Charles Hamilton Hughes.

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be facilitated for the following exhaustive discussion by the
fact that we hold to the simplified conditions of our example.

We have to occupy ourselves still further with the
(voluntary) fiction of a concept centre C. The advance-
ment, which our clinical knowledge has gained from aphasia,
shows most plainly that this present assertion was indis-
pensable for the extension of our knowledge. To trace it to
its true value I have only hinted at heretofore. Permit me
.to carry this suggestion somewhat further.

As I have said above in speaking of the central projec-
tion fields, we can consider it an assured fact that memorial
images and ideas* are localized, i.e.^ joined according to the
content to different anatomical regions of the cerebral cortex.
This localization could be disregarded in the scheme of

*See b«iowforthe different use of these two t«rms.



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C. Wernicke, 147

aphasia, and with some propriety the standpoint could be
taken, that the receiver and sender of any dispatch in the
imaginary concept centre C would be identical with all the
rest of the brain cortex and, as we must again say, the
association system belonging thereto, so that the two pro-
jection fields s and m are brought into an artificial opposition
to all the other projection fields. On this oppositional posi-
tion depends then the differentiation of the terms cortical,
which relates to the two projection fields s and w, and
subcortical or transcortical, according as it is a matter of
paths, which lay on this or that side of these definite pro-
jection fields. By this view the anatomical idea was im-
plicitly given that the sum of the transcortical paths sC and
mC could form a compound column, accessible to destruction
by focal diseases, in the immediate vicinity of the two pro-
jection fields 5 and w, while they must be regarded as
radiating to the most diverse regions of the cortex. The
clinical picture of transcortical motor and sensory aphasia
seems to have been due to the rare accident that disease
foci exactly invade the postulated site. That these rare
cases are included among the focal diseases of the brain,
will be entirely comprehensible. On the other hand the
observation of a patient, whom 1 have presented to you,
proves that such disease types can occur in the course of a
typical mental disease, and so form a natural transition to
mental diseases.

It is essential to our purpose to really refrain from such
rare occurrences. But if we stick to the chosen example
and hold only to the principle of localized ideas, so we
appropriately divide the centre C into two localized ideas
joined by an association path, which we will term A and
Z. A, the initial idea is united by an association path sA
with the sensory speech field. Z, the terminal idea, is
united by a similar path Zm with the motor projection field
of speech. AZ is the association path. The scheme thus
changed corresponds somewhat to the process occurring when
an arithmetical problem is given the patient. Its compre-
hension occurs in the initial idea A, its solution corresponds
to the terminal idea Z, and when this is spoken, the



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148 Outline of Psychiatry in Clinical Lectures,

innervation from m occurs. Between problem and solution
complicated trains of thought may occur, thus showing that
the association path AZ may be conceived as divided many
times. No special proof is needed that normally the whole
process conforms to law, in a certain measure by previously
formed paths, so that the result can be foretold. We can
for the present assume that it is just the same with any
question: the comprehension of the question is represented
by Ay the sense of the answer by Z, and the path inserted
between ombodies the fact that the answer arises from a
more or less simple reflection. If. we do not suppose the
intention of being led astray, so must we recognize in this
case in normal persons, the answers will occur in a very
definite sense, which accordingly may be known before with
approximate accuracy. The conformity to law, which may
be here observed, depends, as we shall see later, on the
principle of the beaten paths.

The previously maintained example admits of an ex-
tension, by which it may become the foundation of the
whole symptomology of mental diseases. We have only to
replace the projection fields of speech by any other projec-
tion field. In the place of speech utterances any motor
manifestation then occurs, and m represents this projection
field, accordingly as the movement occurs \n the arm, leg,
back regions, etci The central projection field of a sensa-
tion replaces the sensory speech field. In fact it occurs the
same in seeing as in the comprehension of the spoken
speech clang. Here also the primary identification takes
place in the central projection field of the optic nerve, but
for the comprehension of whatever is seen the conduction to
other projection fields, secondary identification, is essential.
Without this secondary process the sight impression is. lost
to the one receiving it and remains unintelligible, like the im-
pressions of hearing in transcortical aphasia. And this is
true, as slight reflection shows, of all sense impressions.

