John Hughlings Jackson: Father of English Neurology

John Hughlings Jackson

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John Hughlings Jackson Father of English Neurology Macdonald Critchley Eileen A. Critchley

New York Oxford OXFORD UNIVERSITY PRESS 1998

Oxford University Press Oxford New York Athens Auckland Bangkok Bogota Bombay Buenos Aires Calcutta Cape Town Dar es Salaam Delhi Florence Hong Kong Istanbul Karachi Kuala Lumpur Madras Madrid Melbourne Mexico City Nairobi Paris Singapore Taipei Tokyo Toronto Warsaw and associated companies in Berlin Ibadan

Copyright © 1998 by Oxford University Press Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Critchley, Macdonald. John Hughlings Jackson : Father of English neurology / Macdonald Critchley, Eileen A. Critchley. p. cm. Includes bibliographical references and index. ISBN 0-19-512339-5 1. Jackson, J. Hughlings (John Hughlings), 1835-1911. 2. Neurologists—Great Britain—Biography. 1. Critchley, Eileen A. II. Title. [DNLM: 1. Jackson, J. Hughlings (John Hughlings), 1835-1911. 2. Neurology—biography. WZ 100 J139C 1998] RC339.52.J3C75 1998 616.8'0092 [B]—DC21 DNLM/DLC for Library of Congress

9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper

97-42711

Acknowledgements

It is more than mere courtesy that prompts us to thank the many people who have been of assistance to us in the four years we have been writing this biography. All have given invaluable help and this has facilitated the book's completion. We have relied heavily on written texts, and the sources are acknowledged in the Notes at the end of this volume. For previously unpublished material concerning the Hughlings family and for the portrait of his ancestor, John Hughlings, Collector of Excise, we are much indebted to Dr. T.W. Davies. He generously allowed us to scour his family records. For help, in particular with the story of Hughlings Jackson's three brothers, we thank Dr. W.L.H. Jackson and Mr. John Hughlings Jackson and their families. Their unstinting zeal in going through their papers and passing on family stories, sending us photographs and patiently answering our many questions is much appreciated. New material in the United States was originally researched by Mr. Marcus T. Smith, another descendant of John Hughlings. He kindly sought out papers stored at the University of Utah and Brigham Young University and sent us copies of them, as well as giving us access to his own family records. We are grateful to him. For the cooperation in many ways of other members of the Jackson family, we are thankful. The late Mrs. Madge Parker, daughter of Charles Jackson and our friend, was most helpful; Mrs. Joy Soanes, her daughter, visited the Independent Chapel and Providence Green at Green Hammerton on our behalf; and Mrs. Dee Cunningham, another of Charles Jackson's daughters, passed on to us her personal recollections. Dr. Joyce Galbraith gave us her full cooperation and time by diligently searching the records of the York Medical Society for us. The Reverend Nigel Hall of Llandrindod Wells has our sincere thanks for providing the first piece of information that led us down the Hughlings trail; also for putting us in touch with Miss Jane Cartwright, who gave us details of the holy wells in Wales, and Mrs.

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Betty Lewis who allowed us to see a copy of her old map of land in Llanfihangel Rhydithon. Without the painstaking research of Mr. Alan Powell, B.A., at The National Library of Wales, we would have spent far longer looking for the records of the Hughlings family. His expertise was an invaluable contribution to our book. Mr. Keith Pitchforth obligingly gave us a large amount of information about his ancestor, Solomon Pitchforth, which was important to us. We much appreciate the good nature of Mr. R.G. Oulds of Dolau for allowing us to visit his house, and we thank him for his aid when we were looking for the roots of the Hughlings family in Llanfihangel Rhydithon. Without the help of Mrs. R. Duggan, Clerk to Dolau Parish Council, we would not have discovered the original deed of gift of land donated by John Hughlings. Special acknowledgement is due to Mr. John Potter, F.R.C.S., for his dedicated work on our account at the Bodleian Library and in going through the archives at the Radcliffe Infirmary. First in line among the many librarians who have generously given time to help, as always, is Mrs. Beryl Bailey, long-time custodian of the Rockefeller Library at the Institute of Neurology, Queen Square. Her successor, Mrs. Louise Shepherd, has kindly carried on her fine work. Mrs. Menzies at the University of Leeds was most helpful, as was Miss Claire Nott at the Wellcome Institute for the History of Medicine and the librarians of the Royal Society of Medicine, St. Mary's Hospital and the Royal London Hospital. Mrs. Audrey Burton has been gracious in giving us information from her own records of Providence Green, the birthplace of John Hughlings Jackson and the house in which she now lives. Others who have aided us in many different ways and to whom we wish to record our thanks are Professor Michael Trimble of the Institute of Neurology, Queen Square, Professor Henry Schutta of the University of Wisconsin and Polly Aird of Seattle. Finally, we owe our gratitude to Professor Ian McDonald for his enthusiasm and support in the publication of this book.

Contents

Preface, be 1. The Jackson Family Background, J 2. Maternal Ancestry—the Hughlings, 9 3. Early Education and Life As a Medical Student, 23 4. Leaving Yorkshire for London, 35 5. The Cholera Epidemic in London, 1862, 41 6. First Neurological Papers, 45 7. Herbert Spencer, Evolution and Dissolution, and the Hierarchy of the Nervous System, 53 8. The Epilepsies, 61 9. Jackson's Writings on the Falling Sickness Reviewed, 73 10. Jackson As Morbid Anatomist, 79 11. The Cerebellum, 83 12. Aphasia: The Early Researches of Broca and Jackson, 91 13. Further Work on Aphasia, 97 14. Jackson's Final Writings on Aphasiology, 105 15. Reviews by Freud, Gowers, Head and Others, 117 16. Pierre Marie, the Iconoclast and Later Writers on the Breakdown of Language, 131 17. Jackson's Achievements Assessed by Other Neurologists, 147 18. Foundation of Brain and the Hughlings Jackson Lectures, 157 19. Jackson the Man, 161 20. Marriage, Bereavement and Honours, 171

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21. Tributes, 187 Notes, 197 Index, 215

Preface

Throughout my professional life at The National Hospital, Queen Square, I always felt as though John Hughlings Jackson was looking over my shoulder. He was responsible for fostering my boyhood interest in language, its acquisition and breakdown, and influenced my decision as to which path to take through the pastures of neurology. Dr. Jackson died when I was a schoolboy but my early days as a neurologist were coloured not so much by the reading of textbooks as by recollections of the Master I heard from my Chiefs. Such men as Stanley Barnes, Edwin Bramwell, Anthony Feiling, F.L. Golla, Wilfred Harris, James Collier, Gordon Holmes, Foster Kennedy, Leslie Paton, Risien Russell, James Purves-Stewart, James Taylor, Aldren Turner and S.A. Kinnier Wilson (Jackson's last House Physician at the National Hospital) shared with me the inspiration they had derived from their association with Hughlings Jackson, These great men, my teachers, bore a torch which had been lit by him, and they passed it on to me. Over the years, I wrote about Jackson from time to time. In 1992, having completed most of the writing on which I had been engaged since my retirement from clinical practice in 1984, I decided to write a final paper about him. It had always been my belief, from what I had been told and also had read about Hughlings Jackson, that his mother, Sarah, was a Welshwoman, a Hughlings who had been born in Llanfihangel Rhydithon, a village in the Welsh county of Radnorshire (which is now called Powys). The name of that village, which can be interpreted as "by the church of St. Michael at the ford across the River Ithon", intrigued me, but I had never been there. On impulse, my wife and I decided to visit Llanfihangel Rhydithon the next time we went to Hay-on-Wye on what had become an annual journey. The little town of Hay is a bibliomaniac's promised land and Llanfihangel Rhydithon is not far from it. A county of beauty, Powys has magnificent scenery and some of its villages appear to have changed little over the last century. On the way there, Eileen asked me to tell her exactly where the

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Hughlings family had lived, and I said I did not know. Her curiosity aroused, she spent some time that day looking round the churchyard to see whether there were memorial stones to anyone named Hughlings. Not finding any, on our return to Nether Stowey she wrote to the Vicar of Llanfihangel Rhydithon and asked for a copy of the entry in the parish records for the birth of Sarah Hughlings. To our surprise, Sarah's name did not appear anywhere there. The Vicar was helpful and consulted his congregation. It was discovered that someone in the village—a chapelgoer—had an old map which showed the name John Hulings (sic) as the owner of some land in the area. We were given the lady's address, and she kindly allowed us to have a copy of the map. Thus began Eileen's long quest. She researched Hughlings Jackson's family tree on both sides, and it was the Hughlings branch which proved to be somewhat prickly. There were many blind alleys she explored as a result of information which subsequently proved to be false. Public records have not always been kept accurately, and some "facts" recorded in writing by people now dead turned out to be untrue. It was a task both frustrating and rewarding which lasted for over three years. She uncovered a story of the Hughlings family which has not been told before, and which adds much to our previous knowledge of Hughlings Jackson's ancestry. In the meantime, I had begun to write an article which was intended to be a resume of Jackson's work. However, what started as a short paper about an eminent Victorian neurologist grew gradually into a much more comprehensive review of his lifetime's achievements. Eileen had also written about Hughlings Jackson's life outside medicine, his personality, his standing among his colleagues and other matters, and we found we had far too much material for a short paper. We wove together each of our writings into a whole narrative. This book is the result. When discussing men of the calibre of John Hughlings Jackson, it is all too easy to slip into hagiolatry. While recognising his genius, we realise that Jackson was not omniscient. There were gaps in his knowledge; his assessment of others, like Herbert Spencer, for instance, was not always shrewd. Even so, our conception of Jackson is of a giant. A great deal has already been written about Dr. John Hughlings Jackson and his place within the pantheon of those who have contributed to the rapidly advancing state of our knowledge of the brain. We have tried to write a straightforward, comprehensive biography, not entirely chronologically, of a man we can only know through

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other people's recorded impressions of him and from his own contributions to the medical literature. The work on language to which Jackson devoted a major part of his working life goes on, since there are still many unanswered questions to challenge linguists. Some of his ideas have been superceded but, in the late 20th century, many of them are still valid. Some readers in these modern times may not find it easy to understand the sheer love my teachers had for their colleague 100 years ago. I am fortunate to have experienced it at second-hand. In my 97 years I have never known any other neurologist to arouse such deep affection. This book contains no attempt to place Jackson's work within the context of present-day advances in neurological practice. It is intended to be a tribute to one whose work was based solely on his clinical observation, scrupulous recording and astute judgement, without the benefit of today's technology. Nether Stowey 1997

M.C.

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1

The Jackson Family Background

He possessed the rare combination of characteristics that "sets a man among the little band of whom are Aristotle and Newton and Darwin"1 was one assessment of John Hughlings Jackson. Beginning his career as a provincial medical apprentice and achieving a position at the pinnacle of his profession, Jackson was among the few physicians in the middle of the 19th century who were interested in disorders of the nervous system— neurologists, to use the term coined by Thomas Willis. Jackson was unique. He was held in universal respect among his medical colleagues, even though his work was not always understood during his lifetime. After his death in 1911, many years passed before his original ideas were recognised; they were well ahead of the thinking of most medical men of his time. Born in 1835, when the medical study of nervous disease was beginning to develop, this man of genius became widely known as the Father of English neurology. His influence on neurological thinking was world-wide, especially in the spheres of convulsive seizures and higher nervous activity, in particular the breakdown of language through disease.

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Today we still talk of the eponymous syndrome of Jacksonian epilepsy. Jackson was essentially a simple, uncomplicated man and he was free from the distraction of multiple interests. Even the handicap of deafness in adulthood was a boon to him, in that he was not diverted by social activities. Although he was admired, loved, even venerated, there were inconsistencies in his worldly attainments. Hughlings Jackson—as he is usually known—was never a Professor; never a fashionable practitioner of medicine; never occupied the highest ranks in academic or Royal College circles; never received the accolade of being appointed medical advisor to the Royal Family; and never gained formal recognition from the State by way of a knighthood or any other honour. Although he died 86 years ago, his name is still known to every contemporary neurologist. His life's work was accomplished at a time when all he had to aid him were his powers of thought and observation. Jackson was a clinician par excellence, never an experimentalist. He was a philosopher and a medical man of exceptional intelligence who challenged accepted dogma. There had been many men of ability in the Jackson and Hughlings families, but none was responsible for so much original work in any field. Dr. Jackson's ancestors were English on his father's side of the family and they came from Yorkshire. Since Jackson is a common surname, it has not been possible to trace this particular branch with confidence further back than the beginning of the 18th century. Many church records were damaged during the period of the Civil War (1642—1651), and others were not kept accurately. There were certainly some distinguished Jacksons living in Yorkshire before 1700, but there is no irrefutable evidence of a direct linear relationship with any of them and John Hughlings Jackson. A clear pedigree of this family stems from the time when William III was King, four generations before Hughlings Jackson was born. At the turn of the century, the marriage took place of his great-greatgrandparents, William Jackson and Ann Stephenson, on 29th September 1700 in Pannal. They spent their lives in this Yorkshire village, where each of their six children—Hannah (1701), Ann (1704), William (1707), Timothy (1709), Rebecca (1710) and another Ann (1713)—was born. Ann Jackson died in childbirth on 3rd July 1713. With young children to bring up, William, as was not unusual, married again before long, on 1st April 1714. His bride was

The Jackson Family Background

3

Hannah Abbott and he became the father of three more children— John (1715), Ralph (1717) and Mary (1718). The third child of William Jackson's first marriage, William, is the one who concerns us. On 28th July 1731 he married Hannah Fenton. They, too, lived in Pannal and during the next nine years they had a family of five boys—John (1732), William (1733), Samuel (1736), Joseph (1739) and George (1744). Their third son, Samuel, was described as a merchant. On 24th September 1759 he was married to Anne, the daughter of Thomas Squire of Allerton Mauleverer, another small Yorkshire village. Samuel and Anne Jackson settled there and brought up their family of seven sons and a daughter. Samuel died in December 1787; his wife, Anne, lived on until June 1800. Both were buried at Allerton Mauleverer. The first of the children born to George and Anne Jackson was William in 1760. His brother, Thomas, followed in 1762 and then came Samuel, George, Anne and Richard at two-yearly intervals. John arrived next in 1773 and, finally, James in 1776. Nothing is known about Thomas or Anne. John died at the age of 29 on 13th September 1802 and was buried at Green Hammerton, Yorkshire. The eldest of Samuel and Anne Jackson's family, William, became a merchant and the owner of a three-storey house called Providence Green in Green Hammerton. The date on a corner of the house shows that it had been built in 1790. The property also consisted of a maltkiln, a drying kiln, a brewhouse, a warehouse and barns. William emigrated to America and lived in Philadelphia. When he became bankrupt he moved to New Jersey. In 1802 he sold Providence Green to his brother, Samuel. At the age of 54, William died "of dropsey on the lungs" in the presence of his brother, Richard, on 13th July 1814. Richard Jackson, too, had emigrated to America, and some letters have been preserved which he wrote from Staten Island to his brothers, James and Samuel, both of whom had stayed behind in Yorkshire. Some of these letters indicate that he was awaiting money from them, and in one letter Richard informed his family that he was feeling well after he had cured his yellow jaundice by drinking tea made from old cherry-tree bark. The last of these communications was sent by Richard to his nephew, Samuel Jackson, on 9th January 1829, when the former was 66 years old. He was complaining of pain in his arm, the consequence of which is unknown. The fourth son, George Jackson, a tanner, married first Ann Lumley, aged 22, at Thirkleby, Yorkshire, on 2nd January 1797. His

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wife died two years later and was buried at Burton Leonard, Yorkshire, on 2nd February 1799. George then married Isabella Slater. Their children were Isabella (1803), William (1805), George (1807), John (1809) and Samuel (1812), all of whom were born at Burton Leonard. The youngest child of Samuel and Ann Jackson, James, became a Dissenting Minister and married Mary Clarke. They settled in Green Hammerton, a village situated a few miles away from his birthplace, Allerton Mauleverer, and which lies between York and Huddersfield. All their 12 children were born in Green Hammerton. The Reverend James Jackson lived until the age of 72; he died on 22nd January 1849. His widow, Mary, remained in the village until she died when she was 78 years old, on 9th January 1864. The third born of Samuel and Anne Jackson's children, Samuel, became a prosperous brewer at Providence Green. At the age of 25, he married Isabella Lumley at Thirkleby on 7th October 1800. She was aged 20 and was the third of the seven children born to Francis Lumley, a farmer, who came originally from Ripon, Yorkshire. Her older sister, Ann, had married Samuel's brother, George, the year before. Isabella had been born at Allerton Mauleverer and was baptised there on 3rd January 1780. At the time of his marriage, Samuel's occupation was given as 'common brewer', and he was also described as a 'brandy merchant'. Samuel and Isabella Jackson subsequently had four sons. William was baptised at Allerton Mauleverer on 4th November 1801, Thomas at Green Hammerton on 12th May 1803, Samuel at Green Hammerton on 24th April 1806 and George Lumley, also at Green Hammerton, in June 1808. The last-named lived for only six months and died on 23rd December the same year. He was buried at Green Hammerton on 26th December. Samuel Jackson died of apoplexy on 17th February 1820, when he was 55 years old. He bequeathed his property at Providence Green to his oldest son, William. Four years later William himself died at the early age of 23. Providence Green then passed to his brothers, Samuel and Thomas. Their mother, Isabella, did not remarry and she stayed in Green Hammerton until her death at the age of 59 on 9th March 1839. So we come to the second son, young Samuel, the future father of John Hughlings Jackson. On 24th March 1828, a month before his 23rd birthday, he married. At the time his occupation was given as 'brewer'. Dr. James Taylor described him as "a yeoman owning and farming his own land".2 According to other sources, Samuel

The Jackson Family Background

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called himself 'a gentleman of the county' and 'a maker of brandy'. He was buried as 'gentleman', and was all of these. Samuel Jackson's wedding to Sarah Hughlings took place at St. John's Church, Halifax, Yorkshire. Sarah was 21 years old and was the daughter of John Hughlings, the Collector of Excise for Halifax. The Hughlings family lived in the village of Northowram, near Halifax. We can only speculate as to how a brewer met the daughter of a revenue collector, but because one of the responsibilities of an excise officer at that time was to gather the duties payable on beer, perhaps it was not too difficult. Just over a year after the wedding, Samuel and Sarah's daughter, Ann Jackson, was born at Providence Green on 30th April 1829 and was baptised by her father's uncle, The Reverend James Jackson, at Green Hammerton Independent Chapel on 29th May that year. From a few remaining letters, we know that Ann's health was not good. Her father wrote to her brother, John Hughlings Jackson, on 17th March 1854: "I hope you gave her Ann's note. Knowing Ann's having had a stroke will excuse her writing." (The whole of this letter will be quoted in Chapter 3.) In a letter written by John Hughlings Jackson to his brother, Thomas, on 4th November 1856, he said: "My sister is not well now. She is in bed. I often think that she will never be in even tolerable good health." On the same day, Thomas Jackson had written to his cousin, Andrew Jackson, "I was sorry to hear that my sister is only poorly". Despite her ill-health, on 3rd June 1858, at the age of 29 and not long after her father had died, Ann Jackson married William Langdale. William's father was Dr. Henry Langdale, a surgeon who lived at Green Hammerton with his wife, Maria. Dr. Langdale had attended at the births of at least two of Ann's brothers, Samuel and Thomas. Mr. and Mrs. William Langdale set up home in Manchester. Although Dr. James Taylor referred to William as "Dr. Langdale,"3 an uncle of Ann Langdale, Harry Hughlings, when writing to one of her cousins in June 1858, stated, ". . . her husband is in a good situation as Manager of a silk business at a decent salary of £250 per year." However, William Langdale described himself as "warehouseman". The Langdales' marriage was brief. On 6th August 1859, their daughter, Annie, was born in the house in which they lived at Moss Side, Manchester. Three days later, and only 14 months after her marriage, Ann Langdale died on 9th August 1859. The cause of her

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death was recorded as "convulsions". Apart from the fact that he remarried, it is not known what happened after that to William Langdale. His daughter, Annie, survived and in his Will of 1911, John Hughlings Jackson left his niece a legacy of £2,000. Samuel Jackson was the second of Samuel and Sarah Jackson's children. Born on 16th April 1831, he too was baptised by the Reverend James Jackson at the Independent Chapel, Green Hammerton, on 24th May 1831. Young Samuel studied law in York and went on to the Inner Temple in London. He emigrated to New Zealand in 1856, travelling in the three-masted, square-rigged sailing ship Merchantman. Among the other passengers were the Reverend James Mandeno, his wife, two sons and three daughters. The Mandenos were of Huguenot origin, their forebears having left France for England in the days of religious persecution there. At the end of the voyage, Samuel Jackson was married to Sarah Mandeno, the eldest girl, and they settled in Auckland, where Samuel established a law firm. He practised his profession for the next 57 years. Their eldest son, also named Samuel, was sent to England for his secondary education and then stayed to study law. Returning to Auckland, he joined a legal practice. In 1890 young Samuel decided to migrate to California, and he took his wife and children to live in Oakland. Today his grandson, now retired as a pilot in the U.S. Navy, lives in San Francisco. Another son of Samuel and Sarah Jackson was born in New Zealand in 1870 and was given the names John Hughlings. His own son, another John Hughlings Jackson, lives today in Auckland. William was the third of Samuel and Sarah Jackson's children to be born at Providence Green, on llth October 1832, and baptised by his great-uncle on 12th November the same year. Like Samuel, William Jackson decided to emigrate from England to New Zealand not long after his brother had left. He became a farmer, but he was not to enjoy a peaceful life for long as a consequence of the Maori wars of the 1860s. To combat the native inhabitants' hostility, William formed a group of vigilantes from volunteers he had recruited among other local farmers. Much courage was shown by his wife, Bridget, one Sunday when the vigilantes captured a Maori flag while the owners were swimming. The Maoris attached great importance to their standard and tried to recapture it, but Mrs. Jackson hid the flag under her dress and wore it as a petticoat. It is said that twice William Jackson's house was burned down as a reprisal.

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The band of vigilantes was known as Jackson's Forest Rangers, and they established a reputation for successfully tracking and ambushing their enemy. In time this group was absorbed into the Imperial forces. William was commissioned as Major Jackson, and he was famous for his marksmanship. Later he was elected as the first Member of Parliament for the Waikato district, where he had seen much action during the conflict. Bridget and William Jackson were childless. He met his death accidentally at sea on a voyage from Wellington to Auckland. William's sword is still treasured by the Jackson family. Thomas Jackson, the fourth child and third son of Samuel and Sarah Jackson, was born on 2nd December 1833 and, like the other children, was baptised at Green Hammerton Independent Chapel with the Reverend James Jackson officiating, on 2nd January 1834. Thomas became a mariner and made a name for himself when, as a junior officer, he brought his ship home safely from San Francisco with a make-shift crew after the other officers and men had deserted to the gold fields. The shipping company rewarded him by giving him command of his ship, although he was only 21 years of age at the time. Later, during the Crimean War, Thomas commanded a troopship which brought wounded men back to England. It is said that he was so sickened by the way the injured were treated that he decided to join his brothers, Samuel and Thomas, in New Zealand. After arriving in that country, Thomas married Mary Mandeno, sister of Sarah, his brother Samuel's wife. He bought a paddlesteamer and ran a shipping service which operated round the northern part of North Island. After leaving the sea, Thomas was appointed Resident Magistrate for the Waikato district of North Island, where in the early days of immigrant settlement there had been so much Maori unrest. Thomas and Mary Jackson had four children, two of whom, Dr. William Lumley Hughlings Jackson and Mary Hughlings Jackson, are alive and living in New Zealand. Dr. Jackson has now retired from his medical practice in Auckland. John Hughlings Jackson was the last child of Samuel and Sarah Jackson and, on 4th April 1835, like his sister and three brothers, was born at Providence Green. John was baptised on 19th June, as his siblings had been, by his great-uncle, the Reverend James Jackson, at the Independent Chapel, Green Hammerton. He was the only one of the five children to have been given his mother's maiden name. John was little more than a year old when his mother died, after eight years of marriage, on 16th June the following year. The cause

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of death is not known. Sarah Jackson was buried at Green Hammerton; the memorial inscription on her tomb reads: "Sarah, wife of Samuel Jackson of Providence Green and second daughter of John Hughlings, Esq. of Halifax, Collector of Excise, who died greatly mourned by her various connections on the 16th day of June AD 1836 aged 29." No portrait or any other likeness of Sarah Jackson is known. She remains a hazy figure, for all that can be said of her is that she was born, married and had children—one of whom was to gain recognition throughout the world—and then she died young. Her youngest son ordered his Executors to destroy all his papers when he himself died, and none of her other four children left any written account of their memories of their mother. That is to say, nothing has come to light. Nor is it certain who brought up Sarah Jackson's children after her death, for Samuel remained a widower. We do know, however, that there were servants, Jane Morley and Hannah Webster, living with the family in 1841, when John Hughlings Jackson was six years old. It is believed that Samuel Jackson lost a great deal of money, which might account for the fact that he sold Providence Green. According to Dr. W.L.H. Jackson: "I remember my father [Thomas Jackson's son] saying that his grandfather invested heavily in the early days of railways, that the bubble burst, a lot of money was called up and all was lost. It is this fact, I assume, which later sent the three eldest boys overseas to seek their fortunes. John, the youngest, who was showing scholastic ability, had to stay at home to continue his studies."4 After his two eldest brothers had emigrated and the other one was at sea, John Hughlings Jackson and his sister Ann remained with their father. They had moved from Providence Green but had stayed in Green Hammerton, in Ivy Cottage. A housekeeper, Mary Brown, lived in and looked after them. Samuel Jackson spent the rest of his life in Green Hammerton. He died, aged 51, on 9th February 1858 and was buried in the same tomb as his wife, Sarah, at the Independent Chapel. His youngest son was 23 years old and Samuel had lived long enough to see John Hughlings Jackson qualify to practice medicine. It is a remarkable fact that each of the four sons of Samuel and Sarah Jackson, having pursued different careers, achieved success and distinction in his own field.

2

Maternal Ancestrythe Hughlings

"Dr. Jackson was, on his mother's side, of Welsh descent; he mentioned it with pleasure, which was, I believe, increased when I reminded him that the same was the case with Milton."1 The simple statement that Sarah Jackson (nee Hughlings) was of Welsh origin has been repeated by many authors, but none has added anything to those words nor provided any other information about John Hughlings Jackson's maternal line. In fact, Sarah Hughlings's ancestors came from the county of Radnorshire (now called Powys) in Wales. Both her paternal and her maternal forebears lived in tiny neighbouring villages which lie close to the Radnor Forest and near to the small towns of Llandrindod Wells and Knighton. According to Sarah's grandfather, the Hughlings family had lived in Clun, Shropshire, many centuries ago. They were said to have changed the spelling of their name from Hulin or Hulins to Hughlings after moving to Wales. It is certain that a family named Hulins was living in Clun in the 17th century, but no direct link between them and Hughlings Jackson's mother has been proved. It is possible that the story

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is accurate and that the Hulins of Clun and the family of Hughlings in Wales were related; the distance between the two places is not great and different spellings of surnames were commonly used before the days of compulsory education. Some members of Sarah Hughlings's family believed that they were related to Hannah Hewling, who lived in the 17th century and whose story has been told by the historian Lord Macaulay, among others. It is known that Hannah Hewling married a grandson of Oliver Cromwell after she had bravely tried to save the lives of her brothers, Benjamin and William. As officers in the Duke of Monmouth's Army, they had been condemned to death after being involved in the Battle of Sedgemoor in Somerset in 1685. The three siblings were the children of Benjamin Hewling, a prosperous merchant who lived in Colman Street in the City of London with his wife, Hannah, who was the daughter of another rich merchant living in 'Little Morefields' in London, Alderman William Kiffin (or Kiffen or Kyffin—the spelling varies). The Alderman, a renowned Baptist, was said to have been on friendly terms with Charles II, so much so that he once lent the King £10,000—a big sum of money in those days. Benjamin and William Hewling were sent to Holland to continue their education, but there the two young men joined the Duke of Monmouth's Army and were part of the force which landed at Lyme Regis, Dorset, with him. After a few days of recruiting at the Cobb, the soldiers set off on the fatal journey which was to end at the Battle of Sedgemoor in Somerset. Lieutenant William Hewling actually fought at Sedgemoor and was captured. Benjamin, a Captain of Horse, had been sent to Minehead, Somerset, to fetch cannon. He missed the conflict but he, too, was taken prisoner after the battle. After being imprisoned in London, both brothers were put on trial, William at Dorchester in Dorset and Benjamin at Taunton, Somerset. Their sister, Hannah, tried to intercede with the notorious Judge Jeffreys for mercy to be shown to her brothers, but he ordered his coachman to whip her away from him. There was no reprieve for these young men. It was common practice at the time for bodies to be quartered after a hanging. To avoid this further ignominy, Hannah Hewling paid the not inconsiderable amount of £1,000. Her brother William, aged 19, was hanged at Lyme Regis on 12th September 1685. The next day, "surrounded by the young gentlewomen of the town (he was a remarkably handsome young man)",2 he was buried in the churchyard there. Benjamin, aged 22, was put to death in a similar manner at Taunton on 30th September, and Hannah paid a similar

Maternal Ancestry—The Hughlings

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sum of money to the Lord Chief Justice. His body was wrapped in the woollen shroud which was then required by law and buried the following day at St. Mary Magdalen Church. Neither Benjamin nor William had married, each was childless and they were the "only males of their name". Their father had predeceased them in 1684; he had had no other sons. Hannah subsequently bore ten children, and their lives are well documented. Her three sisters married men whose surnames were Luson, Liddell and Hayes. Surviving Welsh records before the 18th century are sparse, and the story of a relationship between these Hewlings and the branch of the Hughlings family with which we are concerned has not been substantiated. There is certainly no connection in a direct line from Hannah Hewling and her brothers William and Benjamin to John Hughlings Jackson, but whatever the merits of the claim, all have a place in English history. The first record of a Hulins/Hughlings that has been found in Radnorshire is of a Richard Hulins of Kevenllys (sic). His Will is extant and shows that he left his estate, totalling £5.12.8d., to his son, Thomas Hulins, gentleman, in 1664. Cefnllys is a village adjacent to Llanfihangel Rhydithon, a place which figures prominently in the history of the Hughlings family. The next reference is to a John Hughlings in a case brought before St. David's Consistory Court in 1711. John Hullins (sic), son of John Hulings (the spelling of the surname changes in different documents relating to the same case), was accused by the Minister of the parish, Samuel Jones, of fornication with Jane Jones, a maidservant in the Hulings household at Llanbadan Vawr. The defence stated that "John Hullins is a person of good name, credit and reputation and was never guilty of the crime of fornication or adultery with any person or persons whatsoever but on the contrary was allways reputed and taken to be a chaste and vertuous person among his neighbours and in the countrey where he lives." The accusation, it was stated, was made by "malevolent persons and such as bore grudge and enmetity to ye said John Hughlings and more particularly by Mr. Samuel Jones Minister of the aforesaid parish of Llanbadan vawr and one Mr. Buxton of the same parish." Regretfully, the result of this case has not been discovered. The John Hughlings senior mentioned above appears again in 1716. Since there are four successive generations of Hughlings men with the Christian name John, it may add clarity to this narrative if they are numbered. John Hughlings (the First) is described in his

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John Hughlings Jackson

Will as 'yeoman', and when he died in 1716 he left to his son, John (the Second and the accused in allegations of fornication in 1711), the bulk of his goods and chattels. These included cattle, sheep and poultry valued at £66.8s.2d. His daughters, Susan, Mary and Elizabeth, each received from their father the sum of five shillings.

John Hughlings the Second Before his father died, John Hughlings had married Joan Davies at Llanbadan Vawr in 1711. It is not known whether there were any children of this union, but Joan Hughlings died in February 1718 and was buried at Llanbadan Vawr. When John married his second wife, Hannah Jones of Llanfihangel Rhydithon, Edward Jones, John's new father-in-law, provided the couple with a splendid dowry. Under the terms of their marriage settlement, dated 6th June 1722, John and Hannah Hughlings were given a house, a walk-mill, 5 acres of arable land and 18 acres of woodland in Llanfihangel Rhydithon. The property was known as Ty-yn-y-llan, and it remained in the Hughlings family for the next two centuries. The house and walk-mill still stand, although the mill building has now been converted into another house. Both are occupied today, though neither of the owners is a Hughlings. When Edward Jones gave the property to his daughter and sonin-law, the mill was driven by water power supplied by the stream which runs alongside it. Local farmers supplied the wool for the cloth that was made in the mill, which, with the weaving room, was still in operation up to the 1930s. Behind the mill is a field known as Rack Field, the name originating from the time when racks of Radnor Grey cloth from the mill were hung out there to dry. "Radnorshire grey coat" was made from grey or black fleece and was popular at the time because it was warm and durable. Today this place is as tranquil as it doubtless was when John and Hannah Hughlings lived there in the early 18th century. The first of their seven children, named John, was born in 1720 but died soon afterwards. The next baby was born on 10th February 1723 and, as was a quite common practice, he was given the name of his deceased brother. (He was John Hughlings the Third.) Edward Hughlings, the third son, born in 1725, was baptised at Llanfihangel Rhydithon on 11th May 1725. As an adult he was apprenticed to a dyer, Owen Jones, and in 1751 married Charlotte Jones of Llanfihangel Rhydithon. They lived in the Dye House in

Maternal Ancestry—The Hughlings

13

that village, and Edward became a farmer and game-keeper. However, it is said that when he ceased to pay the rent, his brother John turned them out of the house and for the rest of his life Edward lived on an allowance from his family of £20 a year. He died at the age of 84, "sensible to the last". Thomas was the next child born to John and Hannah Hughlings; he died at the age of three. Twins, William and Hannah, followed in 1732. The boy survived for only a short time, but his sister lived until 1768. The last of John and Hannah Hughlings's children were also twins, girls named Anne and Mary. Anne lived for only a month, but Mary grew up to adulthood and married John Donne, by whom she had four children. One of their sons, the Reverend James Donne, is said to have become Master of Oswestry Grammar School. John Hughlings (the Second) was buried at Llanfihangel Rhydithon on 22nd October 1756. His wife, Hannah, lived until 2nd January 1768, when she, too, was buried in that village.

John Hughlings the Third Described as a man of good humour and ability, according to a family record, he is said to have had "a large brain". John Hughlings, great-grandfather of John Hughlings Jackson, was 5 feet 10 inches tall and fat but active and healthy. When he was aged 17 or 18, a Welsh champion pugilist named Llewellyn is alleged to have insulted some of John Hughlings's friends, as a result of which John is said to have fought Llewellyn in the churchyard at Llanfihangel Rhydithon. John won. It appears from the same family records that a friend, the Earl of Orford, was responsible for John Hughlings joining the Excise Service. Two bonds of £5,000—large sums of money—were pledged, which enabled John to become a Collector of Taxes. One bondsman was his cousin, the Reverend James Donne, the other a kinsman by marriage, a Mr. Vaughan of Llwyn Madoc, Radnorshire. On 13th December 1785, John Hughlings married Sarah Powell at St. Clements Church, Worcester. Sarah also was Welsh, and she had been born at Diserth in Radnorshire in 1735. Her grandparents were Thomas and Susanna Powell of Llandegley, Radnorshire. When Thomas Powell died in 1688, he left his land in Llandrindod to his eldest son, Robert, and that in Llandegley to his second son,

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John Hughlings Jackson

Hugh. Hugh Powell married Lucy Evans of The Graig, Llandegley, in 1713. Their daughter, Elizabeth, was aged 15 when she was married to her 16-year old first cousin, Evan Powell, of Maesgwynne, Diserth, in 1732. The estates of these two Powell families were thus amalgamated. One of the four daughters of Evan and Elizabeth Powell was the Sarah Powell who married John Hughlings. Llandegley is another small village which adjoins Llanfihangel Rhydithon, and the church there—in which services are still held— is called St. Tecla's. In the porch is a memorial tablet to Hugh Powell, grandfather of Sarah Hughlings (nee Powell) and the great-greatgreat-grandfather of John Hughlings Jackson. There is a sulphur spring well at Llandegley and, according to legend, such waters were effective in curing disease. They were usually associated with a particular illness and St. Tecla (sometimes spelt Tegla) was the patron saint of the "falling sickness" (epilepsy). In the 19th century, and possibly before that, epilepsy was referred to in Wales as 'clwyf Tegla' (Tegla's disease). A pagan ritual took place at Tecla's Well in which a person suffering from the falling sickness walked three times round the well after sunset on a Friday, repeating the Lord's Prayer and carrying a cockerel in a basket. The bird was then pricked with a pin and the pin thrown into the well. Next, the epileptic entered the church, placed an offering in the Poor Box, and stayed inside the church until daybreak. The afflicted person blew into the cockerel's mouth at this point and departed from the church, leaving the creature behind. If it died, the epileptic would, it was said, be cured. We have no means of knowing whether Hughlings Jackson had ever heard the story of the cure for epilepsy or of the saint whose name had been given to the church in the Welsh village where his maternal ancestors had lived; but it is an intriguing thought that he might have done. The next generation of the Hughlings family began on 8th September 1766, when the first of John and Sarah Hughlings's children was born. He was also named John (the Fourth) and was baptised on 15th September in the church where his parents had married, St. Clements, Worcester. Twins, Sarah and Elizabeth, were born on 28th September 1771. Their mother did not survive for long after the birth; she died, at the age of 36, the following day. Her memorial stone in Diserth churchyard is carved with the inscription: "Beneath rest the remains of Sarah, wife of John Hughlings, Supervisor of Excise and second daughter of Evan Powell of Maesgwynn in ye parish, gent, deceased,

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15

who (in childbirth) left ye transitory life ye 29th of September in the 37th year of her age." Sarah Hughlings's twin daughters lived on. Young Sarah married Thomas Jones of Ox-Hall but, poignantly, at the age of 30 she suffered a fate similar to that of her mother, dying in childbirth. The son she bore, Thomas, lived, only to "die young, of drink". Sarah Jones was buried at Diserth, close to her mother. Her tombstone bears the words "Sacred to the memory of Sarah, wife of Thomas Jones of Ox-Hall in this county, Gent, and daughter of John and Sarah Hughlings on the adjoining tomb mentioned. She died in childbirth ye 4th January 1802, aged 30 years. She endured the pain (which was extremely severe) with resignation and patience and entertained the thought of her approaching change with cheerfulness of one who firmly depended on the Divine Mercy, through the merits of a Redeemer for a glorious reward." Sarah's twin, Elizabeth, married John Price, gentleman. They lived at Maesgwynne, where their six children were born. When John Hughlings's father-in-law, Evan Powell, died, it was found that he had not left a Will. His estate was, therefore, shared equally between his three surviving daughters—Margaret (who married first Walter Griffith of Llandewi Ystradenny and second James Lloyd, also of Llandewi Ystradenny), Elizabeth (who remained a spinster) and Catherine (who married John Welson of Kington)—and John Hughlings (who inherited his deceased wife Sarah's quarter part of her father's land). Thus, John Hughlings acquired more land and property in Radnorshire to add to that which he had inherited from his father and which had been his grandmother's marriage portion. John Hughlings (the Third) lived for another 20 years after Sarah died. In September 1791 he fell from his horse. His injuries were fatal and he was buried in his wife's tomb at Diserth.

