prick the left hand and ask 
him to place the finger of his right hand upon the place stuck, he fails to cor- 
rectly indicate it, but as Igo higher he does better. There is no distinct loss of 
power to distinguish between hot and cold applications. The sense of taste is 
good, the sense of smell is perfect, as is also hearing. All must agree that 
the loss of muscular sense is more pronounced than the loss of sensation. 
We have, therefore, gentlemen, in this patient, besides hemianopsia of the 
homonymous variety associated with retained pupillary reaction, loss of muscular 
sense of the left arm and some disorder of sensibility in the left arm, with very 
slight, indeed doubtful, changes of the muscular force of the left side. The 
seat of the muscular sense and of general sensibility cannot as yet be considered 
fully determined. In a number of experiments Dr. Ferrier found that after 
the destruction of the hippocampus there was a hemiansesthesia upon the oppo- 
site side of the body. On the other hand Profs. Horsley and Schafer, repeating 
these experiments, have failed to get the same result; but in a series of experi- 
ments in which they exposed and removed the gyrus fornicatus, pronounced 
lessening of the sensibility on the opposite side of the body resulted. These two 
series of experiments are not, however, so flatly contradictory as they might 
seem, since the gyrus fornicatus and the gyrus hippocampus are anatomically 
continuous one with the other, and are probably, therefore, only parts of the one 
great centre. You will notice in the brain which I hold before me, how close 
these convolutions come to the cuneus, especially at the point where the gyrus 
fornicatus dips down to become the gyrus hippocampus. It is, therefore, proba- 
ble that we have in this patient a lesion involving primarily the cuneus and, to 
a less extent, the hippocampus and the gyrus fornicatus. 
Having located the lesion in our first case, let us study together a little more 
closely the second case. 
Mr. M. is a clergyman ; two years ago he came under the care of Dr. S. Weir Mitchell 
for convulsive or epileptic attacks. In October, 1887, he became my patient; at that time 
he stated that in 1885 he began to have spells in which he would be giddy and lose himself 
for a minute. This continued until June 30, 1886, when unconsciousness lasted sufficiently WOOD, lateral, or homonymous hemianopsia. 
7 
long for him to fall. Similar attacks to this had occurred repeatedly before his visit to ine, 
hut in only two instances had there been violent convulsions, and there had been no 
history of headache or of any form of nocturnal attack. The attacks were not accompanied 
with aura or warning, except giddiness, which, he said, “seemed to deepen after a few 
■seconds into unconsciousness.” There was no cry, and no sleep after the attacks. The 
week before consulting me he had had three spells on as many successive days. His eyes 
bad been examined by Dr, de Schweiuitz while he was under the care of Dr. Mitchell, with 
Fig. 2. 
Concentric contraction of the fields of vision. The outer boundary marks the limits of 
the normal field; the shading indicates where vision was lost. 
negative results, I sent him myself to Dr. de Schweinitz, who detected nothing abnormal 
except some haziness of the retina and small areas of fatty change in the choroids ; form 
field was unaltered and acuity of vision normal. 
During the winter and spring the attacks of giddiness were of short duration, and, to 
use the words of the patient, “the spells were only commencements, and are off like a 
flash. ’ ’ 
On my return from my vacation in September, 1888, I received word that Mr. M. was suf- 
fering from severe headaches, and I asked him to come up from the country, which he did. 
Fig. 3. 
I.eft hemianopsia, with marked reduction of the remaining half fields, greatest 
upon the right side. 
He then complained of loss of mental power, and inability to concentrate his thought. 
About two weeks before coming to me, he had been taken with violent paroxysmal pain 
over the eyes which had continued ever since. This headache was especially prone to 
waken him from sleep about five o’clock in the morning, and would last for two or three hours 
in its intensest degree. I found that he now had double choked disks, and sent him to the 
University Hospital, hoping that he would have some convulsive attacks which would 
enable us to locate the tumor which was apparently present. The examination of the field of 
vision by Dr. de Schweinitz at this time showed that it was concentrically contracted. 
