An?sthesia in the Insane 1899 W. H. B. Stoddart.pdf

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1899.]
extent,areshownincasesofjuvenilegeneralparalysis,becausestresscomesin
less,althoughitdoescomeinatpuberty;butstillinsomeofthecasesIhave
showntherewasnostress,anditwasduetothesyphiliticpoisonsolelycoming
intothebody.

relatingtothesubjectofthecausalconnectionofsyphilisandinsanityinpatients
belongingtothemiddleclassesofsociety,whichhehaskindlypermittedmeto
'sRoyalAsylum,
Perth,from1880till1898inclusive.—Thetotalnumberofpersonsadmittedwas
266males,244females—,27malesandnofemalesweregeneral
paralytics.
Ofthese27,therewere13undoubtedlysyphilitic,8probablysyphilitic,4doubt
fullysyphilitic,and2probablynotsyphilitic.
Ofthe8probablysyphilitic,iwastemporarilyblindinoneeye,iwastempo
rarilyparalysedononesideoftheface,ihadstrabismusofoneeye,2hadsoft
chancre,ihadurinarystrictureandscarinthegroin,iwassuspectedtobe
syphiliticbyhisfamily,iwasamarineengineerofbadcharacter.
Ofthe6doubtfullyornotsyphilitic,allhadenduredgreatmentalstress;iwas
attributedtohereditaryinsanityandworry,itohereditaryinsanityandalcoholism,
itoalcoholismandgout,3toworryonly.
Theincidenceofthecausesmaybeclassedasfollows:
,8;neuroticheredity,2;parentalalcoholismatthetimeof
conception,3;parentalparalysis,3;nohereditarytendenciesadmitted,io.
—ofworry,15;alcoholism,IO;fallonheadafteralcoholism,
i;sunstrokeafteralcoholism,i;sexualexcess,2;gout,
andremainwell.
Concerningsyphiliticcasesduringthesameperiodotherthangeneralparalytics,
14males,ifemale—
,iisdegradedtotherankofacommonlabourer;2
terminatedindementia(idiedofdiabetes);idiedofapoplexyinacuterecent
mania;iremainsinastateofchronicmania;5remaininastateofdelusional
insanity;4continuedmelancholic(icommittedsuicide).Twoweredischarged"recovered,";4continuedmelancholic(icommittedsuicide).Twoweredischarged"recovered,"
,

,animbecile,acase
ofhereditarysyphilis,maybementionedinadditiontothoseabovedetailed.
Anœ,.,
.,AssistantMedicalOfficeratBethlemRoyal
Hospital.
THEsubjectofthepresentpaperhasoccupiedmyattention
formorethantwoandahalfyears,andduringthewholeof
thattimeIhavefeltdeeplyindebtedtomycolleaguesbothat
BethlemRoyalHospitalandattheLancashireCountyAsylum
atPrestwichforthegenerouswayinwhichtheyhaveafforded

gentlemenhavenotonlypermittedmetoexaminetheircases,
:.
7OOAN/ESTHESIAINTHEINSANE,[Oct.,
but—knowingmyinterestinthesubject—have,atinconveni
encetothemselves,drawnmyattentiontocaseswhichwould
otherwisehaveescapednotice,andhavefurtherassistedand

foretakethisopportunityofmostheartilythankingallthese
gentlemenfortheirvaluablehelpandkindness.
Ihaveentitledmypaper"AnaesthesiaintheInsane."As

ratherbe"AnalgesiaintheInsane."Ofcourse,everyalienist
isfamiliarwiththefactthatmanyinsanepatientsshowno
responsetoapin-
beentodeterminethedistributionofthisanalgesiaonthesur
,
-
clip.
Inmostofthecasestherewasveryconsiderablemental
reduction,andthatiswhyapainfulsensorystimuluswas
usuallyemployed—thesepatientsnothavingsufficientintelli
gencetogivereliableinformationaboutasimpletactile
stimulus.
Inafewpatients,however,itwaspossibletocomparethe
lossofsensationtopainwiththelossofsensationtotouch.
Thesepatientshadsufficientintelligencetogivereliable
answersastowhethertheywereabletofeelasimpletactile

moreextensivethananalgesia,—thatistosay,thatbeyondthe
areaofcompleteinsensibilitytherewasanarrowzoneinwhich
apin-prickorsharppinchwasrecognisedasatactilestimulus.
ImentionthisnowlestIshouldomittorefertothematter
lateron,andalsoinordertojustifymyuseoftheword
"anaesthesia."
Itisnotthepurposeofthispapertodealwithanaesthesia
,
ofcourse,commonenoughininstitutionsfortheinsane;but
itismuchmoreeasilystudiedinthecomparativelysane

beauselesstasktoattemptaresearchonsuchlossesofsensa
tionintheobviouslyinsane.
Althoughitisnotthemainsubjectofthispaper,Iwishto
takethisopportunityofcommunicatingtheobservationthat
•"comparativehemianoesthesia"isamuchmorefrequentcondi-:.
1899.],.?OI

whatImeanby"comparativehemianœsthesia."
Ifapatientisquiteunabletofeelatactilestimulusonthe
rightorlefthalfofthebody—theanaesthetichalfbeingmarked
offbythemiddlelineofthehead,neck,andtrunk,—thatcondi
tionis,ofcourse,called"hemianaesthesia."Ifthepatientcan
feelonbothsidesofthebody,butcanfeelbetterononehalf
thanontheother,thatiswhatismeantby"comparativehemi-
anaesthesia."Thewaytotestthisconditionistotouchthe
patientwithanequalamountofpressureontwosymmetrical
spotsofskin,andtoaskhimonwhichsidehebelievesyouto