John Hughlings the Fourth John Hughlings followed his father into the Excise Service. At the age of 33, while working as an Officer of Excise in Hereford 2nd Division, he married Ann Williams in St. Peter's Church, Hereford, on 7th May 1799. Ann Williams, baptised at Clifford, Herefordshire, on 21st March 1779, was the second of the seven children of William and Ann (nee Phillips) Williams. William Williams of Hay (now known as Hay-on-

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John Hughlings Jackson

Wye) has been described variously as a 'carpenter', 'architect' and 'builder'. He was apprenticed to his wife's father, John Phillips, who was also an architect and builder. John Phillips left a landmark which can still be seen. Until an Act of Parliament was passed in 1773 during the reign of King George III, the River Wye between Hereford and Hay could be crossed only at one of the five or six fording places. However, they were often impassable because of floods. After the Act was passed, in fairly quick succession three stone bridges were erected at Whitney, but by 1795 all of them had been swept away by the force of the water. The property where these bridges had stood was bought jointly by Thomas and John Longfellow of Brecon and John Phillips of Hay. In a further Act of Parliament dated 9th May 1797, the three men were named and appointed as builders of a new bridge which was to be made of stone and timber. When it was finished, the bridge comprised three wooden spans supported on oak pillars which stood on stones in the river. The Longfellows and John Phillips were successful in their venture. Nearly 200 years later, this toll bridge, built by the great-great-grandfather of John Hughlings Jackson, is still in use. A family document states that William Williams (father-in-law of John Hughlings the Fourth) originally came from either Cardiganshire or Caemarthenshire in Wales and that he was related to Oliver Cromwell. This is the second suggestion that has been made about a relationship between the Hughlings and the Cromwells. All that can be said for certain about a possible connection is that there is a Williams in the Cromwell line, namely, a Morgan Williams who married Katherine Cromwell. However, Williams is a common Welsh name, and nothing else is known about Morgan Williams. The son of Morgan and Katherine was Richard Williams. In adulthood he adopted his mother's maiden name and was known as Richard Cromwell. Richard's grandson was Oliver Cromwell, the Protector, and up to the time of the latter's marriage contract, the Cromwells were using the Williams's coat of arms and were listed as 'alias Williams'. No genealogical link between Richard Cromwell and William Williams of Hay has been discovered to date. The first of John and Ann Hughlings's children was Ann, who was baptised at her mother's birthplace, Clifford, on 18th January 1800. The baby died two months later and was buried at Clifford on 13th March. Excise Officers were moved to a different post every four or five years on grounds of efficiency, and on 20th June 1800, John

Maternal Ancestry—The Hughlings

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Hughlings was appointed Supervisor of the Grantham, Lincolnshire, Collection of Excise. His next child, born on 30th January 1801, was also given the name Ann at her baptism at St. Wulfram's Church, Grantham. Ann Hughlings's life was rather more colourful than that of many women of her time. It began conventionally, and she married at the age of 23 in 1825. Her husband was Solomon Pitchforth of Shaw Laith, near Elland in Yorkshire. He had been born there in December 1801, the son of Solomon and Mercy (nee Crowther) Pitchforth and the fourth of their ten children. The Pitchforths were landowners and farmers. Ann and Solomon Pitchforth had seven children, four of whom lived to adulthood. Samuel was the first to be born, in Halifax, Yorkshire, on 22nd November 1826. Their second son, Solomon, was born in 1828 but he died the same year. The third boy, also named Solomon, born in 1832, died in infancy. Their first daughter, Mercy Ann, was born at Brighouse, Yorkshire, on 31st December 1833, followed by Barbara Ann on 18th June 1834 and another son, Solomon, on 6th June 1838. He died two months later. Their last child, Annie, was born on 22nd August 1841. Solomon Pitchforth had owned and operated a wire mill in Brighouse. When it was destroyed by fire, he had to begin again. In 1840, Ann and Solomon Pitchforth left Yorkshire. They went to live in the Isle of Man, where, according to their daughter, they kept a hotel or tavern on the North Quay, Douglas, for the next four and a half years. Ann Pitchforth's life changed dramatically following her meeting some of the first Mormon missionaries who came to England. One of them, John Taylor, lodged with the Pitchforths at their inn, where he held meetings in one of the parlours. Ann played the piano for the hymn-singing. Her son, Samuel, was converted by John Taylor, and in time, so was she. Ann's husband, Solomon Pitchforth, however, was not. It is thought that, because of his objection to his son's conversion, Solomon ordered Samuel out of the house. As a result of this controversy, Ann took their four children to stay for a few months with her father, who had by then moved to Presteigne in Radnorshire. Her strong religious faith impelled her to join the Mormons in America, apparently unbeknown to her husband. She wrote to friends in the Isle of Man that she had gone "through much persecution" and that "to leave a kind and aged parent was almost more than I could endure".3 On 17th January 1845, Ann and her children em-

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John Hughlings Jackson

barked at Liverpool on the sailing ship Palmira. We do not know whether her father, John Hughlings, was in favour of the emigration of his daughter and grandchildren, but he gave Ann an allowance which enabled her to begin life in America. Writing from America in April 1845, Ann expressed her gratitude: ". . , We spent a great deal more money than we had calculated as is all ways the case in travelling, we landed with £32 and felt very gratefull and thankfull you had so liberally supplyed us, which enabled us to get so many comforts in our long journey, and necessary things. ... I am very thankfull for Fathers kind allowance which I hope will be continued; and received with a thankfull heart."4 The journey was a harsh, arduous one, which was vividly described by Ann Pitchforth in long letters, two of which have survived. Finally arriving in New Orleans, the ship sailed up the Mississippi, first to St. Louis and then to its destination at Nauvoo, Illinois, where Joseph Smith, the First Prophet, had established his headquarters. Ann Pitchforth and her children lived in a house at Nauvoo. Samuel, her only living son, had married, and he worked as a printer in the nearby local newspaper office. Ann gave piano lessons in Mrs. Pitchforth's School of Music, which she advertised in the Nauvoo Neighbour in 1845 thus: "Mrs. Pitchforth respectfully informs the inhabitants of Nauvoo that she has commenced teaching Music on the Pianoforte; and wishing to suit the circumstances of the saints, she offers to teach at the very low rate of three dollars per quarter: so that all classes wishful to learn may be accommodated. As Mrs. P. has had the benefit of many years instruction from several of the most scientific English and German masters: and subsequently has had much experience in teaching, she flatters herself that she will be able to give satisfaction to all those who may favor her with their patronage. Reference, kindly permitted, to Elders Brigham Young and John Taylor. Enquire for Mrs. P. at Misses Gray's, milliners, Main street, or at her own residence, corner of Granger and Purley streets, one block west of the Seventies Hall."5 It is known that a daughter of Brigham Young was among her pupils. The following year, the Mormons began to trek West. Shortly before she left Nauvoo with the wagon train, Ann went through a marriage ceremony with John Taylor as his tenth polygamous wife on 8th January 1846. It is thought that this was a "sealing" or unconsummated marriage. The Mormons camped for the winter at Florence, Nebraska, where Ann died "from exposure" on 26th October 1846. She was buried in

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an unmarked grave. Her children continued on the journey and endured much hardship. Ann's husband in England, Solomon Pitchforth, is known to have gone to Australia and opened a feed store in Melbourne, where he is said to have married his second wife, Charlotte Eliott. Eventually, Solomon returned to England and died at Halifax on 19th February 1869. His death was due to "scurvy and exhaustion". Some of Ann and Solomon Pitchforth's descendants were given the name Hughlings among those bestowed at baptism, and several members of subsequent generations live in the United States today. Ann Pitchforth's brother, John Powell Hughlings, was the next child to be born to their parents, John and Ann, at Grantham on 8th July 1802. He was baptised at St. Wulfram's Church there on 11th July. Between 1819 and 1824, he attended Glasgow University as a medical student. On 27th November 1828 John Powell Hughlings married his first cousin, Ann Meredith, at St. Leonard's Church in Shoreditch, London. Ann was the daughter of Thomas Meredith, a linen draper, who lived with his wife, Catherine, in the East End of London. Catherine Meredith (nee Williams) was a sister of Ann Hughlings and aunt of the bridegroom. The first of the five children of John Powell Hughlings, who was given the name John Powell, was born on 29th October 1829. He died as an infant. The next, child, another son, born on 21st August 1831, was also named John Powell. This John Powell Hughlings, first cousin of John Hughlings Jackson, attended Pembroke College, Oxford, and graduated with a Bachelor of Arts degree in 1853. In 1858 he was appointed Professor of English Literature and History at Elphinstone College, Bombay in India "with an income of more than £700 a year—very good for a young man". He died on 5th May 1870. Eliza came after John Powell. She was baptised at Great Budworth, Cheshire on 4th July 1833. In 1840 John Powell Hughlings senior and his family were living at 40 Albany Street, London, but by the time their next daughter, Sarah Ellen, was born on 10th December 1846, they had moved to 32 Clark Street, Stepney, East London. She was baptised at St. Thomas's Church, Stepney, on llth August 1847. Her father's occupation was given as surgeon. However, when his third daughter, Ann, was born on 2nd August 1853, John Powell Hughlings was described on the birth certificate as "scripture reader". The family was then living at 78 Great

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John Hughlings Jackson

Titchfield Street, London, and the child was baptised at All Souls' Church, Marylebone. The next move was with his family, apart from his son, John Powell Hughlings junior, to Boaz Island, Bermuda. Whether he practised there as a doctor or as a preacher, we do not know. Returning to England, John Powell Hughlings and his wife lived in Southsea, Hampshire, until his death at the age of 60 on 13th July 1862. The cause of death was given as "brain disease and anasarca". The second daughter of John and Ann Hughlings was Elizabeth, born in 1803 and baptised at Clifford the same year. She was six years and three months old on 26th December 1809 when she died. Elizabeth was buried in her mother's grave at Halifax. William was baptised at Clifford in 1804, when his age was given as two. His fate is not known. Another son, Henry, always known as Harry, was also baptised at Clifford in 1806. Harry Hughlings became a sharebroker and married Mary Moreton, daughter of Thomas and Mary (nee Whitney) Moreton. Their children, twins Ann and Mary, Sarah, Eliza, John, Hannah and Moreton, were all born at Halifax. Sarah, John and Moreton Hughlings died young and were buried with their grandmother, Ann Hughlings, at Halifax. Harry lived in Halifax all his life, apart from visiting New Zealand on business from 1842 to 1845. He was highly regarded in the local community in Yorkshire and he gave generously to charity. Described as a man of intelligence, uprightness and integrity, this uncle of John Hughlings Jackson was said to be well-read and a genial friend, "one whose word was ever that of a thoroughly truth-loving and honorable man". Harry was present when his brother, John Powell Hughlings senior, died in Southsea. He himself died at the age of 75 on 14th October 1881, having caught a cold a few days before. His wife, Mary, had died 13 years earlier. The last of John and Ann Hughlings's children was Sarah. It was she who was to marry Samuel Jackson and whose own last child was John Hughlings Jackson. It is not certain where she was born; no record has been uncovered of her baptism at Grantham, Clifford or Halifax, but her date of birth was either 1807 or 1808. (Compulsory registration of births in England did not begin until 1837, so parish records of baptisms are the most usual source of such information.) What can be said with confidence, however, is that Sarah Hughlings was of Welsh origin. On 26th July 1808, John Hughlings was appointed Collector of Taxes for Halifax, Yorkshire, and the family moved once more, from

Maternal Ancestry—The Hughlings

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Grantham to Haley Hill, Northowram, which was then a village, near Halifax. His wife, Ann Hughlings (nee Williams), died at the age of 30 on 27th January 1809 and was buried at Holy Trinity Church, Halifax. John Hughlings remarried on 14th November 1811 at the age of 45. His second wife was 23-year old Ann Lewis, who was born in 1788. She was the fourth of the 11 children of Thomas Lewis, gentleman, of The Hengoed, Gladestry, Radnorshire and his wife, Elizabeth, the daughter of Gwynne James, surgeon apothecary, of Gladestry. One of Ann Lewis's brothers, Phillip, was also an Officer of Excise. The task of bringing up her husband's surviving children doubtless became the responsibility of the new Mrs. John Hughlings. The oldest child, Ann, was ten and the youngest, Sarah, was only four at the time. When John Hughlings retired from the Excise Service, he and his second wife moved south to Presteigne, Radnorshire, which lies just on the Welsh side of the border with England close to the ancestral homes of both the Hughlings and the Lewis families, and also near to the land which John Hughlings owned in that county. On 4th April 1848, in a philanthropic act towards the village where his great-grandmother had been born and whose marriage settlement he had inherited through his father and grandfather, John Hughlings gave a plot of land in Llanfihangel Rhydithon in order that a school be built "for the education of children of the labouring, manufacturing and other poorer classes in the parish of Llanfihangel Rhydithon." He also stated in the deeds his requirement that instruction at the school "shall comprise at least the following branches of school learning, namely reading, writing, arithmetic, geography, scripture, history and, in the case of girls, needlework. Further it shall be a fundamental regulation and practice of the said school that the Bible be read daily therein by the children and instruction in the Church catechism and in the doctrines and principles of the Church of England should at all times, namely at least once a week, be regularly given to all children in the said school."6 The school was erected "by the subscription of the Freeholders and inhabitants of the parish" in 1848. Years later, in 1876, John's son, Harry Hughlings, gave to the same village "a piece of land planted with trees containing 650 square yards adjoining the School House." The school remained in use by local children until 1930, when a new building was erected. The original schoolhouse still stands and is now used as a Community Hall, although there are plans for a

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John Hughlings Jackson

modern centre to be built within the parish and, possibly, for the original school building to be sold. When John Hughlings died on 25th November 1848, he was buried in the churchyard of St. Andrew's Church, Presteigne, close to the perimeter wall. The simple inscription on his headstone reads: "In memory of John Hughlings, late Collector of Excise, Halifax. Died November 25 1848, aged 82 years." His widow, Ann Hughlings, had been given a life interest in two of her husband's farms in Llandegley—Graig and Llaniogin—under the terms of her marriage contract. Those properties passed to Ann's stepson, Harry Hughlings, on her death. In his Will, John Hughlings left the remainder of his property and land to his sons, John Powell and Harry, with bequests of £2,000 each to the children of his deceased daughter, Sarah. John Hughlings Jackson thus received a handsome sum of money in time for him to begin his medical studies in 1850. After her husband's death, Ann Hughlings moved a few miles away from Presteigne across the Welsh/English border to a house in Church Street, Kington, Herefordshire, where she lived with her maid, Jane Elcox. Ann's sister, Mary, who had married William Ferrier, lived nearby at Huntington Park, Mulholland. Mary was a devout Wesleyan who taught in Sunday school and who had given land in the village of Gladestry for the erection of a chapel there in 1839. On l l t h March 1854, after a short illness, Ann Hughlings died and was buried at Kington. Her sister, Mary Ferrier, died four years later on 8th May 1858 and was buried close by her.

3 Early Education and Life As a Medical Student

Not much is known for certain about John Hughlings Jackson's early education. According to Dr. James Taylor, he first attended the village school at Green Hammerton. There is a school marked on a village map made in the 1850s, and since the first official school in Green Hammerton was not opened until 1874, it is assumed to be one of the "dame" schools known to exist in the area at that time. This is where Jackson would have received his first lessons. James Taylor also told us that Jackson went on to a school at Tadcaster in Yorkshire and to another at Nailsworth in Gloucestershire. It has not been possible to trace either of these schools because of a paucity of existing records of educational establishments which were open at the time in those towns. A grandson of Thomas Jackson, Dr. W.L.H. Jackson, believes that all four brothers were sent to boarding school after their mother died, and that it was a disappointing one. What is known for certain from surviving letters is that Hughlings Jackson and his older brother, Thomas, attended a school named Longfield, which was run by a Mr. and Mrs. Greenwood. The location of Longfield has not been traced,

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John Hughlings Jackson

but possibly it was the school in Tadcaster to which Dr. Taylor referred. On the other hand, Jackson himself wrote, in a letter to Thomas dated 28th May 1904: "I had been thinking of you in regard to our schooldays at Greenwoods. Yesterday the son of one of our school-fellows at Greenwoods brought a patient from Halifax for my opinion and advice. The father was Hodgson Wright, a surgeon and the son Crosby Wright. What a gulf of time between schooldays at Halifax with the father and yesterday's consultation with the son!"1 This appears to indicate that the Greenwoods' school was situated at Halifax. To the end of his life, Hughlings Jackson was grateful for the care he received at school from his older brother. A letter from him to Thomas dated 18th June 1869 states: "I assure you of my warmest love and that I often look back to our school days when you were so very kind to me."2 In February 1876, he wrote to his brother: "I very often think of our schooldays and your very constant and generous kindness to me. Poor old Greenwood is dead. He went into speculations and lost much of the money he and Mrs. Greenwood had scraped together."3 As late as November 1906, Hughlings Jackson again mentioned his gratitude when writing to his widowed sister-in-law in New Zealand after Thomas had died: "I cannot find words to express how greatly I feel his loss and how very much I sympathise with you and your children in your great bereavement. He was always a most kind father. I often think of his great goodness to me when we were schoolboys together and I find the remembrances of those times more and more vivid as I get older."4 Jackson left school at the age of 15, which would not have been unusual at the time. Compulsory education did not begin in England until 1870, and then the legal school-leaving age was 14. Hughlings Jackson "had a poor opinion of all these schools, and often said that much of his success was due to the fact that he had not been over-educated, quoting a remark attributed to the Duke of Wellington, that it was very unfortunate that the education of a certain noble lord had been so much in advance of his capacity!"5 He often proclaimed that his schoolmasters were not fit to sell penny pies on street corners, and used the analogy that if you drive a racehorse too hard as a two-year old, it will be no good later on. Over-education of the young, he said, produced the mediocrity of intellect of the present day, and "Too early education, especially if rigidly kept to a few things, is narrowing, and tends to hinder the

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25

higher development of mind. . . . Not the least valuable part of a man's culture is from that which he picks up for himself."6 We do not know why Jackson was so scornful of his schoolmasters. Even if he thought they were inadequate, he did not emerge from school at the age of 15 academically retarded. He was an avid reader, an accurate speller and his use of grammar was correct. As far as we know, he never complained of innumeracy. His later record as a medical student belied any hint of a lack of formal education. He qualified early and passed his examinations at the first attempt. Perhaps his criticism of the schools was due to a feeling of being insufficiently "stretched"—a not unusual reaction of a highly intelligent scholar. It is also possible that the regime at his boarding school was harsh, even sadistic, resulting in his life-long gratitude for the support of his brother, Tom. Early in the 19th century, many schools were notorious for the grim way in which children who were away from the parental home were treated. Pupils were often badly nourished, cold and ill, a state of affairs recorded by writers such as Charles Dickens. Dotheboys Hall in Nicholas Nickleby and the evil Headmaster, Wackford Squeers, were not exceptional. The biographer Peter Ackroyd wrote: "There is a good deal of evidence to suggest that Dickens actually underplayed the horror of life in the Yorkshire schools." According to one of his colleagues at the London Hospital, Jackson later said his mind had retained more freedom and energy because he escaped from over-teaching. Jackson might well have agreed with Hazlitt: "You will hear more good things on the outside of a stagecoach from London to Oxford than if you were to pass a twelve month with the undergraduates or Heads of colleges of that famous University." On 20th October 1850, at the age of 15, Hughlings Jackson became an apprentice for five years to a general practitioner in York, Dr. William Charles Anderson, and to his son, Dr. Tempest Anderson. They lived at No. 23 Stonegate. No record of his apprenticeship has been found, but other students of that time, such as William Cowers and Jonathan Hutchinson, left diaries which give an idea of what life was like for Jackson during the next few years. It was customary for an apprentice to live in his master's household. The master "would find him in meat, drink and lodging; while his father would provide good and sufficient wearing apparel and washing."7 We do not know what fee Dr. Anderson charged, but in

26

John Hughlings Jackson

1861 a two-year pupillage for William Gowers in Coggeshall, Essex, cost £150. An account of an apprentice's life in York was recorded by Jonathan Hutchinson when he, too, began his medical training in that city, and Jackson's experiences a few years later would have been similar. The apprentice began as a surgery-boy. His duties included preparing medicaments, which were kept in large Winchester bottles, and acquiring some knowledge of their properties. He was also engaged in pill-rolling and making ointments. He assisted his master in the dressing of cuts, burns, boils, whitlows and varicose ulcers. He paid visits to patients in their homes and even assisted at childbirth. When he was 19 years of age in 1847, Hutchinson wrote in his diary: "Very busy night, up five times. Busy with a very tedious labour case, which has been on ever since yesterday morning and is not yet over."8 On 6th October the same year he recorded: "Attended my 23rd midwifery case this morning."9 Some disgruntled apprentices complained that their principal duties were attending to their master's horses and carriage if a coachman was not employed. They were then obliged to drive the doctor round his practice, too. William Gowers wrote that his chief duties as an apprentice were to dispense medicines and to drive the gig. The brief spells of an apprentice's so-called leisure were spent in reading textbooks and, later, in attending lectures at the nearest medical school. In 1852 Hughlings Jackson became a student at York Medical School, which no longer exists. This school had accepted its first medical students on 30th October 1834. There were two terms, from 1st October to 15th April and from 1st May to 31st July. The outlook at York Medical School was far-sighted in that it was then one of only two provincial medical schools to offer courses in psychological medicine. Lectures began as early as 7 a.m., and Jackson's curriculum was as follows: Chemistry, 2 sessions (Dr. Proctor); Anatomy and Physiology, 2 sessions (Drs. Allen and Hornby) with Anatomical Demonstrations (Drs. North and Hornby); Materia Medica, 1 session (Dr. Caleb Williams); Botany, 1 session (Dr. Moore); Midwifery, 2 sessions (Drs. Allen and Anderson); Principles and Practice of Medicine, 2 sessions (Dr. Laycock); Forensic Medicine, 1 session (Dr. Proctor); Practical Chemistry, 1 session (Dr. Proctor); Clinical Lectures, 2 sessions (Drs. Sampson and Hay). In addition, there were lectures and demonstrations in Morbid Anatomy given by Dr. Paley and in Dissections by Drs. Hornby and North.10

Life As a Medical Student

27

Jackson attended lectures five days a week in addition to attending out-patient clinics, watching operations and post-mortems and being present at inquests. He walked from York County Hospital to the York Dispensary and back again. At the same time, he carried out the recurring duties required at his lodgings by his medical landlord. Students also took it in turns to act as surgical dressers—without extra charge. All the students at York Medical School were male it is recorded in 1853 that there were about a dozen in all. There was no Common Room for the students, and no recreational facilities were available.11 Long days were devoted to the dissecting room. One of Jonathan Hutchinson's entries in his diary reads: "Rose at 4 a.m. Dissected nearly all day. Was fetched from the dissecting-room at 6 p.m."12 A little later, he wrote in his diary that he was considerably annoyed by the disgusting conversation of some of the students in the dissecting room. Clinical work was carried out principally at York County Hospital, where there were 100 beds and where the museum and the medical library were also housed. For 18 months, John Hughlings Jackson attended courses of instruction there as a probationary practitioner, as well as at York Medical Dispensary. Two other hospitals in York were open for the instruction of students. The one in Fossgate was the Institute for Diseases of the Ear, and the other, in the Merchant Taylors' Hall, Aldwark, was the Ophthalmic Institute. Examinations were held annually and prizes awarded to students who excelled, but no record has survived of Jackson's achievements. Every lecturer commented on the work of each of his students. Lecturers received fees for their work and each apprentice handed over the money at the beginning of his course of instruction. The student either subscribed to a particular course of lectures or paid a "perpetual fee", which entitled him to attend any subsequent additional lectures that might be given. Another option was to pay an inclusive annual fee for attending lectures, conducting clinical practice and subscribing to the medical library. In 1858 the inclusive charge at York Medical School amounted to £68.5s a year. One of Jackson's interests among his pre-clinical subjects was chemistry, and he was a favourite pupil of his teacher, Dr. Proctor. Jonathan Hutchinson referred to Jackson's early interest in chemistry (which was not perpetuated) and also to the sterling qualities of Dr. Proctor. "I believe that Chemistry was Dr. Jackson's first love. This was per-

28

John Hughlings Jackson

haps first awakened at the York School of Medicine, where, in the person of the late Dr. William Proctor, both he and I in succession came under the influence of a most able and attractive teacher. It was one of the advantages of these small schools of medicine that the students became personally known to their teachers. The York School in our time numbered only ten or twelve students at most, and some of us were brought into personal friendship with some of the lecturers. Both Dr. Jackson and myself owed very much to our close intercourse with Dr. Proctor, who taught us chemistry and natural philosophy with enthusiasm, but in almost conversational methods."13 On 30th May 1849, Hutchinson wrote in his diary: "Proctor's lecture. In conversation after, he recommends taking notes on one's reading."14 Jackson was also fortunate to be taught by two other very able men at York, Dr. George Shann and Mr. S.W. North, both of whom stimulated his interest in morbid anatomy. At York Medical School the prime importance of anatomy and the superiority of clinical learning over second-hand information were frequently stressed. Paramount among his teachers, however, was the eminent Dr. Thomas Laycock, who was later to occupy the Chair of Medicine at the University of Edinburgh. Laycock was a most erudite physician who was interested in nervous function and dysfunction and, in particular, in the then unpopular views held by Marshall Hall concerning reflex activity. In 1848 Jonathan Hutchinson wrote: "Dr. Laycock: a real treat to listen to—some good observations against materialism."15 Years later he observed that at York Medical School young students who had been taught by Dr. Laycock learnt about heredity. While at York, Jackson became acquainted with psychiatry as taught by asylum alienists. Dr. Daniel Hack Tuke held an out-patient clinic at the Dispensary, and students also visited "The Retreat", which had been founded by Tuke's great-grandfather. Throughout his life, Jackson continued to take an interest in mental disorders, and he was able to pay visits to the West Riding Asylum. The Superintendent there, James Crichton Browne, became a life-long friend. Later in London, Jackson was also to avail himself of opportunities for research offered by Dr. George Savage at the Bethlem Hospital, as well as at Guy's Hospital. However, he did not follow the prevailing attitude in this country when it came to psychiatric illness. It became evident that Jackson was to adopt an organo-dynamic concept of mental illness which was inimical to most British psychiatrists.

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29

When Jackson looked back on his time in York, where he had studied in detail the pathology of disease, he said: "A man's pathology may be too definite in the wrong way, because he has not worked in pathology. It may be only superficially and verbally definite and really crude. He who has made many post-mortem examinations is not so metaphysical in his explanations of the pathology of some of those cases of disease of which there is no known morbid anatomy. . . . As early as possible in our career we should familiarise ourselves with cases of acute disease, with emergency cases—with cases that will not wait."16 Remarks such as this, which Jackson made in his maturity, illustrate the depth of his experience during his apprenticeship. His academic studies at this time bore abundant fruit later. Two years after he began his medical studies at York, Jackson received a long letter from his father, dated 17th March 1854. Fortunately it has survived, for its content is interesting and it is the only letter between father and son that has been traced. Samuel Jackson wrote: As to your general conduct, I have not the least fault to find. It has been to this date as good and exact as I would wish. I believe you have always kept yourself respectable and done your duty to your master and I am led to believe to his satisfaction and hope will do to the end of your pupillage which will be a cause of great satisfaction to me and must to you be a gratifying feeling. That said John there are many things to do, to guard against, which young men often never think about at least in such a way as to make them^rm to do, or, to leave undone. The giving way to improper company, I mean juvenilian company, company likely to take quite an improper tone to a persons desires and impulses. He may be compelled to associate with people whose habits of expenditure is greater, and perhaps not improper on their parts (on account of the means they possess). In such a case it requires a great firmness to resist spending as they do and thus getting into habits that common sense says can not be carried out without sooner or later taking away independence of feeling and with that contentment and happiness. It is a mistake that many young men make that to be respectable, to be respected it is necessary to pay like a man of property pays. I mean pay more than prudence dictates and might have a claim in the main idea that people will respect a man for it. It is the most absurd notion that can be. A certain class (the receivers) may fawn upon you, the wise and sensible will ridicule or scorn a person doing so for his lack of common sense. I write these last few lines because I feel it to be true indeed I know it to be so. I have often seen it and sometimes seen

30

John Hughlings Jackson people laughed at when their backs were turned. A young man that pays what is right and sees that he pays no more than he should is in truth more respected and looked upon in a better light by those he should wish to please and whose esteem he ought to gain than the person that pays like a fool through pride and vanity. You have got a calling in life if not all honey has in prospect a good share of it. Only be content to go steadily to work patiently waiting your time and taking hold of every handle to help you. Trust not to the chapter of accidents but be always strong and speaking so as to gain the respect of all, more particularly those that may be able to lift you up in the stern realities of life's struggle. John do not deceive yourself. There are stern realities in a successful progress more particularly in the beginning and one of these is to learn that money spent is not in the pocket, and although so clear a truism [fear] not as if it was so. Begin now to set habits of strict carefulness. Now begin to resist every desire. Ask yourself can I do without it, or is it requisite I should have it. If so get it, but not for the sake of some sudden desire. Do not lay out money that in a few days you feel would have been as such, better, in your possession. One way in which you lay out more cash than wise is in articles of dress. If you get a neck tye and you afterwards do not like it is that a reason why you should not wear it? Some people such as they would not be worn again. I sometimes think you do not take that care of your clothes you might. As you have not many faults and those not great ones I shall say no more upon that save only I should wish you have a greater respect for money. Rest assured it is a truer friend than most for it will help you in ... and most others and others leave you. Just then and only then and if fortune a second time shines upon a person then those friends like a swallow once aain, but only then, of course their own time. Lasting friends, perhaps not much seen or notice taken of till the end of time comes. As to your music I do not say or indeed wish you to give it up. I will just make these remarks. 1st do you attend punctually to your classes or do you not? 2nd do you feel it is your fate and that you will some day make something out. Srdly have you time to attend to classes and lastly if you feel you would like to give up do so before a 1/4 begins. Do not misunderstand me I leave it to yourself. I cannot write as I would wish to. I cannot express myself as I could like. I should have liked to have put my words together better, more clearly, but somehow I cannot. I feel it is far from a good letter and does not contain my ideas as I could have wished. Still you will I think make them out. To your good sense, to your knowledge of what is right and seemly I leave it. Let your own mind make out and follow what you feel I should have said and be determined to follow not a

Life As a Medical Student

31

foolish sensation but care nothing what the world will say as long as you act right and manfully do your duty to all around and to yourself. You are now just at the age when young people give a cast to their character. Recollect that habits bad or extravagant, false notions John, made now are hard' to shake off. Be careful not to get a habit of being too sarcastic. It will not only lose friends but get enemies. Hoping you will help the writer in expressing himself by your careful reading and lending your reason not to show cause against but to try to come to a proper decision is the wish of your affectionate Father Saml Jackson P.S. 1st 2nd

He is a happy man that learns by other peoples folly. He is a wise man that learns by his own folly and

3rd

He is a fool that learns nothing by his own folly nor other peoples, I hope your next 1/2 years tailors bills will be "nil" except for repairs, as the last was nearly as large as a year's ought to be. S.J. I hope you attend a place of worship every Sunday, at night always. Also, I hope you will for future take great care of your books. There is a book shelf in the place why not use it. Books abused now will cut a poor figure in days to come in a good bookcase. S.J. I expect yet to hear you have run the race and won too. What if you do not? People do not always expect to win, a good second is no disgrace. Common prudence will tell you to take care of this note or put it in the fire. How many specimens of bad spelling are there in this letter. At a guess I say 8 or 9 at least. S.J. I hope you told Mrs. Anderson that Sister was better. She felt much gratified and thankful for Mr. and Mrs. A.'s kindness. I hope you gave her Ann's note. Knowing Ann's having had a stroke will excuse her writing.17

The reference to Hughlings Jackson's musical education is the only one on record; it is not known whether he decided to give up his lessons in this subject. We do know that he did not heed his father's advice about books. Between 1855 and 1856, Jackson continued and then completed his medical training at St. Bartholomew's Hospital in London. There he was deeply impressed by Sir James Paget, who became a friend for life. After four years training, a medical student was then obliged to take an examination in London in order to qualify to practice med-

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John Hughlings Jackson

icine. He could take either the Licentiate of the Worshipful Society of Apothecaries (L.S.A.) or the Conjoint Examination of the Royal College of Surgeons and the Royal College of Physicians, which would give him an M.R.C.S., L.R.C.P. On 10th April 1856, Jackson went to the Apothecaries' Hall in Black Friars Lane to sit his Licentiate. His examiner was Mr. Ansell and he passed this examination. Shortly afterwards Jackson took the other qualifying examination, although it was not necessary to do so, and obtained the diplomas of Membership of the Royal College of Surgeons and of Licentiate of the Royal College of Physicians. On this occasion his examiners were the President, William Lawrence, the Vice-Presidents, Benjamin Travers and Edward Stanley, and J.H. Green, J.M. Arnott, J.F. South, Caesar Hawkins, J. Luke, F.C. Skey and J. Hodgson. Referring to the matter of education, Jonathan Hutchinson said: "Jackson and I often discussed together the question as to whether we had regretted in later life our not having received any university training. Neither of us had been even to any high-class school, and both had, I believe, ended our educational curriculum at the age of 17, when we were apprenticed and became medical students. We thoroughly recognized the advantages offered at the larger colleges; but, in attempting to strike a balance of loss and gain, Dr. Jackson was always unflinching in his avowal [that] he was glad he had not been sent to a university."18 After medical qualification, Hughlings Jackson returned to York and was appointed Resident Medical Officer at the York Dispensary. He held this post for the next three years. In 1855 Dr. Laycock had moved to Edinburgh, where he carried out important studies in psychology. We do not know whether Jackson kept in touch with him, but he certainly read Laycock's subsequent writings and quoted from Mind and Brain (1860) several times. In Notes on the Physiology and Pathology of Language19 for example, Jackson said: "Laycock has some most important observations on this subject" and went on to quote him. Towards the end of his residency, Jackson was elected to membership of the York Medical Society, which had been founded in 1832 (two years before the Medical School was opened in the city). He was also an enthusiastic member of the newly-formed Post-Mortem Club, where clinicians and pathologists met periodically to discuss cases informally, especially those of patients who had been admitted on an emergency basis.

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In 1860 Jackson submitted a thesis for his Doctorate of Medicine at St. Andrew's University in Scotland. At the time it was possible for external candidates to do so, but he was one of the last because the regulations at that University were changed in 1862. There is no record of the subject Jackson chose for his thesis.

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4 Leaving Yorkshire for London

Both as a medical student and as a junior doctor, Hughlings Jackson was overtly enthusiastic. He was also an exceptionally astute young man who realised the value of the opportunities presented to him, and he made the most of them. It is not certain who influenced him, but he had developed a philosophical way of thinking, and this could have been the reason for his leaving York in 1859 to take up residence in London. It was to be a permanent move from the county of his birth, but we know from James Taylor that "his affection for Yorkshire was deep and lasting. He never allowed a year to pass without going there at least once, and a short time before his death he made the remark to his cousin that it was not generally known that the Garden of Eden was close to Providence Green."1 Mr. Samuel North gave Jackson an introduction to another doctor in London who came from Yorkshire and who had also been apprenticed to a doctor in York, had been a student at the medical school there and later was Resident Medical Officer at the York General Hospital. This was Jonathan Hutchinson, who was seven years older than Jackson.

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John Hughlings Jackson

Jackson rented accommodation in Hutchinson's house at No. 4 Finsbury Circus, which at the time was a fashionable area housing several distinguished members of the medical profession. The Hutchinson family had moved to No. 4 from No. 14 Finsbury Circus because "it was a much larger and more convenient house", and six of Jonathan Hutchinson's children were born there. Jackson lived with them for three years. At about this time, Jackson began to think seriously as to whether he might have chosen the wrong profession and whether he ought to change to academic philosophy. Hutchinson told him to abandon the idea of such a career and strongly advised him to apply philosophical thinking to medicine. Hutchinson and Jackson became firm, life-long friends. For a few years after qualification in medicine, Jonathan Hutchinson's principal source of income was from medical journalism, and Jackson joined him in this activity. For a time, both of them were employed by a Mr. John Churchill as medical reporters to The Medical Times and Gazette. We know from Hutchinson that Jackson did not write shorthand but that he "was skilful in the preparation of abstracts from memory. In connexion with this kind of work he became well known to the members of the staff of most of the large London institutions. Although being thus made familiar with the practice of many institutions and those connected with them, attached as a student at St. Bartholomew's, and elected Assistant Physician to the London Hospital, I know that he developed and retained a special attachment to Guy's. Here he had known Gull and his fellow-worker Dr. Sutton, and with them Wilks, a veteran who survived him. He was also intimate with Dr. Moxon, to whom, in reference to the recently passed illustrious careers of Drs. Bright and Addison, he used in joke to remark that they believed 'that disease was made for Guy's Hospital'."2 A description of work on the Medical Times and Gazette under Mr. Spencer Wells was written by Jonathan Hutchinson. He said that, as a reporter, he attended "all the most important cases and operations in the London Hospitals," plus meetings of the medical societies, and reported on the cases brought up—"not only to the Medical Times & Gazette but to other periodicals. . . . The work was of immense educational value." He was introduced to "all the leading doctors in the Metropolis and to all the most interesting work being done." He learned "to collect and arrange statistics, and form judgements on a broad basis."3

Leaving Yorkshire for London

37

Within the congregation of the eminent men of the day whom Hutchinson and Jackson met was the remarkable, but unconventional, physician Dr. Charles Edouard Brown-Sequard, who displayed a deep knowledge of the workings of the brain. Jackson derived much mental stimulus from his contact with this restless intellectual, and Jonathan Hutchinson recorded the important encounter thus: "My friend fell, soon after he joined me in London life, under the influence of Dr. Brown-Sequard, who told him strongly that it was foolish to waste his efforts in wide observation of disease in general, and that if he wished to attain anything he must keep to the nervous system."4 Quite another explanation has been suggested for Jackson's choice of neurology as his medical speciality by H. Bailey and W.J. Bishop, who wrote: "His determination to specialise in neurology was brought about by the following incident. Jackson noticed one morning that one side of his face was paralysed; he had, in fact, an attack of Bell's palsy. It was this personal experience of a nerve lesion which initiated his enquiries into diseases of the nervous system."5 However, the authors gave no evidence to support either contention, and nothing has come to light to substantiate their statements. In 1959 a third edition of their book was published, in which the wording of the story was different: "It is said that Jackson's determination to specialise in neurology came about when he himself suffered an attack of Bell's palsy." (italics not in the original). Could it be that the authors had become doubtful about the accuracy of their earlier statement and modified it by beginning "It is said that . . ."? Before the subsequent edition was published, both authors had died. The fourth edition appeared in 1993, revised by Harold Ellis. He retained the wording used in the 1959 edition. As to whether Hughlings Jackson did sustain a Bell's palsy at any time during his life, we cannot be certain. His later photographs suggest that a facial asymmetry may have existed, and Purves-Stewart commented: "His white beard had a curious twist toward the left side of his chin."6 The earliest known photograph of Jackson as a boy does not show such a discrepancy. Jackson's career was advancing in a direction influenced by Hutchinson, who was then on the surgical staff of the London Hospital. In 1859 Hughlings Jackson was appointed to the staff of the Metropolitan Free Hospital, a small general non-teaching hospital in Dalston Road in the East End of London. The same year he became Lecturer on Pathology at the London Hospital. In 1860 a modest establishment was founded in the Bloomsbury

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John Hughlings Jackson

district of London which in time became the National Hospital for the Paralysed and Epileptic, Queen Square. Dr. C.E. Brown-Sequard and Dr. J.Z. Ramskill were the two doctors originally on the consultant staff. Within a couple of years, the hospital was expanding its staff in order to meet the demand. Brown-Sequard told Hughlings Jackson that a vacancy for the post of Assistant Physician would shortly be advertised. Jackson applied and was appointed on 7th May 1862. His duties were arduous. Jackson was required to attend the hospital twice a day and also to visit at home any patient with a neurological ailment who lived in Bloomsbury or in the adjacent district of Holborn. For this he was paid £50 a year. He soon found it difficult to visit patients outside the hospital, and he resigned on 16th July the same year. The managers of the hospital decided that he should "lose his salary of fifty pounds per annum, but not his functions as assistant physician."7 Brown-Sequard decided to leave London in 1863, thus causing a vacancy for the post of full Physician at the National Hospital. In those days promotion was not automatic. Jackson had to apply for the position the following year, when it was decided to appoint two Physicians. He was not successful. Dr. Russell Reynolds and Dr. E.H. Sieveking were appointed. In 1867, Sieveking, who was also a a physician on the staff of St. Mary's Hospital, resigned, and Jackson was elected as full Physician to the National Hospital. In order to lessen the burden of travelling, Jackson gave up his room in Finsbury Circus and took lodgings at No. 5 Queen Square, a building diagonally opposite the National Hospital. This house had been the birthplace of Rickman Godlee, who was later to gain fame by being the first surgeon to remove a cerebral tumour. Although the change of residence ended his daily contact with Jonathan Hutchinson, their friendship continued and they met often. An important step in Jackson's career was his election as Clinical Assistant at the Royal London Ophthalmic Hospital in City Road, first to Mr. Alfred Poland and then, in 1862, to Jonathan Hutchinson. The hospital is now better known as Moorfields. Jackson thus had an unique opportunity to study the novel discipline of neuro-ophthalmology. He became absorbed in the subject, saying it was "the luckiest thing in my medical life that I began the scientific study of my profession at an ophthalmic hospital."8 On the occasion of the Annual Oration to the Medical Society of London in 1877, Jackson chose ophthalmology as his topic—"the one which interests me more deeply than any other whatever."9

Leaving Yorkshire for London

39

Professor H.L.F. von Helmholtz of Berlin had invented the ophthalmoscope in 1851, so Jackson was able to use this instrument to scrutinize the fundus oculi. For a time he used a type of ophthalmoscope designed by Lionel Smith Beale of London. According to James Taylor, Jackson was one of the first physicians to use the ophthalmoscope. He "used it habitually and diligently and with great skill, in his observations, and was insistent on the necessity of its routine use in the examination of all cases of nervous disease."10 From 1863 onwards, Jackson wrote many papers and delivered numerous lectures on ocular palsies and on the problem of optic neuritis. When looking back in 1877, he said he "did not know of any kind of work better fitted for correcting loose habits of observation and careless thinking than a study of palsies of ocular motor nerves".11 When Jackson had the distinction of delivering the William Bowman Lecture before the Ophthalmological Society of the United Kingdom in 1885, he expressly acknowledged his debt to his friend, Jonathan Hutchinson, for instruction in ophthalmology. In that address he enlarged upon the topic of ophthalmology as viewed according to the philosophical ideas of Herbert Spencer, saying he believed the lecture to be "pervaded by Spencerian ideas" although he had used terms more familiar to medical men. He stressed that Spencer was not responsible for the change. "I should regard it as a great calamity were any crudities of mine imputed to a man to whom I feel profoundly indebted. It is for that reason that I do not quote Spencer in the rest of the lecture."12 Jackson's considerable contributions to neuro-ophthalmology were the subject of an important study in 1937 by Dr. Burton Chance of Philadelphia. Jackson successfully sat the examination which gave him Membership of the Royal College of Physicians of London in 1860. Six years later he was elected to the Fellowship of that College, and as one of the youngest to attain this distinction, he was awarded the Goulstonian Lectureship. His three lectures were entitled "Certain Points in the Study and Classification of Diseases of the Nervous System." He also kept in close touch with another Yorkshireman, Dr. Thomas Clifford Allbutt of Leeds, who in 1892 was elected to the Regius Chair of Physick at Cambridge University. Allbutt wrote many papers, culminating in his classic work "Medical Ophthalmology" in 1871, which he dedicated to Hughlings Jackson.

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John Hughlings Jackson

Jackson's next hospital appointment came in 1863, when he was elected Assistant Physician to the London Hospital. For the previous two years he had been giving lectures at their medical school. Jonathan Hutchinson denied that he had exerted any influence on his friend's behalf, at least directly so, and said it was a foregone conclusion because the only other competitor for the post had retired. However, Jackson, "who had a strong contempt for everything in the nature of red tape and formality, knowing that it was settled, forgot to attend on the day of election, and I had to persuade an obliging secretary to keep the quorum whilst I took a hansom cab and hunted him up."13 On taking up this new position, Jackson resigned from the Metropolitan Free Hospital in order to do justice to the demands of the large and important teaching hospital. His final hospital appointment was in 1874, when he became full Physician to the London Hospital, a post he held for 20 years. In 1878, at the early age of 53, Hughlings Jackson was accorded the honour of being elected a Fellow of the Royal Society, which, according to Jonathan Hutchinson, gave him very great pleasure.

55 The Cholera Epidemic in London, 1862

In April 1866, England experienced its fourth, and last, epidemic of cholera. It originated in the Middle East among pilgrims to Mecca, who took it to Egypt, and from there it spread to British seaports, including those on the River Thames in the East End of London. According to William Osier, cholera is not a highly contagious disease, and physicians and nurses, therefore, are not usually affected. However, washerwomen and those brought into close contact with the infected linen of hospital patients were prone to the disease. Unwashed vegetables, especially lettuce, and milk may convey the disease, but water is the most virulent source of infection. The French physician Gabriel Andral shrewdly remarked, when referring to the prognosis, that the malignant form of cholera begins where other diseases end—in death. The epidemic reached its peak early in July 1866, and the London Hospital bore the brunt of caring for those affected with the disease. Jonathan Hutchinson noted in his diary: "August 3rd 1866. Dr. Jackson called this morning; he is engaged by Government to report on Cholera. I am very glad of it. He looks overworked, and as if he wanted a rest. The

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cholera will, I expect, keep all one's patients away. Already there is great alarm about."1 No account has been found in the files of the London Hospital or in contemporary Parliamentary Reports of Jackson's work on cholera, but it was obviously of an arduous kind. Dr. A.E. Clark-Kennedy has given us a grim account of that time.2 One-third of the London Hospital's facilities were given over to the cholera victims. Extra nurses were employed, and there was a body of volunteer workers under the supervision of Mrs. W.E. Gladstone, wife of the then Chancellor of the Exchequer who later became Prime Minister. Treatment was administered by four physicians and two resident medical officers, each working part-time. In addition, there were 3 resident medical officers, a special staff of 73 nurses and 16 volunteer men and women working full-time in the cholera wards. "Everywhere we had sawdust steeped in carbolic scattered about, and under every bed there was a large bag of it. The beds themselves were sacks of straw, and such was the nature of the disease that, as soon as a patient died or could be removed, we carried away the bed of straw and the sack of sawdust, and took them to an open space at the back of the Hospital where we had a bonfire every night."3 By 4th August, 365 patients had been admitted to the London Hospital, 162 of whom died. Slowly the epidemic subsided, and it had almost ended by October. The total number of deaths was nearly 8,000, more than half of them in the East End of London. The London Hospital had admitted a total of 586 patients with cholera, of whom 306 died, as well as 279 with "choleraic diarrhoea", of whom 21 died. Like other members of the staff, Hughlings Jackson had had no previous personal experience of dealing with patients suffering from cholera, but he had been taught by doctors who were conversant with this deadly disease. In 1832 the City of York had been the seat of a relatively short, but virulent, epidemic of cholera, and some of Jackson's teachers at the medical school, in particular Dr. Thomas Laycock and Dr. Samuel Tuke, had been responsible for the treatment of its victims. Over a period of 107 days, there were 450 cases of cholera (that is, 2% of the population of York). Death accounted for 104 men and 69 women.4 Dr. William Anderson, to whom Jackson had been apprenticed, "had given up his private practice to devote all his time to the cholera hospital where he was living during the epidemic."5 The treatment for diarrhoea was one and a half grains of opium

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twice in 24 hours, with the addition of a grain of calomel if there was no relief. Bleeding was thought to assuage headache and muscle cramps. Frequently the only liquid prescribed was a half teaspoonful of water with the calomel. If patients survived to the later stages of the illness, leeches were applied and a calomel and saline mixture was given. Mustard plasters provided warmth and more purgatives were administered. "One doctor probably summed up the feelings of most of his colleagues at the end of the epidemic in York when he said that their treatment had been empirical, uncertain and frequently inefficacious."6 In 1844 The Report on the State of York was published. It was written largely by Dr. Thomas Laycock, who was Secretary of the committee which had been responsible for an enquiry. It comprised a survey of "water supplies, drainage and disposal of night-soil; sickness, child mortality, death-rates and the availability of medical care."7 It seems possible, therefore, that these men may have passed on to Jackson some of their experiences during the outbreak of cholera in York. After the epidemic in London ended in 1866, Jackson did not write about any of the work in which he had been involved. However, he was presented by the London Hospital with a gold watch in recognition of his services during that time. According to James Taylor, "He was always proud of the gold watch he wore, a gift from The London Hospital authorities with an inscription recognizing his devoted work in the last great cholera epidemic which visited this country."8 Unfortunately, it has not been possible to find any other written record of this event nor the present whereabouts of Hughlings Jackson's prized gold watch.