That this generalization of our scheme is permitted,
even demanded, a closer inspection of our original example
teaches. The answer, which I expect from the patient,
does not need to be spoken; it may be written or com-



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C. IVernicke. 149

municated by silent pantomime and gestures, or in the per-
formance of any chosen command. According to the muscles
engagecj in its execution, the projection field m will have a
different significance and correspond to different places in
the cortex. On the other hand my question, respectively
my command, can be given without a spoken word, either
by writing, pantomime, expressive movements of the hand
or the like.

A short time ago I said that ouf scheme with the
proposed modifications can aid in the deduction of the
symptomatology of insanity, in so far as it consists of
the patients' movements. But then this limitation is only
necessary when we exclude from the movements the speech
utterances, pantomime, attitude and all those manifestations
of the patient within the province of expression, as corres-
ponds to ordinary parlance and the views of the laity. But
in the last instance there are also movements which are
utilized for judging of the inner processes of an insane
person, and for scientific consideration it would be an error
to neglect this condition. And the more you really see
of the insane and become acquainted with their symptoms,
the more you will be convinced that finally nothing else is
to be found and observed but movements, and that the
general pathology of the insane consists simply of the
details of their motor condition; for as a matter of course
the loss of movement may be just as characteristic as its
occurrence.

We conclude from movements as to the processes oc-
curing in the consciousness (in the organ of consciousness)
of another. If these movements are those of speech, so
this fact is much more tangible and evident than all the
other movements. The symptomatology of the insane has
then for its subject the movements, in so far as they seem
to be the function of the organ of consciousness, in other
words of the organ of association. We here find only the
single reservation, which impairs the universality of the
proposition. There are of course motions, which are inde-
pendent of consciousness, like those of vegetative life, of the
heart, respiration, the vascular walls, viscera; as well as



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150 Outline of Psychiatry in Clinical Lectures.

the majority of reflex movements. As we will see later,
these movements may be affected sympathetically in the
insane, but then do not form the real object of observation.
We will further find that in rare cases the state of the tem-
perature and in almost all cases that of the nutrition, as ex-
pressed by the body weight, is of great symptomatic signi-
ficance. But the exceptions are thus exhausted, and we will
see that they are all to be considered secondary and in their
turn possess a conformable dependence on the motor mani-
festations of the patients.

We are then justified in disregarding the exceptions
enumerated, and have merely to keep more closely in mind
the movements as functions of the organ of consciousness.
A classification according to practical points of view is
essential. Therefore we distinguish expressive, reactive and
initiative movements. As we will see, this classification has
the advantage that it embraces the sum of all possible
manifestations of motion, and therefore it is to be preferred
to Meynert's classification into movements of defense and
offense, however portentious and fruitful this has proven in
other respects,* it is defective and needy of improvement,
in that a sharp boundary line between the three kinds of
movement is often impossible. It is in the nature of the
affair that certain movements of the one province come
under another, that, according to the observer's standpoint,
it may be a matter of dispute into which province a certain
movement is to be placed. However, for the present we hold
to the classification, because it has stood the test in the
clinic of mental diseases.

By expressive movements we understand especially all
those by which the affects and emotional state of a person
are manifested. The speech movements largely serve this
purpose, but not exclusively, and as far as they serve, they
are speech movements in the broadest sense, so that they
include, e.g., the plaintive tones and the groans of pain.
Words, which especially serve this purpose, are, as you
know, the majority of interjections. Laughing and crying
are specific expressive movements, like general pantomime.

*See his Sammlune popular-wissenschaftlicher Abhandlungtii.