(See Fig. 2.) 8 
WOOD, DATERAD or homonymous hemianopsia. 
About the middle of January, 1889, Mr. M. again visited me at my solicitation, and 
finding that he was much worse, I sent him back to the Hospital for careful study. Dr. 
de Schweinitz again examined him, and the existence of left lateral hemianopsia (see Fig. 
3) was now, detected, but the most careful study of the case has failed to reveal any other 
symptoms than headache, choked disks, lateral or homonymous hemiarlopsia with the 
contraction of the preserved field of vision—unless it be disturbance of the power of 
balancing himself. The senses of taste, smell, and hearing, and general sensibility are 
intact. There is no muscular palsy, unless it be that connected with the pupil, of which 
I spoke in an early part of the lecture. 
For reasons, which have already been given in full, I believe that this man 
is suffering from a brain tumor which is now involving the posterior portions of 
the superior occipital lobes, probably the cuneus, possibly the superior occipital 
convolution ; but here we must face the fact, that the lesion had been develop- 
ing over two years before the hemianopsia manifested itself, an indication that 
the lesion is progressive, and probably a tumor not primarily located in the 
visual centres ; one that has sprung from some other portion, and has grown 
until it has reached this part. It is possible that a centric glioma might so de- 
velop as to isolate the cuneus during its development, but I can hardly think 
that this could happen without the interference with the function of other 
portions of the posterior central regions of the brain. It would seem, therefore, 
most probable that the growth is outside of the cuneus and outside of the brain 
itself. The tentorium lies not far below the cuneus separating the cerebrum 
from the cerebellum ; and it is conceivable that a tumor springing from the 
tentorium might so grow upward as after a time to involve the visual centres 
above it. It is well known that tumors in the tentorium are apt to be associated 
with excessive pain, and also, from their proximity to the base of the brain, 
that they are prone to give rise to strongly choked disks. The pain in this 
case is excessive, and the choking of the disks is most pronounced. So far as 
these symptoms go, they correspond with the theory of a tentorium tumor. 
A tumor growing from the tentorium so as to produce upward pressure 
would naturally produce downward pressure, so that it is necessary in the 
present case to look very carefully for the presence of cerebellar symptoms. 
Tumors of the cerebellum may be entirely larvated, or may or may not produce 
symptoms which are at all localizing. The only symptom peculiar to cerebel- 
lar lesion is the disturbance of equilibration, and when such disturbance 
amounts to the peculiar phenomenon commonly spoken of as cerebellar tituba- 
tion, it is pathognomonic of tumor or other lesion of the middle cerebellar lobe. 
In cerebellar titubation the feet are held apart and well forward when standing. 
If the attempt be made to bring them close together, peculiar movements of 
extension and flexion occur in the feet, and at the same time the trunk begins 
to rock and stagger more and more violently, until, in extreme cases, the subject 
falls unless he can seize some support. In the present case I think there are 
disturbances of equilibration, although such disturbances are not sufficiently 
pronounced to enable us to say that the man has distinct cerebellar titubation. 
You notice that he stands with his feet widely apart, and that in walking his 
feet are much more widely separated than in the normal man ; also that when 
he walks, the sway of the body is much greater than normal. Standing with WOOD, eaterae or homonymous hemianopsia. 
9 
his feet wide apart, Mr. M. does not sway very much, but when his feet are 
brought close together the movements of the body become pronounced. He is 
entirely unable, as I show you, to stand upon one foot either with eyes open or 
shut ; and both he himself and his wife assert that he staggers sometimes when 
he walks. His wife believes that he staggers always to the left. 
The question is how far these symptoms are connected with muscular 
weakness, and how far they are due simply to lack of the power of balancing. 
[Dr. Wood then caused the patient to walk across the room, take turns quickly, 
and contrasted the gait with that of a normal man doing the same acts. He 
asked the class whether in their opinion there was a distinct loss of coordina- 
tion or balancing power. The class decided unanimously that such symptom 
existed.] 