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6 First Neurological Papers

Hughlings Jackson's role as an important and prolific medical writer began in 1861 when he reported some cases of brain abscess in The Medical Times and Gazette. His contributions to the medical literature continued until 1907, four years before his death. Most of his papers appeared in The Medical Times and Gazette, but many others were published in such journals as The Lancet, The British Medical Journal, The Royal London Ophthalmic Hospital Reports and The Medical Press and Circular. When the first issue of the quarterly journal Brain appeared under the date 1878—1879, Jackson became a member of the Editorial Board as well as a frequent contributor. Indeed, some of his articles, which had been published originally in one of the weekly medical journals, were subsequently reprinted in Brain, sometimes in a modified form and sometimes expanded. Jackson was usually the sole author of his papers, as was the rule then, unlike the multiple authorship of modern times. In his later days he collaborated occasionally with a house physician, W.S. Colman or Stanley Barnes, or with a

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junior colleague like Risien Russell, Douglas Singer or the ophthalmologist Leslie Paton. Later in life, he often published brief articles in The Lancet which he called Neurological Fragments. There were 21 in all, spread over a period of 16 years. Sir Squire Sprigge and Sir Ernest HodderWilliams were Editors of that journal and in a letter the former gave an account of how Jackson would appear at the office on Wednesday afternoons at about tea-time: "He brought them himself by hand, and gave them to me personally. He arrived in a large barouche with a pair of horses: he asked to see a proof the same day, and was told that would be impossible: he was quite pleased to leave the correction of the proof to us, but was desirous that the note should appear the same week, which generally entailed hacking half a column out of the pages which were already made up!"1 Jackson never published a bound volume, and he did not contemplate writing a manual or a textbook of neurology, although he was pressed to do so by William Osier, J.J. Putnam and Weir Mitchell. According to Dr. Wilfred Harris, "When pressed as to his reasons for not writing a text book, he would say that if he were to do that his enemies would find him out. Probably he had fewer enemies than any other successful man who rose to such a height of recognised pre-eminence, but his mentality was not of the type that could sit down to work regularly week after week, and month after month, at the routine of text-book writing."2 Dr. Charles Mercier said of him: "It is lamentable that he never gave to the world a complete body of doctrine. He had in contemplation a book, of which he published now and then in some journal of small circulation a chapter or part of a chapter, but the book was never completed, partly from his difficulty in putting his thoughts into words, and partly from his extreme fastidiousness in expression."3 Jackson took the unusual step early in 1863 of publishing a privately printed monograph for circulation among his friends. It was entitled Suggestions for Studying Diseases of the Nervous System on Professor Owen's Vertebral Theory."4 Professor Richard Owen, a comparative anatomist, had delivered an address at a meeting of the British Association for the Advancement of Science in 1846, in which he suggested that the bones of the skull are in fact modified vertebrae. Later he expanded this hypothesis, and Owen's vertebral theory became well known among British scientists. Subsequently, however, Thomas Huxley rejected it.

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Jackson was interested in these ideas and proceeded, somewhat tentatively to expand the notion of "allotting viscera, nerves and arteries to each corresponding vertebral segment". The pamphlet seems to have escaped the notice of most neurologists, although James Taylor included it in the bibliography of Jackson's writings in both Neurological Fragments and Selected Writings. Dr. Samuel Greenblatt has been one of the few to comment on this publication when, in 1965, he suggested the probable influence of Thomas Laycock in drawing Jackson's attention to Owen's theory. In the Preface to his monograph, Jackson emphasized that he was writing as a physician and as one who did not pretend to have even a moderate knowledge of comparative anatomy or physiology. He explained why, physiologically speaking, a hemiplegia does not represent a paralysis of the whole of one-half of the body. Thus Jackson anticipated Broadbent's hypothesis. He observed that disease occurs in physiological tracts as well as in geographical ones, as evidenced when headache results from lesions in the abdomen or thorax. Just as there is an intercostal nerve associated with a dorsal vertebra, he said, so there may be in the case of a cranial vertebra. The four "cranial vertebrae", each of which is "a sort of independent sub-government", were listed by him as (1) the Nasal or Olfactory or Lachrymal; (2) the Frontal or Ophthalmic; (3) the Parietal or Gustatory or Salivary; and (4) the Occipital or Auditory or Pulmonary-Hepatic. In every sense, he claimed, there are two brains, a central one and a peripheral one. In putting forward these views, Jackson was anything but dogmatic. He said he hoped that the general idea was correct and that his scheme might promote further study "or rather to think of the 'obscure legends of disease' in better order." He regarded diseases of the nervous system "on a mechanical plan—a plan which is like the former systems of botany", but he did not claim for it anything more than an attempt at a natural arrangement. Jackson apparently lost interest in Owen's theory, for he seems not to have referred to the subject again. Not a few writers have criticised Jackson's style of writing; some have even been extreme in their disparagement, like the psychiatrist Sir George Savage. "His whole frame of mind was so careful and exacting that he scarcely ever dares to make a definite statement without qualifying it in some way; so that in studying his writings one meets endless footnotes and parentheses, which are somewhat confusing."5

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One of Jackson's obituarists wrote: "He has been accused of being an involved and puzzling writer, but with all respect to those of his most sincere friends who have expressed this opinion to his face— often to Jackson's half-amused perplexity—we venture to assert that the criticism did him less than justice. It is true that his more important papers had to be read with close attention, but this was not because the thought was obscure, or the style involved, but because the argument was close compacted and the thought was new, and the terminology therefore necessarily unfamiliar."6 According to Dr. Thomas Buzzard: "Jackson showed deficiency in artistic perception and this want, I am disposed to think, acted prejudicially on his style of composition, which, to my mind, lacked lucidity of expression. He and I often discussed this question. He would never agree to the justice of my criticism, and always maintained that, in writing upon scientific subjects, the truth was often sacrificed to elegance of expression."7 Dr. Charles Mercier expressed this opinion: "His writings had the reputation of obscurity, but they were not in the least obscure to those who were familiar with his modes of thought and the subjects of his thought. They had, however, a lack of literary skill and a certain crudity of expression that was in striking contrast with the elaboration and clearness of his thought. Of this lack of skill he was himself conscious. He said that writing on his subjects was like driving six horses abreast, each of which needed continuous attention. I know that he wrote one paper thirteen times, and was still unsatisfied."8 Not a man to mince his words, F.M.R. Walshe said: "As to his language, this was part of his period. . . . In general he is a very untidy writer. Many of his papers give the impression of being first drafts, and that the author has not finally arranged his facts and conclusions, nor subjected their exposition to any pruning. Instead of polishing his presentation, he appends, perhaps out of that impatience of delay he showed in certain of his ways of life, a long footnote purporting to clarify what he allows to be an obscure passage. Thus the reader has to cope with some unnecessary obscurity and a great deal of repetition. Nevertheless, the reader with any theoretical bent will not be put off by these literary shortcomings, nor offer them as a valid excuse for abandoning the study of Jackson's writings."9 It is true that one shortcoming in Jackson's writings lay not so much in a defect of syntax as in overuse of parentheses in his almost obsessional desire to be exact. Lengthening a message is one way of avoiding ambiguity, of course, and prolixity is the result of a desire to avoid imprecision in writing about a complex subject.

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But Jackson was not always guilty of surplusage. It is unfortunate that few specimens remain of his non-professional writings, but a letter to one of his brothers in New Zealand exists which shows he used simple prose when it was appropriate. On 18th June 1869 he wrote: "My dear brother Tom, I have just got your letter dated March 29 1869. We have written to you and to my brothers Samuel and William several times lately and we are much surprised and somewhat alarmed (considering the alarming news from New Zealand) at not hearing from any of you before this time. It gave us the warmest pleasure to receive your letter and to find that you are all well. . . . As to news I fear there is very little to tell you. I think I told you of the death of Mrs. Langdale and you will by this time have heard of the death of William Proude. In July I go to York to be present at a meeting of the Psychological Association which will be held there under Dr. Laycock's Presidency. I think I told you that I delivered two Goulstonian Lectures at the College of Physicians. They will be published in The Medical Times and Gazette, and perhaps afterwards in book form. I am getting on well as far as the spreading of my views on disease of the nervous system is concerned, but it takes a long time for a physician in London to get into practice, and for the present my pecuniary position is nothing very remarkable. However I suppose hard work and patience will tell in time and I feel very well satisfied on the whole."10 Jackson's resort to badinage rescued his prose from dullness. He employed metaphor with discretion, thus avoiding the "as if phenomenon, which is apt to detract from the work of some professional writers. At times Jackson was repetitious but he avoided anaphora. The content of Jackson's writings has not, however, been criticised, and he went out of his way to acknowledge the work of other authors, as well as any assistance he may have received from colleagues or—more especially—from his house physicians. Those who were obliged to read Jackson's manuscripts had difficulty interpreting his handwriting, which, at times, was so illegible as to baffle the reader. When, in later life, his friend Jonathan Hutchinson sustained a stroke and, during convalescence, was practising writing first with one hand and then with the other, he said the result was "very wobbly, but better than Dr. Jackson's at his best."11 At times Jackson's writings were cryptic, but often the topics with which he was concerned were highly complex. He often dealt with ideas that had never been discussed before, for his thoughts were, on many occasions, ahead of his time. In particular, the eponymous lectures which Jackson delivered are

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far from easy to read, partly because of the terminology he used. When writing on themes of considerable obscurity and using unfamiliar ideas, however, he sometimes used simple, homespun terms. He avoided the jargon which characterizes the work of many writers of a later age and went to great lengths to explain exactly what he meant. He did not always succeed. "The meaning did not always peep through the welter of words", to quote Dr. Samuel Johnson. However, Jackson was not consistently enigmatic in his writings. Some papers, such as his address on pathology as the basis of every rational system of therapeutics, are models of clarity. No matter how esoteric the subject, Jackson had a delightful knack of interposing felicitous and pithy phrases or expressions which were sometimes witty and always unexpected. Thus the phenomenon of iterations of speech was alluded to as "barrel-organisms", a term he borrowed from Dr. W.T. Gairdner. Jackson spoke of interjections as "detonating commas", "feminine oaths" or even "offensive missiles". Charles Mercier wrote: "He was the originator of the expressions, 'A clotted mass of spasm', 'An optic disc looks as if it had been trodden on'."12 Jackson distinguished the state of "not-knowing" from that of "pseudo-knowing" according to the depth of the defect of the highest cerebral centres. He wrote, "the brain is the nervous system of the nervous system" and "written words are symbols of symbols". He said that the recurrent utterances of many aphasiacs represent "a still-born proposition" and that "some lower animals think in symbols but little symbolic". Spoonerisms, in his opinion, are "the result of right-brain hurry". The truncated remnants of speech that are often the sole utterance of an aphasiac were likened to "recurring decimals, always the same". Jackson once stated that language is like baking and brewing, an art handed down from generation to generation. Jackson did not hesitate to change his mind and to admit doing so in print. As a result, it is not always easy to determine just what was his final opinion on a given topic. For example, writing about epilepsy in The West Riding Lunatic Asylum Medical Reports, Jackson said: "Loss of consciousness is not an utterly different thing from other symptoms".13 In a later volume of the same journal, and in explanation of that remark, he wrote: "This was a very blundering statement, but the context showed clearly, I hope, that what was meant was that cases of epilepsy, with loss of consciousness at the onset, depend on discharge of sensori-wotor centres, just as do cases of

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epilepsy . . . in which there is no affection of consciousness, the difference being not in the kind of constitution of the centres, but in their degrees of evolution. The following statements are, I hope, free from such blunders. . . . "14 Jackson employed reiteration in two ways. He might repeat himself within a single lecture or an article, even employing the same terms. Or he might make an important observation again and again in different papers, year after year. Such replications are not offensive, however, and they illustrate Jackson's desire to hammer home a novel idea that was probably foreign to current thinking. Thus he was constantly drawing attention to the fact that cerebral lesions do not cause symptoms, though they might permit symptoms to appear. Softened brain, he said, is not brain at all; it is dirt in the the brain, or a hole in the brain and, therefore, devoid of function. When he first made this remark, Jackson was stating something previously unheard of. Today it is accepted as axiomatic. In an important paper published in The West Riding Lunatic Asylum Medical Reports, he appended a footnote to the first page: "Since writing the first part of this paper, I find that there is more recapitulation from former papers than I expected. I have acknowledged this in part by giving quotations from former papers and by footnotes."15 Belated recognition of a textual error occasionally induced him to add a footnote of emendation. For example: "The fault, however, is my own; I freely admit this. By a clerical error which I ought to have corrected, I am made in The Mirror of The Lancet November 26, 1864, p. 606, to say 'limited to softening' of the brain instead of 'limited softening' of the brain".16 This is typical of his compulsion to avoid misinterpretation by the reader. He was concerned about the impropriety of making classifications of a disease-entity, aphasia, for example, according to disparate systems. In his "Remarks on Evolution and Dissolution" he wrote: "Such classifications, perhaps allowable clinically, are, for scientific purposes, as unjustifiable as a classification of plants into endogens, graminaceae, kitchen herbs or ornamental shrubs and potatoes would be."17 Jackson used this metaphor, although not always in the same words, many times to illustrate the fallacy of employing any system of classification that was incongruent or discordant. He returned to it when discussing neurosyphilis: "The term syphilitic aphasia, like traumatic aphasia, may be useful as part of a garden-like arrangement of cases, but it has an odd sound."18

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7 Herbert Spencer, Evolution and Dissolution, and the Hierarchy of the Nervous System

In the 1860s Jackson published many detailed case reports. In the 1870s he marshalled his ideas with increasing precision. His views came to a full flowering in the 1880s. Such was the assessment made by Dr. R.G. Mitchell in I960.1 It is commonly considered that Jackson wrote principally on three topics, namely, Spencerian ideas as applied to neuropathophysiology; epilepsy, especially focal seizures; and aphasia. Important as these subjects were, to limit one's attention to them would be to ignore his other widespread contributions to neurology. Jackson also devoted much of his time to chorea, headache, vertigo, optic neuritis, ocular palsies, neurosyphilis and cerebrovascular disorders. He was obviously catholic in his interests, and to all of them he brought a philosophical attitude which was both attractive and original. Although Jackson had been receptive to the ideas of many teachers, the influence of the English philosopher Herbert Spencer was evident in most of his writings. Like Hughlings Jackson, Spencer had had relatively little formal education but possessed an outstanding intellect. Both lacked cultural taste for the theatre and literature, but

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both were alive to exciting contemporary ideas in the biological sciences in particular. The work and teaching of Jean Lamarck and, later, of Charles Darwin and his conception of evolution, were especially influential for Spencer, who went on to apply this theory widely. Hughlings Jackson first used the word 'dissolution' in 1876 and acknowledged his Vast debt' to Herbert Spencer. "What I have to say of the constitution of the nervous system appears to me to be little more than illustrating his doctrine on nervous evolution by what I may metaphorically speak of as the experiments of disease. I should make more definite acknowledgements were it not that I do not wish to mislead the reader, if, by any misunderstandings of his doctrines on my part, I impute to Mr. Spencer particular opinions he might not endorse."2 Jackson repeated his indebtedness to Spencer in his paper "On Some Implications of Dissolution of the Nervous System". In a footnote he wrote, "I should say that a very great part of this paper is nothing more than an application of certain of Herbert Spencer's principles, stated in his Psychology, were it not that I dare not risk misleading readers by imputing crudities of my own to this distinguished man."3 Hughlings Jackson and Herbert Spencer carried on a correspondence, off and on, for nearly 40 years, but it is not known whether they ever actually met. Unfortunately, few letters have survived, though two written by Spencer are available to us. The first was dated 26th November 1866: My dear Sir, I am greatly obliged to you for your letter of Saturday containing the series of interesting facts which you have been at so much trouble in setting down for me; and also for a copy of the Medical Journal containing the remarks to which you draw my attention. The facts respecting incoherence as you have grouped them appear very suggestive, and would I think, of themselves, when further accumulated and classified, go far towards showing the way in which associated ideas become organised. They seem to me quite in harmony with certain more familiar phenomena that occur in old people whose brains are beginning to fail from (as I presume) enfeebled circulation; as also to certain others presented by brains naturally stupid or temporarily stupefied. I mean they are analogous in the sense that defect of cerebral power shows itself in the use of the more general symbols in place of the more special ones. It seems to me worth consideration whether in some of the cases you name the defect is not more due to the absence of an adequate supply of blood to the

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particular nervous structure that fails in its action, rather than to a lesion of nervous structure itself. Any abnormal states of the vasomotor nerves controlling the blood vessels that supply part of the brain must, if it is of such a kind as to greatly diminish the circulation in that part, involve a defect of function; this defect, if not extreme, may show itself in the reversion of that function to a simpler form—a form in which the more general relations of thought which are the more deeply organised, alone remain possible. This view seems to be quite in harmony with your criticism in hereditary transmission, which so far as I can judge from partial perusal, seem to me very well grounded. I propose to reserve them in the hope of hereafter turning them to use. Very truly yours, Herbert Spencer4 The article referred to in that letter was most likely to be "Notes on the Psychology and Pathology of Language".5 The other letter to which we have access was written by Spencer 37 years later, a few months before his death on 8th December 1903: Dear Doctor Jackson, Thank you for your letter giving me the interesting information concerning Weismann's experiments, and the counter-experiments proposed to be carried out. Now that I am nearly 83, it is not probable that I shall live to see the results, should a result of a noteworthy kind be forthcoming. But I may say that for myself I have never had any belief in the transmission of effects of mutations. My position has ever been that in pursuance of the loss of inheritance as I understand it, there can be transmission only of those changes that are functionally produced— changes produced by increase of function or changes produced by decrease of function. Should it turn out to be otherwise, I shall be greatly surprised. Of course in any case I shall be interested to learn the results should any be realised while I still live.6 The letter had been dictated but was signed "Herbert Spencer". Jackson was not mentioned in Spencer's two-volume An Autobiography,7 but in Life and Letters of Herbert Spencer, published four years after the latter's death, the author quotes a letter which Spencer wrote to his friend, Professor E.L. Youmans, in America: "9th January 1883. I enclose some pages from The Medical Times and Gazette (6 Jan) sent to me the other day by Dr. Hughlings Jackson. The initiative he made years ago by applying the doctrine of dissolution to interpretation of nervous disorders—an initiative that is now being followed and in that direction seems likely to lead to other results. The paper is very clearly and conclusively argued;

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and is to me just as much a revelation as was that which Hughlings Jackson made of the doctrine."8 (The paper referred to is probably "On Some Implications of Dissolution of the Nervous System".) Spencerian ideas ran like a ribbon throughout Jackson's writings and were discussed in detail in his Croonian lectures in 1884. According to Gordon Holmes, Geoffrey Jefferson's impression was that Jackson referred less often to Herbert Spencer in later life. Jackson stressed the importance of Spencer's doctrine of evolution when applied to the nervous system. He said evolution is a passage from the most organised to the least organised, from the most simple to the most complex and from the most automatic to the most voluntary. The highest centres, which are the climax of nervous activity, make up the "organ of mind". The converse process, dissolution, is a "taking to pieces" of the least organised, most complex and most voluntary to the most organised, most simple and most automatic. Total dissolution results in death. The symptomatology of nervous disease is a double condition, Jackson said, for there is a negative as well as a positive element in every case. Disease does not cause the symptoms of insanity. A man suffering from "local softening of the brain has that defect of speech which consists in uttering wrong words. . . . No one objects to the clinical statement that softening 'is the cause' of the defect of speech. But strictly speaking it is simply impossible that softening of the brain can cause any wrong utterances; for softened brain is no brain; . . . the wrong utterances occur during activity of parts not softened but healthy. . . . The softening answers to the patient's negative condition. . . . It is an abuse of language to say that the negative condition is the cause of the positive phenomena, for that implies that nothing causes something. The positive manifestations are indirectly caused, or rather are 'permitted'."9 In a later paper he wrote: "The result of numerous sudden, strong, and therefore conflicting discharges, would of course be the survival of the fittest. . . . Of course 'fittest' here does not mean 'the best', nor the fittest for the external circumstances of the time; it is the survival of the fittest under the internal circumstances. The fittest words or syllables are the victorious words or syllables which have survived during a conflict of very strong and sudden discharges beginning deeply in the nervous system, and ending, so far as we are now concerned, in that of many nervous arrangements for many words."10 Jackson advisedly used 'fittest' rather than 'best' for, as he said, "the evolutionist has nothing to do with good or bad".

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He illustrated these processes with the clinical analogy of alcoholic poisoning, which "taken into the system, flows to all parts of it; but the highest centres, being least organised, 'give out' first and most; the middle centres, being more organised, resist longer; and the lowest centres, being most organised, resist longest. Did not the lowest centres for respiration and circulation resist much more than the highest do, death by alcohol would be a very common thing."11 Jackson also applied the principle of evolution and dissolution to such disorders as progressive muscular atrophy, aphasia and epilepsy. Degrees of seizures, he said, illustrate different depths of dissolution, the degrees ranging from a spasm of the thumb and index finger to a universal convulsion. He used the expression "compound order of spreading" to describe the stages of the fit. Patients' symptoms differ according to the varying depth of dissolution and the different "shallows of evolution remaining." He stressed that in each of these degrees there is a negative, a positive and often a "super-positive" element. Jackson was here referring to the complex manifestations of epilepsy. He said that the super-positive elements are illustrated by elaborate behaviour in some states of post-epileptic automatisms. He wrote that progressive muscular atrophy is caused by wasting of the lowest motor centres; that paralysis agitans is due to wasting of cells in the middle motor centres; and that general paralysis is the result of wasting of cells of the highest motor centres. "The doctrine of evolution implies the passage from the most organised to the least organised, or, in other terms, from the most general to the most special. Roughly, we say that there is a gradual 'adding on' of the more and more special, a continual adding on of new organisations. But this 'adding on' is at the same time a 'keeping down'."12 Jackson set out what he believed constituted the hierarchy of nervous centres. He visualized three levels of nervous function in an ascending order from a lowest through a middle to a highest stage. He said the lowest centres are represented by the anterior horn cells of the spinal cord together with the nuclei of the motor cranial nerves. The cerebral convolutions which make up Ferrier's motor region represent the middle motor centres. The highest centres are made up of the convolutions of the most anterior region of the brain. In 1887 Jackson expressed his point of view by saying that the central nervous system consists of three levels—lowest, middle and highest—and that these respectively represent, re-represent and rere-represent all parts of the body. Hughlings Jackson repeated himself, using a geopolitical meta-

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phor: "The higher nervous arrangements evolved out of the lower keep down those lower, just as a government evolved out of a nation controls as well as directs that nation. If this be the process of evolution, then the reverse process of dissolution is not only 'a taking off' of the higher, but is at the very same time a 'letting go' of the lower. If the governing body of this country were destroyed suddenly, we should have two causes for lamentation: (1) the loss of services of eminent men; and (2) the anarchy of the now uncontrolled people. The loss of the governing body answers to the dissolution in our patient (the exhaustion of the highest two layers of his highest centres); the anarchy answers to the no longer controlled activity of the next lower level of evolution (third layer)."13 In his Croonian Lectures,14 Jackson also discussed what he called the "doctrine of concomitance." He said that for every mental state there is an associated nervous state, and while the two come about in parallel, one does not interfere with the other. Jackson firmly believed that activities of the highest (least organised) nervous arrangements, during which consciousness arises, are determined by activities of lower (more organised) nervous arrangements. The highest, least organised, least automatic, most imperfect reflex centres are the physical bases of consciousness (or of most vivid consciousness), he said. Jackson also stated that his doctrine of concomitance had evoked some disapproval, and that one critic—who in all other respects had dealt with his opinions very good-naturedly—said that "the doctrine of concomitance is Leibniz's 'two-clock theory'."15 Jackson's rejoinder was "It may be; it matters nothing for medical purposes whether it is or is not." H.T. Englehardt, on the other hand, regarded Jackson's doctrine of concomitance as his way of freeing neurology from metaphysical problems.16 Towards the end of his second Croonian Lecture in 1884,17 Jackson introduced his concept of multiple factors in insanity. Later he brought up this idea again in his teaching, but not consistently so. In 1894 he devoted an entire address to the subject.18 In that Croonian Lecture of 1884, Jackson expressed the principle of what he termed the four factors of insanity as (1) the differing depths of dissolution; (2) whether the person concerned was young or old, educated or uneducated, intelligent or unintelligent; (3) the rate at which dissolution was effected; and (4) the influence of external circumstances and local bodily states. Jackson stated his belief that the posterior regions of the brain were chiefly sensory in function. The occipital lobes, he said, rep-

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resent the highest sensory centres. In 1887, he stated: "But now I have misgivings as to the occipital lobes being the highest sensory centres, consequent on reading Gowers's masterly work 'Diseases of the Brain', especially pages 22 and 174."19 Jackson recapitulated by stating that the highest centres are: the most complex; the most special; the most integrated sensori-motor centres; and associated with the most numerous interconnections. "They represent all parts of the body . . . and represent them triply indirectly. They are the anatomical substrata of consciousness."20 The four factors of the insanities were also invoked by Jackson in 1888 at a meeting of the Neurological Society when he was discussing Dr. Charles Mercier's paper entitled "Inhibition."21 Jackson had been discussing rapid and slow discharges (or physiological fulminates) in epileptiform seizures. 'Slow' and 'rapid' are not really the appropriate words, he said. Rapid discharges are those nerve-impulses which are more often emitted in a given time. After slow discharges, the post-epileptic exhaustion lasts a comparatively long time. After rapid discharges the exhaustion is diffuse, slight in degree and short-lived. As to the third of Jackson's four factors of the insanities, namely the rate at which dissolution is effected, he said that senile dementia—which proceeds very slowly—is quiet, while the postepileptic maniac, who has undergone dissolution a thousand times more rapidly, is the most furious of all maniacs. At the same time, Jackson emphasized that, not being an alienist, he spoke subject to correction by those with greater experience of what are called mental diseases. In 1898 he delivered the first Hughlings Jackson Lecture.22 Here he brought up to date many of his ideas, expanding and modifying his earlier conceptions, including that of a hierarchy of nervous function. He now spoke of the lowest level as extending from the tuber cinereum to the conus medullaris. He visualized within this level a number of superior centres representing such functions as defaecation, micturition, sexual activity and parturition. Regarding the middle (cerebral) level, he stated that he now felt unable to say with confidence which areas were sensory in function. Taking the middle and highest levels together, he spoke of them as "chiefly motor, chiefly sensory". Referring to the highest levels, he said they were the acme of nervous evolution—the "anatomical substrata of consciousness", the "mental centres", the "physical basis of mind". Sometimes he modified his opinions or even actually changed his

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mind, which makes difficult reading for anyone seeking to discover Jackson's ultimate point of view of a particular problem. Fortunately, a few neurologists have studied Jackson's writings and have provided a relatively succinct but accurate interpretation of Jackson's thoughts. Conspicuous among them was Sir William Broadbent. When he delivered the third Hughlings Jackson Lecture in 1903, his topic was "Hughlings Jackson as Pioneer in Nervous Physiology and Pathology".23 It was not, however, until 1915, when Henry Head reproduced Jackson's studies of language and its disorders, that Hughlings Jackson's genius in that field came to prominence in Great Britain. Subsequent interpreters have been less ambitious, other than when dealing with one particular aspect of Jackson's work. A number of noteworthy articles from the United States include papers by Walther Riese, Samuel Greenblatt and Max Levin. A comprehensive volume, Hughlings Jackson on Psychiatry, by Professor Kenneth Dewhurst appeared in 1982.24 F.M.R. Walshe wrote a brilliant paper, "Contributions of John Hughlings Jackson to Neurology" (which he liked to dub "A child's guide to Jackson"). He said "A man who used neither apparatus nor animal experiment could nevertheless, in the Nineteenth Century, make fundamentally important contributions to neurophysiology by the application of a scientific imagination to the material of his observations, namely, disease of the human nervous system."25 He went on to say: "We know that Jackson could not identify, describe, or classify all the trees that make up the neurological wood to the degree we now can do, but he knew his Wood, and saw deeply into its role in the territory of the organism which it dominates and integrates. The modern student finds it difficult to see the wood for the trees, and the modern writer rarely helps him to do so. He does not always have a synoptic concept of the nervous system in his mind, and he has too often been apprenticed to the use of highly complex research tools without any adequate preliminary or accompanying introduction to scientific theory or intellectual method."26 Walshe stated that Hughlings Jackson was more interested in the "where" of localization than in the "how" and summed up his work thus: "There are no finalities in scientific theory, and not all that may have been valid in Jackson's concepts eighty years ago can now be adequate. Yet when all that is obsolete or irrelevant is discarded, there remains a rich treasure of physiological insight we cannot afford to ignore."27 The views of these writers will be discussed more fully in later chapters.

8 The Epilepsies

The medical man who is not well-versed in neuropsychiatry might associate the name of Hughlings Jackson mainly with a particular variety of epilepsy. Jackson began to write on the subject as early as 1861, and he continued to probe the mysteries of this disorder until 1902. Epilepsy is one of the earliest affections mentioned in medical history but, until two centuries ago, its nature was a matter of conjecture. When Hughlings Jackson began to practice medicine, epilepsy, though no longer known as the 'sacred disease', was still regarded as a social disorder. Even when Jackson was Resident Medical Officer at the York Dispensary, a physician at St. Mary's Hospital, London, produced a monograph on epilepsy in which he stated, "We should regard the fit as the flower of a noxious weed".1 In the same publication the author also said: "It may be admitted that the epileptic paroxysm is peculiarly of a character to convey the impression that it is altogether beyond the ordinary range of physiological disturbances."2 The author of the monograph was Dr. E.H. Sieveking, who in 1864 joined the staff of the National Hospital, Queen Square. He left after three years.

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A decade later, Jackson was well on his way to overthrowing this nihilistic attitude, and as Ernst Niedermeyer put it, he represented the beginning of the "neurologization" of epileptology. The young Jackson's alert and receptive mind was intrigued by the protean manifestations of the convulsive disorders, which constitute one of the most dramatic experiences in clinical practice. His cooperation with Jonathan Hutchinson and their contact with BrownSequard led to the publication of some unusual cases of epilepsy. No doubt this study stimulated his interest in some of the more uncommon types of epilepsy, and he realised that it was a fascinating though puzzling aspect of Medicine which demanded clinical investigation in great detail. Isolated features of the disorder called for research, such as the manifold phenomena which might sometimes herald an attack; the various degrees of impairment of consciousness; the spasm involving part or the whole of the musculature; the clonic involuntary movements which might follow the initial spasm, their duration and their violence; the mode of termination of each attack; and the various post-paroxysmal phenomena that often entail extreme disorders of behaviour. Jackson stated that to observe cases of convulsion minutely requires a vast amount of time. The understanding that paroxysms vary in nature from patient to patient, but that each epileptic shows a specific pattern of attack, demanded the closest clinical observation as well as accurate recording. He summed up the importance of such intense scrutiny: "Why should not a carefully observed convulsion . . . associated with central disease so local as a tumour ... be considered as an anatomical and physiological experiment, although a rough one, on part of the brain?"3 This statement was to be repeated many times over the years, for it constituted the keynote of his conception of Jacksonian epilepsy. Electrophysiological data were not then available and epilepsy presented a problem to the clinician, for apart from the actual paroxysm, there was little to be observed that was abnormal. Therefore, any opportunity to witness a convulsion has to be utilised to the full. It is only then that the rapidly changing neurological pictures appear. At the beginning of Jackson's hospital work in London, it was generally thought that epilepsy was a malady associated with a discharging lesion within the ponto-medullary region of the nervous system. When Jackson first observed convulsions, it appeared to him that he was seeing "a clotted mass of innumerable movements" brought about

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by "an excessive, sudden and abrupt cerebral discharge". When he closely scrutinized an increasing number of patients who were convulsed, a pattern of movement peculiar to each individual was revealed to him, as well as overall clinical manifestations. He began to refer to 'the epilepsies' rather than to 'epilepsy'. "There is, scientifically speaking, no entity to be called epilepsy; but innumerable different epilepsies, as there are innumerable seats of discharging lesions."5 The type of aura which precedes an attack indicates the location of the discharging lesion in the cerebral cortex. Paraphrasing Fere, Jackson said "there are, at any rate, as many different epilepsies as there are warnings."6 By 1873 Jackson had formulated a definition of epilepsy as comprising occasional, sudden, excessive, rapid and local discharges of grey matter. He said that, as any part of the brain may be unstable, there will be many varieties of epilepsy, depending upon the precise site, extent and degree of the focus of instability. Jackson had thus abandoned the conventional ponto-medullary hypothesis of Schroeder van der Kolk in favour of a lesion sited in the corpus striatum "raised to a higher power." Idiopathic epilepsy, which Jackson repeatedly dubbed 'epilepsy of authorities' or 'epilepsy of some nosologists', may show itself clinically in a number of ways—a sudden olfactory aura with a fleeting loss of consciousness; a transient aura alone; spasm of the right side of the face together with transient stoppage of speech; tingling of the thumb and forefinger ("the hand is the most important part of the body") followed by spasm of the hand and forearm; a convulsion almost immediately generalised, with rapid loss of consciousness; or a certain type of vertigo. The common feature underlying all these is that each is the result of a sudden, excessive discharge of unstable grey matter. However, as Jackson emphasized, "The investigation does not end here; rather it begins here. . . . Although the functional alteration is the same in all epilepsies, the seats of those functional alterations are various."7 From the start, Jackson was particularly interested in the association of the epilepsies with localized loss of power. In many ways they seemed to him to occupy two extremes of a clinical spectrum, one being the positive pole and the other the negative pole of nervefunctioning. A few years before Jackson went to live in London, Dr. Robert Bentley Todd (1809-1860) had described the phenomenon of tern-

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porary paralysis of a limb or limbs which had been most involved in an epileptic paroxysm. This became known as Todd's paralysis or, at times, as epilepto-hemiplegia; the loss of consciousness was ascribed to exhaustion after the violence of a discharging lesion. Not long afterwards, Dr. Alexander Robertson also reported a series of similar cases. Other clinical links between loss of power and convulsion in which the modus operandi was clearly different attracted Jackson's attention. He was intrigued by convulsions which began in a sharply demarcated segment of the body (usually the thumb and index finger, less often the face and tongue and rarer still in a big toe—regions which Jackson spoke of as the 'leading parts'). The spasm would spread slowly and steadily and even become generalised. As a rule, consciousness was then lost. On recovery there would be a temporary impairment of power, but it might be so mild as to escape casual notice. This is the well-known syndrome of Jacksonian epilepsy, although he rarely used that term. Indeed, he seemed to be in doubt as to what to call it. Some of his expressions were 'hemiplegic epilepsy', 'corpus striatum epilepsy' and 'epileptiform seizures', but he was not enamoured of any of them. 'Convulsion beginning unilaterally' was the expression to which he least objected. However, there is at least one occasion when Hughlings Jackson employed the phrase "Jacksonian epilepsy": in a letter he wrote to Dr. Kinnier Wilson on 29th April 1908 he said: "I will be very greatly obliged if you will tell me whether or not in paroxysms of Jacksonian Epilepsy you have yourself witnessed, the spasm is tonic or tonicclonic or clonic only, or sometimes clonic only. I refer to the initial spasm, e.g. of a hand."8 In a footnote to a paper written in 1876, Jackson said: "I find that the clinical facts of the varieties of epilepsy under remark were stated before I was born. I make the quotation because I am under the impression that it is useful for an investigator to show, as some evidence of his earnestness, that he is not putting forward hastily considered opinions. The following disposes of any priority I might have supposed myself to have. Charcot writes: Enfin M. Hughlings Jackson s'est attach^ depuis plusieurs annees & demonstrer que certaines lesions supern'cielles du cerveau peuvent determiner une forme spe'ciale d'epilepsie dont 1'etude clinique avail 6te pousse'e fort loin deja longtemps avant, en France, par Bravais (Recherche sur les symptomes et le traitement de epilepsie h6miplegique, 1827) dans une these tres remarquable qui denote chez 1'au-

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teur une suretd de jugement et une finesse d'observation peu com-

munes.""99

Time after time thereafter, Jackson conscientiously inserted in parentheses the words "They were first described by Bravais in 1824" whenever he referred to epileptiform seizures. Geoffrey Jefferson's paper "Jacksonian Epilepsy" gives a good account of the contrasting contributions of Bravais and Jackson to the subject.10 Jefferson referred to Bravais's "These de Paris" as being published in 1827, although Jackson always said it was 1824. The expression 'Jacksonian epilepsy' was promulgated by no less a person than Charcot himself. In 1877 Charcot had written: "Lately, an English savant, M. Jackson of London, has raised this subject and has treated the subject so thoroughly that it has repeatedly happened that I spoke of this disorder as Jacksonian epilepsy and the name has been perpetuated. Such was just. I do not regret it. I have done Bravais a little injustice but in fact the work of M. Jackson is so important that truly his name deserves to be attached to that discovery. If one could link Bravais and Jackson, the Frenchman and the Englishman, and speak of the Bravais-Jacksonian epilepsy that would be more correct; it is true that this would be a little lengthy."11 Apart from the focal, unilateral convulsions which we know as a 'Jacksonian' attack, the epilepsies in general appealed to Jackson's Spencerian philosophy. When subjected to scientific analysis, the detailed, mobile manifestations of a fit displayed to Jackson striking analogies with the dissolution of nervous functions. He stated explicitly that there is no task in neurology so worthwhile as the investigation of an epileptic, although comparatively little had then been done to analyze a fit. Jackson said the object should not merely be to determine whether a case is or is not one of 'genuine epilepsy', but rather to describe all that happens in a paroxysm. The questions are whether the spasmodic movements involve the whole of the body, where the movements are and what the march of the convulsion is, that is, the route taken by the advancing spasm. Jackson pointed out that, as a rule, there is a 'compound sequence', in that the spasm does not abate in one part of the body as it advances to involve another bodily part such as the face. It is necessary to note the rate of advance, and he said that when the secondary movement appears, the primary movement has not ceased; on the contary, it has increased. A study of precisely what occurs during a convulsion is the only clue to the localization of the discharging lesion in the brain, Jackson said, and he emphasized that the observation must be intimate. To

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state that the arm was involved is not enough, when in one case the spasm 'went up' and in the other 'went down'. He said two different areas of the cortex must be diseased in these different spreadings. Jackson expanded his description of events which occur during and after an attack by saying that some slight seizures are positively agreeable, while a particularly severe episode may seem 'to clear the air'. There were, he said, two sorts of defect of consciousness, namely one in which the mind goes blank and another in which the patient is thinking of a thousand different things. At the beginning of the 19th century the doctrine of Flourens, that is, that the brain is an equipotential organ, was still in vogue, even though it had been attacked by Dr. F.J. Gall and his followers. Hughlings Jackson's work on unilateral epilepsy was a direct challenge to both schools of thought, even though it was based on purely clinical observation. According to David Ferrier, Hughlings Jackson's views were at first regarded by many as ingenious but rather fanciful speculations devoid of experimental corroboration. Hitherto all experiments which entailed mechanical or chemical irritation of the surface of the brain had failed to produce similar phenomena. However, in 1870, Drs. H. Fritsch and J.E. Hitzig of Berlin found that direct application of a galvanic current to the surface of the brains of dogs provoked movements in certain regions of the body or limbs. By these experiments they were able to find foci in the cortex which, when so stimulated, produced movements of the contralateral limbs. They also found centres corresponding with movements of the head, face and neck. Stronger currents evoked convulsions. Thus there was laboratory confirmation of Hughlings Jackson's clinical findings over the previous decade, which was the result of an experiment set up by disease. Jackson repeatedly quoted the dictum that epileptic seizures are to be looked upon "as experiments on the brain made by disease".12 Further confirmation of Jackson's work came when David Ferrier experimented with electrical stimulation of monkeys. He found that faradic currents gave better results than galvanism. Ferrier's findings were more impressive than those of workers in Berlin, in that he was able to elicit very discrete movements in the animals on which he experimented. A correspondence began between him and Fritsch and Hitzig, which Ferrier described as "at times acrimonious". Ferrier's researches, which were the subject of his Croonian

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Lecture for 1875 at the Royal Society, excited considerable attention. The following year he brought out his volume The Functions of the Brain.13 On the flyleaf, Ferrier's dedication was: "To Dr. Hughlings Jackson, who from a clinical and pathological standpoint anticipated many of the more important results of recent experimental investigation into the functions of the cerebral hemispheres. This work is dedicated as a mark of the author's esteem and admiration". It is interesting to recall that Bravais had regarded his type of hemiplegic epilepsy as having a more favourable outcome than idiopathic types of epilepsy. Jackson demonstrated that the brain lesion found in cases of his eponymous epilepsy was often removable. For this reason, he can be looked upon as instrumental in the advance of neurosurgery. In an address read before the Harveian Society in 1879, Hughlings Jackson presented a simple classification of the epilepsies, distinguishing epilepsy proper from epileptic seizures. He said it was not a scientific categorization but an empirical and practical one. A scientific or theoretical classification, "whilst of value in extending and simplifying our knowledge, is worthless for practical purposes. I would, I think, include migraine. To arrange migraine along with ordinary epileptic seizures—with cases of loss of consciousness and convulsion—for practical purposes, would be as absurd as a scientific zoological classification would be for fishermen, hunters and graziers . . . it would be as absurd to classify it along with ordinary cases of epilepsy for practical purposes as to classify whales with other mammals for purposes of practical life. A whale is in law a fish; in zoology it is a mammal."14 This homely metaphor is an effective artifice much favoured by Jackson, who made use of it, in one form or another, many times to emphasize the impropriety of using classifications that were partly workaday and partly scientific. "We may best judge of a man's intellect by his classifications, for, as Spencer says (Psychology, 309—316), classification is really a process of reasoning. . . . From a person's classifications we judge of his 'form of mind'". 15 Jackson believed we can best appraise a man's character by what he finds laughable. An important principle that pervaded Jackson's writings, particularly on epilepsy, was that of the interplay between positive and negative symptoms. This dualistic hypothesis possibly played a part in psychiatric thinking on the Continent of Europe and may, to some extent, have influenced the ideas of Sigmund Freud and Professor Eugen Bleuler.