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C. iVernicke, 151

But the expression of the face while at rest, depends on
certain muscular actions, and also the attitude of the whole
body, which may betray, as well as words or pantomime,
the person's affective state and affective condition. The
movements of the entire body, serving for the expression of
joy, mirth, arrogance, egotism, scorn, anger, anguish, sor-
row, trouble, despair, hope, hatred and love are sufficiently
known and appropriate that it will be unnecessary to de-
scribe them here. Normally the person awake is always
animated by an expression, therefore we have become ac-
quainted with lack of expression as an important clinical
phenomenon.

The reactive movements are those following actual
external stimulation. A person's answers to questions,
regardless of their content, are always to be regarded from
this point of view of reactive movements. Also an answer,
which does not consist of words, but of other expressive
movements, when the person questioned, with a significant
mien, places his finger to his lips, comes under the concep-
tion of reactive movements. The absence of an answer
may often be regarded as a significant symptom. The re-
active movements, which are of great significance in the
clinic of mental diseases, are especially the patient's con-
duct during the physical examination, toward the little favors
shown by the nurses, toward requests of any kind, on the
approach and greeting of the physician, toward the entirely
changed situation in the rooms of the asylum. Also those
movements, which are ' necessary for the gratification of the
bodily wants, although they are to be traced to Internal
stimuli, must be included among reactive movements. It
might, however, be proper to add the last category of move-
ments to the initiative, while again many of the former at
the same time fall into the province of expressive movements.
At any rate it is to be again stated, that the absence of
reactive movements is just as characteristic and valuable as
a symptom in the insane as their morbid modification.

By initiative movements we understand all those which
arise spontaneously and are not due to an actual external
stimulus. This negative definition includes a part of the



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152 Outline of Psychiatry in Clinical Lectures.

expressive movements, while another part belongs to the
reactive. We will then always have to judge of the ex-
pressive movements, whether they belong to the initiative
or the reactive. It might be asked, whether there are really
initiative movements, t.^., those, which occur without any
external cause; for usually an external cause may be dem-
onstrated for an apparently spontaneous action. But such
causes often have only the significance of exciting causes
and recede in their importance before the preponderating
internal motive, so the assertion of initiative movements is
justified. In general the initiative movements consist usually
of a whole series of individual motor processes and then* are
to be called actions. The whole conduct, behavior, actions
of a person in a certain situation, all his movements, so far
as they are not expressive and reactive movements, belong
to the initiative.

The nerve excitation, which takes place over the path
sAZm, may be compared to a reflex process and this path
called a "psychical reflex arc." The movement innervated
from m then appears as the result, as the tangible conse-
quence of this process of excitation. The clinical method
of psychiatry consists in studying the final result, in draw-
ing a conclusion from the process as to how it occurred.

As you will likewise notice, it is really the reactive
movement alone, which may be compared in this way to
the reflex process. If the reactive movement may now
consist, as in the example we started with, of a spoken
wofd or any other movement, it may always be very readily
considered a consequence of an external stimulation, an
external impulsion depending on processes of mbtion. How
is it then with the other kinds of motion, the expressive
and initiative? Evidently these also permit of the same
consideration; for with the exception, that in initiative move-
ments it seems questionable, whether they occur entirely
without external cause, we will be justified in replacing the
external stimulation by the memorial images of past stimu*
lation and in every case, where the present external stimulus
is wanting, to consider those memorial images as initial
members of the movement occurring in the psychical reflex



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C. Wernicke, 153

arc. We may even go so far as to use the existing move-
ment as a proof of this assumption. For as it is not con-
ceivable without a cause, while an apparent cause is wanting
for the movement, the actually existing movement can only
be due to a force treasured up somewhere. But these sup-
plies of reserve force are memorial images, as we shall see
later.