I think myself that our patient has a disturbance of the power of equili- 
bration. If this symptom really exist, it of course strengthens very much our 
idea that there is a tumor springing from the tentorium, or at least occupying a 
position near the tentorium pressing upward and downward. 
Having made a diagnosis we must consider what is, after all, the practical 
question connected with these two unfortunate patients ; that is, whether, as 
neurologists, it is our duty to call in the aid of the surgeon. In regard to the 
first case, I must decide against surgical interference, because the man is nearly 
seventy years old ; has a pronounced general arterial atheroma ; and has a dis- 
tinct aneurismal enlargement of the innominate artery if not of the aorta itself. 
In such a case the dangers from the operation are far greater than in the normal 
individual. Moreover the symptoms are, in the main, making very slow 
progress, whilst the absence of headache and epileptic fits seems to me to make 
it more probable that the patient is suffering from a diffused gliomatous growth, 
than that he has a tumor springing from the brain membranes. The chances of 
removing a meningeal tumor successfully are far greater than is the case with 
an intracerebral glioma. 
In the second case which is before us, I believe that surgical interference is 
justifiable. Our patient is a young man whose general bodily health is good, 
whose arteries are normal, and in whom the chances of recovery after a severe 
surgical operation woiild be very good. In answering the question as to surgi- 
cal interference in such a case, you must ask yourselves two questions : In the 
first place, are you sure the tumor is at the place you have located it ? In the 
second place, is it possible for surgeons to get at such tumor if the location be 
fixed ? In answering the first of these questions, I can only say that I believe 
our reasoning has been logical and wTould be entirely reliable if we were only 
sure of our premises, but there are some of our premises concerning which we 
are not certain. I have taken it for granted in the discussion, that there is a 
distinct lateral or homonymous hemianopsia. I believe that it does exist, but 
there is so much secondary disease of the optic nerve, and so much secondary 
contraction of the field of vision, that in one eye nearly the whole field has 
been obliterated, and in the other eye, that half of the field of vision which 
retains some functional activity, is vety much contracted—so that the possi- 
bility suggests itself that the apparent hemianopsia is not real, but that the optic WOOD, LATERAL OR HOMONYMOUS HEMIANOPSIA. 
nerve itself has undergone such an irregular change as to produce an irregular 
alteration of the visual field and an apparent hemianopsia. Ido not think that 
this has occurred, but herein certainly lies one source of doubt. Then again 
we have relied upon the absence of mind blindness as disproving the possibility 
of tumor in the region of the angular gyrus. Here, however, I think we are a 
little ahead of our times. At present we can only say, that what light we have 
indicates that the recognition of objects is the function of the gyrus angularis, 
and that interference with this function produces mind blindness. We have 
not, however, sufficient light to make our generalization a certainty. We have 
evidently two possibly mistaken premises ; if we were sure of the supposed 
cerebellar symptom, if the disturbances of equilibration were more marked, and 
pronounced cerebellar titubation existed, we would have firmer ground under 
our feet ; we would know that we had a tumor involving the cerebellum and 
the visual centres of the posterior occipital region. I repeat that I believe that 
some lack of coordination exists, and that although the diagnosis is not an abso- 
lutely positive one, and although possible fallacies underlie our reasoning, yet 
we have sufficient light to require us to search for the tumor in the man’s brain. 
The man must die if the surgeon is not able to remove the tumor, and I think 
we are bound to look for it in the place where it is most probably located. If 
after exposing this region, the surgeon fails to find the tumor, it will become 
our duty to disregard the supposed mind blindness and visual perception 
function of the gyrus angularis, and direct him to cut down upon the region of that 
convolution. As neurologists we decide that this is a case for an operation. 
As to the possibility of the removal of a tumor of the tentorium I believe it can 
be done, but am not prepared to-day to give a positive answer. I have referred 
the case to Prof. Agnew, and if he believes there is any possibility, as it seems 
to me there is, of reaching a tumor at the position assigned at the present, I 
have no doubt that he will perform the operation. 
Lecture ll.—Delivered at the University Hospital, February 8, 1889. 