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According to Dr. G.E. Berrios, however, Jackson was not the originator of this concept. He said the terminology, at any rate, probably had been borrowed from Dr. J. Russell Reynolds.16 In 1857 the latter delivered an address "On the Pathology of Convulsions", in the course of which he said, ". . . some symptoms are negative, i.e. they consist in the negation of vital properties . . . other symptoms are positive, i.e. they consist in the excess or alterations of vital properties."17 It is strange that Jackson, usually so meticulous, does not seem to have mentioned Reynolds in this connection. The apparent oversight probably stems from the fact that Reynolds's concept of positive-negative symptoms was entirely different from his. They were not discussing the same entity. Berrios said, "According to Reynolds, positive and negative symptoms were independent of each other; for Jackson they resulted, respectively, from contiguous functional centres linked by a 'top to bottom' inhibitory process."18 The role of positive and negative symptoms in psychiatry has been the subject of a recent study by Professor M. Trimble. He stressed the fact that these terms have been freely employed in psychiatric teaching, but inconsistently so. Jackson specifically said that others before him had referred to the dualism of brain functioning. Trimble considered that Jackson's conception of positive and negative symptomatology is more appropriate than the purely descriptive attitude in present-day psychiatry. "It is the line of Jackson that today we should be following, and to ignore completely historical etymology is not only improper but will merely serve to obfuscate."19 Hughlings Jackson's contributions to epileptology went further. In a series of informative papers, he drew attention to the existence of what today is termed 'temporal lobe epilepsy' or 'psychomotor epilepsy'. Not yet aware of the anatomical basis of these attacks, Jackson, to begin with, spoke of 'reminiscences', Voluminous mental states' or, more often, of 'dreamy states'. The occurrence and nature of these phenomena were but dimly recognised in the United Kingdom, though a relevant case-report had been published by Dr. Joseph Coats of Glasgow in 1876, he said.20 Two years earlier, a medical man writing under the pseudonym Quaerens (The Seeker), described his own propensity to periodic attacks of 'bemazement', in which he did not quite lose consciousness, but his face became flushed and he appeared as if considering something.21 In 1880 he became a patient of Jackson's because, in addition to having had hundreds of these 'turns', he had sustained 18

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major epileptic fits. Jackson recognised the mild 'turns' as belonging to his category of dreamy states. The patient also began to suffer from mental experiences of the deja vu type, which Quaerens had associated with Coleridge and Tennyson, as well as with Charles Dickens. Quaerens was later spoken of under the sobriquet "Dr. Z.", but eventually it was realised that he was actually Dr. Alfred Thomas Meyers, a physician at the Belgrave Hospital in London. When his general health deteriorated, he came under the care of Dr. Drevitt, who, at the time, lived next door to Hughlings Jackson at No. 2 Manchester Square, At the age of 42, on 13th January 1894, the patient lost consciousness and died under suspicious circumstances. The case was written up by Dr. K. Dewhurst, and also by Dr. D. Taylor and Dr. S. Marsh. The explanation of death fluctuated between suicide and an accidental overdosage of chloral. At autopsy a small area of softening in the right uncinate gyrus, of indeterminate nature, was revealed. The dreamy states were familiar to the French neurologists J. Falret, A. Voisin, A. Trousseau and Th. Herpin. They used the expression 'intellectual aura', which Jackson disliked. He argued that, strictly speaking, the phenomenon was not an aura but an integral part of a condition which was much like a dream, this term often being the one volunteered by the sufferer himself. "Of the patient's slight seizures we may learn much, of the severe ones without warning, very little that is definite. I urge strongly that the great thing as to the diagnosis of epilepsy is not the 'quantity' of the symptoms, nor the severity of the fits, but paroxysmalness . . . there may be defect of consciousness only; and, as we have been saying, there may be 'over-consciousness' ('dreamy state')."22 Jackson's early papers on this theme attracted little attention but his clinical experience grew over the years. By 1888 he had seen about 50 such cases. Some of the patients had died while under his care and came to post-mortem study. As a consequence, Jackson adopted the expression 'uncinate epilepsy'. Attacks of uncinate epilepsy varied in severity. Some of the mildest were even known to occur in otherwise 'normal' individuals, but in an attenuated fashion. Jackson quoted from Charles Dickens's David Copperfield: "We have all some experience of a feeling which comes over us occasionally, of what we are saying and doing having been said or done before, in a remote time—of our having been surrounded, dim ages ago, by the same faces, objects, and circumstances—of our knowing perfectly what will be said next, as if we suddenly remembered it."23

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In complete form, an uncinate attack comprises a series of complicated physical and mental phenomena. The first is a duplex mental disturbance consisting of a negative state of confusion, a feeling of blankness, even loss of consciousness. Simultaneously, or before, or even after, comes a positive state of 'superconsciousness' wherein the patient's mind may be filled with compulsive thoughts. They are always the same, but subsequently the patient has no clear recollection of their nature. Associated with the disorders of mentation, complex emotional disturbances may arise, such as an odd feeling of familiarity as though the thoughts were well known or the environment (or its contents) had been seen many times before. Hence the expression 'deja vu'. This experience may be linked to a slight confusion in which all is not clear, although it is familiar. This is the 'presque vu' phenomenon. Jackson himself used neither of these French terms. Commonly, there is also a feeling of horror or of impending death. Exceptionally, the associated affect is pleasurable. Together with or even independent of these psychic phenomena are usually feelings of gastric disturbance (the 'epigastric aura') and hallucinations of smell, less often of taste. As a rule, the patient is not able to identify the smell or taste but knows that it is disagreeable. One of Jackson's patients described the experience as a 'tasteless taste'. When consciousness is lost, the patient may be seen to make movements of munching, lip-smacking, swallowing or spitting. Aberrations of this phenomenon are common. Jackson also had an unusual patient who showed odd behaviour during consciousness. The boy had a kind of pica, or perverted habit of eating. At the seaside he would stuff sand into his mouth; at school, drink ink; and in the countryside, chew butterflies. While he was unconscious, his face registered disgust. When a patient regains consciousness from his dreamy state, he often displays disordered behaviour of various kinds. Jackson recognised five types of what he called 'actions': 1. The patient continues with what he was doing or was about to do when the attack starts, but in a disintegrated, uncoordinated fashion for a while. The most common example is when beginning to undress. 2. After the patient recovers from a collapse, he gets to his feet and walks away—but in the wrong direction.

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3. A grand mal convulsion may occur. 4. There may be a convulsion in which the patient behaves dramatically and histrionically, kicking and screaming. 5. On regaining consciousness, the patient may be up but acting in a violent, maniacal way. With the growth in the number of Jackson's cases, more and more autopsy findings became available. As a result, it was found that the responsible discharging lesion lay in one or other temporo-sphenoidal lobes of the brain, in that gyrus known as the uncus or hook. It was then that Jackson dubbed the dreamy states 'uncinate attacks'. Even more important, in an appreciable number of cases the discharging lesion was amenable to surgery. Once more, Jackson emerges not only as a cerebral localizer but also as a catalyst of neurosurgery. Jackson repeatedly emphasized the multiplicity of different warnings representing different types of epilepsy, and stated that there are different epilepsies, each with its own warning, and some with no warning. Each case, he said, should be studied from start to finish, which is an extremely difficult matter. Jackson made these remarks with diffidence. "He who undertakes a task of this kind is sure to make mistakes, however careful he may be. This short paper, I may say, represents great labour."24

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9 Jackson's Writings on the Falling Sickness Reviewed

In 1879, Dr. W.R. Cowers, a colleague of Hughlings Jackson's at the National Hospital, was elected Fellow of the Royal College of Physicians. As is traditional, one of the youngest in the group is chosen to deliver the Goulstonian Lectures; Cowers gave them in 1880. His topic was epilepsy, based upon his personal experience of 1,450 cases. Cowers published the lecture in book form in 1881. A second, much-expanded version, based now on 3,000 cases personally studied, appeared in 1901.l Epilepsy achieved great popularity. The author's approach to the subject was different from that of Jackson. Just as the two physicians were dissimilar in personality, so was their attitude towards neurology. Gowers's monograph was a meticulous analysis of the clinical findings in his cases. His research was the bricks and mortar of epileptology, without any hint of a philosophical or speculative approach to the subject. Nevertheless, Cowers recognised the importance of Jackson's conceptions of the disease and quoted him, appreciatively, many times. There were some minor differences of opinion, particularly regarding treatment. Thus Cowers and

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Jackson did not agree on the use of iron in epilepsy. Gowers said that Jackson, among others, believed that iron, while improving the general health of epileptics, was apt at times to increase the frequency and violence of the paroxysms. Gowers, however, thought that in some cases of epilepsy, iron was actually beneficial. In the second edition of his book, Gowers stated that fits beginning unilaterally had been reported before either Bravais or Jackson. Herpin had mentioned them as having been described by Aretaeus, Galen, Alexander Trallianus, Ali-Rodoham, Brassavola, Sylvius, Faventius, Dovinctus and Hollier. Gowers's work on epilepsy appeared during Jackson's lifetime. More recent evaluations of Jackson's work on the subject have been made by O. Temkin and M.J. Eadie. In 1945 Dr. Oswei Temkin of Baltimore published his weighty monograph The Falling Sickness.2 It is a history of our knowledge of epilepsy and an account of its symptoms, its explanation and its treatment. Opinions from doctors of medicine, laymen, philosophers and theologians are included, and the result is a scholarly, close-knit book with footnotes in profusion. The author regarded Hughlings Jackson as having outlined a neurological theory of epilepsy and that, along with Charcot, he confined the disorder to the realm of neurology. Temkin gave a detailed overview of Jackson's thinking about epilepsy, as well as about those epileptiform seizures which start unilaterally and which are associated with his name. He pointed out that whereas Bravais anticipated Jackson, he made no attempt to explain what he had found. Temkin also said that Richard Bright (1789—1858) of Guy's Hospital, London, was a forerunner of Jackson, for he not only described cases of this type of epilepsy but added important new anatomical evidence. Richard Bright described in some detail two cases in which, at post-mortem, definite lesions of the cerebral cortex had come to light. Bright went on to say that epilepsy generally depends upon irritation on the surface of the brain. Temkin said Bright's observations did not receive the attention they deserved. Certainly Jackson seems to have overlooked them. According to Temkin, too, Jackson's attention was drawn early on to the first volume of another author, Dr. Theodore Herpin (1799—1865), written in 1852, but Herpin's posthumous work in 1867 did not come to his notice until quite late. In a paper written in 1899 in collaboration with his House Physician, Dr. Purves-Stewart, Jackson quoted remarks made by

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Herpin about 'epileptic hallucinations', which were what he (Jackson) called 'crude sensations'. Jackson went on to say, "I wish to show by the quotations from Herpin that statements essentially the same as those I make were made by a great authority long ago."3 Temkin pointed out the difference between these two men. He said Herpin's observations were valid, regardless of any hypotheses. "This cannot be said of Jackson, whose clinical observations directed him to anatomy, physiology and pathology, and then back to the bedside. The fact that he reasoned rather than dissected or experimented does not alter the essential scope of his work."4 After that, Temkin wrote a chapter of 18 pages devoted entirely to Hughlings Jackson's contributions to epilepsy, starting in 1861. He said that by 1863 Jackson had come to definite conclusions about the morbid anatomy of unilateral convulsions and that, in the following year, he advanced his ideas about the genesis of an epileptic attack a step further by implicating morbid activity of the middle cerebral artery. According to Temkin, Jackson had obviously been impressed by Herbert Spencer's statement in Principles of Psychology, published in 1855: "Localization of function is the law of all organization whatever: separateness of duty is universally accompanied with separateness of structure: and it would be marvellous were an exception to exist in the cerebral hemispheres."5 Somewhere between 1863 and 1870, it had occurred to Jackson that instability of the grey matter of the cerebral cortex might account for the convulsions he had been studying. Temkin said that, over the ensuing years, Jackson believed that epilepsy and epileptiform convulsions were explicable along parallel lines. He thought the difference in symptoms was mainly due to alterations in the seat of the discharging lesion. Temkin emphasized that Jackson's neurological account of epilepsy and of insanity rested on philosophical views, which had their limitations. He said they become clear when viewed within the context of neurology and psychiatry around 1880. In his Epilogue, Temkin described how Jackson's views were vindicated by the work of neurosurgeons such as William Macewan and Victor Horsley, but he did not mention the pioneering experience of Rickman Godlee. Temkin also pointed out that, although incomparably more is known than was the case in 1890, a level has not yet been reached "where the scientific explanation of epilepsy presents a harmonious picture in which all true results fall into place and from which all false results are eliminated."6

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He predicted that the day might soon come for a new historical synthesis of epilepsy. The 'falling sickness', he said, may then no longer be an appropriate term, and epilepsy may have ceased to appear as a "paradigm of the suffering of both body and soul in disease." In 1990 Dr. Mervyn J. Eadie of Brisbane described the evolution of Jackson's thoughts on epilepsy and discerned three overlapping periods in his (Jackson's) understanding of the genesis of the disorder.7 In the 1860s Jackson had collected cases illustrating the manifold aspects of epilepsy, culminating in his classic paper "A Study of Convulsions",8 written in 1870 at the age of 35. Eadie said most of Jackson's original ideas were expressed therein, though not always in their fully developed form, and the paper constituted a landmark in his thinking about epilepsy. Eadie went on to say that Jackson elaborated these concepts during the next 10 years, and from 1880 onwards, he endeavoured to reconcile his ideas with current thinking on the subject. He also allied the clinical varieties of epilepsy with his doctrine of neural hierarchies. Jackson's main achievements in the sphere of epilepsy, Eadie wrote, were twofold: his interpretation of epileptogenesis and his location of the discharging lesion within the cerebral hemispheres. Eadie stressed the seminal paper of 1870 and went on to quote what Jackson wrote three years later: "Working on a novel method I run continual risk of making novel blunders. But in thinking for one's self there are certain kinds of blunders which almost must be made."9 As Eadie put it, "Jackson had the courage to make his blunders as he struggled to build a new conceptual edifice."10 Eadie also said that Jackson's great lecture of 1870 contains the essence of nearly all our modern ideas concerning the nature of epilepsy. He was, however, inclined to be critical of Jackson's writings over the next 30 years: ". . . today's reader of Jackson's later papers can be left rather bewildered and it is only by reading the whole corpus of his work that his enormous conceptual contribution to presentday epileptology can be appreciated."11 According to Dr. E.H. Reynolds, Jackson's work on epilepsy has endured and will continue to endure. He said Jackson's observations are on a par with those of Hippocrates, and that although the latter wrote in Greek, his writings were perhaps easier to read.12 In his Victor Horsley Memorial Lecture of 1946, Dr. F.M.R. Walshe evaluated Jackson's work on epilepsy in his inimitable way.

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He wrote: "I know of no more fascinating episode in the history of clinical medicine in modern times than Jackson's intensive study of the convulsion beginning unilaterally, as he called it, and the masterly fashion in which he made it yield up so many of the secrets of the cortical organization of movements."13 Jackson's clinical studies had two important consequences. They established the localization of motor function within the cerebral cortex and thus made it possible for neurosurgery to develop. Though carried out before the advent of cerebral electrophysiology, these studies harmonized perfectly with the novel additions to our knowledge of how the brain works.

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10 Jackson As Morbid Anatomist

In August 1882 Jackson was invited to speak at the Annual Meeting of the British Medical Association, which was held in Worcester (the birthplace of his grandfather, John Hughlings). He addressed the Section of Pathology, and his lecture was, in many respects, unlike his usual contributions, being simpler in character and didactic.1 He made a strong plea to members of his audience to obtain post-mortem examinations whenever possible and, having achieved the statutory minimum requirement in training in morbid anatomy, to continue to be present at the autopsy of any patient of his who had died. It was Jackson's opinion that pathology is the basis of every rational system of therapeutics. Verification or disproof of the diagnosis made in life—even though the latter might be humiliating, he said—is highly informative and will produce a realistic and critical mode of thinking, although if a man wished "to be thoroughly comfortable in his diagnoses, he should never make a postmortem examination."2 "Unless you are in the habit of facing the facts, your diagnoses will be untrustworthy, and much of your therapeutics indefinite."3

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Jackson advised the students and junior doctors in the audience that a trustworthy diagnostician must first be a sound pathologist. If the study of pathology is not mastered when young, he said, it is unlikely to be learned properly later on. "Scientifically I am a democrat",4 Jackson stated, and said he would like every man to be his own pathologist, as far as possible. No great discoveries—which are largely a matter of chance—might be made. "I mean that he should think for himself".5 Hughlings Jackson told his audience that when he was a house surgeon at the York Dispensary, a Clinico-Pathological Club was established. At its meetings, cases which had recently come to autopsy were discussed, and he urged the young men listening to him to form similar clubs. He believed there were advantages to be gained over just reading papers and attending demonstrations. Jackson mentioned with gratitude the help he had had in his earliest pathological work from two of his teachers in York, Dr. George Shann and Mr. S.W. North, saying he had learned many things of inestimable value from them. He emphasized the advantages and the special problems of those who were in private practice rather than working in a hospital, saying that, although he had a large field for investigation in hospital, many of the most useful cases he had seen had come from the private practices of his friends. In private practice, he said, work is "done under responsibility. . . . There is nothing like responsibility for sharpening the wits; and post-mortem examinations will prevent our being too sharp."6 Jackson went on to say that the doctor who acquaints himself fully with the signs and symptoms of such disorders as cerebral haemorrhage, uraemia, epilepsy and so on finds the problem turned upside down when he comes to the bedside. The inversion is not a pleasant process, and the man who began with adequate, systematic knowledge may be confused; several kinds of cases look alike at the bedside. He believed that a good practitioner must know much of physiology and pathology, as well as of clinical medicine. Metaphorically speaking, he said—what has often been said before— diseases are experiments on the human body. "Charcot, in doing the best kind of pathological work, has, I should suppose, done as much for the anatomy and physiology of the spinal cord as anyone living. He is clinical all round."7 Jackson pointed out the complexities facing a doctor at a patient's bedside, saying, "There is not only the organ diseased or most diseased; there is also the rest of the patient to whom that organ be-

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longs, or did belong. I say 'or did belong', because sometimes part of an organ is anihilated." He stressed the "wider pathology" and stated that instead of speaking of a patient being "attacked" by a disease, it is better to say he has bred the disease or, better still, "a certain part of a universally unsound system has fallen to pieces."8 Hence the necessity for examining a patient all over, clinically and pathologically. To illustrate this wider pathology, Jackson quoted the following case-report: A man has hemiplegia. To think of the case as one of paralysis only, is like the habit of thought of old-fashioned zoologists, who spoke of animals as if they had nothing particular inside them, or, as Forbes said, as if they were skins stuffed with straw. We have three very different things to do, each easily done in most cases of this kind. From noting the region affected—face, tongue, arm, leg, etc.—we conclude that there is a lesion of the opposite corpus striatum. Now, this is only anatomical knowledge. Speaking figuratively, it is only an experiment made by disease on an organ. To locate disease is an admirable thing; but localisation is not the most important clinical thing. If we stop in this stage, we know nothing of any value for rational treatment of the patient; we may have some good empirical expedients. Next, observing that the region mentioned is paralysed, we conclude that there is loss of function of some nerve-elements—probably destruction of them. This—physiology—also is a knowledge by itself, of no avail for therapeutical purposes in such a case. But, lastly, by examining our patient all over—for now we have done for the time with his paralysis—and from certain empirical evidence, not needing to be stated now, we conclude that loss of function of the organ is caused by cerebral haemorrhage, that a clot has smashed up part of the corpus striatum. This is not enough. There is yet the wider pathology. A patient looks on this illness as an accident; the pathologist never takes that view of it. We often get to know with certainty that the local pathological change is but a local manifestation of a slowly progressing wide state of degeneration; that the man is rotten all over, and that he has one day broken down suddenly in a certain place; that he has chronic Bright's disease, atheromatous arteries and a hypertrophied left ventricle. By considering these things and their interaction, we see that he has long been preparing for what seems to him to be only an accident. I submit that the process by which, in such a pathological state, he comes to have the local lesion—why an artery bursts—is in chief part a physiological problem; there is a physiology of the organism made up of bad materials as well as of the healthy organism. Further widening our pathological investigation, we may find that the patient is a twig of a gouty family tree.9

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Jackson followed by saying that the pathology of most nervous diseases is indirect. "If we could look into the man's head we should see that a part of his brain is boycotted. We cannot get at it by drugs."10 He said that when nerve-fibres are destroyed, "part of the patient is annihilated, and to seek to cure the local lesion is to treat a hole in the nervous system."11 He went on to discuss briefly those nervous disorders in which no obvious pathology is found at autopsy. He scorned the common tendency to regard such cases as belonging to the realm of metaphysics: "Some call anything very difficult and complex about mind and body metaphysics; some use it merely as a term of abuse".12 In concluding his Worcester Address, he said "We should deal with the difficult and the complex in as realistic a manner as we do with the simple. The hysterical patient, who is said to have paralysis of the will, has some material change. What it is we do not know: and we shall never know, if we be content with metaphysical explanations which, in one sense, explain everything, but really explain nothing. I have long expressed the opinion that, for the scientific study of diseases, we should regard them as examples of Dissolution— using this term as the opposite of Evolution. In this way we shall avoid the errors of confusing the psychical with the physical, and shall steer clear of metaphysical explanations."13 Some years later, one of the great practitioners of general medicine, Sir Norman Moore, wrote: "The best physicians were all morbid anatomists, who regarded the post-mortem room as the place from which, after the wards, a physician should fill his mind, and where he should acquire a familiarity with the interpretation of symptoms and the course of diseases. Those physicians whose early years had been spent in the post-mortem room seemed to talk a more lucid language than any others, and always understood one another."14

John Hughlings Jackson as a young man. (Courtesy of Dr. W.L.H. Jackson)

John Hughlings Jackson in early middle age.

John Hughlings Jackson in later life.

Portrait of John Hughlings Jackson by Lance Calkin. (Courtesy of The Royal College of Physicians)

Bust of John Hughlings Jackson by Herbert Hampton. (Courtesy of The National Hospital)

Portrait of John Hughlings, maternal grandfather of John Hughlings Jackson. (Courtesy of Dr. T.W. Davies)

Samuel Jackson, father of John Hughlings Jackson. (Courtesy of Dr. W.L.H. Jackson)

Elizabeth Dade Jackson, wife of John Hughlings Jackson.

(Left) Silhouette of Thomas Jackson, aged 14, brother of John Hughlings Jackson. (Courtesy of Dr. W.L.H. Jackson) (Right) Silhouette of William Jackson, brother of John Hughlings Jackson. (Courtesy of Dr. W.L.H. Jackson)

Providence Green, birthplace of John Hughlings Jackson.

Commemorative plaque at Providence Green.

Commemorative plaque at No. 3 Manchester Square, home of Dr. and Mrs. John Hughlings Jackson.

Name-plate outside No. 3 Manchester Square.

Silver claret jug presented to John Hughlings Jackson on his retirement from The London Hospital. (Courtesy of Mr. J.H. Jackson)

Inscription on the silver salver presented to John Hughlings Jackson on his retirement from The London Hospital. (Courtesy of Dr. W.L.H. Jackson)

Title page of paper published for private circulation by John Hughlings Jackson in 1863, with the author's inscription to his uncle, Harry Hughlings.

Cartoon of Herbert Spencer published in Vanity Fair.

Sketch by Dr. Stephen Mackenzie accompanying article by John Hughlings Jackson in Brain, 1906.

Poster displayed in London during the cholera epidemic in 1866. (From Mrs. Macdonald Critchley's collection)

Sir Jonathan Hutchinson.

Dr. Thomas Laycock.

Dr. Charles Brown-Sequard.

Sir Henry Head.

Dr. Pierre Marie.

Dr. James Taylor. (Courtesy of The Royal College of Physicians)

Dr. Thomas Buzzard. (Courtesy of The Royal College of Physicians)

Dr. Paul Broca.

11

The Cerebellum

It is sometimes forgotten that Hughlings Jackson held original views on the role and function of the cerebellum in certain neurological disorders. As early as 1863, in the course of discussing Owen's vertebral theory, Jackson referred briefly to the function of the cerebellum, saying that instinctive actions were well illustrated by the winding-up of a watch at night. In 1869 he reported a case of a patient with disease of one cerebral hemisphere and of both lobes of the cerebellum.l An important case-report followed in 18712 of a five-yearold male patient with a cerebellar tumour. During life he had shown rigidity and periodic tetanus-like seizures, and enlargement of the head had been noted four months prior to admission to hospital. The child started to cry a great deal, complaining of headache, and he began to lose weight. Two months later, the family were regarding him as stupid. Two weeks before entering hospital the boy's walking became difficult, and two or three days prior to admission he was doubly incontinent. On examination it was found that the child's head was large. He was apathetic and he rarely spoke unless spoken

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to. His memory was deficient, and it was doubtful whether he recognised his mother. There was no obvious impairment of vision but bilateral papilloedema (optic neuritis) was discovered. The boy did not complain of headache when he was in hospital, but he frequently vomited. He was unable to walk unaided because he was so unsteady and liable to fall. Later, both legs became stiff and set in an attitude of full extension. During his last days in hospital, the patient often suffered what the nurses called 'shocks'. Sometimes preceded by a cry, the child would stiffen so as to adopt a 'tetanus-like attitude', his head being fully retracted, his arms and hands flexed and his legs extended. Sometimes he was doubly incontinent at such times. The seizures lasted for three or four minutes. Hughlings Jackson's House Physician, Dr. Stephen Mackenzie, made a number of sketches of the patient while in an attack and these were reproduced in the article. Jackson likened the attacks to a 'brutal caricature' of someone running very fast. The child's general condition steadily deteriorated. He became emaciated, and in bed for his last three days was "lying in almost exactly the same position as in his seizures." (cerebellar paralysis with rigidity). He died, and at necropsy a considerable hydrocephalus was found. The tentorium was much bulged upwards. The middle lobe of the cerebellum was replaced by a tumour the size of a billiard ball, which had infiltrated the right corpus albicans. Later physiological researches have shown that, in the tetanus-like seizures reported by Jackson, we are actually witnessing the phenomenon of 'decerebrate rigidity', originally described by C.S. Sherrington in 1896 and 1898. In 1881, Jackson's paper "On Tumours of the Cerebellum"3 dealt with a fatal case of left-sided cerebellar tumour. The first attacks, which were irregular, of stiffness and pain at the nape of the neck occurred when the patient, a 3 5-year old man, was writing. Attacks of neck pain and stiffness began with a throbbing pain in the front of his throat and then "flew backwards, drawing his head back". About a month before admission to hospital the man noticed that his gait was unsteady when he got out of bed, although the ataxy wore off later in the day. Two weeks later, his eyesight became dim. On admission to hospital, he had pain in the back of his head and was found to have bilateral optic neuritis. Occasionally he vomited. His head was drawn back constantly, and attacks in which his head and neck were retracted still further occurred for a few minutes at

The Cerebellum 85 a time now and again. From time to time a state of opisthotonos developed. He then sustained an attack "of greater range", with twitching of the limbs and nystagmus. He was slightly ataxic, and both legs were stiff. Then, rather unexpectedly, the patient died. At postmortem a walnut-sized tumour was found in the inner part of the left lobe of the cerebellum, reaching up to the middle lobe. According to Jackson, the symptoms indicative of cerebellar disease were reeling, a certain rigidity and tetanus-like paroxysms. The reeling—an early symptom—was ascribed to paresis of spinal movements and was "like the walk of a drunken man". The patient's legs had acted erratically because they had had to "run after the trunk, to prop it up in its various over-inclinings". Jackson stated that it is necessary to study all degrees of locomotion, from getting up to swift running, in such cases. He said rigidity occurred in some cases of cerebellar paralysis, starting in the spinal muscles, drawing back the head and curving the spine. Ultimately, the legs and arms would become rigid. Tetanus-like sei/ures would sometimes occur. Jackson thought it possible that such attacks were due to an involvement of the corpora quadrigemina. He believed that, in some parts of the cerebellum, there was a unilateral representation from movements of the trunk to those of the limbs. Two articles Jackson had written, "Rigidity in Hemiplegia" in 1877 and "Paralysis Agitans" in 1878, were reprinted in Brain in 1899 under the title "On Certain Relations of the Cerebrum and Cerebellum (on rigidity of hemiplegia and on paralysis agitans)".4 He examined the rigidity occurring in cases of hemiplegia and speculated that the symptom was due to the unantagonised influence of the cerebellum. In health all the muscles of the body were doubly innervated, namely, by the cerebrum and by the cerebellum. The latter was the centre for contiguous movements and the former for changing movements, that is, tonic versus clonic. "Thus, in walking, the cerebellum preserves the equilibrium of the body, tends to 'stiffen' all the muscles; the changing movements of walking are the result of cerebral discharges overcoming in a particular and orderly way the otherwise continuous cerebellar influence."5 At the Neurological Society meeting on 7th July 1887, a discussion gave Hughlings Jackson the opportunity to make some observations, first on the use and abuse of the term 'functional', as used in neurology, and secondly on why there is an increase in the kneejerk in some types of Nervous disease.

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Jackson advanced several explanations for the phenomenon of increased tendon jerks. A lesion seated in the internal capsule mostly "so to speak, 'waits for' the 'descending wasting'." He explained the increase of the knee-jerks in cases of post-epileptiform paralysis of the leg by supposing that the small inhibitory centres are alone exhausted. He went on to consider the possibility of cerebellar influence being a factor in causing super-positive effects, such as rigidity and an increase of tendon reactions. He suggested that the cerebellum was partly involved in producing the tremor in paralysis agitans and the rigidity of hemiplegia. Hemiplegia, he said, was the inverse of cerebellar paralysis; in the former, the order is arm, leg, trunk; in the latter, trunk, leg, arm. "The attitude (emprosthotonos) of an advanced stage of paralysis agitans is the inverse of the attitude (opisthotonos) in the paralysis and rigidity of some cases of tumour of the middle lobe of the cerebellum."6 According to Dr. J.F. Stein,7 Jackson never really came to terms with the cerebellum, having no clear idea how it fitted in with his hierarchical scheme of nervous functioning. It is particularly interesting, therefore, to turn to Victor Horsley's Hughlings Jackson Lecture of 1906. His theme was "On Dr. Hughlings Jackson's Views of the Functions of the Cerebellum as Illustrated by Recent Research."8 Horsley referred to "the great service he [Jackson] has done to humanity by his work on the functions of the nervous system"9 and then confirmed Jackson's opinion that the cerebrum and cerebellum were intimately correlated; both must be considered as invariably working together. The cortex cerebelli and the intrinsic nuclei of the cerebellum must be looked upon as two separate organs, as first stated by Thomas in 1897. Researches showed that, histologically speaking, the cortex of the cerebellum was a structure per se. The tonic muscle contraction and the source of its maintenance could only be investigated physiologically, said Horsley. He stated that evidence resulting from experimentation indicated that the source of the so-called cerebellar influx "must be looked for in the basal or nuclear region of the cerebellar complex, and that the activity of the cortex cerebelli, though physiologically antecedent thereto, was not essential to the maintenance of the contracture phenomenon."10 Excitation methods (mechanical, chemical or electrical) had shown, he said, that it was probable that the effects observed were due to irritation of the underlying nuclei and tracts rather than of the cortex.

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Using specially refined methods of stimulation, Horsley, in conjunction with Dr. R.H. Clarke, had shown that the cortex of the cerebellum is inexcitable compared with the cortex of the cerebrum (ascending frontal gyrus). The attacks of atactic helplessness which had been described by Jackson were, Horsley stated, probably due primarily to loss of information, that is, of afferent impulses. A further conclusion resulting from Horsley and Clarke's researches in 1905 was that the intrinsic and the paracerebellar nuclei are the afferent mechanisms of the cerebellum. That is, they are the immediate source of what Jackson called the 'cerebellar influx'. As to representation of body-parts, Horsley tentatively suggested that the intrinsic nuclei of the cerebellum are associated with movements of the eyes and head, while the paracerebellar nuclei subserve the trunk and limbs. Referring to the muscular contraction, Horsley asserted that "the character of the motor effects obtained from excitation of the efferent side of the cerebellar apparatus is very striking and precisely of the kind originally ascribed by Dr. Jackson to it, viz. tonus and hypertonus."11 (italics not in the original). In a later passage Horsley said, "Enough has now been said to show that Dr. Jackson's views of the nature of the cerebellar motor output, and his mode of interpreting the stimulation effects of gross cerebellar lesions have been amply substantiated by the findings of experimental differentiation."12 Horsley concluded his address by thanking Jackson for bringing order out of confusion in this and many other departments of neurology. Flourens, Luciani, Jackson and Edinger all shared the view that "the cerebellar cortex is the first chief station of representation of the afferent basis of movements of all the skeletal muscles."13 Sixteen years later, when Gordon Holmes delivered the four Croonian Lectures to the Royal College of Physicians, he chose as his topic "The Clinical Symptoms of Cerebellar Disease and Their Interpretation."14 They were based upon his personal experience of almost 70 cases of war-wounds of the cerebellum together with 25 cases of subtentorial tumour, and Holmes was able to establish the clinical signs and symptoms that characterize cerebellar lesions. These masterly lectures represented to clinical neurologists the ne plus ultra of cerebellar phenomenology. On 16th December 1939, Gordon Holmes gave the tenth Hughlings Jackson Lecture. His address was entitled "The Cerebellum of Man".15 Holmes spoke of "the unique place that

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Hughlings Jackson occupies in the history of neurology".16 It depended, he said, not on descriptions of diseases or syndromes previously unrecognized, but on the methods he introduced into the clinical study of the nervous system and on the numerous contributions he made to the mode of its activity in health and in disease. Jackson, he said, had insisted upon accurate observation, on a careful and systematic analysis of the facts observed into their simplest components, and on a study of the latter for the light they may throw on the normal functions of the affected organ. As the cerebellum repeatedly claimed Jackson's interest, a study of its functions by the methods he taught is, Holmes stated, an appropriate subject for a lecture devoted to his memory. During the 16 years which had elapsed since his previous contributions in 1917—1922, an enormous amount of experimental work had been devoted to the cerebellum, but the conclusions drawn from them were so discordant that Holmes omitted them. Animal experimentation had tended to suggest that the neocerebellum was not essential for the functions atttributed to it by clinicians. Only Fulton's work with apes provided more valuable information. Holmes again emphasized the importance of hypotonia in patients with cerebellar lesions, despite Jackson's description of 'tonic seizures'. The most important disorder of voluntary movement was slowness in its initiation, he said, coupled with a lack of uniformity in its velocity. Holmes quoted Jackson's assertion that "co-ordination is the function of the whole and of every part of the nervous system" and that "there are two factors in the causation of irregularity of movement",17 namely, positive and negative. Holmes did not discuss these statements in greater detail. Throughout his lecture, Holmes analysed with great care the nature of disordered movements. The function of the cerebellum, he stated, is 'to tune up' or reinforce the cerebral motor apparatus. Jackson's views were referred to only sketchily. More than half a century has elapsed since Holmes's lecture, during which time there has been a plethora of physiological studies on the cerebellum. Notable among the many researchers have been Eccles, Ito, Marr, Moruzzi and Stein. The last-named's address, at the 150th anniversary symposium at the London Hospital in honour of Jackson's birth, is of special interest and importance. Dr. J.F. Stein showed that the cerebellum plays an important part in Jackson's scheme. It helps the transfer of information between the Jacksonian levels. According to Stein, sensory physiologists re-

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ject Jackson's hierarchy, while motor physiologists "recognise that the brain is a democracy rather than a dictatorship".18 In the conclusion of his paper, Stein stated: "The cerebellum is a sensory structure mediating between the highest, middle and lowest levels of Hughlings Jackson's hierarchical motor scheme. It is responsible for the sensory guidance of movement, passing information between sensorimotor association and motor areas of the cerebral cortex, and executive motor structures in the brain stem and spinal cord . . . functionally the cerebellum probably provides three crucial, but unusual, elements for motor control and the acquisition of motor skills, namely sampling, prediction and optimisation of system parameters."19

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12 Aphasia: The Early Researches of Broca and Jackson

Jackson's contributions to aphasia were the most important, the most original, the most contentious, the most tantalising and probably the least understood of all his writings. His earliest appearance in the literature on the subject came three years after Dr. Paul Broca's seminal presentation to a meeting of the Paris Anthropological Society on 18th May 1861 of the brain of a patient of his who had suffered from paralysis and loss of speech and who had died the previous day. Broca (1801—1880), a most able man of diverse abilities, was a general surgeon interested in ethnology and in craniology in particular. On 4th April 1861, he had attended a lecture at the Paris Anthropological Society given by Dr. E. Auburtin (1825-1895) entitled "On the Seat of the Faculty of Language". Dr. Auburtin was a physician and son-in-law of Professor Jean Baptiste Bouillaud, Dean of the Faculty of Medicine in Paris. Broca recognised the importance of this paper, and he invited Auburtin to see a patient just admitted under his care, a simple-minded hemiplegic named M. Leborgne, who had developed an infection in his leg. On 17th April the patient died. An autopsy revealed a long-standing lesion in the frontal lobe.

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The same year, another patient with a frontal lobe lesion, M. Lelong, came under Broca's care at the Hopital Bicetre; he was followed by several other patients with loss of speech. Broca's series of fatal cases of hemiplegia with an affection of speech now began to attract widespread attention. The common pathology was a lesion at the foot of the third frontal gyrus, a region which subsequently became known as 'Broca's area'. Broca stated ruefully that the title of 'discoverer of the speech-centre' was more or less forced upon him. By the end of November 1864, Jackson's first paper on the subject was published in The British Medical Journal, entitled "Hemiplegia on the Right Side with Loss of Speech."1 Thereafter both Broca and Jackson paid close attention to aphasia and wrote regularly on the subject, each in his individual fashion. Their respective attitudes, however, were different. In 1865 both Broca and Jackson realised that the significant lesion was not bilateral but almost always left-sided. Jackson has stated that he had looked upon the matter of handedness from two standpoints—the radical as opposed to the conservative. His radical side led him to believe that the faculty of language resides in the left side of the brain. But a long-held conservative respect for principles stood in the way. The one pointed to facts he himself had held independently and which had been confirmed by Broca. The other side of him protested that the observations were not yet sufficiently numerous. Jackson considered that much might be said in favour of both sides of the argument; there were advantages in being neutral. He discussed briefly the difference in attitude between Broca and Trousseau, saying he thought the attitude of the latter was more conservative. Broca's focus of interest was essentially along conventional clinico-pathological lines; Jackson's principal concern was the nature of the impairment of language shown by his patients. In some, it was slight; in others, severe. Often the number of accessible words varied from day to day. He commonly found that the available speech to a patient was reduced to the single word 'yes' or else 'no'. Often these particles were used inappropriately, the patient saying 'yes' when 'no' was intended or vice versa. No matter how fragmentary the speech, however, Jackson never encountered a patient who was incapable of emitting a vocal response of some kind. He found it intriguing to analyse the fragments of speech uttered by his patients. He soon realised that speech is not a simple phenomenon, whether in a healthy person or in an aphasic patient, and that at least two

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levels are detectable—a superior and an inferior level. Jackson discovered that in an aphasiac, superior speech suffers far more than inferior speech. It also explained why a patient with aphasia was frequently able to emit such oft-employed expressions as 'yes', 'no', 'please', 'thank you' and 'goodbye'. He could, moreover, often say emotionally-charged words like 'Oh!', 'don't', 'I want', 'give me' and 'go away'. More striking still was the ability to swear, to utter oaths or even obscenities. This retention of speech, Jackson said, represents an automatic, emotional level of utterance which is more resilient than superior speech. The latter level included simple statements of fact, which he called 'propositionizing'. Jackson realised that it was wrong to regard a word as a unit of speech unless an isolated word happened also to act as a proposition. His first papers dealing specifically with speech-loss appeared in 1864, when he was 29 years of age. They were a model of simplicity, and they brought a novel approach to a subject that promised to be far more complex than Broca's writings would indicate. In August 1866 Jackson wrote a letter to the Editor of the Medical Times and Gazette stating that he had under his care a patient with a left hemiplegia together with considerable loss of speech. The patient was left-handed. Jackson said: "One case proves nothing but it may serve to point out a direction for inquiry."2 The British Association for the Advancement of Science held its Annual Meeting in Norwich in August 1868. Broca was invited to attend by Dr. J. Bateman, and Jackson, too, was there. Whether the two men actually met and conversed is not known. Both read papers, but we do not know whether there was an exchange of ideas. An abbreviated account of both contributions appeared in the medical Press.3 Judging from the reports of the proceedings, there was nothing like an altercation between Broca and Jackson, as has been asserted. Of the various papers read, three dealt with language and its disorders. These were delivered by Jackson, by Broca and by a Mr. R. Dunn. Jackson's paper, entitled "Observations on the Physiology of Language",4 was accomplished, thoughtful and perspicacious, and dealt with the various aspects of language and how they behaved when disordered. He described and analysed the diverse effects of language-impairment encountered in clinical practice, and discussed defects in writing and in sign-making. Speechless patients, he said, can occasionally, in certain circumstances, utter words. Hence, there

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must remain sensori-motor processes for words somewhere, though the 'will' cannot get at them. The 'somewhere' can scarcely be on the left side of the brain, for damage of that side made the man speechless. Jackson said that the left side of the brain is the leading side and the right the automatic side. The cerebral hemispheres are twins, but the left is the first born. Jackson did not attempt to localize language to any limited spot and said speech resides in each part of the brain. He stated that there may be points—probably in Broca's convolution—where the most immediate processes for talking are specially represented, but there is no localization in the sense that one part superintends one thing and no other. The basis of Jackson's paper at the Norwich Symposium was a series of 34 cases of hemiplegia coupled with impairment of speech to a greater or lesser degree. No autopsy findings were available. It seemed likely that most of the cases were the result of embolism of the middle cerebral artery consequent upon valvular disease of the heart. Jackson stated that he had independently arrived at certain physiological conclusions, but he freely admitted that he had been anticipated by Broca "on every point of importance". He was being unnecessarily modest, for he went on to stress that much clinical work must be done before the pathological findings at post-mortem are to have precise value as physiological evidence. He said the subject has great psychological interest as well as important medicolegal bearings. Jackson took for granted two considerations: (1) we are not born able to speak: but we are born with the anatomical possibilities that can be trained in the acquisition of language, which is an art, like baking and brewing, handed down from generation to generation; and (2) we think by help of words. The paper Broca gave at the Norwich Symposium was entitled "On the Seat of the Faculty of Articulate Language".5 A demonstration involving a diagram and a plaster cast accompanied it, his view of the localization of articulate language being in the third frontal convolution on the left side. An original organic force determines the left side of the brain's role in articulate language, he said, and pleaded for a more precise terminology: alogia for loss of speech from defective intelligence; amnesia for impaired memory for words; aphemia for a defect in the special faculty of language; and alalia for imperfect articulation. Mr. Dunn's paper was the next one to be read at the Norwich Symposium, and there was then a general discussion in which Dr.

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Bateman and Dr. Humphry participated. The former had examined the brains of 27 patients with aphemia; in only 5 was the lesion limited to the third frontal convolution, and in another 5 there was no lesion at all. Dr. Humphry regarded the brain as a whole and its functions as spread over all of it.