After these preliminary remarks we are now able to
familiarize ourselves with the morbid derangements of move-
ment, which are observed in the insane. They all depend
on disorders of secondary identification, as I have above
shown. But still 1 must remind you, that we have consid-
ered as secondary identification, not only the relation of 5 to
A, i.e., of the nearest sensory projection field to the initial
idea, but also the process of excitation proven in the inverse
direction of conduction from the terminal idea Z to the motor
projection field m. We were justified in this, because the
path Zm is an association path, as well as the other s/l,
and in these association paths the physical process occur-
ring in them must always be identical, in whichever direc-
tion it occurs. For the same reasons we can also infer the
relation of A to Z to secondary identification.

As it is always a matter of nerve paths, so a morbid
change of excitability, respectively capacity for conduction,
is always to be based on the disorder of secondary identifi-
cation, and all possibilities are exhausted, if we keep in
mind the three cases of lowered excitability, respectively
capacity for conduction, increased excitability and perverse
excitability. We will call the path sA psychosensory, the
path Zm psychomotor, the path ZA intrapsychical. The
possible cases are then, contained in the following summary:

Psychosensory Psychomotor Intrapsychical
Anaesthesia Akinesis Afunction

Hyperaesthesia Hyperkinesis Hyperfunction

Paresthesia Parakinesis Parafunction

The objection may be raised against this, that there are
always disorders of motion, which oppose us in the insane,
as 1 have stated, and that therefore, the Whole symptoma-



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154 Outline of Psychiatry in Clinical Lectures.

tology is exhausted in the three cases of hyperkinesis,
akinesis and parakinesis. This objection is justified in a
certain sense, and needs an exhaustive discussion. It is
the easiest to refer it to the example of conversation, with
which we started. If the patient is silent when he should
speak, we will be able to consider this symptom a circum-
scribed form of akinesis limited to the province of speech.
If he presents the symptom of loquacity, it is likewise a
circumscribed form of hyperkinesis. Whereas, if his answer
is nonsensical in its purport, so one will be justified in
ascribing this to parakinesis, but still a closer inspection
would always be necessary, because then a certain mis-
conception is to be expected and presumed. For practical
reasons we will always be obliged to differentiate two
entirely different things in the act of speech, namely the
motor act as such and the purport of the works spoken.
But as there are now really morbid modifications of the act,
or as we may term it, of the formal part of speech, so it
would be the more correct to employ the word parakinesis
in this restricted sense. We have an example in the
symptom of imperative speaking and the monotonous repe-
tition of the so-called verbigerator. The same consideration,
that the content must be differentiated from the formal part
of movement, applies to all the expressive, as well as
to the reactive and initiative. As it is possible for a
patient to utter the veriest nonsense in formal words per-
fectly correct, so the expressed affective condition in language
perfectly correct can of itself be of a morbid nature, as well
as his acts formally correct, but false in content. In all
these cases then we will not assume a disorder of the
psychomotor identification, but be constrained to seek the
derangement in more remote parts of the psychical reflex
arc. This corresponds to common parlance and the usual
view, in that the means the patient uses to communicate
his feelings, express affects, etc., are generally overlooked
completely as self-evident affairs. After this discussion you
will comprehend that in the insane, we often find symptoms
of disordered identification, when the motor mechanism
itself is perfectly fntact.



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C. Wetnicke, 155

III.

NATURE OF MEMORIAL IMAGES. AFTER-IMAGES OF THE
RETINA AND OPTICAL MEMORIAL IMAGES. THE AS-
SUMPTION OF SPECIAL PERCEPTION AND MEMORY
CELLS DO NOT SUFFICE FOR EXPLANATION. LOCAL
SIGNS OF THE RETINA. IDEAS OF SIGHT.

Ere I can introduce you further into the symptomatology
of mental diseases, 1 must again return to the concept centre,
so often mentioned, or rather, as you can apprehend more
correctly, to the localized memorial images. You have be-
come convinced, I hope, in the course of the discussion,
that the presurhed concept centre, as well as the concepts
themselves, is incapable of localization in a certain sense.