materialdifferenceonthetwosideswhereveryoumaytest
him,
patientcanappreciateatactilestimulusoneithersideinde
pendently;butiftouchedontwosymmetricalspotsofskinhe
isonlyabletoappreciatethetactilestimulusupononeside.
Thehemianaistheticsideisnearlyalwaystheleftinaright-
handedindividual,andtherightinaleft-handedindividual.
Iamnotpreparedtomakeanydefinitestatementastothe
othersymptomsassociatedwithcomparativehcmiannesthesia
intheinsane—Ihavenotyetaccumulatedasufficientlylarge
numberofcasestodrawsatisfactoryconclusionsfromthem.
Mypresentcollectionofcases,however,wouldappeartoshow
thatthesymptomisespeciallyassociatedwithdisturbanceof
,climactericcases,and
womenwithuterineorovariandiseaseareapttoshowthis

havehallucinationsofsmell;butnoneofmycasesofcom
parativehemianaesthesiahaveshownthissymptom.


thisisthecasewithboththeanergicanddelusionalformsof
,itmattersnotwhetherthestuporoccurin
thecourseofatypicalhereditaryinsanity,delusionalinsanity,
epilepsy,

stuporbeonlysufficientlysevere,thepatienttakesnonotice
ofprickswithapin,pincheswithatie-clip,orofthestimulus
,however,thesepatients
recovered,orwhentheirstuporgaveplacetosomeotherevent:.
7O2ANAESTHESIAINTHEINSANE,[Oct.,
intheirinsanity,theywerewithoutexceptionabletoconvince

theyfeltthepainquiteacutely,butthattheywereunableto
speakortomoveinanywayinordertosignifythattheyfelt

limitedregiononthesurfaceofthebodywheretheywere
,onemale(caseofanergicstupor)
andonefemale(caseofdelusionalstupor),Iexplainedtothe
patientsthatIwishedthemtorememberwhichpartsoftheir
bodywereanalgesic,
carefullyoverthewholesurfaceofthebodywithapin,and
impresseduponthemduringthewholeoftheexaminationthat
Iwishedthemtorememberonwhichpartsoftheirbodythey
wereanalgesic,
orderthatIshouldnottiretheirmemoriesIspreadeach
examinationoverseveraldays,takingthebodypiecemeal,and
duringtheremainderoftheirillnessIusedtokeepreminding

toldmethattheycouldfeeleverystimulusalloverthebody.
Inthecaseofthefemalethiswasfivemonthsafterthe
examination,andsovividwasherremembranceofitthatshe
haddevelopedand(forallIknow)stillhasideasofpersecution
byme.
Inowcometoavarietyofanaesthesiawhich,forsome
reasonwhichIhavebeenunabletodiscover,appearstohave
hithertoentirelyescapedobservation;andIcannotresistthe
beliefthatitwillsomedaybeofsomeimportanceinhelping
ustounderstandthephysiologyandpathologyofthenervous
,Iamof
opinionthattheexplanationofthisanesthesiamuststand
overuntilwepossessmorephysiologicaldatatoworkupon.
Itwillperhapsbemostclearlydescribedbyfirstindicatingits
maximumdistribution,andthenshowinglessandlessextensive
distributionsuntilwearrive'attheminimum.
Inthecasepresentingthemostextensiveanesthesiaofthis
variety,thepatient(—,)wasunabletofeelexcept
inthefollowingareas:
(a)AnareaaboutiinchbyJinchovereachsupra-orbital
ridge.
(¿)Anareaabout2\inchesby2inchesabovethemiddle
ofeachPoupart':.
1899-]BVw-H-B-STODDART,).703
(¿•)Twonarrowstripsoverthedorsalandcervicalregions
ofthespine.
Thiswasacaseofstuporwithcatalepsyoccurringina
PolishJewesswhohadsufferedfromhysteriaforaboutsixteen
years,andhadreceivedtreatmentatnearlyalltheleading
;
shehadlossofsmellandoftaste,andhervisualfieldshad
beencontractedforyears.
Ionlymentionthispatientbecauseheranaesthesia,while
veryextensive,conformedmoreorlesstothetypenowunder

presentstandpoint;wemustnotforgetthatshehadbeen
hypnotisedmanytimes,andthatprobablyeveryneurologist
underwhosecareshefellhadattemptedtoarrestherhysterical
fitsbypressureonthesupra-orbitalnervesandupontheovarian
,ofcourse,extremelyrare.
Thenextstage,however,issufficientlycommonformeto
havediscoveredthreeexamplesamongabout1000casesof
insanity,
possiblethatImayhavelostoneortwoexamples,because

thatIhaveseveraltimescomeacrossanexampleofthis
varietyofanaesthesiainitslessextensivedistributions,have
delayedchartingitforafewdays,andattheendofthattime

arecordinwriting.
Inthestagenowunderconsideration(—,
3)sensationisretainedinthefeet,inanirregularkindof
bathing-drawersarea,insmallmoreorlesssymmetricalspots
aboutthenose,andperhapsasmallstripoverthedorsal
regionofthespine.
Whentheanaesthesiaisstilllessextensivetheaboveareas
arelarger(—,).Tospeakfiguratively,thesandals
andbathingdrawersarereplacedbysocksandknickerbockers,
andthereisamask-likeareaacrossthefacewheresensation
,and
theremaybesmallareasofsensibilityinthepalmsofthe
hands.
Ifthecaseimprovesgraduallyitispossibletoobservethe
upperlimitoftheknickerbockersrisingandthelowerlimitof
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JOURNALOFMENTALSCIENCE,OCTOBER,1899.
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JOURNALOFMENTALSCIENCE,OCTOBER,1899.
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JOURNALOFMENTALSCIENCE,OCTOBER,1899.
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