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13 Further Work on Aphasia

In subsequent papers, Jackson elaborated on the various patterns of disordered speech which occur in aphasia. He also discussed the difficulties which an aphasiac might experience when carrying out a voluntary or deliberate act. During ophthalmoscopy, for instance, the patient might make futile attempts to deviate his gaze in a particular direction but would never do what Jackson told him to, whether it was to keep his eyes still or his eyes open; the patient might open his mouth instead. These surely are examples of what came to be called 'apraxia'. In 1866, two years before the Norwich Symposium, Jackson had delved deeply into those cases in which a patient with a defect of speech seems to have lost much of his power to do anything he is told to do, even in those muscles which are not paralysed. "There is power in his muscles . . . but he, the whole man, or the 'will' cannot set them a-going. Such a patient may do a thing well at one time and not at another .. . the brain is not only the 'organ of mind', but it is the nervous system of the nervous system . . . words, especially such as 'mind', 'sensory1, 'motor', etc., fetter our thoughts as well as define them."1

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Jackson later made the important statement: "I must here say that I believe less in some of the views propounded by Broca than I did, although I think the scientific world is under vast obligation to him for giving precision to an important inquiry. Yet I cannot but think that my disagreement with M. Broca, as well as many of the differences of opinion on this subject, are to a great extent due to different ways of putting the same thing. Indeed, I think the evidence I have collected goes to confirm many of his statements as to facts, but I have for some time ceased to go with him in a few of his inferences. I think, then, that the so-called 'faculty' of language has no existence, and that disease near the corpus striatum produces defect of expression (by words, writing, signs, etc.), to a great extent, because this is the way out from the hemisphere to organs which the will can set in motion."2 In 1876 Jackson modified his views even further on the localization of speech. "I have never acceded to the opinion that speech is to be localised in any one spot, although I do believe most firmly that the region of Broca's convolutions is, so to speak, the 'yellow spot' for speech, as the macula lutea is the centre of greatest acuteness of vision, although the whole retina sees."3 In his important paper of 1868, Jackson wrote: "Since speech or words enter into thought, it seems incredible that 'speech' can 'reside' in any limited spot. This is not contradictory to the statement that damage to the brain in the region of the corpus striatum only causes loss of speech. To the corpus striatum will converge those motor processes which serve in speech, and thus a small quantity of damage in its neighbourhood will, at least does, produce a greater defect of speech than a larger quantity at a distance."4 It is worth remembering that the frequency with which the corpus striatum finds a place in Jackson's earlier papers is because, until 1875, neuro-physiologists commonly believed that the motor tract originated in the corpus striatum, not the cortex. Jackson described an important aphasiological phenomenon, which he spoke of as the 'occasional utterance' of patients who are virtually bereft of speech. They are plausible statements which, ordinarily, he would be unable to utter; they are emitted unexpectedly, possibly under the influence of emotion. He gave examples. A patient whose sole utterance was a fragment of jargon suddenly remarked to his son, "How is Alice getting on?" Another speechless patient once broke silence to announce that he wanted some chops. Yet another, whose single attempt at communication was the particle 'no', suddenly said to his wife just before he

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died, "Five nights, six nights, seven nights, and then five nights out of seven."5 On another occasion, Jackson referred to an aphasic patient who astonished the others in his hospital ward by unexpectedly exclaiming "What's all this bloody nonsense about?" Jackson believed that such utterances were the product of the right half of the brain, but he was not able to explain how the words are set going from that hemisphere. He discussed what is meant by the loss of memory for words, which was really an ataxy of articulation, or loss of memory of the movements of articulation which go to form a word. In making this statement, he said, he was following the precept of Professor Alexander Bain. "When we recall the impression of a word or a sentence, if we do not speak it out, we feel the twitter of the organs just about to come to that point. The articulatory parts . . . are all sensibly excited; a suppressed articulation is, in fact, the material of our recollection, the intellectual manifestation, the idea of speech."6 The phenomenon of occasional utterance indicates a certain severity of a speech affection. In milder cases the trouble in verbalising is more often a disorder in particularising, Jackson said. In an effort to find the appropriate term, an aphasiac substitutes a more general statement for one which is more precise. Jackson referred to a patient who, searching for the word 'kitten', compromised with the phrase 'little furry creature'. The error conforms to the law of destroying lesions. In his speech the patient is reduced to a more automatic condition. Jackson was to go back to this subject in later papers. Jackson went on to distinguish between the disturbances of speech which Broca termed 'aphemia', from disorders of voice ('aphonia') and from defects in articulation. The third condition results from weakness of the lips, palate and tongue. There is no such weakness in aphemia (aphasia), yet in many cases the patient often is not able to protrude the tongue voluntarily (i.e., to command) but will do so automatically (as in the act of licking the lips, for example). In subsequent papers he always gave credit to Dr. Brown-Sequard, who had pointed out to him that an aphasic patient has lost the genr eral faculty of language and not merely the most particular manifestation of that faculty, namely, articulate words. The aphemic (aphasic) patient is unable to express himself, not only in spoken words but also in writing. However, he may be able to copy and, in some instances, to sign his name. Jackson often drew attention to the fact that many patients, even those with extreme poverty of speech, were often able to swear. He

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gave an interesting disquisition on the nature of swearing and its role in speech. "The study of swearing", Jackson said, "in spite of the nastiness of this habit, is one of the very greatest interest and importance."7 He stated that swearing is not, strictly speaking, a part of language but a practice which has grown up from the impulse to add the force of passing emotions on to the expression of ideas. It belongs to the same category as loudness of tone and violence of gesticulation. He quoted Dr. Samuel Johnson's remark to a boisterous antagonist: "Sir, you raise your voice where you should enforce your argument." Oaths are generally used in talking to make up by vigour of delivery what is wanting in precision of expression. Jackson said that vulgar people insert an oath at intervals in their speech as a sort of detonating comma, thus uttering forcible statements which are otherwise commonplace. "Oaths are phrases which emotion has filched from the intellect to express itself in a more definite way than it could do by mere loudness of tone or manner."8 An aphasiac might also be able to emit ejaculatory expressions under the stimulus of sudden excitement. Like oaths, such interjections are used to clothe feelings (in ordinary speech) rather than to express an idea. The aphasiac cannot utter these oaths and interjectional phrases to command. But, Jackson said, somehow an emotion, such as anger, enables the words to pass through the convolution of language. Bearing in mind the doctrines of his teacher, Professor Laycock, Jackson wondered whether these particular utterances might not be reflex in nature. The foregoing is a summary of Jackson's early opinions about aphasia. It is obvious that his ideas on the nature of disordered speech were already formed and would be expressed more fully later, as Henry Head observed in 1915. In a later paper, Jackson elaborated his developing thoughts about emotional language. He reported the case of a hemiplegic patient whose speech was limited to the meaningless vocalization 'dick'. Whenever he was vexed by other patients in the hospital he would swear, blurting out "the common explosive sound so much in favour with English writers".9 He was not able to repeat the swear-word when requested to do so; he tried, but 'dick' was the only sound to emerge. Another case Jackson reported was that of an aphasic woman whose vocabulary was reduced to 'lor', 'deah' and 'me'. He said it would be safer to call such fragments 'sounds' rather than words, as they were but the "rags and tatters"10 of talk. They are certainly not

Further Work on Aphasia 101 what are properly called 'parts of speech', being no use whatever to the patient in conveying any intellectual meaning. Such sounds are, however, important parts of emotional language. By varying the tone of the sounds, the patient could show that she was perplexed. She was also able to sing, utilizing truncated sounds instead of the appropriate words. Her husband told her to go and talk to their bird in its cage. She was delighted to do so, excitedly varying the melody of her gabble. At the same time she gesticulated wildly, accompanying her voice with a sort of dance of her arms. Jackson also referred to the early theory as to the origin of speech which envisaged it as an elaboration of interjections. This notion, which was put forward by Epicurus and his pupil Lucretius Carus and later by Vaco, spoke of an evolution from 'cry to call'. This hypothesis was, however, rejected by Descartes (1637), Herder (1772), HackTuke (1892) and Max Muller (1877), the last-named dubbing the idea the 'Pooh-Pooh theory' of the origin of speech. Interjections, according to Muller, "are only the outskirts of real language. Language begins where interjections end."11 Throughout his writings, he tended to avoid such terms as 'aphasia' or 'aphemia', preferring to speak of 'loss of speech' or 'loss of expression'. For the first time Jackson mentioned the phenomenon of recurring utterance, which particularly interested him, although he did not use that term in his earliest papers but spoke of 'a stock phrase'. He offered an explanation for the choice of words so emitted, saying that it probably represented the leading sensori-motor process at the moment when the brain was damaged. Two case-reports were given in support of this contention. A man who had been working long hours compiling a catalogue suddenly lost consciousness. On regaining his senses he was speechless, except for the solitary phrase 'list complete'. The other example was of a man who had been struck on the head during a brawl. When coming to, he could say nothing other than "I want protection!"12 The subject of recurring utterance, like that of occasional utterance, in aphasiacs was one which always intrigued Jackson. As his clinical experience of these cases grew, he continued to discuss the matter. The subsequent observations he made will appear later. Jackson dealt with the relationship between thought and speech in yet another paper published in 1868.13 To say that thought was identical with 'internal speech' is inappropriate, he stated. To say that speech consists of words is not enough. "It consists of words referring to one another in a particular manner; and without a proper in-

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terrelation of its parts a verbal utterance would be a mere succession of names embodying no proposition." This is perhaps the first time that Jackson used the term 'proposition'. Along with its allied 'propositionizing', it was to appear over and over again in his writings and was used to indicate a fragment of intellectual speech. Jackson's favourite example of propositionizing was 'gold is yellow'. He did not vary this phrase over subsequent decades. An aphasic patient obviously cannot propositionize audibly, nor can he do so internally. He cannot say 'gold is yellow', either aloud or to himself, as evidenced by the fact that he also cannot do so in writing. However, he can copy, even from print to print. Jackson made clear that the same nervous processes take place in internal as in external speech. The sole difference is that, in speaking to oneself, the nerve-currents engendered are so slight that they do not spread to the articulatory muscles. "There is no essential difference betwixt internal and external speech. We speak, not only to tell other people what we think, but also to tell ourselves what we think. Speech is a part of thought—a part which we may or may not exteriorise. Again, it is not well to say that thought is internal speech, for the man who is speechless (the man who has no internal speech) can think. How well or ill he can think we will discuss later."14 Henry Head pointed out that the terms 'internal speech' and 'external speech' mean different things to different people, and there is likely to be confusion unless one understands the meaning which Jackson applied to these terms. Jackson dealt with the duality of the brain and considered in depth how much a speechless person can do in the realm of language, as well as what he cannot do. Because there is great diversity of speech-impairment, Jackson discussed an 'ordinary' case of aphasia in which there is loss of the most voluntary use of language without loss of more automatic aspects. The patient may smile, laugh, vary the tone of his voice and even be able to sing. Pantomime suffers but little and gesticulation not at all. Many speechless patients lose all speech except for the most automatic of propositions—the words 'yes' and 'no'—Jackson stated. At times, even these words are used as interjections and not as propositions. A speechless person may not be able deliberately to say 'yes' or 'no', and yet can reply to a question with a 'yes' or a 'no'. In a state of speechlessness, the most voluntary use of the word is lost and is therefore reduced to more automatic language. Characteristically, Jackson enlivened his text with illustrative case-

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reports. A patient of his who could not say 'no' angrily shouted 'No! no! no!' when his children were misbehaving. Jackson tried many times to make the man say 'no' but had no success until he asked the preposterous question 'Are you 100 years old?'At once, the patient blurted out 'No!' Then Jackson asked the man to say 'no' again, but he could not do so.15 He wrote again on this topic. These contributions will be discussed in the next chapter, as will be Jackson's further writings on the subject of occasional utterances. Jackson referred to the mechanism of what today might be called the preverbitum.16 Verbalising, he stated, is the result of an earlier process. Before a proposition is spoken, words must have been automatically revived. "A person speaks as he likes; but how comes it that he does like to utter any particular proposition. If I say, 'This blotting paper is red', the words must have been automatically revived before I uttered them, or why should I have said that"? But saying they are automatically revived is not saying that they revive themselves. I had the images blotting paper and red in my mind, and these roused the two words automatically before those words could be put in propositional order—before speech was possible."17 The final pages of the address dealing with the duality of the brain contained various opinions which aroused contemporary criticism and which today would be rated as dubious. Jackson often spoke as though speechless patients fully retained their ability to comprehend what was said to them. He was inclined to attribute this factorial integrity to the action of the right cerebral hemisphere. He believed that one hemisphere was concerned with the automatic and the other with the voluntary revival of images. The speechless man has but one side of the brain for verbalizing—the automatic side; he has two sides for the revival of images, and thus he can still think and still have certain relations of likeness and unlikeness, he said. "No doubt he is lame in his thinking. He will be unable to learn novel and complex things, for he will be unable to keep before himself the results of complex arrangements of images. He cannot speak to himself, to tell himself what he has managed to think of things presented or represented in very novel and complex relations. He cannot bring two images into co-existence".18 A phenomenon which we now regard as a manifestation of apraxia, and which had evaded the notice of some great clinicians for centuries, was described by Jackson in an article in 1866.19 He had long observed that many hemiplegics, especially soon after the onset of paralysis, could not (or would not) protrude the tongue when asked

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to do so. The patient understood the request, for he tried to obey by opening his mouth or by putting his fingers to his mouth in an attempt to pull out the tongue. There was no paralysis of the tongue; the patient could eat, swallow or drink without any trouble. More cogently, he would automatically put out his tongue in order to lick his lips or to moisten a postage stamp. This defect would pass off in a matter of days, though the associated hemiplegia persisted. Many of Jackson's patients with such an inability to protrude the tongue deliberately also had an impairment of speech. He pointed out that the same physiological defect was responsible in both instances. Jackson's work anticipated that of H.C. Liepmann by over 30 years.

14 Jackson's Final Writings on Aphasiology

The first issue of the journal Brain, under the editorship of Sir James Crichton-Browne, was dated 1878—1879 (see Chapter 18). Jackson was a member of the Board of Editorial Assistants, and he contributed a lengthy, somewhat diffuse and obscure paper entitled "Affections of Speech from Disease of the Brain."1 With characteristic modesty, Jackson acknowledged the work of various British neurologists who had written about disordered speech. These included Broadbent, Wilks, Gairdner, Moxon and Ferrier. Others mentioned were Bastian, William Ogle, John W. Ogle, Watson, Ireland, Robertson and Bristowe. Among other European contributors to the subject of aphasia, Jackson was impressed by the works of Kussmaul, published in Ziemssen's Practice of Medicine. It is interesting to note that not once in all his writings did Jackson refer to Wernicke, except as a synonym for word-deafness on two occasions. Jackson began by mentioning the researches of Dax pere et fits and of Broca. In fact, Broca seemed to have lost interest in aphasia by 1870 in favour of a study of the comparative

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anatomy of the limbic lobe and its role in olfaction. The work was interrupted by such events as the Franco-Prussian War, the fall of the French Second Empire and the intervention of the Commune. Jackson said that, like many other disorders of the nervous system, aphasia obeys certain general principles of dissolution. There are degrees of loss of the most voluntary processes, with "conservation of the next most voluntary or next more automatic".2 Instead of the word he intends to speak, the patient may utter one of comparable -meaning (for example, "worm-powder instead of cough-medicine") or comparable sound (such as 'parasol' for 'castor oil'). He is, presumably, using what to him is an 'earlier' or 'more organized' word, thus illustrating the principle of dissolution. It is often impossible, however, to trace any relationship between the word intended and the word articulated. Jackson said, "the subject is already complex .. . but we must face the complexity."3 He quoted the familiar dictum of J. Curnow: "The tendency to appear exact by disregarding the complexity of the factors is the old failing in our medical history."4 Later, Jackson expressly stated that he preferred to use the term 'affection of speech* rather than 'aphasia', which had been suggested by Trousseau. He hardly ever used Broca's 'aphemia*. Jackson also tended to avoid the term 'dysphasia', as did Gowers. The latter said: "The inaccuracy of applying an absolute negation to a partial defect has led to the suggestion of 'dysphasia' as a frequent substitute. The term does not, however, seem likely to come into use, a matter of little regret, since the word has not the merit of unimpeachable exactness, and it has an unfortunate resemblance in sound to 'dysphagia'."5 The fact that it is not wholly appropriate to speak of 'loss of speech' was also stressed by Jackson, since in many cases of aphasia there is more than loss of speech; pantomime may be impaired, and there is often a defect in symbolizing the relationships of things. He approved Dr. Hamilton's use of the Greek term 'asemasia', which was derived from 'a' and 'semaino' (an inability to indicate by signs or spoken language).6 Jackson said he feared, however, that it was too late to displace the word 'aphasia'. He took the opportunity in this same article to reiterate certain principles which pervade all his writings on language and its disorders. He said the unit of speech is a proposition. Single words are meaningless unless other related words are employed. Elaborate oaths are devoid of meaning despite their propositional structure; they are actually 'dead propositions'. A speechless patient should not be looked upon as one who has lost the power or the faculty of

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speech, nor should it be said that the 'memory of words' is a function of any part of the nervous system. Memory—or any other psychical state—arises during, not from, the functioning of nervous arrangements. Reverting to one of his favourite metaphors, Jackson said that classifying speech-affections on a mixed basis of anatomy, physiology and psychology was no more correct than classifying plants on "a mixed natural and empirical method as exogens, kitchen-herbs, graminaceae and shrubs".7 A speechless person's condition is two-fold, he stated: it is made up of both negative and positive phenomena. The former comprise an inability to speak (except for recurring utterances, occasional utterances and interjections); an inability to write; and, in most cases, an inability to read. The positive features are recognisable in the patient's ability to understand what is said or read to him; that is to say, though speechless, he is not wordless. "The hypothesis is that words are in duplicate; and that the nervous arrangements for words used in speech lie chiefly in the left half of the brain; that the nervous arrangements for words used in understanding speech ... lie in the right."8 Another positive feature is that the "articulatory organs move apparently well in eating, drinking, [and] swallowing,"9 as well as in the correct enunciation of such scraps of speech as are intact. Furthermore, the patient can commit to writing what he can speak, for he still has internal speech. Jackson went on to say that the speechless person can recognise objects and also think about them. In other words, perception (or the 'proposition of images') is intact, at least as far as simple matters are concerned. On command he can point to objects, provided they were known to him before he was taken ill. He continues to be able to play cards and dominoes. He can recognise handwriting even though he is unable to read the text. He can tell poetry from prose, for the pattern is different. It is misleading to ascribe some of the phenomena to the patient's defective memory. Jackson said there is no general loss of memory, apart from things remembered. Jackson referred to an aphasic patient of his who had lost the ability to read, and to point to a letter or to a figure on a clock, and yet she was able to pick out a particular page in a magazine. In other words, he said, her image series was unaffected. Therefore, loss of the ability to read was not due to loss of perception or to nonrecognition of letters or figures as particular marks or drawings, but

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to loss of speech. "Written or printed words cease to be symbols of words used in speech for the simple reason that those words no longer exist to be symbolised; the written or printed words are left as symbols of nothing, as mere odd drawings."10 Jackson repeatedly asserted that the speechless man is not wordless; there is an automatic and unconscious or subconscious service of words. Reverting to the function of the two hemispheres, he said that mentation is dual and that physically the unit of function of the nervous system is double the unit of composition; not that one half of the brain is 'automatic' and the other half Voluntary'. Jackson referred to those persons who are unable to speak but who are not aphasic, having in mind individuals who never had the ability to talk, namely, untrained deaf-mutes. In such cases, the brain is not diseased but is uneducated (or, in anatomical and physiological terms, underdeveloped). An aphasiac is not deaf; "part of our speechless patient's brain is destroyed, he has lost nervous arrangements which had been trained in speech", but he "retains a service of words which is not speech; untrained deaf-mutes have no words at all. Further, the untrained deaf-mute has his natural system of signs, which to him is of speech value so far as it goes. He will think by aid of these symbols as we do by aid of words. . . . But when not taught to speak, he is not in a condition even roughly comparable with that of a man who has lost speech. No doubt by disease of some part of his brain the deafmute might lose his natural system of signs, which are of some speech value to him, but he could not lose speech, having never had it."11 Jackson's words have, of course, been abundantly substantiated by the subsequent publication of cases of 'aphasia' in deaf-mutes. Unfortunately, he did not consider deeply the matter of language and language-disorder in the deaf—congenital or acquired—but he was not in a position to refer to the elaborate, artificial systems of sign-language that can now be taught to an intelligent deaf-mute in favourable circumstances. However, he did point out that the ability to think entails the use of words, but that for conceptual thought it is necessary to possess symbols of some sort. He said that those who rely upon 'natural signs' for communication do not attain the same degree of abstract thinking as those who have words at their command. That an aphasiac may, in certain circumstances, emit a word he cannot ordinarily utter had been stated at a discussion held in Paris at the Academy of Medicine in 1865 by Jules G.F. Baillarger, a physi-

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cian at the Hopital Salpetriere, who was known for his work on the histology of the cerebral cortex. He had been listening to a paper by a M. Lelut about the work of Dax, who, "30 years before Broca had ventured to locate speech in the left half of the brain."12 Baillarger said, "During the observation of aphasic patients, you may notice this singular phenomenon, that it is impossible for them to pronounce certain words when they try to do so, even when they put in action all their will-power, on the contrary, a moment after, they are able to pronounce the same words in an involuntary fashion: so, there is in these patients loss of voluntary motor action and a persistence of spontaneous motor action."13 A year later, Hughlings Jackson described the same phenomenon. He wrote: "M. Baillarger has already, I find, considered this question in an admirable manner."14 Again in 1879, Jackson brought up this subject, once more quoting Baillarger. "I am following pretty closely the principle this distinguished Frenchman has laid down. I fear M. Baillarger's acute remarks have attracted little attention, and I say with regret that I had forgotten them. I do not remember from what book I took the quotation."15 The Baillarger-Jackson principle was admirably discussed in 1960 by Professor Th. Alajouanine.16 Next, Jackson directed his attention to patients with speechlessness of extreme severity. As a rule, such patients manage to emit some sort of utterance. However, to form words is not necessarily the same thing as to speak, that is, to propositionize. He referred to those who had a recurring utterance and described four types of recurring (or 'stock') utterances: (1) jargon ('yabby', 'watty'), which is devoid of prepositional value; (2) an isolated word ('man', 'one', 'awful'), which means nothing at all. (Such a word does not alter over the course of time, as a rule, though it does so exceedingly rarely, as in Jackson's patient whose stock remark was 'Dick', but who changed it later to 'Jimmy', 'Jim' or 'Jigger'. He said that these "rags and tatters of what was once the patient's speech"17 could be made to express emotion by varying the tone; in other words, the patient 'sings'his recurrent utterance.); (3) a phrase ('come on to me', 'Oh! my God!', 'Ace of Spades') which, though it may have the appearance of a proposition is actually not speech at all; it is 'intellectually dead', but if the tone is varied, the phrase could be made to attain simple propositional functions; (4) the word 'yes' or 'no', or both these particles can be uttered. Jackson returned to the part played by 'yes' and 'no' in a speechless person's attempts to speak, which he considered to be of great

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importance. To refer to them as words is convenient but not strictly accurate. A healthy person, he pointed out, can use the word 'no' in a variety of ways. It can be used as a response to a question, or it may be a deliberate expression of negation, rejection or disapproval of something said to him. It then becomes a proposition. The word 'no' may be spoken in many different tones, indicating that the dissent is charged with a variety of emotions. The same word may be uttered as a simple interjection, and sometimes it may be charged with an element of surprise. The word 'no' to an aphasiac has many roles, appearing at times as a recurring utterance. It may even be used to express affirmation, especially if that particular particle is not in his vocabulary. The same applies to the word 'yes'. Jackson spoke again of 'yes' and 'no' as the two most general, most organised, most automatic of all propositions. "They are indeed very significant exceptions to the empirical division into loss [in speechless patients] of intellectual and conservation of emotional language; for, even regarded superficially, they stand on the border ground. These words are used by healthy people, now one way, now the other; they are sometimes parts of emotional manifestations, and may then be combined with an ordinary interjection, as in 'oh! yes', or be duplicated as in 'no, no'; here the second 'no' at any rate is interjectional. They are at other times used with full and definite prepositional intent to signify 'this is so', or 'is not so'. The word 'yes' may be used at the same time, both for sympathy and agreement, it being occasionally hard to say whether the intellectual or the emotional side is more visible."18 When 'yes' and 'no' are used as interjections, they take a lowly rank in language and are little more than 'bodily starts'. In such circumstances, 'yes' and 'no' are at the 'bottom' of intellectual language and, at the same time, at the 'top' of emotional language. Once again Jackson discussed in detail the subject of occasional utterance. He now stated that these rare ejaculatory exclamations could be divided into (1) utterances which are not speech; (2) those which are inferior speech; and (3) those which represent real speech. He went on to talk about what he himself had earlier described, recurring utterance in speech-impaired persons. He now had greater experience of this phenomenon and began by alluding to some of the examples given earlier by Trousseau. For instance, one patient could say nothing except 'Oh! how annoying'. Jackson attempted to explain the content of those recurring ut-

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terances by consigning them to his third category, namely, the ones that are prepositional in form but not of use as propositions to the speechless person. They were spoken—or were about to be spoken— at the moment the patient was taken ill. As to the duality of the brain, Jackson stated that the words of the recurring utterance had been revived during activity of the right half of the brain. Such words made up the last proposition, or rather the last stage of verbal revival (what he called the subject-proposition) prior to the last proposition (the object-proposition). The words had been meaningful at one time but meant nothing when used after the onset of the illness. As an explanation of why a recurring utterance may be a snippet of jargon rather than a meaningful phrase, Jackson said that both are the product of right brain activity, but when the outcome is jargon the cerebral activity had been hurried because of strong emotion. He described other interesting features of these phenomena. In characteristic fashion, he made three observations on what happens when only the recurring utterance emerges as the patient tries to speak: "(1) he has it [i.e., the recurring utterance]; (2) he has no other utterance (except perhaps 'yes' and 'no'); and (3) he cannot get rid of it."19 The last suggests a high degree of organization in the nervous arrangements. These "have somehow achieved a degree of independent organisation greater than that of any other wordprocesses except 'yes' and 'no'; probably by repeated utterance."20 The two most common stock phrases which constitute the recurring utterances of an aphasiac are the monosyllables 'yes' and 'no', Jackson stated, but he did not go into the question of which of these two words is more likely to appear. Perhaps the answer depends upon the personality of the individual who becomes aphasic. There are no-men as well as yes-men, and 'no' is a stronger word than 'yes'. Jackson also spoke of the phenomenon of transposed consonants (Spoonerisms) in both healthy and speech-disordered subjects, attributing these occurrences to right brain hurry. He said that Spoonerisms which occur in writing ('Mear Dadam', for example), are even more interesting, and that such an error reveals that expression by writing is really speech. (It should be pointed out that Jackson did not use the term 'Spoonerism', a word coined to describe the mannerism which affected the speech of the Reverend W.A. Spooner (1844-1930), Warden of New College, Oxford.) Jackson talked of jargon, in the sense of gibberish or incoherent utterance, as being the product of the fusion of various syllables (sur-

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vival of the fittest), emitted hurriedly as the result of strong emotion. One-word recurring utterances, he said, are also the product of deep emotion. His explanation of recurring utterances led Jackson to consider some other types of dissolution within the nervous system. Not only the depth of dissolution is important but also the rate at which it occurs. "I believe we may say that the deeper the dissolution, the more general and more automatic are the processes remaining, and that the more rapid the dissolution, the more excitable are the nervous arrangements of those processes."21 Recapitulating his ideas, Jackson said we may be able to explain the type of recurring utterance according to the following three relevant factors: (1) the circumstances around the patient at the moment he was taken ill; (2) his emotional state at the time he was about to speak; and (3) the gravity of the lesion. Jackson also discussed the phenomenon of 'barrel-organism', a term he borrowed from Dr. W.T. Gairdner. It refers to that variety of repetitiousness whereby the patient succeeds in bringing out an answer to a question (the reply being correct or incorrect) and continues to repeat it, irrelevantly, in reply to further questions. The patient knows that what he is saying is not appropriate. The word or words become a temporary, recurring utterance. This type of verbal perseveration can also apply to written speech. Jackson reproduced a letter written by one of his patients. It began with an address, which, quite inappropriately, would crop up again and again within the text. There were also other perseverations. The letter read: "Dear Sir. I feel very well just now" ['for now' and 'I feel' came next, but are crossed out] "for Hurst Row I feel very well just now for thingg in the first way for the thamk now. I know now I was in the first now in the first now in the Newington Road. I keep you first way in Newington Road the poor way is the best way is the best way for me is the best way for me is the best way for me is the best way the way is the best for me for ways kept for me for kept ways kept me for way kept for me."22 Jackson then stated and restated a number of generalisations. "We have to consider speech on this wider basis [loss of certain voluntary actions, with conservation of the more automatic ones] in order that we may be better able to see how speech is part of mind, and thus to get rid of the feeling that there is an abrupt and constant separation in mind and speech."23 Jackson spoke of a quality of mental processes; of a preconception which occurs before a voluntary action; a 'dream' of an opera-

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tion. "Before I put out my arm voluntarily I must have a 'dream' of the hand as being already put out. So too, before I can think of now putting it out I must have a like 'dream', for the difference betwixt thinking of now doing and now actually doing is, like the difference betwixt internal speech and external speech, only one of degree; in one there is slight discharge of a certain series of nervous arrangements, in the other strong discharge of that series. The 'dream' must occur before I either think of now doing something, or before I actually do that thing, just as words must be reproduced in me before either I can say them to myself or aloud. To say that we know what we are going to do, or that we are intending to do this or that amounts to admitting the above hypothesis. These expressions imply our having a nascent excitation of nervous arrangments representing the parts formerly concerned in doing that which is now to be done again. If we say we are trying to do something, we mean similarly, and so we do if we say we remember how to do anything; there being no 'faculty' of remembering an action apart from having the action (as it was formerly doing), again actual, although faintly actual, nascent. To 'will', to 'know', to 'intend', to 'try', to 'remember', have each, in their several contexts above, the same meaning."24 The duality of speech in normal conditions is restated in simple phraseology by the remark "we must first remember the words and then say them."25 Jackson's last paper on language (apart from a short article in 1894 which dealt with a patient with epileptic seizures who, in even the slightest attack, was temporarily 'word-deaf and 'word-blind') was published in 1893.26 The final pages of this last work are largely taken up with analogies between the pathophysiology of willed movements and that of speech. He said a speechless man's inability to say 'no' is of the same order as his failure to protrude his tongue. Jackson argued his case at length. His writing becomes obscure at times, but it is lightened by impressive case-reports. Jackson stated that a word is a physical entity with an auditivo-articulatory correlate. Words—or some other symbols, such as pantomimic actions, for example—are essential for thought. To think is to propositionize. Untrained deaf-mutes rely upon pantomimic symbols, having no words. Some animals think, but, having no words, they employ inferior symbols but little that is symbolic, which serve in their lowly mentation. To indicate the manifold ways in which words operate, Jackson chose the term 'verbalising'. He then asserted that both halves of the brain are alike in respect of verbalising. The role of the left hemi-

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sphere is evident, for when damaged, it makes one speechless. The participation of the intact right half of the brain can be inferred from the fact that the speechless man understands what is said to him 'on ordinary matters'. But he cannot repeat the message, even in writing. Word processes are not of the same kind in each half of the brain. The speechless person is not without words, thanks to the undamaged right hemisphere. It was here that Jackson made one of his infrequent references to his colleague at the National Hospital, Dr. H. Charlton Bastian, whose views upon aphasia were vastly different. He always indicated the divergence of their views, never failing to refer to Bastian in terms of almost exaggerated courtesy. "And I suppose no one doubts that very strong discharges of Broca's region in man (such discharges, I mean, as occur in cases of 'cortical epilepsy') produce convulsion of the muscles of the same parts; this convulsion is nothing other than a 'running-up' of many movements of the muscles of the parts mentioned into a stiff struggle. Dr. Charlton Bastian, however, thinks that the whole of the so-called motor region (Rolandic area of the cortex cerebri) is not motor but kinaesthetic. The opinions of this distinguished physician deserve most respectful consideration. Possibly, nearly all I say about what I call the motor part of the physical basis of words might be accounted for on Bastian's doctrine of kinaesthesis. I continue, however, to speak of Broca's region as motor."27 The article contains a reference to 'word-deafness', a term coined by Bastian and which Jackson employed infrequently. Reverting to the place of language in thought, Jackson stated that cases of loss of speech are no proof that thought is impossible without words. In an oddly self-deprecatory manner, Jackson admitted that he did not think anyone agreed with him in believing that the right half of the brain is 'educated in words'. He thought he was alone also in distinguishing the middle from the highest cerebral motor centres. Speaking to oneself, Jackson said, entails neural discharge so slight that no active articulatory movements take place. Speaking aloud evokes such strong discharges that there are movements of the muscles of articulation in a particular sequence. A patient with severe bulbar palsy cannot articulate, but he can speak 'internally* and can commit to writing his internal speech. Jackson then considered various non-verbal symbols in mentation. Should he be engaged in the task of arranging books on a table, both visual and tactual images would be involved as well as actions. Should

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he be only thinking of arranging the books, the visual and tactual ideas will now be faint, and the actions as well. Central discharges will be slight, and peripheral discharges non-existent. The actions are now scarcely symbolic "and yet probably to some extent so; so far, at least, as they are not mere repetitions of the former actions, but incomplete and modified reproductions of them."28 He was of the opinion that while some lower animals 'think' in such rudimentary symbols, they are very lowly homologues of what in man are pantomimic. Jackson believed that there was a class of symbols besides words and pantomimic actions which also serve in mentation. He spoke of them as 'arbitrary images' and said that when we think of the proposition 'gold is yellow', we have our general notion of yellowness to begin with, a particular image of some particular object. This image serves us when no particular yellow object is referred to. "This arbitrary image is associated with other, possibly with all other, images of yellow objects seen and remembered, and from their secondary excitation there is a fancied notion (or concept) of yellowness."29 Jackson did not imply that a man has only one arbitrary image for the fancied notion of yellowness; there may be many. Jackson repeatedly stressed the fact that it is one thing to localize the negative lesion which destroyed speech and quite another thing to say that 'speech resides' in any particular part of the cortex. Words serve us during thought, that is, during propositionizing, as when speaking aloud. The paper concluded with a series of observations on ideation and perception, their resemblances and differences. His remarks were profound, but they appear to be somewhat remote from the topic of symbols in mentation. Over nearly 30 years, Jackson gave us in his papers his ideas that grew out of Broca's finding of a diseased frontal lobe in a speechimpaired person. Jackson maintained that aphasia is more than an affection of speech; it is a disorder of language. His beliefs developed over the decades, though at times, they fluctuated a little. He never wrote a monograph on the subject; it was not his way of working. But the last few articles Jackson wrote were the nearest to a comprehensive thesis of his mature thinking on this particularly recondite subject.

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15 Reviews by Freud, Gowers, Head and Others

Jackson's conception of language and its disorders grew more and more profound. But few of his colleagues were ready to accept his ideas; most failed to understand them. A few—F. Bateman, W. Broadbent and H.C. Bastian in Great Britain and J.M. Charcot, J. Dejerine and F. Moutier in France—however, were interested in aphasia although more attracted by the notion of alleged centres strictly localized in the cortex cerebri as being associated with fancied faculties of speaking, speech-hearing, writing, reading, articulation and grammatical construction. One of the earlier British writers on aphasia, Frederick Bateman of Norwich, wrote an elegant, scholarly monograph which was not so much concerned with speech-loss per se as with a collection of medical curiosities. He said that, beyond all doubt, Jackson was the observer in this country who had done most to elucidate the subject of cerebral loss of speech. Nevertheless, Bateman's references to Jackson were comparatively few. He asserted in a footnote that Jackson located the automatic power of uttering words in the right hemisphere and the voluntary act of speaking in the left. "Kussmaul combats, and I think successfully, this hypothesis," he said.1

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For his part, Jackson explained that Bateman was in error when he stated in his article that he (Jackson) and Broca were in agreement as to the location of the centre for speech. Jackson was merely pointing out that priority was due to Broca, but there was no question of agreement between them. In 1869, Dr. H. Charlton Bastian, at the age of 32, had attracted wide recognition by reason of his article "On the Various Forms of Loss of Speech in Cerebral Disease".2 In 1880 his wide-ranging tome The Brain as an Organ of Mind3 appeared, and in 1898 he published probably the best-known British monograph on the subject, Aphasia and Other Speech Defects.4 Two years younger than Jackson, Bastian was his colleague at the National Hospital, Queen Square. Their views on aphasia were poles apart. Bastian was a robust advocate of the theory of localised speechcentres which were associated with the names of Broca and Wernicke. He also postulated two additional centres subserving worddeafness and word-blindness. Bastian was a rigid exponent of a highly materialistic notion of language and its disorders. He vizualized a number of anatomical structures, the disturbance of part or whole of which would be followed by clear-cut clinical pictures characterised by loss of one or other component of speech and of thought—reading, writing, speaking. He said all high-grade disorders of speech are due to the destruction of either the auditory and visual centres or the fibres transmitting impressions between them and the lower motor mechanism for the tongue and lips or for the hand in writing. The motor centres of the cortex were, according to Bastian, in reality sensory. He had already invented the word 'kinaesthesia' in this connection. It was inevitable that Bastian and Jackson would disagree in their attitude towards such complex subjects as language and thought in health and in disease. But, like two duellists, they maintained a posture of extreme politeness in their debates. Whether there was also a bond of friendship is difficult to say, but, in all probability, there might well have been. One source of contention was the matter of recurring utterances, occasional utterances and their cause. "No one," Bastian wrote, "has treated this side of the question with more zeal and thoroughness, or with anything like so much wealth of illustration as Hughlings Jackson; and yet, as it has been done from a rather peculiar point of view, I find myself, unfortunately, as little able to agree with him here as I am in regard to the fundamental positions from which he

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starts". He went on: "Some quotations may now be given in illustration of Hughlings Jackson's other special views with which I find myself unable to agree, but which, on account of his eminence as a thinker and clinical observer, cannot be lightly passed over."6 In a footnote Bastian complained: "Hughlings Jackson is, in fact, so oblivious of other modes of registration of words, and therefore of other forms of verbal memory, that he actually says, I suppose by way of reproach to some of us which think differently: 'It is not always vividly realised that retention of memory of words can mean anything more than a retention of words, the word "memory" in that context being really surplusage.' "7 Undoubtedly Bastian attained widespread recognition during his lifetime, largely because of his dogmatism. It was not until the 20th century that others besides Jackson began to question the views of Bastian and his followers. When passing judgement on the merits of work which is conspicuously implausible and yet argued dogmatically, it is as well to examine the personality of the critic. Throughout his professional life, Bastian rode an odd hobby-horse, believing firmly in abiogenesis, or spontaneous generation; he imagined that it was possible to produce living tissue in the laboratory. His beliefs were not substantiated. Bastian was a close friend of Herbert Spencer (and one of his Trustees), although it is doubtful whether he had the same depth of understanding of Spencer's philosophy as had Jackson. Among other London physicians interested in language and its disorders was Sir William Broadbent (1835—1907). His principal contribution to neurology was to establish, in 1866, what is generally known as 'Broadbent's hypothesis'. He was an erudite, all-round doctor who also gave much to cardiology. Broadbent was born a few months before and only a few miles away from Jackson, and in boyhood each had been apprenticed to a doctor before entering medical school. Later, he had acquired a large, fashionable consulting practice in London. Jackson quoted or referred to Broadbent many times in his writings, almost always in a highly complimentary manner. In one place he stated that he had carried the famous hypothesis even further than Broadbent himself, although "... I have added nothing to the principle of that hypothesis."8 In 1903 Broadbent was invited to give the Hughlings Jackson Lecture.9 This was the third in the series, Jackson himself having delivered the first and Professor Eduard Hitzig of Berlin the second. The address was given at the Medical Society of London in Chandos

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Street; the Neurological Society did not have accommodation of its own. Broadbent began by paying warm homage to Jackson, expressing affection and respect for his old friend and fellow-worker, "the acknowledged chief amongst neurologists."10 The distinction had come about, said Broadbent, even though Jackson had not given to the world either a monumental treatise, a superb series of clinical investigations or any profound histological studies. Jackson had been accorded "unanimously the first place among those who have contributed to neurology as a science ... he has been a pioneer in nervous physiology and pathology both in methods and results, has continuously raised our ideas of nervous action to a higher plane of thought, and has penetrated more deeply than even experimental science into the relations of the different nerve centres with each other and with the periphery, bringing to bear upon nervous physiology and pathology the speculations of evolutionary philosophy."11 Jackson had anticipated the experimental demonstrations of Hitzig and Ferrier, Broadbent said, and had shown that experiments made by disease could be used to supplement laboratory findings. Broadbent then described Jackson's work on epilepsy, a disorder which had been a terra incognita before he directed detailed attention to its clinical phenomena. The correlation of unilateral convulsions with a coarse lesion of the motor cortex led to what became known, appropriately, as 'Jacksonian epilepsy'. Broadbent said it was a happy inspiration which led Charcot to employ this expression. Further, Broadbent said, he regarded Jackson's work in confirming the motor function of the Rolandic cortex and the elucidation of the true nature of epilepsy to be his greatest and most permanent achievements. Jackson's views on evolution and dissolution, as represented by disease of the nervous system, constituted, according to Broadbent, his most original and comprehensive ideas. Next, the lecturer discussed Jackson's hypothesis of levels of function in the nervous system and confessed: "We may not be able to follow him in this high degree of abstraction."12 The final part of the lecture dealt with language and here Broadbent—no mean aphasiologist himself—took issue with Jackson on a number of points, saying: "Hughlings Jackson has not given us any complete theory of language, but I am not sure that he has not done more towards the elucidation of the problem of speech than those of us who have attempted its solution systematically."13 Precisely what Broadbent was trying to say is not clear.