Gentlemen ; In regard to the case of Mr. Morgan, whom I showed at the last 
clinic, February Ist, I will read you the following letter from Dr. de Schweinitz. 
February 6th, 1889. 
My Dear Doctor : I made a very careful examination of F. M. M.’s ociilar con- 
ditions this afternoon, and found distinct changes from the last examination a week ago, 
as follows:— 
Right eye.—This is now totally blind. In no portion of the field of vision is there the 
faintest light perception, not even to strong condensed light. The optic nerve is distinctly 
more swollen, and there are several fresh retinal hemorrhages. Of course no determination 
of the field is possible inasmuch as every particle is obliterated. (See Fig. 4.) 
Left eye.—The field is as before, showing complete absence of the left half, with partial 
preservation of the right half of the field. That portion preserved, however, is consider- 
ably contracted in comparison with what we found one week ago. 
There is a slight divergent squint, probably due to the lack of fixation in the eyes, in- 
asmuch as the excursion of the eye-balls in all directions is still preserved. 
The pupils, facing a bright light, are slightly unequal, the right being the larger. Both 
pupils react sluggishly to the changes of light and shade, but the right pupil is more slug- 
gish in its action than the left. WOOD, DATERAD OR HOMONYMOUS HEMIANOPSIA. 
11 
The consensual contraction of the pupils is preserved. It was not possible to demon- 
strate the hemiopic pupillary reaction. 
I do not presume to explain these changes, except that it strikes me that the indications 
are that the local conditions in the eye (the increasing neuritis) may explain them, and that 
the case should not be looked upon as a typical hemianopsia. Certainly I have never seen 
such rapid changes taking place in hemianopic fields. 
You see at once that the case is a doubtful one on account of the uncertainty 
as to the existence or non-existence of a true lateral or homonymous hemi- 
anopsia. I still believe, however, that the probabilities are in favor of the 
existence of a tumor at the position where I have located it. I myself have 
never seen a case of simple choked disk produce such rapid and peculiar altera- 
tions of the visual field, whilst the preservation of the reflexes, the absence of 
the hemiopic reaction indicate that the alterations of sight are not the result of 
Yours truly, G. E. df Schweinitz. 
Fig. 4. 
Left hemianopsia of the left eye, with marked reduction of the remaining half field 
Total blindness of the right eye. 
direct pressure upon the optic nerves ; further, a tumor producing so much 
choked disk if situated at the base of the brain, almost certainly reveals itself 
by distinct ocular or other localizing palsy. 
It is conceivable that a very large tumor in the frontal or latent region of the 
brain might produce no localizing symptom, and derange sight by a secondary 
inflammation of the optic nerve ; so that it seems to me as probable that the 
tumor is frontal as that it is situated on the anterior base of the brain. I adhere 
to my original view as the most probable one, because the rapid loss of sight 
may be very well explained by the supposition that the tumor growing upward 
and from the tentorium primarily involved one cuneus, but is now pressing upon 
the cuneus of the opposite side. Further, I think the cerebellar symptoms 
in Mr. M.’s case have become somewhat less uncertain, in that there has 
been increase in the swaying movements of his body during standing and 
walking. After all, however, the position of the tumor is uncertain, but the 
certainty of death unless relief be obtained by surgical interference makes such 
interference our duty, although the operation must be tentative and with a con- 
siderable probability of ending in failure. Dr. Agnew believes that if the 
tumor be in the location named he can extricate it. It is proposed that the 
patient be operated upon in the coming week, and the result will be reported 
at my next clinic. 12 
WOOD, LATERAL or homonymous hemianopsia. 
Lecture' Hl.—Deeivered at the Hospital, February 16, 1889. 
I propose to devote the first portion of our hour to the continuation of the 
study of the case which has been before us in our thoughts during the previous 
two meetings. I refer to the case of Mr. M.—brain tumor. 
On morning, February 9th, Dr. deSchweinitz found that the 
vision had returned in the right eye, and that the fields of vision were the same 
as when the hemiopic defect was originally found. (See Fig. 3.) Under all 
the circumstances, for the reasons which I stated in the last clinic, it was decided 
to operate on Mr. M. on Monday, February nth. 