In the introduction to my first lecture I have asserted
as a fact, confirmed by the experiences of pathology, that
the central projection fields are localized in different terri-'
tories of the cerebral cortex. We nnist likewise ascribe to
them the attribute of being places of memorial images,
whence then a definite localization of the memorial images
was to follow. We will have to make ourselves better
acquainted with the nature of these memorial images.

I might very briefly cite the clinical facts, which, in my
opinion, completely prove the princfple of localized memorial
images: they are the clinical experiences of sensory and
motor aphasia and the cases of so-called tactile paralysis
of the hand. The first are now so well known that I need
not go into them, but the latter must be especially consid-
ered as to their significance. Here are two series of facts,
which by their relation to each other, furnish the evidence.
Cases of circumscribed cortical injury in the region of the
so-called middle third of the two central convolutions, which
leaves as a permanent defect the inability of the hand to
recognize objects by touch, while real so-called sensory
disorders are demonstrable only to a slight degree. Con-
versely, cases of spinal or peripheral disease are observed,
which are accompanied by the gravest disorders of sensa-
tion, and, as I have especially shown, also of the so-called
muscle sense or sense of position, and yet present only



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156 Outline of Psychiatry in Clinical Lectures.

insignificant disorders of the tactile function. The last cited
cases in a certain measure prove that even a very defective
and faulty projection system conducts reports to the brain,
which suffice for primary identification, if only the central
projection fields and hence memorial images, tactile images,
as we may call them in the preceding case, are retained.
But the cases of the first kind can only depend on loss of
the primary identification, if disorders of the projection
paths are so slightly demonstrable. The principle of memor-
ial images localized according to the projection fields is
placed beyond doubt by such facts, and hence its application
to all projection fields is warranted.

If we return to our example of the organ of speech, we
find the process of recognition — primary identification — joined
to the hypothesis, that a fixed possession of memorial
images is present. So the question arises: How is such a
possession brought? Evidently it is a matter of a very
special attribute of the nervous system, that it undergoes
permanent changes by temporary stimulation, an attribute
which we call memory. The memory of the nervous system
is manifested, e,g,, in that the faradic excitability of a nerve
can be increased by frequent faradisation* The same stim-
ulus later acts more readily, when it has often occurred
previously, so that theg a permanent change has taken
place in the nerve, in consequence of temporary stimulation.
All dexterity depends on this principle, all accomplishments.
Paths, which were only passable with difficulty, become
readily passable by repeated use, they become hollowed
out, so to speak. Now, if such a memory is perceptible in
the nerve fibres, it is very especially attained in the nerve
cells or ganglion bodies. A reflex in the spinal cord, which
is effected by these ganglion cells, occurs the more readily,
as the more often it has previously taken place, and that it
is here a matter of a special attribute of the ganglion cells,
has been proven by the researches of Ward,t Jarisch and
Schifft and others. The after-images of the retina have



*Mann. Deutsches Archiv fur klinlsche Medlcin. 1893.

tUeber die Auslosun^ von Reflexbewes:unc:en durch eine Summe schwacher Reize. Du
Bois-Reymond's Archiv. 1880.

lUntersuchunKen uber das Kniephanomen. Wiener med. Jahrbucher. 1882.



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C. IVemicke. 157

with good right been referred to the ganglion cells. In the
brain cortex it is in the ganglion cells, to which must be
especially ascribed the attribute of being permanently
changed by momentary stimulation, that residues of it re-
main, which we call memorial images.

4fter what has been said it seems self-evident that the
possession of memorial images or content of consciousness^
as we will call it, is directly dependent on the condition of
the projection system and the sense organ, by means of
which it has been acquired. The consciousness of a weak-
sighted person, or one with generally poor senses, is there-
fore different from that of an individual with normal senses.
The person born blind will not be in possession of optical
memorial images and therefore, in case he can be operated
upon, will represent a state, which is also known to us
from its pathological occurrence as the so-called mental
blindness. Like the person born blind, the one born deaf



Online LibraryCharles Hamilton HughesThe Alienist and neurologist → online text (page 14 of 63)