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He pointed out that the act of articulation takes place in accordance with the hypothesis associated with his (Broadbent's) name, but the employment of only one side of the brain in intellectual expression "can never cease to be a matter of astonishment."14 Broadbent then elaborated his own view of the evolution of ideas and of the relevant nervous mechanism. "Impressions are transmitted from each perceptive centre to a higher cortical centre, where they are coordinated into a complete idea or mental picture of the object."15 All these qualities, he said, are brought into consciousness by the name—an arbitrary auditory symbol. He called this cortical area the 'naming centre' or, alternatively, the 'idea centre'. The assumption that such a centre exists and is the starting point for further intellectual operations seemed to Broadbent to be the simplest, and indeed the only explanation which his imagination could grasp of the different forms of sensory aphasia. He said one of these forms is word-blindness (Broadbent had been one of the first to report a case of word-blindness.) He also referred to worddeafness, a more complicated entity. He was not able to agree with some of Jackson's physiological interpretations of speech, he said, and could not regard the comprehension of spoken words as being an automatic process—as Jackson did. Nor could he agree that words expressing abstract ideas and revived in thought are really revived articulatory movements: nor that motor aphasia represents a loss of articulatory motor movements. Whether Broadbent interpreted Jackson correctly is, perhaps, debatable. However, he gracefully concluded his lecture with the words: "It will be understood, I hope, that in these remarks I speak as a disciple not as a critic."16 In the 19th century, relatively few neurologists paid much attention to the complex subject of aphasia. Many of them were frightened off altogether and others accepted only the most simple attempts to explain its puzzling features. As far as Medicine is concerned, the 19th century was an era of anatomo-clinical advance, and the idea of Broca's aphemia associated with a lesion in Broca's area was a neat and tidy conception which was easily taught and readily accepted as a basis upon which other anatomo-clinical elaborations could be erected. However, most general physicians felt it necessary to have some acquaintance with aphasia, both as a common phenomenon in clinical practice and as a tiresome item in the curriculum for students. Writers of textbooks in particular found the undertaking of a chap-

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ter on aphasia a vexatious, unrewarding task. Usually the author, not himself an experienced aphasiologist, approached the subject as an exercise in clinico-anatomical correlation based upon the 'discovery' made by Broca in 1861. The fact that disorders of speech varied in severity, as well as in quality, made the later 'discovery' of other alleged 'speech centres' a welcome addition to the isolation of various 'types of aphasia', which, it was hoped, were localisable. Such an approach was easier than the alternative, which was to address the aphasias from a psychological angle. This applied to the monumental Manual of Diseases of the Nervous System, written by that master of clinical neurology, William Gowers.17 He tackled the matter of aphasia boldly and, perhaps, reluctantly. He wrote a lengthy chapter on the subject, preceded by a well-argued account of the difficulties of this complex topic. Gowers relied upon the notions of discrete speech-centres, and he was obviously influenced to some extent by Bastian; even more so by Wernicke. Hughlings Jackson was mentioned two or three times. Gowers shared Jackson's interest in recurring utterances in aphasiacs but differed from him in believing that they probably represent the words actually spoken by the patient immediately before losing consciousness. Gowers, like Jackson and Kussmaul, believed also that there is more than one memory for words. The chapter in Gowers's Manual was pre-eminent as far as it went, but perhaps he failed to do justice to Hughlings Jackson. Both men were alike in their brilliance as clinical observers but quite different in personality. There were, of course, other Victorian writers of textbooks to whom aphasiology was an alien subject. It is apparent that, although Jackson was held in the highest esteem by his countrymen, few of them really understood his opinions upon language and its disorders. It was not so much that they disagreed with him as that they failed fully to comprehend him. A friendly critic once said, to Jackson's amusement, that his writings resembled "the love of God, in that it passeth all understanding". Not until 1891, and in Vienna rather than in Great Britain, was Jackson's attitude towards aphasia adequately appreciated. A slim but scholarly monograph appeared by Sigmund Freud, entitled Zur Auffassung der Aphasien.18 Freud stated that he had based almost all the arguments he had advanced in refutation of localization theories of the aphasias on the work of Hughlings Jackson. Freud said that he adopted as a guiding principle Jackson's doctrine that all these modes of reaction represent instances of functional retrogression

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(disinvolution) of a highly organised apparatus, and, therefore, that they correspond with earlier states of its functional development. Unfortunately, the book attracted scant attention at the time and its sales were disappointing—142 copies in the first year and 115 in the second. However, Dr. E. Stengel did a great service to Englishspeaking neurologists by translating this valuable volume and publishing it in 1953.19 Later still, in 1981, Professor E. Bay of Diisseldorf wrote a valuable paper on Freud's contributions to aphasia.20 According to Stengel, Freud was the first German-speaking neurologist to subject the then current theories of cerebral localization to critical analysis. He wrote: "None of the leading authorities in the field of aphasia escaped Freud's criticism, with the notable exception of Hughlings Jackson[,] for whom the author had nothing but praise and whom he pronounced his guiding spirit in the study of speech disorders."21 Two passages from Freud's text are worth quoting. In the English translation we read: "Perhaps there is no better illustration of the degree to which a moderately severe modification of the speech apparatus can persist in spite of damage, contrary to all theories of localization of ideas, than the following which I am borrowing from Hughlings Jackson. This author, on whose views I have based almost all the arguments which I have advanced in refuting the localizatory theory of the aphasias, discussed the not unusual case of the motor aphasic who, apart from 'yes' or 'no', has retained a residue to speech which otherwise would represent a complex activity of language."22 The other quotation from Freud is to be found under the heading "Conclusions": "I am well aware that the considerations set out in this book must leave a feeling of dissatisfaction in the reader's mind. I have endeavoured to demolish a convenient and attractive theory of the aphasias, and having succeeded in this, I have been able to put in its place something less obvious and less complete. . . . I should like to formulate the essence of my views briefly in a few sentences. Previous writers on aphasia who knew only of one cortical area with a special relation to speech disorder, found themselves compelled by the incompleteness of their knowledge to seek for an explanation of the variety of speech disorders in functional peculiarities of the apparatus of speech. After Wernicke had discovered the relationship of the area called after him to sensory aphasia, the hope was bound to arise that this variety could be fully understood from the circumstances of localization. It appears to us, however, that the significance of the factor of localization for aphasia has been overrated,

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and that we should be well advised once again to concern ourselves with the functional states of the apparatus of speech."23 Such lines might well have come from the pen of Hughlings Jackson. In 1913, two years after Jackson's death, the importance of his contributions to our knowledge of aphasia became apparent when Arnold Pick (1851—1924) of Prague dedicated his impresssive monograph on aggramatism, Die agrammatischen Sprachstorungen, thus: "Hughlings Jackson, the deepest thinker in neuropathology of the past century."24 This volume came to the attention of Henry Head in England, and he was aroused to study all of Jackson's writings on aphasia. Henry Head, who was elected Assistant Physician at the London (now the Royal London) Hospital in 1896, went a long way in elucidating many of Jackson's notions, and still more the often cryptic language in which the text was couched; he also rescued Jackson from putative neglect on the part of contemporary neurologists. Three circumstances contributed to Head's interest in this subject. First, his researches into disorders of tactual sensation resulting from highest-level cerebral lesions showed that there was an underlying communicative defect. Some cutaneous tactual stimuli would be missed altogether, while an increase in the force of the stimulus would not necessarily increase the accuracy of the patient's score. One aphasic patient, tested with compasses for tactile discrimination, could not say whether he was being touched by one stimulus or by two except by pointing to the appropriate numeral on a card. Sometimes he indicated he was being touched when no stimulus at all was being applied. Secondly, Head found that the classical writers on aphasia were unhelpful to him until he came across the many papers of Hughlings Jackson among relatively little-known journals. When the First World War broke out in Europe in 1914, Head was put in charge of the Empire Hospital for Officers. The appointment gave him an opportunity to see a number of cases of head injury occurring in otherwise healthy and intelligent young men. This was the third factor to contribute to Head's interest in language and its disorders. Head said that his work on brain-injured men in World War I would have been "insufficient to lead me to the conceptions I now hold had I not read Hughlings Jackson's long-forgotten papers on aphasia . . . for the first time I began to see light in the confused medley of clinical observations, and with each patient I examined by

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the new methods I came to understand more clearly Jackson's attitude to the problems of these disorders of speech. . . . During the later years of his life, he rarely if ever touched on his views concerning disorders of speech. . . . he seemed to have lost heart with regard to his papers on aphasia, in consequence of the complete neglect into which they had fallen. After his death, when I read through them in order, they came as a revelation, and not only explained the observations I was making on patients with war injuries but also indicated the route of further advance."25 In 1915 Head published his important paper "Hughlings Jackson on Aphasia and Kindred Affections of Speech".26 It appeared in a double issue of Brain, of which he was then Editor, and he appended some reprints of Jackson's more important papers on speech. Head put forward four explanations for the previous neglect of Jackson's work on aphasia: (1) Because of his great modesty, Jackson had taken little care to ensure that his views were known widely; he published his articles in journals which were relatively inaccessible; (2) Jackson's literary style was difficult to read; qualifications and explanations abounded in a manner which complicated the text and confused the reader; (3) He relied too much on the philosophy of Herbert Spencer; and (4) Jackson's dynamic approach to language and its disorders was quite different from that held by contemporary neurologists. In the Introduction to his 1915 paper, Henry Head did not mince words when challenging the current theories about aphasia and its protagonists, conspicuous among whom was Bastian. Referring to case-reports in the literature, Head wrote: "Each patient with a speech defect of cerebral origin is stretched on the procrustean bed of some theoretical scheme; something is lopped away at one part, something added at another, until the phenomena are said to correspond to some diagrammatic conception, which never has and never could have existed."27 Eleven years later, in a milder manner, Head wrote: "It was an era of robust faith and nobody suggested that the clinical data might be insufficient for such precise localisation; still less could they believe that the conclusions reported by men of eminent good faith might be grossly inaccurate. In reading these admirably written papers, we are astonished at the serene dogmatism with which the writers assume a knowledge of the working of the mind and its dependence on hypothetical groups of cells and fibres".28 In 1920 Head was nominated to give the sixth Hughlings Jackson Lecture. Dejerine had been invited to deliver it, but he died in 1919

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before doing so. Head's chosen topic was "Aphasia, An Historical Review".29 The next meeting of the Neurological Society was devoted to a full-scale discussion of his lecture, a most unusual procedure. Head's two-volume publication Aphasia and Kindred Disorders of Speech (an expanded version of his 1915 paper) appeared in 1926. In it he repeated what he had said earlier: "Dr. Hughlings Jackson was a man of such profound personal modesty that he laid little value on the publication of his views, although firmly convinced of their utility in explaining the phenomena of disease . . . The nature of the ideas he propounded was foreign to the current views of the day. He was always accustomed to say that 'it generally takes a truth twentyfive years to become known in medicine', a dictum certainly founded on his personal experience . . . But no one assimilated his views on defects of speech, and applied them to a series of actual examples of this condition. We failed to appreciate how much closer these conceptions would have led us to the phenomena of aphasia than the glib generalities founded on the anatomical facts of cortical localisation . . . In the last forty years philologists, psychologists, and students of philosophy have steadily progressed away from the conceptions expressed by neurologists, even in their most recent monographs and text-boooks. Neurology has become frozen stiffly in the grip of pseudo-metaphorical classifications which neither explain the conditions nor correspond to the clinical facts. The dangers of such false classifications were recognised by Jackson in 1878."30 The pervading influence of Jacksonian ideas was still evident in Head's writing, although there were developments of his own. Thus, instead of using Jackson's term 'propositionizing', Head suggested the phrase 'symbolic thinking and expression' or else 'symbolic formulation and expression'. He had drawn up a formal testing procedure which included a number of non-verbal items. He also introduced two novel concepts into his aphasiological thinking, namely, the factor of vigilance and the notion of schemata. Finally, he ventured, somewhat tentatively, to draw up a four-fold classification of the aphasias along psychological lines. At the Henry Head Centennial Meeting at The London Hospital on 31st August 1961, among the papers read was an evaluation of Head's contributions to aphasia.31 The last of Hughlings Jackson's house physicians at the National Hospital was Dr. S.A. Kinnier Wilson. Throughout his all too short professional career, Wilson was interested in aphasia. Although he was a dedicated advocate of Jacksonian ideas, Wilson's views on apha-

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sia were individual and out of harmony with notions that were neither conventional nor wholly Jacksonian. He contributed to the discussion which followed Henry Head's lecture in 1920 and published an article in The Lancet on the subject.32 Wilson's best-known literary contribution to aphasia was a minimonograph of about 20,000 words, which appeared as one of the Psyche Miniature Series in 1926.33 If not the most informative, it is certainly one of the most attractive essays on a difficult subject. There were a few specific references to Jackson's work, all of which were more or less laudatory. (Wilson was not the type of man to admit that he owed allegiance to anyone greater than himself.) But there were some ideas he put forward that were out of harmony with Jackson's teaching. Wilson was impressed by the hypothesis of localizable 'centres', though he was obviously in doubt as to the precise morphological nature of these alleged centres. He was out of sympathy with some of Henry Head's theories (which were not discussed by Jackson). Wilson favoured the idea (one which would not have appealed to Jackson) that so-called motor aphasia was really an aspect of apraxia, while the alleged sensory aphasias were a part of agnosia. He was sceptical of Head's contention that the 'pure' cases of word-blindness and of word-deafness reported in the literature were the product of inadequate clinical testing techniques. Thus, he believed that there was a clear-cut aphasic syndrome comprising an ability to hear words and to know that they were words, but without understanding what they meant. He said the affected person can repeat, parrot-fashion, correctly what he hears but without knowing what the words signify; he can write to dictation without comprehending what he has written; he can copy and even read aloud, but without understanding. However, Wilson rejected the term suggested for the alleged syndrome—'transcortical sensory aphasia'. It is doubtful whether Jackson would have approved of either the concept or the suggested terminology. Conspicuous within the coterie of loyal supporters of Jacksonian ideas was the erudite and deep-thinking neurological critic Sir Francis Walshe. It was he who, along with Gordon Holmes, assisted Dr. James Taylor in collecting and editing some of Jackson's scattered writings.34 A profound neurophysiologist as well as a clinical neurologist, Walshe had a deep philosophical trend of thought. He was a strong supporter of every aspect of Jackson's teaching. Though not particularly interested in the aphasias, Walshe realised the depth and soundness of Jackson's contributions to our understanding of speech and its disorders.

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In his paper "Contributions of John Hughlings Jackson to Neurology"35, Walshe discussed Jackson's attitude towards the physiological workings of the nervous system and their application in health and in disease. He used simple language to make clear Jackson's notion of levels within the nervous system, the duality of nervous symptomatology, the processes of evolution and of dissolution, and movements and their organization. In this account Walshe gave a brief, simple disquisition, honing Jackson's text of its prolixity and making clear what was obscure. He mentioned one of Jackson's more controversial beliefs concerning the role of the minor hemisphere in the use of words without taking issue with him. In one of the concluding paragraphs, Walshe said: "If I may use the metaphor, we know that Jackson could not identify, describe, or classify all the trees that make up the neurological wood to the degree we now can do, but he knew his Wood, and saw deeply into its role in the territory of the organism which it dominates and integrates. The modern student finds it difficult to see the wood for the trees, and the modern writer rarely helps him do so. He does not always have a synoptic concept of the nervous system in his mind . . . Perhaps this crude analogy may point the difference between much modern research on the nervous system, and that mode of study from which the genius of Jackson derived so much of this system's operational principles. Both modes have their place and limitations; and they complement one another, but the literature suggests that the larger harvest of general ideas comes from men who have not allowed themselves to become bogged down in the intricacies of apparatus and techniques, nor have fallen victims to the fallacies these so easily introduce into research."36 In his History of Neurology, W. Riese described F.M.R. Walshe as "a cyclopedic figure . . . with strong philosophical tendencies and a great sense of history; he is the legitimate trustee of the Jacksonian heritage in contemporary British neurology.' He described Walshe's textbook as small in content but embodying "the most consummate experience of the author in an unsurpassed didactic presentation."37 Mention has been made of writers of textbooks not being deeply cognisant of the complexities of aphasia. Walshe, the neurological critic par excellence, produced one of the shortest but most successful textbooks on nervous disorders, Diseases of the Nervous System.38 The section dealing with 'The Speech Function: Organization and Symptomatology' is outstanding. One would look in vain for a mention of Broca, Wernicke, Head or even Jackson, yet nothing of importance was left unsaid.

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A characteristic paragraph on the localisation of aphasia-producing lesions stated: "All we are entitled to say is that the integrity of this region [a fairly well-defined region of the left cerebral hemisphere, in a right-handed individual, bounded anteriorly by the second and third frontal convolutions and by the angular and first temporal convolutions posteriorly, the whole having roughly a quadrilateral form, as viewed on the convexity of the cerebral hemisphere] is essential to speech, but not that no other region of the cerebral cortex is concerned in the speech function. It is difficult to believe that a function so wide and diversified in range is wholly due to the activity of the small region we call the speech area."39 A handbook for students by W.B. Matthews and H. Miller reflects the modern trend towards dynamic attitudes in aphasiology. A brief account of aphasia ends: "The enthusiasm with which apparently 'pure' defects were greeted by an older generation of neurologists was due to their laudable desire to localize each specific function. A more dynamic approach to the physiology of speech has rendered such localization less captivating."40

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16 Pierre Marie, the Iconoclast and Later Writers on the Breakdown of Language

The first paper Pierre Marie wrote about aphasia was a casereport published in 1882.1 He was then 29 years old and assistant to J.M. Charcot at the Hopital Salpetriere. Over the next few years he wrote a few more purely descriptive papers dealing with one aspect or another of aphasia. They were simple in character and orthodox in viewpoint. His opinions were based largely upon the teachings of his master, Charcot, and were supplemented by his reading the contributions on the subject by Bastian and Broadbent of London, by Kussmaul of Strasbourg and by Wernicke of Breslau. Marie seems to have lost interest temporarily in aphasia for another decade or so, as there was then a lull in the output of papers on that topic. When Charcot died in 1893, Pierre Marie was given charge of the Neurological Service at the Bicetre. Over the following ten years his interest in aphasia revived, and he made a detailed examination of nearly 100 cases and studied the post-mortem specimens of over 50 of them. He then began to write a series of short papers which dealt with the 'mental life' of aphasiacs. They could be considered Jacksonian in spirit, although Hughlings Jackson's name did not appear at any time.

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These papers, published in the medical Press early in the 20th century, dealt with phenomena occurring in aphasiacs such as the speed of auditory reaction time, the immediate memory, the association of ideas and mental automatism. In 1905 Pierre Marie drew up a testing strategy suitable for recording the nature and type of speech disorders. He was one of the first to do so. Unexpectedly in 1906, Pierre Marie published a paper with the arresting title "La Troisieme Circonvolution Frontale Gauche Ne Joue Aucun Role Special dans la Fonction du Langage" ("The Left Frontal Convolution Plays No Special Role in the Function of Language.")2 The paper was in three parts, and it represented an arrant desecration of the holy places of contemporary dogma. Henry Head likened Pierre Marie's criticism to a harrow passing over a weed-choked field.3 What Jackson made of the attack is not known. He had recently given up much of his professional activity, for his health was no longer robust. However, some aspects of Pierre Marie's remarks would have appealed to him. According to Marie, Wernicke's placement of an auditory speech centre within the first temporal gyrus on the left side was radically false. All patients with aphasia exhibit some degree of difficulty in the comprehension of spoken language and always show an attentuation in general intellectual capacity, though a methodical and searching psychological examination may be necessary to demonstrate it. Pierre Marie rescued from the Musee Dupuytren the hardened brain of Leborgne, Broca's first patient. The specimen had not been cut and inspection now showed that the lesion was far more extensive than had been described. Not only was the Broca area involved but also the so-called Wernicke area. According to F. Schiller, Marie said: "I shall at least have the satisfaction that as a former interne of Broca's, and most proud of it, I may show that my chief has been mistaken, his mistake being highly excusable, and even inevitable, given the state of knowledge and the prevailing conditions of the period."4 Marie's criticism evoked an angry response from neurologists. Hostile reactions appeared in the Press, the chief antagonist being Dejerine. Marie was summoned to attend a special meeting of the Societe de Neurologic to defend his thesis; the meeting lasted for three days and was presided over by Dr. M. Klippel. Dr. Klippel contented himself by giving the floor to the various discussants still in

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heated debate, until suddenly he closed the meeting with the remark, "We are all agreed on the need to re-examine certain questions concerning aphasia."5 This statement concluded the controversy. It is astonishing to learn from a letter Pierre Marie wrote to Professor Th. Alajouanine6 that he had no innate interest in the subject of language and its impairment. His attention had been aroused in a roundabout and quite humdrum fashion. Primarily concerned with a straightforward problem in morbid anatomy, Marie became interested in the frontal lesions which Broca had described. Having discovered that the extent of the disease-process in the preserved brain specimens did not correspond with Broca's description, he set out to disprove the equation of aphasia with lesions at the foot of the third frontal gyrus. Investigating further the whole subject of speech-loss became imperative, although it was not a congenial task for him. So, reluctantly, Pierre Marie developed a philosophical, critical attitude towards a subject which most of his colleagues regarded as a clear-cut chapter in atomistic neurology. He said: "Thus I found myself the father or the godfather of a theory about aphasia, of which a few weeks before I had had no idea whatever. . . . Initially I had one and only one object in mind; to demolish the dogma of the third frontal. I had no desire to discuss the question of aphasia in general—a question which I looked upon as too difficult and which was not ripe within my mind."7 (translation from the original text in French). One of his loyal interns even dared to reproach Marie sadly: "Ah! Monsieur, comment avez vous pu ecrire un pareil article!!!"8 But none was more bitter in polemics than his old adversary Dejerine, whose tidy, conventional mind (the mind of an anatomist) was profoundly shocked. The quarrel grew and feelings ran so high as almost to culminate in blows—an affray deflected by the personal intervention of J. Babinski. This unfortunate, unhappy, unpropitious environment was not conducive to abstract or creative thinking. Speaking of Pierre Marie, Professor Henry Cohen said: "Even if we now regard Marie's ideas as perhaps too rigid and absolute, we must concede that they have stimulated newer conceptions and have had a deep influence on subsequent studies on the clinical disturbances of speech. One of the recurring lessons of science is that until the right question is posed, the right answer is seldom forthcoming. Have we yet formulated our problems on speech disturbances in terms of normal speech mechanisms, correlating so-called psychological and physiological knowledge? And do we know enough to do so?"9

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Marie had within his grasp an opportunity for a brilliant intervention on this special domain; he had been granted a glimpse of high windows from which he might have surveyed the broad acres of philosophy. Alas, his attention was distracted and he seems to have lost interest in the problems of speech-impairment. Pierre Marie was a quiet, dignified man who must have known Hughlings Jackson personally. When the latter retired from the London Hospital in 1893, his ex-students and colleagues subscribed to present him with mementoes. Among the subscribers was Pierre Marie (who Professor Jean Lhermitte said was the finest neurological teacher he had ever had). Biographical sketches of him have been written by H. Cohen, by M. Critchley and by M.F. Cole and M.C. Cole. In 1908 Dr. F. Moutier, Pierre Marie's principal assistant at the Bicetre, published the massive tome L'Aphasie de Broca10, and dedicated it to his master. Hughlings Jackson was quoted briefly in casereports of 1860, but there was no reference at all to his ideas or philosophies. This monograph was mentioned by Kurt Goldstein. Referring to the attempts to construct an ideal of a complete brain-map, he said of Moutier's book: "Today, one cannot read this survey without deploring the enormous, but mostly futile scholarship, which these attempts represent."11 Charles Karsner Mills (1845-1931) of Philadephia—often referred to as the 'Dean of American neurology'—was a learned practitioner of clinical neurology. Despite the handicap of a visual impairment which made reading difficult, in 1898 he published a textbook, The Nervous System and Its Diseases.12 Mills was especially interested in cerebral localization and is said to have been stimulated by the work of Hughlings Jackson. This is not revealed in his lengthy chapter on aphasia. Mills's view was largely orthodox, and he was an exponent of the hypothesis of speech centres. He was bold enough to venture a definition of a centre: "A collection of gray and white matter . . . which represents physiologically some action."13 In discussing aphasia, Mills relied largely on the writings of Brissaud, Bastian, Dejerine, Broadbent and, in particular, J. Wyllie. Freud's volume on aphasia was obviously known to him, but it is doubtful whether Mills was influenced by his prescient ideas about aphasia. He referred to Hughlings Jackson in the section on language disorders, where pantomime and gesticulation are described as the kinetic manifestations of voluntary as opposed to automatic speech.

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At a meeting of the Philadelphia Neurological Society in 1914, Mills opened a discussion at some length.14 His object was to reconcile conflicting views about the genesis of aphasia. He identified them as (1) the multi-centre theory of Broca, Wernicke and Bastian; (2) the 'intellectual' hypothesis of Pierre Marie; and (3) the 'apraxic' theory of Liepmann. Mills pleaded for the inclusion of the lenticula within the anatomical infrastructure of language. At no point did he invoke the dynamism of Hughlings Jackson. One of Mills's pupils, T.H. Weisenburg (1876-1934), was inspired by the subject, and when he delivered the first C.K. Mills Lecture, he chose as the title of his address "A Study of Aphasia."15 Weisenburg was an admirer of Hughlings Jackson, and in his book Aphasia, A Clinical and Psychological Study, written with a clinical psychologist, Katharine McBride, he discussed how the notion of speech centres had come about.16 The authors contrasted the work of Broca, Wernicke and Bastian with that of Jackson. That Jackson was 'ahead of his time', is a statement often made nowadays. But to Weisenburg, the phrase was hardly adequate. "Even now . . . with the far greater knowledge of cerebral functioning and of the abnormal changes in language and behaviour, there still appears every year work which has not caught up to Jackson. A greater tribute to his advanced thinking, however, is the larger amount of important modern work which is still based on some of his principles and still inspired by his conception of cerebral and nervous functioning."17 He pointed out that Jackson's theories about an aphasiac's ability to comprehend speech are less in accord with modern concepts. Jackson's strong views about the important role of the non-dominant hemisphere were unorthodox to his contemporaries, but his statement that "the 'faculty' of language could not be localized anywhere in the left hemisphere, 'or anywhere else except in the whole brain or whole body'", anticipated a point of view which had now become prominent, Weisenburg said.18 Weisenburg went on to declare that, following the work of Pick and of Head, Jackson had received the recognition he so long deserved, although he believed there were certain limitations. The author included in these Jackson's theory of pre-verbal formulation and the allegedly important role of the minor hemisphere in speech. Jackson's observational methods of studying an aphasiac had given way to various testing procedures, Weisenburg said. "That the work which has proved of lasting importance should so far outweigh the part which has been discarded is the final demonstration of Jackson's advanced thinking."19

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Something of a hiatus in American medical literature had occurred before the publication of Weisenburg and McBride's excellent book. In 1897, Dr. Joseph Collins was awarded the Alvarenga Prize by the American College of Physicians, Philadelphia, and his book The Faculty of Speech: a Clinical and Psychological Study of Aphasia was published the following year.20 It was written with some literary elegance and is largely the narration of unusual case-reports collected partly from the world's literature and partly from his own practice. Collins was a fervent localiser, an exponent of various cerebral centres. He held strong views and appeared to accept firmly the ideas propounded by Dejerine and his pupils. Broadbent was often quoted, sometimes critically. His remarks about Charcot were almost hostile, and his attitude towards Hughlings Jackson (the 'Nestor of English neurology') was odd. In one place Collins asserted that, apart from Broca and Wernicke, above all others who had increased our knowledge of aphasia, the three greatest were Trousseau, Hughlings Jackson and Kussmaul. He does not, however, seem to have read Jackson's work diligently because he quoted him rarely and then not always accurately. Although he was only 31 years of age when he was awarded the Alvarenga Prize, Dr. Collins seems never again to have written about aphasia. Still in the era before the publication of Weisenburg and McBride's book, mention should also be made of one of the smallest and most ambitious books on aphasia, namely, that written by Michael Osnato in 1920.21 It received the imprimatur of a preface penned by Professor F. Tilney. Within the fewer than 200 pages, Hughlings Jackson was referred to several times, and Osnato mentioned the neglect which had so often befallen Jackson's work. Osnato spoke of the researches of the many neuroanatomists and neurophysiologists of the 19th century and then wrote, rather ambiguously: "The keen and masterly work of Hughlings-Jackson (sic) is not mentioned with those of Charcot, Hitzig, Wernicke, Dejerine, etc., as the clinicians who helped in the localization of cortical function. Nevertheless, Head regarded Jackson's work of such great importance that he undertook to gather and edit a number of his publications which appeared together in an issue of Head's periodical Brain"22 Osnato regarded Kurt Goldstein as one of the greatest aphasiologists and said Jackson and Goldstein had much in common; both had sacrificed a career in academic philosophy for one in neuropsychology; both served an apprenticeship in morbid anatomy,

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Goldstein for a time having been first assistant to Edinger in Frankfurt. Kurt Goldstein's principal teacher at the medical school in Breslau had been Karl Wernicke, who directed his attention towards aphasia. After a while, however, Goldstein became critical of at least some of Wernicke's work. Goldstein's researches on aphasia extended over several decades, and from the start he was strongly influenced by Hughlings Jackson's teachings—a fact which he freely acknowledged. Shortly after migrating to the United States, Goldstein published his monograph Language and Language Disturbances.23 In it he stressed that, to Jackson, speech was not an unrelated succession of words but a matter of propositionizing. The loss of speech in aphasia represents a defect of a basic mental function which Goldstein called the 'abstract attitude*. He was an outstanding figure in neuropsychiatry, on a par with Henry Head and Alexander Luria. Goldstein continued to make important contributions on the subjects of aphasia and other aspects of higher nervous activity. Goldstein's longest and warmest tribute to Hughlings Jackson came in 1959, when he was 83 years of age. In a chapter in the American Handbook of Psychiatry, he wrote: "This particular problem [the determination of the relationship of an individual symptom to specific brain damage] had been seriously considered fifty years before by the famous English neurologist and psychopathologist, John Hughlings Jackson, who reached a general point of view in psychopathology to which ours bears much similarity. "Jackson, as an outgrowth of his experiences with aphasic patients, emphasized that psychopathological phenomena can be understood only if one gives up the theory of images, and he stopped considering disturbances of images in brain defects as causes of symptoms. He believed that, in order to understand psychopathological phenomena, one has to begin by analyzing the modification—due to its damage—of the function of the brain, and by considering the different symptoms of aphasic patients as expressions of a disintegration of the brain matter; expressions of a lowering of the function of the brain to a level where automatic and emotional rections still are possible, while the highest function, the propositional symbolic function, is more or less lost. "Jackson's ideas were so far ahead of his time that he found little approval. In the famous discussion between him and the French neurologist, Broca, at the British Association for the Advancement of

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Science in London [sic] in 1868, in which both men defended their contradictory theories about the function of the brain, Broca emerged as victor; afterward, Jackson had little influence on the work in psychopathology. Although some great men in the field at that time, A. Pick, C. von Monakow, Adolf Meyer, and others, stressed Jackson's great significance, referred to his ideas, and used them in their work, he was nearly forgotten for a long time. He had to be newly discovered. This rediscovery occurred during the period referred to previously when clinical practice demanded better procedures for helping brain-injured soldiers in England. It was the English neurologist, Henry Head, who based his treatments on Jackson's ideas and demonstrated their fruitfulness for understanding much of the aphasic symptomatology and for its treatment. A little earlier, other unbiased studies by Storch, Heilbronner, Pierre Marie, Lotmar, Boumann, Gruenbaum, Woerkom and K. Goldstein, influenced more or less by Jackson, gave different new interpretations of psychopathological phenomena which can be considered as precursory to the organismic approach."24 As well as Goldstein, other medical men in America held Hughlings Jackson in great respect, even affection. It is said that, on a visit to London, Silas Weir Mitchell—'the most versatile American since Franklin'—met Jackson, who introduced him to Herbert Spencer. However, this piece of information has not been substantiated. Jackson more than once referred to Weir Mitchell's masterly work Injuries of Nerves, published in 1872.25 When Weir Mitchell wrote Lectures on Diseases of the Nervous System, Especially in Women, in 1881, he dedicated the book to "J. Hughlings-Jackson [sic], M.D., F.R.S., with warm personal regards and in grateful acknowledgement of his services to the science of medicine."26 Adolf Meyer (1866—1950) first became acquainted with Hughlings Jackson's work during his early Wanderjahr throughout Europe. He said: "A much more decisive constructive step forward in dealing with pertinent issues came to me through the reading of Thomas Huxley's essays and Hughlings Jackson's neurological writings, through which an imprtant aspect of British thought came to exert a definite, more than merely epistemological, influence upon me."27 He went on to say, ". . . Hughlings Jackson's broad and inclusive concept of the hierarchy of evolution and dissolution processes, with a distinctive psychological level, called for correlations with my comparative neurological and neuropathological work, and my personal human interest in the causal efficiency of suggestion and mentation generally in psychiatric cases."28

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Meyer also said: "We owe a great debt to Hughlings Jackson—the foremost representative of those who rose to the principle which Spencer made the central thought of his philosophy, and which reflected British scientific thought and work from the middle of the 19th century."29 He then referred to Jackson's capacity for observation, his use of the principle of evolution and dissolution rather than narrower conceptions of structure and function, and his caution in the use of psychological terms. Referring to his early days in psychiatry, Adolf Meyer again spoke of the influence exerted on him by Jackson, whom he followed in avoiding loose identification of psychological and neurological concepts. Another important person in America associated with Hughlings Jackson was James Jackson Putnam (1846—1918). After medical qualification, he visited neurological clinics in Leipzig and Vienna, and also spent some time in London in 1870 attending the National Hospital, Queen Square. He was much impressed by William Gowers (ten years his senior), whom he described as "assistant" to Hughlings Jackson—a man he greatly admired. Ten years later Putnam revisited London. This time he saw a great deal of Jackson, attending his ward rounds at the National Hospital. Putnam was impressed with Jackson's teaching and in March 1913 gave an address in Boston on "Certain Features of the Work of the Late J. Hughlings Jackson of London."30 He described Jackson as a man endowed with a remarkable mind, capable of reaching with ease important generalisations but not overlooking the principle. He was, Putnam said, one of those individuals who stand midway between philosophers by profession and practical men of science. In philosophy he went as far as he knew technically, tending to adopt the mode of thinking of Herbert Spencer and his school; he might have gone much deeper had circumstances favoured his so doing. Putnam's later remarks suggest that Herbert Spencer's reputation as a philosopher was already in decline. One of Jackson's viewpoints which particularly appealed to Putnam was the concept of negative and positive manifestations of damage to the nervous system. He recalled that Jackson would draw a pyramid on the blackboard to illustrate the hierarchy of the functions of the nervous system. "But still, shining through this structure [the brain] and towering over it, he saw, with the prophetic vision of the true man of genius, what might be characterized, not alone as the function of the brain, but the possibilities of the personality, of which the brain is only an imperfect, and in some measure a retrograde, manifestation."31

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Analogous conclusions were subsequently arrived at by Goltz and by von Monakow, but as far as Putnam knew, Jackson's generalizations were not expressed by either of them. Putnam concluded by pointing out that many of Jackson's ideas later became absorbed and elaborated within the corpus of Freud's psychoanalytic doctrines. "Dr. Jackson showed himself a wise prophet and a keen observer in seeing the importance of a principle."32 In 1975 Marinusz Maruszewski, Professor of Psychology at the University of Warsaw, brought out an English version of his valuable monograph Language, Communication and the Brain?* originally published in 1966. The author surveyed the steps taken in the search to unravel the structures and functional properties that permit verbal communication. He produced a study of the history of aphasiological research. A review of Broca's theories, which constitute the beginning of a century and a half's quest for the mechanism of speech in man, is followed by reports of other cases of aphasia which differ, both clinically and in the site of the lesion, from Broca's cases. The work of Bastian, Ogle and Wernicke led to the popular localizational theory of aphasia, he said, and simultaneously the practice grew up of describing and explaining cerebral speech mechanisms. Later the localistic view began to founder and neuropsychological points of view began to deviate from static analytic approaches toward dynamic and holistic interpretations of the clinical phenomena. They gradually gained in popularity, he said, assuming the existence of a fundamental language factor dependent upon total brain functioning without assignment to any particular site within the cerebrum. It was at this juncture that Hughlings Jackson's writings appeared, which, Maruszewski remarked, remained forgotten [more accurately, neglected] until early in the 20th century. He went on to say that the state of euphoria accompanying the discoveries of 'centres' deflected interest from the articles Jackson wrote. Maruszewski next gave a brief outline of some of Jackson's views on speech and aphasia. He also said that the period between Broca's discovery and Pierre Marie's expostulation was one of "cerebral mythology and speculative schematization."34 Jackson has often been looked upon as a rigid anti-localizationist, but Marusewski pointed out that this notion is not correct. He was certainly critical of abrupt demarcation of speech centres, but Jackson had strong views as to the role of the non-dominant hemisphere. "I do not accept the current hypothesis as to the nature of

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Localisation ('abrupt localisation') any more than I do the one sometimes called 'Universalisation'."3' The author did not linger over an explanation or a criticism of Jackson's writing but proceeded to discuss contemporary ideas about the genesis of speech disorders. Mention should be made here of the teaching and writing of Professor Eberhard Bay of Diisseldorf, some of whose views would surely have appealed to Jackson.36 Bay rejected the notion of clinicoanatomical types of aphasia which reach their nadir in the WernickeLichtheim hypothesis with its seven such varieties. He believed that there is really only one form of aphasia, and that this represents a disorder of conceptual thinking. The study of aphasia benefited considerably from the careful researches carried out over an extended period of time at the University of Minnesota Graduate School of Medicine. The monograph written by H. Schuell, J.J. Jenkins and E. Jimenez-Pabon is an important contribution to aphasiological literature.37 After a brief historical survey, a couple of pages were devoted to Hughlings Jackson's views. His arguments were received sympathetically but were not discussed in great detail. When the authors quote him in the text, it is always in a complimentary way. They say it is helpful to specify what aphasia is not; that is, it is neither a loss of memory for events nor even a loss of memory for words. They refer to Jackson's remark that aphasic patients have words, saying that 'most good clinicians know tricks to elicit them'. The difficulty lies in retrieving words; good clinicians know they do not teach words to aphasiacs, but they use words to stimulate language-processes. When they are successful, more comes out than has been put in. Probably the most stimulating and the most original work on aphasia in recent years has emanated from Alexander Romanovich Luria (1902—1977). His views represent a retreat from anti-localizationist attitudes and a return to a dynamic type of localization. Luria emerged from a multi-disciplinary background as the person who succeeded in giving clinical psychology its present cachet, having derived considerable inspiration from his senior colleague, L.S. Vigotsky and, before him, I.M. Sechenov. Inevitably, too, he owed much to I.P. Pavlov. Luria did not recognise local speech centres in the brain. He believed that there were special cortical areas which can be identified as forming complicated systems for the analysis and synthesis of vi-

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sual, acoustic, motor and kinaesthetic impulses. Focal brain lesions, he said, cause a breakdown in such functional systems and lead to complicated secondary disturbances. He held Hughlings Jackson in great respect and often quoted him. Luria acknowledged Jackson's recognition of the fact that aphasic patients who are unable to name an object or to repeat a word might be able to do so involuntarily. It was Jackson, he said, who recognised levels of the organization of language or of mental processes in the brain rather than looking for their 'localization', and who stated that the brain organisation of these processes deals with their 'rerepresentation' or even 're-re-representation' in different levels of the brain. "Jackson," said Luria, "whose views were almost a hundred years ahead of their time, spoke not of the loss but of the 'disintegration' or 'dissolution' of function, of the reorganization of a function, of its descending to a more primitive level."38 He went on to say: "About fifty years ago Hughlings Jackson suggested that the entire anterior part of the cerebral cortex is related to the organization of motor activity at its highest level. Subsequent investigations have altogether confirmed his view."39 Luria recognised that Jackson was the first to direct attention to the level of speech activity that is disturbed rather than to the precise site of the underlying brain lesion. In this approach Luria preceded Pick, Goldstein and Ombredane. In 1966, Luria wrote: "During the 1860s, the celebrated English neurologist Hughlings Jackson, formulated a series of principles in sharp opposition to the contemporary ideas of narrow localization. These principles, destined to play an important role in the subsequent development of neurological thinking, were enunciated by Jackson in the course of a discussion with Broca . . . During the following decades, however, these principles were overshadowed by the successful progress of the localizationist's views, and it was not until the first quarter of the 20th century that these ideas came to be widely accepted."40 Luria also said: "The occurrences on which Jackson based his theories were irreconcilable with Broca's fundamental ideas and with the concepts proceeding from the belief in the cellular localization of functions. During his studies of motor and speech disturbances accompanying local brain lesions, Jackson observed a phenomenon that, at first glance, appeared paradoxical, namely, that a lesion of a circumscribed area of the brain never leads to the complete loss of a function. A patient with a lesion of a particular zone of the cortex

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frequently cannot perform a desired movement or repeat an arbitrarily given word, although he may be able to do so involuntarily, i.e. he may be able to reproduce the same movement or pronounce the same word when in a state of emotion or by habit."41 "Jackson's contemporaries took an incorrect and biased view of his ideas. His hypothesis pertaining to the complex character and vertical organization of functions was many decades ahead of the development of science at that time, and for a long time it remained forgotten, having been confirmed only very recently."42 Luria and Jackson had many qualities in common. Both were endowed with a simple personality which was overshadowed by a great intellect. It was unknown for either of them to make a derogatory remark about anyone, and both quoted freely, always in a complimentary vein, from the work of others. Like Jackson, too, Luria was a modest man with a good sense of fun. But whereas Jackson was reserved and detached, Luria was outgoing and gregarious. In 1972 Professor N. Geschwind reviewed Luria's Traumatic Aphasia at some length. At the outset, the reviewer said it was wise to disregard what an author in the field of aphasia states is his philosophical presupposition. The stated premises of most authors of works about aphasia, he said, seem to be little reflected in the actual content of their work. "Thus Luria approves strongly of Jackson, but so do all other writers on aphasia (except perhaps myself, who can approve only mildly)."43 This is the only deprecatory remark about Hughlings Jackson's work that has come to notice. Probably the most exhaustive textbook of neurology in the English language in modern time is the multi-volume Handbook of Clinical Neurology, edited by P.J. Vinken and G.W. Bruyn.44 The section on aphasia was written by F. Lhermitte and J.-C. Gautier. It represents the views on aphasia that have evolved as a result of decades of teaching and research at the Hopital Salpetriere. Following Pierre Marie were the investigations carried out by Professor Theophile Alajouanine and his pupil, Professor Francois Lhermitte. Prominent among their co-workers was their clinical assistant, Dr. A. Ombredane. This school of aphasia was strongly influenced by Hughlings Jackson. According to Lhermitte and Gautier, Jackson took an entirely different attitude during a time when interest in aphasia was monopolised by a quest for anatomo-clinical localizations, and his clinical studies led him to a dynamic outlook. Jackson's distinction between propositionizing and emotional speech had been anticipated by Baillarger, they said. As pointed out earlier, Jackson fully recognised

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this fact. The authors stated that Jackson is also to be remembered for his pioneer descriptions of apraxia and of agnosia, the latter having been called 'imperception' by him. They recognised that Jackson's views had had a deep, lasting influence on aphasiology, and said that among those whose work developed from his conceptions were Pick, Goldstein, Isserlin, Head, van Woerkom, von Monakow, Mourgue, Alajouanine, Ombredane, Lhermitte, Critchley, Bay and Russell Brain, among others. The 20th-century French-speaking school of aphasiology was described by Tissot, a Swiss neuropsychiatrist, as constituting neoJacksonian or super-Jacksonian thinking. He did not give a clear explanation of what was meant by these terms. Franfois Lhermitte, in collaboration with Dr. J.L. Signoret, produced a fascinating study of the development of aphasiological concepts in France following Charcot.45 They said Charcot "launched into strange ideas" about aphasia but, nevertheless, he went beyond simplistic mechanisms and introduced some dynamic factors, such as the suppleance fonctionelle, or the plasticity of neurophysiological activity. It is strange that Charcot's ideas of aphasia were never really promulgated except in a paper written in 1883 by Pierre Marie, who, 23 years later, "was virulent concerning the localizationist doctrines that he himself had accepted."46 Ten years on, Pierre Marie's ideas underwent a revolutionary change. The authors give a detailed account to the reaction to Pierre Marie's iconoclasm and of his bitter quarrel with Dejerine at the three-day special meeting of the Societe de Neurologic in 1907. For the next 30 years aphasiology advanced only outside France, until the appearance of Alajouanine's writings. "One of the sources of Alajouanine's thought is found in the works of Jackson, who analysed linguistic errors according to the psychological conditions of language."47 Alajouanine was responsible for establishing the first Centre du Langage at the Salpetriere for the rehabilitation of aphasiacs. Lhermitte and Signoret concluded their summary with a striking passage from Valery: ". . . one is terrified, humiliated, annihilated when language is destroyed, because one destroys forthwith . . . all civilisation and the lights and shadows of the 'world' and the world and nothing remains which resembles anything, formlessness."48 After working on various aphasiological projects with Professor Alajouanine, Andre Ombredane left Paris for the University of Brussels, where he occupied the Chair in Psychology. In 1951 he

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produced his considerable volume L'aphasie de I'elaboration de la Pensee Explicite.49 He wrote about the great influence of Jackson on his own thinking and included numerous quotations from Jackson's work. Ombredane mentioned Jackson's quip that it takes 25 years to establish a new idea in Medicine, and said the profundity of his ideas was not realised until the appearance of Arnold Pick's dedication of his Agrammatism to him in 1913. The long-awaited encyclopaedic Neurology by S.A. Kinnier Wilson was published in 1940.50 Unfortunately, the author had died in 1937 and the work, though revised by his brother-in-law, Dr. Ninian Bruce, was incomplete. Wilson had not written the sections on aphasia, apraxia and agnosia. For the second edition, published in 1961, Russell Brain (Lord Brain) had been invited to write the missing chapters. He did so, and also received permission to produce an enlarged version of the text in a separate publication in 1965. This brief, clearly written volume may well be regarded as the most successful book on aphasiology published in Great Britain since Henry Head's. It has the merit of containing chapters on the origin of language, the relationship between thought and language, and the development of speech in the child. Unlike most works on aphasia, it did not include details of personally observed cases—which is to the good. The substance of Russell Brain's Hughlings Jackson Lecture, "The Neurology of Language", was published, thus bringing up-to-date in 1961 the most recent researches in the field.51 It was a valuable contribution. Brain pointed out that there were three schools of thought on the then contemporary aphasiological scene: (1) the classical anatomo-clinical approach; (2) the holistic or anti-localizational viewpoint; and (3) a more recent empirical attitude. Brain seems to have belonged to the third category. Dealing with the history of thought about aphasia, Brain gave a full account of Jackson's revolutionary outlook. He said most of Jackson's remarks referred to the type of aphasia which came to be regarded as 'motor'; later on, he spoke of what became known as 'sensory' aphasia, but Jackson had far less to say on that matter. Brain stated that Jackson spoke of 'imperception' when referring to what Bastian and others called 'word-deafness' and 'word-blindness' and was less interested in the correlation between disturbance of function and the site of the lesion. At the same time, he believed that the subordinate hemisphere played an important role in the genesis of automatic speech.