Dr. Agnew opened the brain and exposed the cuneus, the region where I 
had located the tumor ; this was apparently absolutely healthy. We felt of the 
brain cortex and of the tentorium, but there were no evidences of disease. 
When, however, the attempt was made to replace the brain into the dura mater. 
Fig. 5. 
The dotted area represents the situation of the tumor. The lines A and B represent the posi- 
tion of softening running through the centre of the occipital lobe. The shaded area shows 
the portion of the brain exposed at the operation. 
it was found impossible to put it back, showing that it was under great pressure. 
I then insisted on the cuneus being opened. When this was done, Dr. Agnew 
said at once, “ There is a cystic tumor.” The cavity was found immediately 
beneath the gray matter of the cuneus of a considerable size, and since the 
autopsy it has been determined that it is a patch of hemorrhagic inflammatory 
softening with definite walls formed by the infiltration of the brain substance 
by leucocytes. 
Mr. M. lost a great deal of blood during the operation, and after a length 
of time it showed hardly upon him ; but he rallied to a certain extent and 
regained consciousness, but two or three hours later commenced to fail in his 
circulation, and the same evening at 9 or 10 o’clock died. 
When the autopsy was made, the brain, which is now before us, was 
removed. You see that there is occupying the second and third temporal and 
encroaching on the fourth convolution an enormous tumor, and, although we WOOD, LATERAL OR HOMONYMOUS HEMIANOPSIA. 
13 
have cut down nearly two inches into the brain, still the tumor is perceptible. 
It occupies the centre of the lobe and reaches anteriorly and posteriorly through 
nearly the whole lobe. The uncinate convolution, the hook convolution, is not 
encroached or pressed upon. I want next to call your attention .to the fact that 
there is a patch of hemorrhagic softening in the cuneus which is known 
as the region of visual perception ; and that there is a line of softening running 
nearly the whole length of the centre of the occipital lobe. (See Fig. 5, lines B 
and A respectively.) 
In cases of excessive choked disk, contraction of the field of vision occurs, 
and the ophthalmologists were inclined to believe that in the present case this 
contraction had occurred irregularly in such a way as to produce the fields of 
vision that I have represented to On the other hand, I myself was of the 
opinion that two factors entered into the formation of the visual field ; that 
there was a centric hemianopsia coincident with an irregular contraction from 
choked disk. I did not, and do not, believe it possible that such fields of vision 
can be the result of generalized disease of the two nerves. The question is an 
important one, for in perhaps a majority of cases hemianopsia co-exists with 
some contraction of the field due to choked disk. If it be possible for optic 
neuritis to produce such a field of vision as that of the present case, I think the 
recognition of centric hemianopsia could rarely be a certain one. So far as this 
question is concerned, the autopsy shows that my opinion was correct, and that 
there was a lesion far back in the centres of visual perception. 
During life I believed that there was a lesion of the optic centres, and that 
it was secondary and not primary, because the hemianopsia had developed so 
late in the case. So far I was correct; but when I came to locate the position 
of the original lesion I was wrong. I made my location because the absence 
of distinct symptoms showed that the tumor was located somewhere in a 
region of silence, and because of my belief there are only two such 
regions in the brain : one in the frontal lobe, one in the cerebellum. The fron- 
tal lobe is so far distant from the occipital lobe that I considered it exceedingly 
improbable that the tumor was in it. On the other hand, the cerebellum is so 
near the occipital lobe that it seemed extremely probable that the tumor was 
connected with it. Moreover there were certain symptoms in regard to equili- 
bration which we now know must have been the result of the general brain 
pressure, but which during life gave at least a plausible pretext for supposing 
that they might be produced by a cerebellar tumor. The fallacy iu the reason- 
ing was in the premise, i. e., in considering the temporal lobe to be a region 
in which tumors produce active symptoms. 