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Brain emphasized the disregard which followed Jackson's writings on aphasia, the result of their not being understood, but noted other contributors to the dynamic mode of thought, notably Finkelnburg and Kussmaul. Although Jackson did not know German, he must have read some articles in translation, according to Brain, for he referred approvingly to Kussmaul's work. In 1970 it was said: "Ideas, whether they be true or false, have stupendous potentialities in human affairs. But ideas catch on slowly, as Jackson himself used to remark, especially in medicine where an innate conservatism obtains. The second half of the nineteenth century was a period in neurology when clinico-pathological correlation was winning easy prizes. The work was descriptive in character, not reflective. It was self-evident and easy to comprehend. Much of it was worthy factual bricks-and-mortar stuff. Little wonder Jackson's ideas especially on aphasia were temporarily overshadowed by those who made brief clinical studies high-lighting the obvious, and who sought by way of morbid anatomy a key to the understanding of the normal faculty of language. But the seeds had fallen and in due course they germinated."'2

17 Jackson's Achievements Assessed by Other Neurologists

Hughlings Jackson's work has been the subject of many contributors to the neurological literature over and above formal monographs and lectures on aphasiology. Papers have also been written by colleagues and friends which referred to his personality rather than his philosophy. He has probably attracted more attention than most other neurologists of his time. Among the serious items of Jacksoniana was the dissertation in 1978 of Professor Kenneth Dewhurst of the University of the West Indies, Jamaica.1 It dealt with Hughlings Jackson's contributions to psychiatry. Dewhurst discussed the various psychological states which had interested Jackson— notably the phenomenon of consciousness—and quoted the interpretation of his own views on the unconscious state which were formulated by Dr. D. Williams. Jackson's rather ambiguous conception of hysteria was referred to; his description of epileptic dreamy states is relegated to the collection of psychiatric conditions which especially interested Jackson. Dewhurst's opinion was that contemporary British psychiatrists either ignored Jackson's work in neuropsychiatry or

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misunderstood it. He also suggested that Jackson had given too much credit to Herbert Spencer, an opinion shared by Jonathan Hutchinson and Dr. Charles Mercier. The latter said that reading Spencer's autobiography destroyed not only his respect for the man but also—illogically, perhaps—his faith in his doctrines. "It seems impossible that the opinions of a man who depicts himself as the glorified quintessence of a prig can be worth anything."2 (In this connection, Carlyle spoke of Spencer as an 'immeasurable ass'). Dewhurst mentioned Jackson's influence upon Freud's thinking about aphasia, and he joined Binswanger and Stengel in wondering how much this extended to Freudian psychopathology. He thought that, among European psychiatrists, Henri Ey of the University of Paris conspicuously remoulded Jacksonian ideas. "Ey emerged and modified Jacksonian neurodynamics with aspects of Freudian psychoanalysis and Janet's phenomenology, with emphasis on the reflective explanation of the content of consciousness."3 According to Professor Ey, Jackson regarded consciousness as "a mere abstract concept equivalent to 'mentation', which itself was parallel to higher nervous activity. This view appears to have been held by several neurologists and neurophysiologists, but most psychiatrists have regarded disorders of consciousness as part of reality, so that consciousness itself must also be regarded in a similar light; such disorders are thus the basic symptoms of organic brain disease."4 When Dr. A.W. Campbell of Sydney, Australia, gave an address to the New South Wales Medical Association, he had intended to present a summary of Jackson's teaching but, in preparing his lecture, he said, he might as well try "to abstract the Psalms of David".5 Dr. Campbell (1868—1937), an Australian who received his medical education in Edinburgh, was pathologist to the Rainhill Asylum near Liverpool for 13 years and was famed for his original work on cortical cyto-architectonics in Man. He returned to Australia and practised neuropsychiatry in Sydney. He said Jackson's writings must be read as a whole and then reread: they cannot be epitomized. Dr. Campbell recapitulated many of Jackson's contributions to neurology and said his writings could not be read quickly. "Diligence, therefore, is demanded, and the reward of diligent reading may be that meanings at first dim will break forth in a clear and at times a brilliant light."6 He paid tribute to Jackson as a doctor and said he was a singularly astute physician. He quoted Jackson's remarks on a patient with heart disease: "However noisy the first sound may be at the base of

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the heart, if the apex be in the right place, if there be no signs of hypertrophy, no anaemia, if the pulse be good, and above all, if the patient does his work well, we have nothing to treat. Never treat a patient on stethoscopic evidence only. To treat such a case would be to treat a sound. It would just be as great a mistake as that of the drunken captain who tried to navigate his vessel round a speck of dirt on his chart which he mistook for an island."7 As for the man himself, Campbell said: "In his hospital work there was a charm of character of Jackson which endeared him to his house physicians."8 Campbell's concluding words were interesting: "... I must mention that though I attended Queen Square when Jackson was an active member of the staff, I held no office; my personal contact with him was no closer than that of a newly fledged graduate and ward follower. And I must frankly, though sadly, make the confession that at this time I failed to realize his greatness. He spoke as he wrote, in terms which were beyond the young disciple. As a teaching instrument he preferred his pen to his tongue. Besides, there were other giants on the staff—Cowers, Buzzard and Bastian, with Victor Horsley and Risien Russell as juniors—and it was Cowers who attracted most, because, when he was in the mood, this man had no equal as the demonstrator of a neurological case. It was not until later days, when I studiously read Jackson, looked back upon his kindly and meritorious life and upon the inspiration he had breathed for so many years into generations of house physicians, and recognized how much more it was the thinkers than the teachers who advanced medicine, that the real depth and worth of his wisdom came upon me."9 On the occasion of the Hughlings Jackson Centenary in 1935, Dr. Donald McEachern of the Montreal Neurological Institute wrote a warm appraisal of him. Unlike some subsequent authors, McEachern emphasised that Jackson was not a classifier of facts in the same sense as the nosology of French neurologists; rather, he was a confounder of ideas and precepts. McEachern spoke of the impossibility of indexing Jackson's contributions or of listing his attainments. "One feels that Jackson's integrating principles have been woven into the fabric of neurology with less credit to him than his genius deserves."10 McEachern ended his paper thus: "Jackson was not just an armchair philosopher. He was the general of a regiment of facts with a genius for marshalling and moulding them into fundamental principles of science."11 A symposium was held at the London Hospital (now the Royal London Hospital) on the 150th anniversary of Jackson's birth. Among

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the papers were some dealing with modern attitudes of neurophysiologists to Jacksonian concepts. The proceedings of the meeting were published in 1989.12 A few writers have specialised in Hughlings Jackson's writings. They include Walther Riese, Max Levin and Samuel Greenblatt. Among American writers who have given special attention to the life and works of Dr. John Hughlings Jackson, Samuel Greenblatt occupies a prominent place. His first contribution was his M.A. thesis for the Faculty of Philosophy at Johns Hopkins Hospital, published in The Bulletin of the History of Medicine.13 It is a wellresearched paper which attempted to explore the circumstances leading to Jackson's becoming the outstanding British neurologist of the 19th century. Greenblatt said that Dr. Thomas Laycock is recognised as probably the first and most important person to influence Jackson's thinking, and that probably he was also the first to turn Jackson's interest towards neurology. (But the contact between Laycock and Jackson was early and brief, Jackson then being a medical student. He left York to sit his qualifying examinations in London at about the time that Laycock left York for Edinburgh.) Greenblatt believed that Laycock was greatly influenced by the French school of anatomo-clinical diagnosis, which, he said, led the world of medical thought. It is possible that Greenblatt over-estimated not only the role of French medicine at the end of the 18th century, but also its alleged influence on Laycock. It is unlikely that Jackson owed any considerable debt to French medical tradition or, in particular, to Dr. Pierre Louis, which was Greenblatt's opinion. The next person to have had an effect on Jackson, Greenblatt asserted, was Jonathan Hutchinson. He said that "the great men of Guy's" were carriers of the Hunterian tradition and that they, too, had a potent impact on Jackson's medical thinking. Probably this statement again went too far. Greenblatt did not mention the great and enduring impact of Sir James Paget of St. Bartholomew's Hospital. According to Greenblatt, Jackson came upon his understanding of unilateral convulsions relatively slowly, assisted by his acquaintanceship with the pathology of syphilis, as evidenced by Hutchinson, Wilks, Addison and others. "It does not detract from Jackson's genius to say that this understanding grew out of his associations with other men."14 It was Hutchinson who said that the young Hughlings Jackson was well aware of his own abilities; Greenblatt went further and suggested that Jackson might have had a sense of his own destiny. "He

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may have been careless about the details of his day to day life, but he cared very much about his place in the broader scope of events."15 However, this seems to be out of character, as we know that Jackson was notoriously modest. Another man who reinforced Laycock's influence on Jackson, stated Greenblatt, was that 'wandering scholar', Edouard BrownSequard. Hutchinson told us that it was Brown-Sequard who urged Jackson to specialise in diseases of the nervous system. Moreover he drew Jackson's attention to a vacancy at the National Hospital for the Paralysed and Epileptic, Queen Square in London, where he himself was a Physician. In discussing Brown-Sequard's influence on Jackson, Greenblatt again emphasized the alleged French connection, pointing out that the former was born in Mauritius of a French mother and also that he received his medical education in Paris. Greenblatt wrote that Jackson's first references to Herbert Spencer were in 1864, which suggests that he (Jackson) was familiar with Principles of Philosophy and probably with also Essays: Scientific, Political and Speculative. It is also evident, he said, that the young Jackson had read some of the writings of that self-taught polymath, George Henry Lewes (sometimes dubbed 'Mr. George Eliot'. It was Lewes whose writings first directed Herbert Spencer towards philosophy in 1851). In his paper Greenblatt did not refer to Alexander Bain (1818-1903), Professor of Logic at the University of Aberdeen. Undoubtedly he should have been included among the philosophers whose writings had some impact upon Jackson's thinking because Bain is often mentioned by him (Jackson). In 1969 Greenblatt read a paper at a meeting of the Academy of Aphasia on the first encounter between Jackson and Broca.16 Again he emphasized that Jackson owed the conception of internal as opposed to external speech to Brown-Sequard, who, in turn, had been taught it by his teacher in Paris, Jean Baptiste Bouillaud. It is probable that such a communicative chain is too tenuous to be plausible. Bouillaud was Dean of the Paris Faculty of Medicine, but no evidence has come to light that he was Brown-Sequard's tutor. Another of Greenblatt's papers, written in 1977, dealt with Hughlings Jackson's literary work from 1863 to 1866 inclusive, "a period when his major theories began to take shape".17 Greenblatt postulated that the lull in his writings in 1865 might be explained by it being the year of Jackson's marriage, but the following year saw an increased outpouring. Here he detected the

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beginning of Jackson's mature concepts about convulsive seizures and cerebral localization. Jackson had already observed 500 cases of hemiplegia and stated that hemiplegia did not entail a paralysis of one-half of the body's musculature, for axial muscles were spared. When the next year Broadbent published his hypothesis on the cause of axial sparing, Jackson accepted the principle and repeatedly quoted it. According to Greenblatt, Herbert Spencer's influence on Jackson began later than was commonly supposed, and Jackson seemed to accept Broca's faculty psychology in 1864, only to reject it two years later in favour of his previous associationism. Jackson did not, he said, often refer to Spencer until 1866. A further article written by Greenblatt was published in 1991, his object being to explain the abrupt upsurge of medical philosophy which took place in the 1860s and 1870s. He compared the contents of the neurological textbooks of M.H. Romberg (1851), William Hammond (1876) and Houston Merritt (1963). Greenblatt said that the modern mode of neurological thinking was evident in Hammond's volume, and that the striking advancement recognisable at that date was largely due to the influence of Charcot and of Hughlings Jackson. "We are still living and working within the nosological paradigm that was bequeathed to us by Charcot and Jackson and the other pioneers of their exciting era."18 Walter Riese of Richmond, Virginia, was another neuro-psychiatrist who contributed largely to the literature about Hughlings Jackson. He had trained at Edinger's laboratory in Frankfurt, where his immediate senior colleague was Kurt Goldstein. Riese's writings included views on consciousness, cerebral localization and aphasia. His essays revealed his wide knowledge and deep thinking. He also wrote a short but valuable history of neurology.19 Riese showed a profound, sympathetic appreciation of Jackson and his work, in particular in his paper "Hughlings Jackson's Doctrine of Aphasia and Its Significance Today."20 He quoted Jackson's refutation of Broca's notion of a faculty of language: a lesion close to the corpus striatum induces a defect of expression (by words, writing, signs) because this is the way out from the hemisphere to the organ which the will can set in motion. Riese referred to this formula as a master-stroke; it afforded the brain an instrument of speech while denying it any claim to serve as a centre of language. This was an observation of stupendous simplicity that inspired Jackson to conceive and to develop his doctrine of aphasia, he said. A speechless person who is unable to utter a

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word when asked to do so may yet, a moment later, emit that same word automatically. "Here was demonstrated", said Riese, "for the first time in the history of aphasia, the flexibility of defects. This meant the end of the famous doctrine of speech centres."21 The latter part of that statement is acceptable, but surely Riese had omitted the Baillarger principle, which had been enunciated two years before Jackson. Another American psychiatrist who was an enthusiastic advocate of Jacksonian doctrines, and who wrote several papers on the subject, was Dr. Max Levin of New York. Over three decades he published many articles on psychiatric themes and contrived to introduce Jackson's observations into the text as illustration, especially on disorders of mentation. In a paper which appeared in 1962, Levin criticised the common type of psychiatric research, he said, which is more a gathering of facts to be analysed statistically than seeking an explanation.22 Levin told how he first became acquainted with Jackson's teachings. He happened to come across the first two volumes of Brain and, prompted by a desire to see what neurologists were saying in those days, he read Jackson's "On Affectation of Speech from Diseases of the Brain", printed in Volume 1. He was enchanted by Jackson's exposition of a complicated subject. "Readers justly complain of his obscure writing, for he lacked the literary grace of a Sherrington. But no one can complain of his thinking. Jackson was no giant of the pen, but he was a giant of the intellect."23 Shortly after he 'discovered' Jackson, Levin encountered a delirious patient who, when asked, was unable to name Levin's profession. Yet he never failed to address him automatically as 'doctor'. This was the phenomenon Jackson had portrayed so explicitly. Levin said that Jackson's great achievement was to develop a conception of the organization of the nervous system commensurate with its function as the organ of adaptation. He compared it with the architectural plan of a great cathedral. However, Levin was on less secure ground when he went on to say that the work on Jacksonian epilepsy was more like a detail in the ornamentation of the ceiling of such an edifice. He also asserted that Jackson's colleagues expressed the opinion that he was not a good clinician, but Levin gave no supporting evidence for the remark. It cannot be true; Jackson was an inspired, punctilious observer. One can only imagine that the remarks of Farquhar Buzzard, one of Jackson's house physicians, must have been misinterpreted. Could Dr. Levin have read Jackson's pamphlet which

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was privately printed in 1863? Though only 28 years of age, Jackson had abundantly revealed his stature even then as a thorough clinician. He showed that particular attention was paid to a study of the circulatory and respiratory systems in patients presenting with neurological problems. Jackson believed that the general health and vigour of patients with epilepsy or paralysis were all-important in their overall assessment. We know, too, that, as late as 1907, Jackson was asking Kinnier Wilson to make a detailed examination of a patient. "Please examine the patient's face very carefully. Is it not a little drawn to the right? Does she close both eyes equally firmly? How is the face when she 'shews her teeth'? How is the face when she puts out her tongue?"25 In his excellent, exhaustive biography of Paul Broca,26 Francis Schiller described in detail the circumstances which led up to the 'discovery' of the 'speech-centre', and also the events at the meeting in Norwich which was attended by both Broca and Hughlings Jackson. Schiller commented on Jackson's fairness, "one might almost say humility", and stated that his minimising the controversy was "wholly admirable". But, Schiller asked, if Jackson's statement that the so-called faculty of language has no existence (as Jackson seemed to be saying), what are we trying to localize? He also spoke of what he terms Jackson's "compromising and psychologizing", contrasting them with the clean-cutting, surgical French mind of Broca. It may be asked, however, whether such a remarkable and highly individual aspect of personality as language can be related to a tiny segment of the cerebral cortex. Schiller might well have quoted the words of that distinguished linguist Edward Sapir, who wrote in 1921: "Language as such is not and cannot be definitely localized, for it consists of a peculiar symbolic relation—physiologically an arbitrary one—between all possible elements of consciousness on the one hand and certain selected elements localized in the auditory, motor, and other cerebral and nervous tracts on the other. If language can be said to be definitely 'localized' in the brain, it is only in that general and rather useless sense in which all aspects of consciousness, all human interest and activity, may be said to be 'in the brain'."27 Later in his book, Schiller admitted that speech—a function hard to define—is localized in an area equally hard to determine. Aphasia cannot be tied to any histologically circumscribed cortical area. He said that, however reluctant one is to talk of a seat of language, "in practice we cannot abandon 'Broca's area'."28 Most of the writers mentioned so far never met Jackson in per-

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son. Many were born after he had ceased to write in 1903 or after he died in 1911. For that reason, Gordon Holmes's judgements are particularly valuable. Ordinarily Jackson would have retired from the National Hospital in 1900 at the age of 65, but the Medical Committee extended his tenure of office for another ten years. Holmes, therefore, knew Jackson personally when he was elderly, deaf and liable to dizziness, but still venerated by his younger colleagues and by his pupils. It must be borne in mind that Holmes was no ordinary man himself. During the first 30 years of the 20th century, he was probably the world's greatest neurologist in active practice. Holmes was indeed a neurological colossus. In 1954 Gordon Holmes wrote a small volume on the history of the National Hospital, Queen Square. He began his remarks about Jackson by saying "than whom there is no greater figure in the history of modern neurology".29 He sketched Jackson's early days in York and in London, as well as his association with the National Hospital from the time of his appointment as Assistant Physician at the age of 27. Holmes went on to say that hidden in Jackson's many papers (and often discovered only after repeated readings by those who had the insight and perseverance to overcome the difficulties caused by an obscure style and a passion for long parentheses) were penetrating generalisations and cues for future investigators. "It is easy to lapse into a kind of ancestor worship of Jackson, but those who know his thought best know that it has a life and a pertinence to modern problems in neurology that justify the admiration of the most critical, and we can salute his genius without believing that all he said is final and forever adequate to generalise the great additions to knowledge that have accrued since his day."30 In considering these qualifying remarks, it must be remembered that Holmes was no philosopher. For all his pre-eminence, he had a blind spot. His strength lay in accurate observation and scrupulous recording; speculative thinking actually angered him. For this reason, Holmes was probably not the best person to evaluate Jackson and Jacksonian concepts. Perhaps the most successful assessor among British neurologists of Hughlings Jackson's work was Sir Francis Walshe, that shrewd, if at times censorious, medical philosopher. In his comprehensive paper of 1943, "On the Mode of Representation of Movements in the Motor Cortex, with Special Reference to 'Convulsions Beginning Unilaterally (Jackson)'",31 he summarized his thoughts as follows: "The so-called 'classic' theory of the cortical representation of move-

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ments proposes a cortical mosaic of 'points' in the excitable motor cortex, each of which represents a single small movement, sometimes one activating but two muscles reciprocally."32 " . . . The phenomena of Jacksonian convulsions and of hemiplegia also afford support to the hypothesis of -widespread fields of localization that Jackson formulated, and are inexplicable on the basis of the punctuate theory of localization."33 (italics not in the original). Jackson did not live to witness two considerable changes in the field of aphasiology. Since his time, there has been a gradual and increasing influence of linguists upon the understanding of languagedecay. Once regarded as the Cinderella of disciplines, linguistics has developed into an important aspect of the behavioural sciences. With the researches of Roman Jakobson in the 1960s and fostered by a few far-sighted neurologists, an interest focused on the scientific study of language in all its aspects gradually evolved: language in operation; language in drift; language in its nascent state; and language in dissolutiom. This factor determined the second change in the aphasiological scene, namely, a decline in interest among clinical neurologists in disorders of language. Partly this was due to advances in technical aids to diagnosis, so that a detailed clinical study to locate the site of an aphasia-producing lesion was no longer essential. There was also a lack of concern with the pure neurology of aphasia (that is, what Jackson would have called the nervous arrangements of language-disorders), and the upsurge of such subjects as speech therapy. The latter decades of the 20th century also witnessed a remarkable development of systematic testing procedures directed towards an assessment of the levels at which language performance breaks down. Many aspects of contemporary linguistics would have appealed to Jackson, but he would not have liked the lack of concern among many present-day neurologists with the inscrutabilities of languagedisorders. Among the late-20th-century coterie of advanced thinkers in the deeper waters of aphasiology is the distinguished Professor Peter Kennedy. He concludes his remarkable essay: "In my view the writings of John Hughlings Jackson, both general and those specifically related to speech disorders, continue to have considerable relevance to modern neurology, neurobiology and linguistic philosophy. His ideas are strikingly original, his style distinctive, and some of his general principles still applicable to modern neurological practice."34

18 Foundation of Brain and the Hughlings Jackson Lectures

James Crichton-Browne retired from the post of Superintendent of the Wakefield Asylum in 1875, and he was then appointed the Lord Chancellor's Visitor in Lunacy. His successor was not willing to continue publishing the West Riding Asylum Reports, and there was no obvious medium in Great Britain suitable for representing neurological opinions. In 1878, under the joint editorship of J.C. Bucknill, James Crichton-Browne, David Ferrier and John Hughlings Jackson, the prestigious quarterly journal Brain was founded. The first number appeared in April 1878. To begin with, Crichton-Browne did most of the editorial work. Dr. A. de Watteville came to assist the harassed Editors in 1880; in 1883, he joined the Editorial Board and was appointed Acting Editor in 1885. In 1885 de Watteville organized the establishment of the Neurological Society of London. The first meeting took place at his house, 30 Welbeck Street, on 14th November 1885. The first general meeting was held on 14th January 1886. Hughlings Jackson was elected President, and the Society's officers consisted of Samuel Wilks, James Crichton-Browne, J.S. Bristowe, H.C. Bastian, William Broadbent, J.C. Bucknill,

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Thomas Buzzard, David Ferrier, Francis Gallon, Jonathan Hutchinson, GJ. Romanes and E. Schafer. The two Secretaries were Hughes Bennett and A. de Watteville. There were 95 original members. The first ordinary meeting of the Neurological Society took place at the National Hospital, Queen Square, on 24th March 1886, and Jackson gave the inaugural address, "On the Scope and Aims of Neurology." In February 1887 Brain became the official journal of the Neurological Society and de Watteville its sole Editor. The Neurological Society merged with a number of other specialist bodies to form The Royal Society of Medicine in July 1907. Pending the construction of its premises at No. 1 Wimpole Street in 1912, the Neurological Section of The Royal Society of Medicine met in the Royal Medical and Chirurgical Society's building at 20 Hanover Square, and then for the next two years at Jonathan Hutchinson's house at 15 Cavendish Square. On 15th October 1897, at a meeting of the Neurological Society and at the suggestion of Dr. W.S. Colman, it was decided to institute a Hughlings Jackson Lecture, to be delivered every three years, and that Jackson himself should be invited to give the first of these addresses. Replying to the two Secretaries of the Society, F. Mott and J.S. Risien Russell, Jackson said: "I am highly gratified by the kind intentions of the Council of the Neurological Society, and need scarcely say that I gladly accept their offer to deliver the first lecture of the new course." Jackson gave the first of his named lectures on 8th December 1897. His subject was "Remarks on the Relations of Different Divisions of the Central Nervous System to One Another, and to Parts of the Body."1 Seven years later, in 1904, Jackson was elected an Honorary Member of the Neurological Section of the Royal Society of Medicine, and two years after that a special edition of Brain2 was published as a tribute and a mark of respect and affection for Hughlings Jackson in the 50th year of his medical practice. The photograph published as a frontispiece was used as a basis for the portrait on the medal given to future Hughlings Jackson Lecturers. The second Hughlings Jackson Lecture was delivered on 29th November 1900 by Professor Eduard Hitzig, then of Halle, his theme being "Hughlings Jackson and the Cortical Motor Centres in the Light of Physiological Research."3 The third lecture was given three years after that, on 5th November 1903, by Sir William Broadbent, who chose "Hughlings Jackson as

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Pioneer of Nervous Physiology and Pathology" as his subject (see Chapter 15). In a letter to his brother Thomas in New Zealand dated 29th March 1904, Jackson wrote: "You will have received from me a copy of the third Hughlings Jackson lecture. I was present at the delivery of it and heard nothing" (because of his deafness). Sir Victor Horsley was the fourth Lecturer on 29th November 1906. He spoke on "The Illustration by Recent Research of Dr. Hughlings Jackson's Views on the Functions of the Cerebellum."5 Some other eminent neurologists who were invited to give this prestigious lecture refused on the grounds of ill-health. They included Thomas Buzzard, H.C. Bastian, Sir David Ferrier and Sir Byrom Bramwell of Edinburgh. The Hughlings Jackson Lecturer on 25th November 1909 was Sir William Gowers, whose title was "Special Sense Discharges from Organic Disease."6 He was due to be followed in 1913 by Professor Dejerine of Paris on "Les Radiculites", but the lecture was postponed because of his ill-health. The First World War broke out in 1914, and in 1919 Dejerine died without having delivered his address. Sir Henry Head became the next lecturer in 1920. He chose as his topic on 7th October "On Aphasia: An Historical Review"7 (see Chapter 15). A combined meeting of the Neurological Section of the Royal Society of Medicine and the American Neurological Association took place in London in 1927, and the Americans were invited to nominate one of their members to give the Hughlings Jackson Lecture. They chose Dr. Charles Dana of New York, and he delivered his lecture on 28th July. His speech was not published other than in abstract form in The Lancet8 and The British Medical Journal.9 Dr. Dana donated a sum of money to start a fund with which to give an honorarium to subsequent Lecturers, but it was not until a dinner at the Langham Hotel, London, on 29th January 1931, presided over by Mr. Leslie Paton, the neuro-ophthalmologist, that it was officially proposed that such a fund be started. The object was to award the Hughlings Jackson Lecturer with both a gold medal and an honorarium of 100 guineas. Dr. Wilfred Harris became the enthusiastic Treasurer of the Fund, assisted by a small committee consisting of Leslie Paton, James Taylor, J. Purves-Stewart, Gordon Holmes and Kinnier Wilson. The Treasurer received 146 subscriptions totalling £1,174. Among the distinguished donors were Drs. Harvey Gushing, J.F. Fulton, Smith Ely Jeliffe, Foster Kennedy, Hugh Patrick, Bernard Sachs, Th.

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Weisenburg, Pierre Marie, Georges Guillain, J. Babinski, Otfried Foerster and B. Brouwer. From Great Britain, donations were received from almost every neurologist and neurosurgeon, as well as from those eminent medical men Lord Dawson, Lord Adrian and Lord Horder. The 4V2-ounce gold medal was designed by Percy Metcalfe and made by the Royal Mint. The next Hughlings Jackson Lecture took place on 29th January 1931, delivered by Sir Charles Sherrington. He spoke on "Quantitative Management of Contraction in Lowest Level Coordination."10 Professor Otfried Foerster of Breslau delivered the next Lecture on the occasion of the 2nd International Congress of Neurology in London in 1935, and in 1938 Gordon Holmes was the Hughlings Jackson Lecturer. No award was made during the Second World War but the lectureship resumed in 1946, when Professor E.D. Adrian gave the address. He was followed successively by J.G. Greenfield, F.M.R. Walshe, Sir Geoffrey Jefferson, Sir Charles Symonds, Sir Russell Brain, Macdonald Critchley, C.S. Hallpike, John Cumings, Charles Phillips, John Spillane, J.Z. Young, Karl-Erik Hagbarth, Sir John Walton, Sidney Brenner, Lawrence Weiskrantz, J. Newsom Davis and, in 1996, P.K. Thomas.

19 Jackson the Man

Most of the world's great neurologists have been men of strong personality, and Hughlings Jackson was no exception. He was also endowed with qualities which made him an unusual person. "Even his habits and peculiarities, his whims and crochets may help us towards understanding the powerful influence he exerted on those who were fortunate enough to come within its spheres."1 Perhaps his most conspicuous feature was great modesty ("a gentle soul and unbelievably modest", according to Wilfred Harris), a characteristic which stood out markedly against his intellect. For this reason alone, he was essentially a likeable man. Jackson was an inherently good, simple individual and, for all his foibles, was universally respected and held in great affection. He was also shy and self-effacing, ready to express gratitude for even trivial services rendered by colleagues and subordinates. His writings show meticulous acknowledgement of the work of others and he never failed to express his gratitude for their contributions. Sometimes he carried such marks of recognition to excess, even when mentioning people whose views he disagreed with

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or questioned. Repeatedly he made comments such as: "Dr. Bastian's most valuable papers"; "his important article"; "a physician whose opinion deserves the greatest respect"; "Bastian, who advanced proof, where I have only speculated"; "Dr. Argyll Robertson kindly examined the eyes for me with the ophthalmoscope"; "Dr. Percy Langdon Brown drew my attention to this important point"; "Very careful notes were taken by Mr. Ingall." According to James Taylor, "Often his house physician was almost embarrassed by his explicit acknowledgement in print of some almost forgotten and trifling assistance in some investigation."2 It was said that he became impatient if confronted with delays. "He could not bear waiting", said James Taylor, and if Jackson called to see him while the former was engaged with a patient, he would wait outside Taylor's study door and ask the maid to call him out at once.3 Formal meetings, committees and assemblies bored him, and if he was not able to avoid such occasions, he soon became restless. On this account, he rarely went to medical meetings or to the theatre. It is said that he usually left the theatre after the first interval when he attended a performance in the West End of London. Jackson's "distaste for general society" increased in his later years as a result of his deafness, which was remarked on by Jonathan Hutchinson: "I suspect that there are but few who have ever seen him at a public dinner or on a platform. He disliked such occasions intensely, and it was always very difficult to convince him that it was necessary for him to do that which was distasteful. About eating and drinking he did not care in the least, and he always hurried through his meals and turned to his easy-chair and his book as quickly as possible. Even in company with others it was very frequent for him to rise and exclaim, 'Excuse me', and, without further ceremony, to turn aside. This was done with a special emphasis and at an earlier stage if there was a fire in the room."4 It was said by Sir Andrew Clark ("The Good Physician" in Sir Luke Filde's painting of that name and a colleague at the London Hospital) that Jackson had no sense of humour. This may tell us something about Clark, since, on the contrary, Jackson was described by others as having a great sense of humour. It seems to have been that subtle type which is spoken of as 'donnish', quiet and quizzical rather than boisterous. It was certainly not bawdy or Rabelaisian, for Jackson was anything but hearty. According to Jonathan Hutchinson, Jackson was "in the main a grave man, and although it has, I know, been said by our late col-

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league, Sir Andrew Clark, of both myself and him, that we had no sense of humour, yet Dr. Jackson was certainly not without it. He loved a joke, and had no objection to one which was in some degree personal to him."' They made many jokes at one another's expense, too, and Hutchinson averred that Jackson's sense of humour was of the keenest. A man who knew Jackson well and was a friend of his for 45 years was Thomas Buzzard. He, too, said that Jackson's sense of humour was "of the keenest", and "his innate drollery, finding vent in most amusing and fanciful ideas, contributed in no small degree to make of him a delightful companion."6 Another person to disagree with Sir Andrew was James Taylor, who stated: "There were the lighter moments when Jackson's quiet 'pawky' humour asserted itself. He had the keenest sense of humour I have known in anyone."7 It was also David Ferrier's opinion that Jackson "had a fund of dry humour, and enjoyed a joke, even at his own expense."8 Further evidence of Jackson's drollery was recorded by Dr. Charles Mercier. He described how, on hearing a witticism, Jackson's face would light up and he would throw back his head "with uncontrolled delight".9 Jackson had a quirk which has been mentioned by more than one of his biographers. He would refer to an imaginary Mr. Harris as being responsible for his day-to-day frustrations. "He haunted Dr. Jackson in order to hide his things."10 Jackson would blame this 'Mr. Harris' for mislaying his papers or for disappointing changes in the weather. ('Mr. Harris' was the make-believe husband of Sarah Gamp's mythical friend 'Mrs. Harris* in Martin Chuzzlewit, written by Charles Dickens, said to be one of Jackson's favourite authors.) He had a critical view of those who lacked humour, saying, "The man who has no sense of humour, who takes things to be literally as distinct as they superficially appear, does not see fundamental similarities in the midst of great superficial differences, overlooks the transitions between great contrasts . . . because he has not the surplus intellect which sense of humour implies."11 In October 1887 Jackson delivered that year's inaugural address at the Medical Society of London and chose "The Psychology of Joking" as his topic.12 Much of the lecture was taken up with the phenomenon of punning, which Jackson regarded as "a slightly abnormal state". He looked upon it as the least evolved system of joking. In fact, he said,

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it is an example of 'double consciousness' or, even better, 'mental diplopia'. "We have the sensations of complete resemblance, with the sense of vast difference." He also regarded punning as playing at being foolish. Jackson went on to describe an instance of mental diplopia other than punning. The smell of roses would immediately make him think of a room where he passed most of his childhood. Or, whilst writing, he might suddenly think of York Minster. Here, too, he said, are instances of narrowed awareness of present surroundings and "a cropping up of consciousness of some quasi-former surroundings."13 This mechanism is the same as that of punning. Referring to people who "are deficient in appreciation of jokosities", Jackson said they are "in corresponding degrees, deficiently realistic in their scientific conceptions."14 He showed his own jocosity by saying that there was a new way of making a ring. First, one takes a hole and then places the material on the outside of it. Such, he said, can be compared with a psychologist's method of beginning with volition, considering it to be an entity and a simple state, and then setting other mental states about it. "There is no such abstraction as a round hole, and there is no such thing as volition over and above a person doing or intending to do something."15 As James Taylor remarked, if Sir Andrew Clark had read this paper and lamented that Jackson had no sense of humour, it "passes comprehension".16 Herbert Spencer had also made a contribution to that subject in his essay on "The Physiology of Laughter", which appeared in Macmillan's Magazine in March 1860. Spencer had obviously derived some interest in the subject from the writings of Alexander Bain. He came to the conclusion that laughter results when consciousness is unwittingly transferred from great things to small—a phenomenon he called 'descending incongruity'. Jackson's lecture on joking, however, seems to owe little, if anything, to Spencer's essay on laughter. One of Jackson's outstanding traits was self-effacement. If he felt that any credit given to him was undeserved, he deprecated it. Once, when a brain tumour was found in the exact spot where he said it would be, Jackson refused to acknowledge any acumen for the prediction. He said he had already seen a patient with similar symptoms who proved to have a tumour in the same place, and he would have been entitled to credit only if he had some other reason to predict the location.17

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Jackson's modesty was not due to any lack of self-appraisal. As Cezanne said, modesty arises from an awareness of one's own strength, and Jackson was conscious of his own great potential. Greenblatt's interpretation was that Jackson had a sense of destiny. He had a reputation for a Yorkshireman's plain speaking, and his love of truthfulness did not lead him to soften his remarks to patients. "In this way he often sacrificed his own interests by giving opinions to patients which were not sufficiently hopeful or confident" said Jonathan Hutchinson. 18 Jackson chose his words with care in order to convey his precise meaning. "I once heard him say with a smile that he was distressed to think that in speaking of a man as being covered with a rash from head to foot he had been speaking unscientifically, for what he should have said was from the tip of his nose to his perineum."19 Another instance of Jackson's direct speaking, his love of calling a spade a spade, came when a colleague had reviewed a piece of work so severely that the author threatened him with violence. The reviewer protested to Jackson that the author's anger was not justified, for he had only reviewed the book, not the man. "That is very true", said Jackson. "You did not shoot at the man; you shot only at his coat, but you must remember that it was on his back."20 Jonathan Hutchinson compared Jackson with Dr. Samuel Johnson, saying it might appear strange that a man "so gentle and polished was best compared with Dr. Samuel Johnson, who had a reputation for being rude", but the two men were much alike. "Dr. Jackson had the same power that Johnson possessed, of brushing aside all subterfuges and going to the very essence of the matter. He had the same contempt for prevarication and make-believe, the same love for the essential truth. I refer, of course, not so much to his professional or scientific attainments as to his general character. I have never known a man whose verdict on all social questions were more trustworthy, or who arrived at them apparently with less effort."21 On the other hand, Jackson never said anything that might hurt anyone's feelings, nor did he utter unkind remarks. "I know of one instance in which he was deeply disappointed in being deceived by one whom he had trusted. But even of him he only remarked that he had been mistaken in his estimate of him, and he never mentioned the subject again."22 Sir William Gowers said of Jackson: "Not even the semblance of an unkind remark was ever heard. A difference of opinion was explained away if it was possible; otherwise it was ignored."23

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Dr. Charles Mercier commented: "It was very rare to hear from Dr. Jackson a word in disparagement of any one. I have heard him speak, without mentioning his name, of a medical practitioner as the kind of man who would ask what is good for a cough, and whose talents would be appropriately employed in keeping an eel-pie shop; but when he referred to any specific person as 'a man I should be very polite to', you knew it meant that the man was a bounder, or a humbug, or worse. A man who held the ophthalmoscope with the glass side next his eye, and declared he saw the disc, was a man Dr. Jackson would be very polite to."24 Jackson was known to tell stories against himself, including the occasion when he was trying to convince his house physician that a patient did not have ankle clonus. "But, sir," the young man blurted out, "You don't do it right!" It was said that a favourite maxim of Jackson's was "No good ever came of telling lies", and it seems to have been acted upon stringently. Once when Dr. Mercier was telling a little girl that they would not hurt her, Jackson remarked: "I would not tell her that. We might hurt her, though we don't mean to."25 It was Mercier's opinion that, although no man had a better claim than Jackson to the title of genius and no one was more gentle or understanding, he did not express much sympathy with suffering. Mercier's explanation was that Jackson felt uncomfortable at the sight of that for which he was unable to offer relief, and he "would take some pains to avoid passing the bed of a patient he was powerless to help."26 According to Mercier, too, Jackson's memory was erratic and he did not always remember patients' names, even though they might have been under his care for years. Instead he used labels such as 'the man behind the door' or 'the woman with the hammer toe'. Jackson, he said, could never find his way to his own wards without a guide. Nor did he always remember his own doctrines, according to Mercier, and, if asked what he thought of so-and-so would say, if it were not one of the things that then occupied his attention, "I forget now, but you will find my opinion in The Medical Times for last October."27 Although he was regarded almost universally as a simple, uncomplicated man, Hughlings Jackson has sometimes been rated—rightly or wrongly—as a rather enigmatic figure. This was the opinion of two striking individuals who shared a deep interest in psychiatry as well as intense intelligence, namely, Charles Mercier (1852—1919) and Sir George Savage (1842—1921). Both were consultants in psy-

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chiatry, Mercier (who had studied at the London Hospital) at the Westminster and Charing Cross Hospitals and Savage at Guy's Hospital, Bethlem Asylum and the Royal Earlswood Institution, all in London. Each held the office of President of the Royal MedicoPsychological Society, and both contributed widely to the literature on mental disorders. Mercier and Savage had many qualities in common, but they differed widely in some respects. George Savage used to say that the study of nervous disorders, particularly epilepsy, gave Jackson endless interest, but that he disliked insanity and would have nothing to do with insane patients if he could help it. According to Savage, Jackson's mind was one which needed order and precision, and mental disorders perplexed him. He seemed, at times, he said, to have a real dread of such patients. "He looked upon many of the insane as rather useless cumberers of the ground."28 Dr. Mercier said: "No one could be associated with Dr. Jackson without being impressed with his high standard of rectitude. In [the] face of a gross injustice that he was powerless to remedy, he would say, 'The only thing to do is to say a great big damn, and have done with it'."29 Jackson was notorious for his absent-mindedness. During one of his rare appearances at a dinner party, he is said to have drawn his handkerchief from his pocket in order to blow his nose and a sizeable portion of brain-tissue fell on to the table. As mentioned in Chapter 4, a more serious lapse occurred when he applied for the important post of Assistant Physician to the London Hospital. He was called to appear in person before the Appointments Board but forgot the engagement. Fortunately, Jonathan Hutchinson discovered that his friend would not be present at the vital meeting, and he went by hansom cab to the place where Jackson was working to take him to the meeting, arriving just in time. Not much is known of Jackson's ability as a lecturer, although it seems that he was not a brilliant speaker. Often his subject matter was abstruse and even dull to a general audience, but his pupils were quiet and attentive. Mercier recorded that Jackson was able to keep order "and could draw blood from a boisterous student by a cutting sarcasm."30 David Ferrier went so far as to write that Jackson was "a bad teacher in the ordinary sense, and lectured over the heads of the rank and file of his students". He confirmed that "there was never any unseemly behaviour in his class, such as occurred in that of

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some of his colleagues, or whenever a teacher is not en rapport with his pupils. Though he was essentially unpractical in a worldly sense, no one took liberties with him, and he enjoyed the reputation of being a genius, and of a higher level than ordinary men."31 Another commentator declared: "His quiet humour added to the charm of his teaching, and cannot be better illustrated than by a way in which he has been known to terminate one of his illuminating discourses, saying that he must not be taken too seriously, as it had been said that he was only a 'Bedlamite theorist'."32 A man who had attended Jackson's lectures when he was a student, Dr. FJ. Smith, later said that Jackson was "never a popular or showy lecturer; those who went round the wards with him did so because they really wanted to learn, and because they felt sure that what Jackson said would stand any test."33 On the other hand, Risien Russell wrote: "Nothing could equal the charm and fascination of his teaching to those who were in a position to understand him . . . Dr. Jackson was at his best when a privileged few were collected around him at the bedside."34 It has been said that Jackson had a weak voice and that his lectures were not well attended. Mercier stated that Jackson was aware that he tended to talk over the heads of his audience and, "when lecturing to a mixed class", was "almost too elementary".35 However, he went on to contradict himself by telling of the occasion when Jackson was scheduled to lecture on the cranial nerves. A large audience was attracted and afterwards Mercier said he hoped Jackson was satisfied with the attendance. He received the reply: "There would have been as many if you had put up a notice that Dr. Jackson would kill a pig."36 On the same subject, Risien Russell said of Jackson: "Successive generations of house physicians and clinical clerks who worked at the National Hospital in Queen Square knew him best and understood his teaching in a way that was not possible to the ordinary student of neurology, and nothing could equal the charm and fascination of his teaching to those who were in a position to understand him."37 No one seems to have commented on any possible regional accent in Jackson's speech. Like Jonathan Hutchinson, he had been born in Yorkshire, and of the latter it has been said: "There was a distinct north country intonation in his voice that seemed somehow to make what he said more trustworthy."38 Herbert Hutchinson said that his father always left out the 'h', "like a true Yorkshireman"39 (presumably when it was the initial letter of a word).