We all know that it is not positively settled where the centres of conscious 
audition are ; but the general drift of authority is strongly toward locating the 
auditory centres in the temporal lobe. Without entering into a discussion of 
the evidences, let me read to you two quotations. Dr. Gowers says : “Only 
one symptom is caused by disease of the outer aspect: deafness in the oppo- 
site ear when the disease involves the hinder half of the highest convolution, 
and an auditory aura if convulsions are caused by a lesion in or near this 
part.” 14 
WOOD, LATERAL OR HOMONYMOUS HEMIANOPSIA. 
Dr. Mills, in his recent paper on “ Cerebral Localization,” says : “ While 
auditory localization remains in a somewhat uncertain state on the whole, the 
evidence is in favor of the localization of the cerebral centres of hearing in the 
temporal lobe, and probably in its upper portion, that is, in the first or second, 
or in both the first and second temporal gyres.” 
In the case of Mr. M. unfortunately no test was made to determine whether 
there was any restriction of the power of distinguishing high and low notes 
but he was a man of such intelligence that any alteration of this character in 
hearing, if at all pronounced, would in all probability have been noticed by 
him. So far as testing with the watch is concerned, his hearing was normal; 
nor were the convulsions or giddy spells at any time ushered in with an auditory 
aura. The present case therefore proves that the whole right temporal lobe, 
except the first convolution, may be involved in a tumor, without the produc- 
tion of any immediate direct symptom, and that this region must therefore be 
put among the silent regions of the brain. The first convolution was some- 
what flattened above the tumor which impinged upon it directly, and at one 
place had bridged over the sulcus and encroached upon the convolution itself. 
If the first temporal convolution be the seat of exclusive hearing for one ear, as 
alleged, it is very extraordinary that no disturbances of hearing were caused by 
this enormous growth. In all future localizations, I shall myself believe that 
wTe have to deal with three possible silent regions—the cerebellum, and the 
frontal and the temporal lobes. 
Another very important question in connection with the present case is as 
to the cause of the secondary brain degeneration. You will remember that the 
posterior portions of the occipital lobe are fed by the posterior cerebral artery, 
and the thought immediately arose that the tumor may have pressed upon this 
and caused thrombic arrest of respiration. Careful examination however failed 
to find any thrombus or any apparent disease of the posterior cerebral artery ; 
moreover this artery supplies the cortex as well as inner portions in the 
occipital lobe, and the cortex of the cuneus was normal. It is evident then 
that there was no large thrombus or other wide-reaching arterial implication. 
You will no doubt also remember that there are two sets of arteries arising from 
the posterior cerebral artery, one set of perforating arteries going up to supply the 
inner portion of the brain—the other, cortical arterioles dipping down into the 
cortex ; that these two sets of arterioles are each independent, terminal, non- 
anastomosing vessels ; and that further there is a portion of the brain which lies 
between the territory supplied abundantly by these terminal vessels —a zone 
between the inner and outer zones which is not very vascular and which is 
always liable to softening from starvation when there is serious interference with 
the general brain circulation. It is apparently in this zone that softening has 
occurred, and it would seem at present as though we must account for these 
secondary lesions by supposing that they are the result of impairment of the 
general nutrition of the occipital lobe by excessive pressure. Possibly when 
the brain has been hardened and very carefully studied other explanation may 
be found. 
The study of secondary lesions in brain tumor, as shown by the present WHITE, SURGICAL ASPECTS OF BRAIN TUMOR. 
case, are very important. Mr. M. had been long under observation, and it was 
known that the hemianopsia was developed late in the case ; but most cases of 
hemianopsia come to the physician’s notice with the symptom fully developed, 
so that it may be impossible to say whether it is an original or a secondary 
symptom. Such is the case with the man whom I had at the clinic along with 
Mr. M. We do not know whether his hemianopsia is an original symptom, or 
whether it is a symptom which has been developed secondarily upon a tumor 
existing in the temporal lobe or in some other silent region. 
In the light of this case, it is evident that a very serious embarrassment to 
the neurologist must frequently arise from his inability to determine whether 
certain symptoms are secondary or primary.