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It seems likely, therefore, that Hughlings Jackson retained throughout his life the native speech of the county of his birth. Of Jackson's house physicians, A.W. Campbell, who knew many of them, wrote: "One and all worshipped him. Perhaps in having no children of his own he treated them with paternal interest, helping them in their work, screening their mistakes, delighting them by invitation to collaborate with him in writing case reports which he considered worthy of publication, and sending them away with testimonials which were models of brevity and satisfaction."40 Earlier, Henry Head had written of Jackson: "Each generation of house physicians and clinical clerks at the National Hospital passed out impressed by the beauty of his character and his simple-hearted simplicity."41 Hughlings Jackson never travelled abroad "if he could help it."42 Once, when he and Jonathan Hutchinson were Presidents of their respective societies, it was necessary for them both to attend the Donders Festival at Utrecht. "It was with great reluctance on his part, however, and he insisted on leaving the place as soon as the chief ceremonial was over."43 It was with particular pleasure that Jackson received an honorary degree bestowed upon him by the University of Bologna, but it is not known whether he travelled to Italy to receive it. Whenever Jackson was away from home it was never for more than ten days at a time, although he might come back for a day and then go away again. At such times, James Taylor dealt with his letters. "His itinerary was very varied, but he always found himself in Yorkshire at least once a year. In his holiday arrangements the restlessness already alluded to was very noticeable. He always sent me a telegram in the morning, usually to some such effect as this, 'Station Hotel, York, till tomorrow morning', to which I replied, giving any information which I had gleaned from his letters or simply saying 'Nothing important'. The next morning there might be a telegram from Wolverhampton, or an address would be given in some more distant place. He did not often remain in the same place more than a day or two, and if he were met at some place like Scarborough he would probably be seen driving in an open landau behind a pair of horses, as he was usually seen in London. He always drove in an open carriage by preference, and he once told me that he thought his heat-regulating mechanism could not be properly organized, for he never felt cold!"44 Although Jonathan Hutchinson said that Jackson had no great love of the country and did not care for shooting or even walking, they

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took many walks together. They might leave at noon and always returned to London at the latest by Sunday evening. "On one occasion we made a pilgrimage to Selborne, and here, of course, we read portions of Gilbert White's history and visited his haunts. Here Jackson remarked to me, speaking of White and the charm of his book: 'He Boswellized the birds. He took down the familiar conversation of Nature'." 45 Hutchinson also said that Jackson was a "good walker" but that he went out "chiefly in search of fresh air and exercise."46 However, according to Wilfred Harris, Jackson "hated exercise and would rather sit over a novel by the fire than go for a walk in the winter sunshine."47 Jackson did not participate in any sporting activity, although it is said that he had, as a boy, been accustomed to shoot. "On one occasion I persuaded him to carry a gun and shoot at rabbits, but he laid it aside in an hour or two."48 Yorkshiremen have a reputation for not being profligate with money, but Jackson was known to be generous. "Not only did he give large sums, together with kind and cordial expressions, but he was very particular in ascertaining that all to whom he was in any way indebted were well paid. The cab-drivers on his rank knew him well, also some of the railway porters recognized him with pleasurable hopes."49 There is a story, too, of Jackson's visit to Carlisle to see a very rich patient, who paid him the large fee of 200 guineas. The money was said to have been given to the London Hospital for the benefit of indigent patients.

20 Marriage, Bereavement and Honours

After a courtship which was said to have lasted for 11 years, John Hughlings Jackson married his first cousin, Elizabeth Dade Jackson, at St. Giles Church, Northampton, on 25th July 1865. The bride was 28 and the bridegroom was 30 years of age. Elizabeth and John had known each other all their lives. They shared paternal grandparents. Both were born at Green Hammerton and had been neighbours there as children. Elizabeth was the daughter of Hughlings Jackson's father's brother, Thomas Jackson, and his second wife, Mary Smith Jackson. Thomas Jackson was married first to Elizabeth Dade at Pontefract, Yorkshire on 3rd August 1830; he was 27 and his bride was 20 years old. She was the fifth of the six children of James and Mary Elizabeth Dade of North Elmsall, a village near Pontefract. James and Mary (nee Smith) had married at South Kirkby in Yorkshire on 4th July 1797, when he was 25 and she was 23. James Dade worked as a groom. Their first child, Ann, was baptised at South Kirkby church on 26th September 1798, followed by Mary Smith on 1st June 1803, William Smith on 25th September 1805, John on 23rd

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August 1807, Elizabeth on 5th December 1810 and Sarah on 25th April 1814. The marriage of Thomas and Elizabeth Jackson ended abruptly two years later, for Elizabeth died on 24th August 1832. She was buried at Green Hammerton. On 4th August 1834, Thomas Jackson married his deceased wife's older sister, Mary Smith Dade, at Wakefield, Yorkshire. Their twins, Andrew and Elizabeth were born two years later, on 24th September 1838, at Green Hammerton. Like their cousin John, they were baptised at the Independent Chapel there by their great-uncle, the Reverend James Jackson, on 2nd November 1836. Thomas Jackson was a farmer who owned 300 acres of land around Green Hammerton, and he employed seven farm labourers. He died on 17th December 1853 at the age of 50. Eight years later, his only son, Andrew, died at the early age of 22 on 3rd July 1861. Elizabeth Jackson was married in Northampton, so it is probable that she and her widowed mother had left Yorkshire after Thomas died. With no father or brother to fill the role, the bridegroom's friend, Jonathan Hutchinson, gave the bride away at the wedding ceremony in the church. Afterwards he wrote to his wife, "We got them well married yesterday and had a very pleasant day. Both bride and bridegroom looked remarkably well and happy. I bungled a little in the performance of my paternal duties, but was so zealous that I got in the bridesmaid's way, but still we got through it. I have a huge lump of cake for the children and the bride's bouquet for thee."1 According to Wilfred Harris, part of the honeymoon was spent in Yorkshire. Some years after the death of his wife, Jackson went to stay one weekend at The Black Horse at Clapham, near Giggleswick. In conversation with another guest, Jackson mentioned that he "had come there for a quiet time and to recapture the sentimental feelings of his honeymoon, part of which he had spent at 'The Black Horse' with his wife."2 Dr. and Mrs. John Hughlings Jackson set up home in rented premises at 28 Bedford Place, near Russell Square, Bloomsbury, in London and a short distance from Queen Square. Mary Smith Jackson, Elizabeth's mother, lived with them until she died, aged 65, on 27th December 1867. John and Elizabeth Hughlings Jackson then moved to another rented house at No. 3 Manchester Square in the West End of London, not far from the Harley Street medical enclave. The marriage was obviously a successful one. James Taylor said:

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"His married life was peculiarly happy, and he assured me on more than one occasion that 'there was nothing in the world to compare with domestic happiness'".3 In one of the few surviving letters from Jackson to his brother, Tom, in New Zealand, we read: "My own Lizzie makes me a capital wife in all ways. I never tire of her. We are always together. She is now sitting in my study copying something I am going to print." Later in the same letter, he wrote: "I get on well . . . but I do not get as much money. I am thoroughly satisfied however and am as happy as any one of my age is likely to be. My health is much better than the last few years."4 Little is known about Mrs. Hughlings Jackson. Jonathan Hutchinson said she was "a most accomplished woman" and had been her husband's "associate since childhood".5 Her only known photograph shows that she had a serene face. She obviously was helpful to her husband in his work and was able to transcribe his untidy handwriting. Elizabeth Jackson also wrote at least one children's story. Posthumously in 1879, "A Day at Uncle Ben's" by E.D.J. was printed, probably privately, by Marcus Ward & Co. of London. It is a short, simple tale, but one which provides an interesting picture of the social mores of the time. Hughlings Jackson gave a copy of the book to one of his relations in New Zealand, but few others seem to have survived. The Jacksons had no children, and their happiness was relatively brief. After 11 years of marriage, Elizabeth Dade Jackson died in May 1876, when she was nearly 40 years of age, after a short illness involving a cerebral septic thrombo-phlebitis. Ironically, it is said that her fatal illness had been complicated by a succession of fits of the Jacksonian type. Dr. Albert Huhn of Cologne has written that Jackson "observed the type of seizure named after him on his own wife, who developed a sinus thrombosis during her puerperium from which she perished."6 He does not, however, give the source of this information. Mrs. Jackson was attended by Sir William Jenner, Physician-inOrdinary to Queen Victoria and also to the Prince of Wales. Later, Sir William became President of the Royal College of Physicians. Despite the attentions of her husband and the other distinguished doctor, Elizabeth Jackson died. She was buried in Highgate Cemetery on 26th May 1876. Jonathan Hutchinson said that Jackson was "always keenly conscious of the debt he owed to her in the development of his character, and her great loss to him was unspeakably great".7

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Hughlings Jackson's unhappiness after his wife died was described by James Taylor: "Mrs. Jackson's death was a lifelong sorrow to him, and when he did speak of her—the occasions were very rare—it was evident how perfect his married life had been, and how deep and lasting was the loss he felt."8 An entry in Jonathan Hutchinson's diary for 4th January 1886 tells us: "Dr. Jackson and I had a pleasant walk in the Park and the Zoo yesterday morning; we did not look at anything in the latter, but simply talked. He seemed to have pleasure in going back to old times, and talked much about his wife, who he still very bitterly regrets. All would be well with him if she were only living."9 After his wife's death, Jackson lapsed into a semi-cloistered, reclusive existence. He did not allow anyone at No. 3 Manchester Square to occupy his wife's place at the dinner table. Later in his life, his brother Thomas, with his wife and two of their children, Ruth and Cissy, visited Hughlings Jackson. At the age of 80, Cissy recalled that Jackson "would not countenance a woman housekeeper after his wife's death. The four of us were asked to sit along one side of the dining table."10 Presumably, his wife's place had been on the other side. Jackson did not marry again, and it seems that his old age was an especially lonely period of his life. Some time after his wife's death, Jackson met Mrs. Farquhar Buzzard in the street. Aware of his loneliness, she warmly invited him to drop in for a meal informally and without giving prior notice. Jackson did not do so and when they met again accidently she reissued her invitation. It was not until their third such encounter that Jackson quietly accepted. Dr. and Mrs. Farquhar Buzzard had enjoyed an intimate friendship with Dr. and Mrs. John Hughlings Jackson and, after Elizabeth's death, he subsequently became "a constant, almost daily visitor" to their house.11 Jackson's behaviour on his visits to them was hardly conventional. "He was, in regard to social amenities, intensely shy and completely embarrassed by anything approaching effusiveness or affectation of manner."12 The Buzzard family always had a place reserved for him at their table at lunchtime. Jackson might or might not turn up, but he never gave notice of an impending arrival. He entered the room unostentatiously and slipped quietly into his place. "No one would rise; he would pull a chair up to the table, exchange a few remarks, perhaps tell a humorous story with only a twinkle of the eye disturbing the solemnity of his features, and after five, perhaps ten min-

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utes, he would mumble something about remembering an engagement and leave the room."13 Or he might invite one of the Buzzard children, often the young daughter, to take a ride with him in his landau, which was waiting outside. Miss Buzzard later wrote an account of her frequent drives with Hughlings Jackson: The loss of his wife had been a great blow to him and he was a lonely man. His quiet, rather reserved manner would not lead one to expect that the companionship of a child would be of much interest to him, but he constantly called for me, and took me with him—sometimes when he had professional visits to pay, sometimes to the city "to buy a newspaper", when he would leave me at Birch's sitting by a small table, and trying to get through a large ice before he called for me again. We did not talk much on these expeditions; he sat in one corner of the landau and I in the other. He sometimes read a paper—he was very short-sighted but did not use glasses—but I remember him chiefly leaning back in the corner of the carriage with his arms folded, and with a thoughtful, rather wistful, expression. He was impatient in that he disliked being kept waiting—I think it would have been agony to him to sit and watch me eat those ices at Birch's—and I have seen him fidget on a doorstep if his ring were not answered at once. I never remember his showing any other form of impatience; he was always kindness and gentleness itself. He was engaged for years in writing what he always referred to as 'The Memorial' (referring to Mr. Dick in David Copperfield), and if bored by an interview and anxious to get home, he would say gravely and quietly: 'I must go now and write the memorial'. He had no particular taste for music or art in any form, he often admitted he could not distinguish the National Anthem from 'Rule Britannia', but he liked going to the theatre, and he took me to my first play, 'Uncle Dick's Darling', in which Toole was acting. On that occasion he sat through the whole performance, but this he did very rarely. His natural restlessness made it impossible for him to remain in the same place for as long as three hours, so he would see one act at a time.14 Miss Buzzard's brother remembered Jackson as a generous, kind, if grave, family friend, a kind of 'pseudo-uncle'.15 These are not the only recorded examples of Jackson's kindness to children. David Ferrier wrote: "Childless himself, he was passionately fond of children, and delighted to bring toys to the children of his colleagues, who all loved and trusted him with their confidences."16

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Jackson spent many hours reading and writing at home. He was an omnivorous reader, even though he was sometimes unconventional in his treatment of books. Jackson "was tolerant of almost all kinds of fiction, and devoured novels merely to absorb his attention, without allowing them to excite emotion, and without any wish to retain them in memory. He had, however, his favourites, and of these Jane Austen and Anthony Trollope were, I believe, if not the first in esteem, at any rate the most fequently re-read. Dickens and Thackeray came possibly next."17 In addition, he read thrillers and popular novels of the day, which were published as 'yellow-backs' for two shillings. He would select them for reading during journeys by train or by carriage. It was his practice to tear the book in two, throw away the covers, and put one half in the left-hand coat pocket and the other half in the right. James Taylor said Jackson once carried out this ritual at a railway bookstall. The boy in charge gazed in astonishment. "You think I am mad, my boy", said Jackson to him, "but it's the people who don't do this who are really mad."18 Jonathan Hutchinson told us that "Dr. Jackson was a great reader, and as he never smoked and was not addicted to any kind of sport, the reading of light literature took its place as a kind of resource for otherwise idle moments."19 Henry Head reinforced this opinion: "For recreation he reads novels—not those with pretensions to literary value but the ordinary novel of the circulating library. Stacks of such books occupy a corner of his room: but he never speaks of them. They form a pure pastime."20 Further confirmation of Jackson's reading habits came from James Taylor, who wrote that he "read as a pastime the most trivial rubbish, and the perusal of this would send him to his serious writing with added zest and spirit."21 According to Jonathan Hutchinson, Jackson was not a lover of books: "He was a lover of knowledge, but for the book itself he cared absolutely nothing. . . . He bought books liberally, and when a new edition of any work of reference which he was in the habit of using appeared, he always procured it and threw aside the old one. The latter had, indeed, often become unsaleable, and not improbably quite useless from the depredations it had experienced. 'I did not want the book', he would say, 'I wanted only the information that was in it.' Thus his library in its ultimate condition must have been of very little value."22 "Books as books", said James Taylor, "he treated with the greatest

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disrespect . . . he had no compunction about tearing out of a book any portion which interested him."23 He went on to tell another story concerning the four published volumes of The London Hospital Reports. A complete set belonging to Jackson was sold by his cousin, presumably after the former's death. They were bought by one of Jackson's colleagues, chiefly on account of the contributions in the books which had been written by Jackson himself. The buyer found, however, that all those papers had been torn out by the author.24 It was not only his own books which suffered in this way. Jackson had a habit of borrowing from his colleagues, and the lender was often dismayed to find that pages that had interested him had been removed. It seems as though Samuel Jackson's written advice to his young son about caring for books was unheeded (see Chapter 3). When Hutchinson read Macaulay's Life, he made the comment: "Dr. Jackson does not like him, and says for one thing that he disparaged Wordsworth. I believe he had read a great deal more of Wordsworth than Jackson has; and that if Jackson compelled himself to wade through as much as he had done, he too would speak in not very complimentary terms. Jackson knows only a few picked passages."25 Hutchinson also said: "His reading in poetry was not large, and I think did not include any of more recent date than Keats. The 'Ode to the Nightingale' was, I think, almost the only one from which he would quote passages, and it he passionately admired."26 In his boyhood, Jackson was expected to attend church regularly, but any religious beliefs he might then have held lapsed. They were of "the simplest kind of agnosticism. To any one who had asked his belief as to the possibility of miracles he would have replied with a smile, and he was an absolute disbeliever in personal immortality after death."27 His political inclinations were firmly Conservative, and he was a strong advocate of the House of Lords. Wilfred Harris described Jackson's appearance thus: "Of middle height, he wore a bushy beard and moustache of the Victorian fashion, a buttoned-up frock coat, black stiff made-up tie and open collar."28 We come now to the saga of the inconsistent hyphen. On 14th June 1871 Jackson wrote to the House Governor at the London Hospital, asking that "a slight dash" be inserted between his two names, Hughlings and Jackson, "so as to show that I use both. The

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name of Jackson is so common that it is necessary to tack another to it to individualise one's self."29 The request seems totally unlike Jackson's character as we know it, so much so that one wonders whether someone or something had influenced him. No documentary evidence has been found at the National Hospital of a similar plea for his name to be hyphenated, and the out-patient notes there—on which his name was printed and which survive—do not show a hyphen. Jackson's hyphenated name is, however, shown on the London Hospital case-notes after the date of his request, as well as from 1878—1879 on the cover of Brain, of which Jackson was a member of the Board of Advisors. Other than this, he himself seems not to have made use of such a hyphen. He was always 'Jackson' to his colleagues, never 'Hughlings-Jackson'. No other document has been discovered that includes a hyphen. Occasionally a hyphen has been used by other people when writing about him, though not always consistently so. In David Ferrier's Functions of the Brain, for instance, 'Hughlings-Jackson' appears in one place and 'Hughlings Jackson' in another. His name is also sometimes hyphenated and sometimes not in the otherwise excellent compilation of texts edited by Martha Taylor Sarno entitled Aphasia: Selected Readings.30 It must have been disconcerting to the indexer. Jackson had a brass plate on the door of his house at No. 3 Manchester Square. This plate is still in existence, and Hughlings Jackson's name shows no hyphen. Nor is one shown on the plaques which were posthumously erected outside that house and also at his birthplace at Providence Green, Green Hammerton. There is no hyphen in the signature on Jackson's Will, nor is one to be seen on his gravestone. Nor can it be seen in any obituary that has been traced. Jackson's wife did not seem to have adopted a double-barrelled surname; she was buried as Elizabeth Dade Jackson. When Jackson retired from the London Hospital in 1895, that is, 24 years after his letter about the hyphen was written to the House Governor, his colleagues presented him with an intricately carved silver ewer and a silver platter. They are now in the possession of descendants of one of Jackson's brothers. The platter is engraved with the following tribute to him: "Presented to John Hughlings Jackson, M.D., F.R.C.P., F.R.S. together with his portrait in oils by his colleagues and friends on the occasion of his retiring from the Office of Physician and being appointed Consulting Physician to the London Hospital, in recognition of their esteem and admiration for

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his great services to the Hospital and Medical College, his distinguished position in the Profession, and of the advances he has effected in Medical Science by his laborious investigations and profound insight into diseases of the nervous system. October 1st 1895." As can be seen, there was no hyphen. The assumption is, therefore, that it was no longer being employed by the London Hospital. Present members of the Jackson family think that Hughlings Jackson suggested to his brothers, Samuel and Thomas, that they might care to use a hyphen (although neither of them, unlike he himself, had been given the name Hughlings at baptism). They did not do so. Dr. W.L.H. Jackson, grandson of Thomas Jackson and grand-nephew of John Hughlings Jackson, has told us that every member of the Jackson family of his generation in New Zealand was given the Christian name Hughlings, apart from him. When his father later decided to add it to his son's names, it was done legally by deed poll and attached to his surname, which then became Hughlings-Jackson. Later, Dr. W.L.H. Jackson found it to be too cumbersome and dropped it for plain 'Jackson', but he now uses 'Hughlings' as a Christian name. It is to be hoped that the hyphenated name will not be reintroduced in the future in printed matter. Apart from anything else, virtually all the world's literature shows Jackson to be indexed under ']', not 'H'. Jackson sometimes used a graphic symbol based on his initials. Four oblique strokes (I/If) represented the letters J.H.J., and this form of identification was inscribed on the lining of his hat.31 It is believed, too, that as a boy he had scratched a version of this symbol on a window-pane at Providence Green. When members of the Jackson family were visiting from New Zealand and were at Providence Green in 1934, the then owner of the house offered to give them a pane of glass with the initials J.H.J. scratched on it. The offer was not taken up, but there is still a glass-pane in the house which has a scratched symbol upon it. It is not easy to say whether or not it represents Hughlings Jackson's initials. In 1868 Jackson rented a house in London which had been built between 1776 and 1788 in an area which was to become occupied largely by medical consultants. It was No. 3 Manchester Square, named after the then owner of the land, the Duke of Manchester, and located at the periphery of what has flippantly been called 'pill island'. The house was spacious but rather dark and gloomy. Other doctors had rented premises in the same quiet Square, notably H.

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Charlton Bastian and P. Victor Bazire, both of whom were on the consulting staff at the National Hospital. Jackson occupied the house for the next 45 years, most of that time as a solitary widower. He was cared for by a maidservant, Miss Mead, and, according to Henry Head, there was also a butler. John Brown, his coachman, lived nearby, and there was an adjacent stable for the two horses and landau. Most of the furniture in the house was heavy and dark, some of it made of ebony. Pictures of cats, including one by Louis Wain, hung on the walls. Scattered around the drawing room were small pieces of contemporary Japanese art, and there were papers, books and family photographs in profusion. Jonathan Hutchinson said: "He collected no curios. . . . It might indeed be said that he was no collector of anything."32 The young Henry Head visited Jackson in Manchester Square, and his recollections were recorded thus by Dr. Ronald Henson: "The door of a small house in the corner of Manchester Square is opened by a very old butler who says he will see if the doctor can see me— 'he has not been well lately but is better now'. I am ushered into a large room in which my eye is at once attracted by two immense arm chairs. By each of them stands a low table with notebooks and pencils. Roundabout, in apparently hopeless disorder, lie innumerable books, pencilled journals and scraps of typewritten manuscript. From one of these chairs rises a white haired man in a wrinkled old fashioned frock-coat. Standing with his head a little on one side like a giant bird, he stretches out to me a most friendly hand. His words come thickly through the veil of his heavy white beard and moustache which entirely cover his mouth. I draw close to his great chair and plunge into the middle of a scientific conversation. At first he is somewhat shy for his life during many years has been lonely and his loneliness has been increased by the onset of deafness. Although nearly 70 years old he is still full of ideas and has maintained a wonderful freshness of interest. But he has a curious and embarrassing habit of assuming, in his great modesty, that fundamental principles enunciated by him a quarter of a century ago are still unknown to me, to whom they have been elemental steps in intellectual training. During our conversation he repeatedly rises to fetch some paper or book or to refer to one of his many notebooks. "Under his shyness he hungers for affection and has been a fairy godfather to a multitude of children, many of them are grown up, some are married, and a host of photographs fills the mantlepiece."33

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As already stated, when Jackson retired from the London Hospital "by the force of an invariable rule", he was presented with his portrait in oils painted by Lance Calkin, and a silver salver and claret jug. A sum of £300 had been collected; among the contributors were Herbert Spencer, Sir Joseph Lister, Sir James Paget, Sir William Broadbent, Sir William Roberts, Sir F. Grainger Stewart, Sir Henry Acland, Professor Pierre Marie, Professor William Osier, Sir F. Spencer Wells, Professor Hitzizg, Professor Baiimler, Sir B.W. Richardson and Professor Burdon Sanderson. The presentation ceremony was held in the College Library on 1 st October 1895, and in an account of the proceedings, we read: "It may be surmised that Dr. Jackson found the sittings for his portrait somewhat of an ordeal, but the still more trying ceremony of having to listen to his own praises was robbed of most of his terrors under the guidance of Sir James Paget. Nevertheless, it would be interesting to have a description from Dr. Jackson's pen of his exact 'mental state' during the hour he spent on the Library platform. Probably it oscillated between that characteristic of a visit to one's dentist and of one's reception into the celestial regions."34 Throughout this account in The London Hospital Gazette, he is referred to as 'Dr. Jackson' other than in the headline. There his name is given as "Dr. Hughlings Jackson"—with no hyphen. At the time of Jackson's retirement from the National Hospital, his colleagues arranged for a marble bust to be made of him by Herbert Hampton, a fashionable painter and sculptor who made several likenesses of Queen Victoria for various memorials in England and abroad and, later, of King Edward VII and King George V. Dr. J. Purves-Stewart said that the bust did not do Jackson justice. "It gives him a stern expression which he never displayed to any of us."35 When Kinnier Wilson asked him whether it was tiring to sit for it, Jackson replied: "It is hard work doing nothing. Sitting still is being under restraint, and that is an active inhibitory process."36 The presentation of the sculpture was made at the National Hospital on 21st November 1907 by Sir William Gowers, who, it was said, when unveiling it, finished his address with the words "Let us look upon this bust and then turn to the living counterpart—our Master." From that time, the bust stood in the Front Hall of the National Hospital until it was moved about two decades ago to the Dean's Room in the Institute of Neurology, which was then located in

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Alexandra House, a building opposite the hospital. Later it was moved once more, this time to the entrance hall of No. 23 Queen Square, below the present premises of the Rockefeller Library. About 10 or 12 years ago, the bust was stolen from its plinth. The thief had been clumsy and had apparently dropped the bust because a handful of marble chips was found on the floor. Nothing further was heard of it for a while, until it was discovered that the bust seems to have been sold from an antiques stall in London, without the buyer having been aware whose likeness it was, where it had come from, or that it had been stolen. Efforts by a member of the present staff of the National Hospital, Professor Michael Trimble, failed to locate it, but through the generosity of colleagues at the Montreal Neurological Institute, a copy was made of their own copy of the original bust. This latest reproduction of the sculptured head of Hughlings Jackson, which had been commissioned by our predecessors at Queen Square to honour a great neurologist, was restored to its rightful place on 18th July 1996. During the last ten years of Jackson's tenure as Physician to the National Hospital, his visits became more unpredictable. He would suddenly appear and ask any resident doctor he saw to show him cases which were of particular interest. The house physicians were eager to do so and competed among themselves who should fill the coveted role. After he had completed a ward round, Jackson often invited the house physician to join him in his carriage for a ride. Such an offer would be eagerly accepted, and they would set off to one of the outlying areas of London—Epping Forest, perhaps, or Richmond Park. Jackson might or might not talk to his companion during the journey. On arrival at their destination, he signalled to John Brown, his coachman, to reign in the horses. Then he would warmly shake the young doctor's hand and leave him to make his own way back to the hospital. Wilfred Harris described one such occasion: "He might invite a house physician to drive with him down to the Poplar Hospital to see a patient in whom they were both interested, and on the return journey he would perhaps get bored with his young companion, and stop the carriage in the Commercial Road and say to him, 'You will find your way quite easily from here!'."37 Dr. J. Purves-Stewart has told us that he was one of those asked to drive with Hughlings Jackson from time to time, "during which his conversation roamed over various by-ways of physiological psychology, such as the origin and nature of laughter, the functions of

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the deeper parts of the brain, the sensations of hunger and thirst, and so on."38 One house physician, S.A. Kinnier Wilson, always had a small notebook with him, and he would write down a verbatim account of what Jackson said to him; also, characteristically, what he said to Jackson. Wilson flourished this notebook before the audience when he was speaking at the dinner given in honour of Jackson's centenary in 1935. It seems possible that, even late in his life, Jackson occasionally attended Medical Committee meetings. There is a story that, when that Committee met to elect an Honorary Physician to the staff, Jackson was present but was too deaf to follow the discussion. He therefore scribbled a note to James Taylor: "Whom shall I vote for?" The reply came back "Gordon Holmes". The question naturally arose comparatively early in Jackson's lifetime—and has continued to be raised—as to why he received no State recognition. Several of his colleagues, both at the London Hospital and at Queen Square, had been honoured, yet their claims to such distinction had not been greater than Jackson's. "It is surely strange that none of the honours usually conferred by the State for distinguished service should have come his way, and I think many must have felt as a colleague of his did, who had a welldeserved honour conferred upon him, when he said he felt that he should not have had a Knighthood before Jackson had the Order of Merit" wrote James Taylor.39 Just after William Osier received a baronetcy, he wrote to Frederick C. Shattuck on 4th September 1911: "These honours are very unequally distributed. Some of the most deserving men never receive any recognition—Hughlings Jackson for example and imagine chucking at 80 a knighthood to Jonathan Hutchinson!"40 Of course, Jackson was not a man to seek publicity for himself or his work, and his great shyness contributed to his being overlooked in the lottery of honours distributed by the Government. On l l t h March 1876, Queen Victoria paid an official visit to the London Hospital, during which she declared open the Grocer's Wing. It was the duty of every member of the staff to attend the ceremony, but Jackson was absent. It happened that on that day one of his relations was arriving at Tilbury Dock from New Zealand, and either this took precedence or, perhaps more likely, he forgot the Royal visit. As Oscar Wilde observed: "The public is wonderfully tolerant. It forgives everything except genius."

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Jackson was made an Honorary Member of the American Neurological Association in 1881, one of a distinguished group who were elected that year; the others were Charcot, Erb, Westphal and Meynert. From 1885 to 1887, Jackson was a Member of the Council of the Royal College of Physicians, and he served as Censor of the College in 1888 and 1889. He was also awarded the Moxon Gold Medal by the Royal College of Physicians. It is given every third year to the "person who should be deemed to have most distinguished himself by observation and research in clinical medicine."41 In 1887 Jackson was awarded an Honorary Doctorate of Laws by Glasgow University. Another honour which gave him great pleasure, because it came from the county of his birth, Yorkshire, was bestowed on him on 6th October 1904. The occasion was the inauguration of the University of Leeds, and the degree of Doctor of Science, honoris causa, was conferred on him. Jackson was in august company, other recipients being the Archbishop of York, the Duke of Devonshire, the Earl of Harewood, Sir Hubert Parry and Sir Edward Elgar (who were awarded the degree of Doctor of Laws). At the same time, a degree of Doctor of Science was awarded to Sir William Broadbent, Jonathan Hutchinson and Dr. Tempest Anderson, to whose father Jackson had been apprenticed in York. The Dean of the Faculty of Medicine presented Hughlings Jackson to the Chancellor of the new university, the Marquis of Ripon. The citation read: "The great advances made in the latter part of the nineteenth century in our knowledge of the physiology, pathology and treatment of the brain and nervous system, are founded upon the investigations of a few eminent men in Europe who first broke ground in this direction. One of the most distinguished of these, a native of this county, Dr. Hughlings Jackson, for forty years has been giving to the profession the results of his original researches and observations. He is esteemed by the members of the medical profession as one of the greatest living authorities on the subject which he has made so peculiarly his own." Jonathan Hutchinson said later: "The fact that he was remembered by the University of Leeds in his later life was one of which he frequently reminded me, and which added, I am sure, much to his happiness in old age."42 Six months later, Jackson was honoured by the University of Edinburgh, which bestowed upon him an Honorary Degree of Doctor of Laws. Fellow-recipients were William Watson Cheyne, Professor

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of Surgery at King's College Hospital, London, and Sir Arthur Conan Doyle, M.D., author of the Sherlock Holmes stories. The ceremony took place on 7th April 1905, and the Laureation Address was given by Sir Ludovic J. Grant, Bart., Dean of the Faculty of Law: "Amongst the shocks to which flesh is heir none have proved more perplexing to the practitioner or more baffling to the scientist than those which have their origin in the brain and nervous system. These mysterious maladies the eminent physician who now stands before us has taken as his special sphere of study, and in particular he has long been recognised as one of the foremost authorities in the country on the subjects of paralysis and epilepsy. More than one of the great London hospitals for the treatment of these diseases is under his charge, and the numerous papers which he has contributed to the medical journals mark him out as a worker of truly scientific attainments, who unites a faculty for close observation with the gift of original thought. Indeed, fertile and far-reaching results may be claimed for the theory of epilepsy which his long study of the phenomena of that disease led him to form. By establishing a connection between muscular movement and brain-lesion in epileptic cases, Dr. Hughlings Jackson suggested the idea of the motor significance of the cerebral convolutions. The clue which he reached by clinical observation was followed up by other investigators experimentally, with the result that the dependence of different movements upon different parts of the brain has been exactly determined. Dr. Hughlings Jackson was the first President of the Neurological Society of the United Kingdom, and the annual lecture instituted by the Society is known by his name. Upon none can our highest honour be more fittingly conferred than upon the Nestor of English Neurology."

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21 Tributes

Facts are rare, and those already gathered have been made to yield their lessons by the Master himself, beyond whom we cannot hope to go. Sir William Gowers1

In 1901 William Osier, writing on behalf of Weir Mitchell and James Putnam as well as himself, asked Jackson whether he would consider publishing a collection of his papers. On 12th February that year, Hughlings Jackson replied: "Many of my papers, all the old ones, are very old-fashioned and are not worthy of reprint (I have been working on neurological subjects for thirty-six years). As to more recent papers there is much in them too antiquated for republication. As to some others which I think do contain something of little value, there is recapitulation from one to the other—the same thing in various papers. But I am so highly stimulated by a request from three such men that I shall endeavour a kind of reproduction. I hope to make a volume which will contain in a methodical way most of what I have done in neurology, and another volume of minor contributions to neurology. I am not sure that I shall succeed in these projects. My health is not so good as it was. I will do my best, especially as I fear it would not be possible for any one but myself to reproduce in any orderly way what is scattered in many of my papers."2 According to James Taylor, Jackson's "health was never very good after this time and he wrote very little. His increasing

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deafness became a great trouble to him, and although the attacks of vertigo were less severe he was not quite free from them. The laboriousness of the work which he wished to undertake rather appalled him, and he never really began it."3 On 24th May 1904, Jackson wrote to his brother, Thomas, in New Zealand: "You say you are not very well. You soon get tired. So do I. But I do not think that is a serious symptom at our age. I think my deafness is not as great. I have my ears syringed sometimes."4 We know from Wilfred Harris that Jackson was deaf in the left ear and, in later life, was subject to attacks of labyrinthine vertigo. "Myopic in one eye and emmetropic in the other, a most useful combination, as he said, he never required glasses, reading with the one and using the other for distant vision."5 During the remaining years of his life, "Hughlings Jackson's pen remained idle, and he withdrew more and more from active particiption in scientific or social life. The familiar figure sitting quietly observant at a meeting of one of the medical societies, or perched in the corner of the high old-fashioned carriage in which he went about his business in London was no longer to be seen, and he led a life more and more solitary, pervaded by a gentle melancholy, perhaps anticipating, with a serenity of mind inseparable from our conception of him, the end which he may have been conscious was not far away. But up to the last he retained an interest in the lives of his pupils and their families."6 On 7th October 1911, Hughlings Jackson died at No. 3 Manchester Square, the cause of death being pneumonia. He was buried at Highgate Cemetery in North London on 12th October 1911 alongside his wife, Elizabeth. In his Will, dated 24th February 1911, Jackson left the portrait of himself, which had been given to him by his colleagues at the London Hospital and painted by Lance Calkin, to the Royal College of Physicians. Legacies were left to past and present servants, to Dr. James Taylor, to various members of his family, and to his Executors, his cousins Charles Samuel Jackson and George William Jackson. Charles Jackson was instructed to "destroy with his own hands all my letters and diaries and all my case books and all correspondence relating thereto." Charles Jackson appears to have carried out these instructions fairly thoroughly, since few of Jackson's personal papers exist. However, a few letters escaped destruction and were given, much later, to a cousin of Jackson's in the United States. Many tributes were paid to Jackson immediately after his death.

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Among them was one from Thomas Buzzard, who wrote: "The son of a Yorkshire father and a Welsh mother, Jackson displayed characteristics which appeared to derive from the nationality of each parent. On the one hand he was energetic, courageous, cautious in drawing conclusions, but when convinced, sturdily indisposed to change them, except under the influence of more or less overwhelming evidence; at the same time eminently reasonable, and far from displaying obstinacy. On the other hand, he had a disposition of a singularly tender and affectionate nature, far from impulsive in the acquisition of a new friendship, but ever staunch and firm in support of an old one. "Jackson was possessed of energy which it would be wrong to describe as untiring, for he was never physically very robust, and after a spell of hard work of much less duration than can easily be borne by perhaps the majority of ardent students, he would feel much fatigued, and need repose and simple food. I do not think that he had ever, even in his youth, indulged in athletic pursuits of any kind, and certainly had not experienced the need of physical recreation by amusing exercise, which appears to be considered a necessity by very many at the present day. In spite of this he lived a life of 76 years, which was mainly passed in work."7 Henry Head's tribute included the following: "When we speak of Dr. Hughlings Jackson as the greatest scientific clinician of the nineteenth century in this country, we emphasize the fact that the whole of the material from which he drew his conclusions was found in the wards of a hospital. He never performed an experiment, and yet he has influenced the course of knowledge in medicine more profoundly than any other single observer. Each patient was to him an example of some disturbed process and helped to elucidate the laws of normal and morbid functions."8 In a further statement from Henry Head, we read: "If neurology holds up a brave head in this country it is largely because every man now working here has, at one time or another, received from that generously opened mind some seed which has germinated into a piece of orderly work."9 An appreciation of the life and work of Hughlings Jackson was written by Dr. Charles Mercier, who said: "No man ever had a better claim to the title of genius, for his mind was of extraordinary quality. Not very wide, perhaps in range, it had, within its range, a grasp and penetration truly wonderful. His speculations on the ultimate nature of mental processes and their connexion with brain processes are the most profound and, over a wide field, the most

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consistent and explanatory that have ever been attained; and they will undoubtedly form the foundation of a future system of psychology that is yet to be elaborated."10 In the obituary written by Risien Russell, he declared: "Dr. Jackson has been fitly described as the 'father of English neurology'. No father has been more loved, and no father has ever set his sons a better example of how best to live their lives. No sordid motives influenced him in his life-work, which goes down to posterity as a monument of his greatness. "While fully recognizing that none of the honours that usually fall to members of the medical profession at the hands of the State would have been fitting for one so peculiarly different from the generality of men, there were nevertheless those of us who hoped that some special distinction might be thought of that would have been worthy of his acceptance. It is certain that in no other country in which men of science are selected for distinctions by the State would a Hughlings Jackson have been allowed to go to his rest without receiving the highest honour that could be paid him. It is not, however, surprising that Dr. Jackson never received any such acknowledgement of his services to his fellow-beings and to his country, for it was the privilege of few to know and understand him and the great work that he has done. His was a brain the workings of which were too profound to permit of its real worth being appreciated by the large majority of those who came into contact with him. Only those who were allowed to come into close and almost daily relations with Dr. Jackson were in a position to recognize his real worth, and to appreciate that he was like a giant among pigmies."11 Sir William Gowers, who, said James Taylor, "really reverenced Jackson"12, wrote: "In his clinical work Dr. Hughlings Jackson subordinated everything to observed facts. In each department his search for these was pursued indefatigably. He determined what was likely and devoted himself to their detection, ignoring mere obtrusive facts, which he left to the observation of others, and recognizing the least indication of those which he expected. The process was repeated on every opportunity and the observed facts compared and acutely analysed."13 David Ferrier ended his contribution by saying that Jackson's "name will for ever remain enshrined in the annals of medical science."14 It was the opinion of Dr. F.J. Smith that Jackson would "be known in the future as the greatest genius in his speciality that the world has ever seen."15

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In 1954 Sir Gordon Holmes published The National Hospital, Queen Square, in which he said: "In its outward aspect Jackson's life may be called uneventful. Notable public occasions or public honours did not enter into it, and indeed these are without importance in the life of a man of genius, whatever prominence a biographer may give them."16 Holmes also said of Jackson: "He left a rich legacy of thought to his successors; one not yet exhausted either in its content nor in its stimulating quality . . . Yet if all he taught were to be replaced by wider and more perfect generalisations, we should still remain deeply in his debt for the lessons in method and philosophic thinking which his writings provide for those willing to learn from them. His method was simple, and owed nothing to apparatus or instrumental techniques; it may be summed up as that of the unresting contemplation of facts of observation, scrupulously and untiringly acquired . . . Those who understand the nature of scientific observation will see how much Jackson owed to the fact that he approached new facts well provided with ideas in good order, and thus able to discern the relevant and the significant in the welter of phenomena and of processes that passed before his eyes. We find in his writings not superficial statistical reviews of a large material but the close study of a relatively small material. Nor was the recording of newly observed phenomena an end in itself for Jackson. Behind them he ceaselessly sought for the natural laws which they exemplified; this is the true philosophic method . . . In short, Jackson's work does not simply belong to the history of neurology. It remains today a live and vitalising force in the thought of all who seek depth as well as width of knowledge in the field of neurophysiology and clinical neurology, and who wish to understand more than the reading of instruments of precision can tell them."17 In 1935, Sir William Hale-White, Physician to Guy's Hospital, London, wrote: "Hughlings Jackson's desire was to preach a creed, hence by a multitude of papers and addresses he tried to reach a large audience. His sermons have so soaked into the medical mind, that most doctors, without knowing it, think as he would have had them think."18 He continued, "I met him three or four times. Nevertheless, from such a slight acquaintance, his kindly face, his courteous manner, the sweet reasonableness with which he listened to me and my knowledge of his master mind made me love and venerate him. I understood, at once, the devoted regard, the admiration and the reverent

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affection felt for him by those fortunate house physicians and colleagues who worked with him."19 Hughlings Jackson has not been forgotten by neurologists who followed him in the decades after his death. On 4th April 1935, 100 years after his birth, a commemorative dinner was arranged by the Section of Neurology of the Royal Society of Medicine at the Mayfair Hotel, London. Among the many guests were two of the original members of the Neurological Society of London, of which Jackson was the first President when it was founded in 1886, Sir Thomas Barlow and Sir William Hale-White. Dr. S.A. Kinnier Wilson, who first arrived in Queen Square at the end of 1904 when Jackson was nearly 70 years of age, presided at the dinner. He spoke of his friendship with Jackson for "a few precious years" and went on to say: "I loved Dr. Jackson, and more or less attached myself to him. I saw more of him than anyone of my generation, and I yielded to none in my appreciation and affection. It is difficult to say exactly what it was in Jackson that made the appeal. Partly, no doubt, seniority, which I had been brought up to respect. But it was his philosophic theorizing that fascinated one. I never knew him in his heyday, but even in age the stimulus of his mind was deeply felt."20 Wilson said he made a practice of writing down Jackson's conversations—the only man he had ever Boswellized—when he went on drives with him in his carriage. Jackson made remarks of "penetrating insight or playful humour", and Wilson mentioned that he had described Carlyle's writings as "glorified swearing". Dr. James Taylor, who also attended the dinner, said that Jackson was subject to migraine. Once when Taylor approached him he was waved off abruptly. "Stop!", said Jackson. "I am just observing my migraine."21 In his speech, Dr. Wilfred Harris referred to Jackson's "remarkable concentration, careful observation and unprejudiced recording."22 The Professor of Psychiatry and Neurology at the University of Amsterdam, K.H. Bouman, also spoke at the dinner. In an address given by Sir Farquhar Buzzard, he retailed a story of his having been seen by Jackson when only a few days old. Jackson demonstrated on the newly-born Buzzard how a baby could be lifted by the grasp of its fingers.23 A visitor from New Zealand, Dr. A.M. Douglas (who had married a granddaughter of one of Hughlings Jackson's brothers), made a few remarks on behalf of the Jackson family in his country.

Tributes 193 Speaking of Jackson's last years at Queen Square, Professor Edwin Bramwell told how he would arrive at the Front Hall of the National Hospital and ask if there was anything to interest him. "His attention would be directed to some point on which he might spend five minutes or half an hour, and then he would leave and return in an hour or two with some paper elucidating the point under discussion." He said that Sir James Paget, Jonathan Hutchinson, BrownSequard and Thomas Laycock were "personal influences which went to the shaping of Jackson."24 Among the young neurologists present at the dinner were Drs. Derek Denny-Brown, Swithin Meadows and Macdonald Critchley. Writing in The Lancet on 13th April 1935, Kinnier Wilson described Jackson as "the neurologist's neurologist". He went on to say: "Jackson's genius consisted in his power of combining the little and the great, of uniting an unsurpassed faculty of detailed clinical observation with a philosophic breadth of thought and with the use of a gifted imagination. Thus did it come about that on the one hand his fame was founded on clinical minuteness—for example in Jacksonian epilepsy and in the syndrome of Hughlings Jackson (unilateral palsy of motor tenth, eleventh and twelvth)—and, on the other, was established by his marvellous comprehension of the underlying significance of phenomena ... In these and other ways, then, Hughlings Jackson contributed to the science of neurology foundation stones on which others are building—some, doubtless, who know not whence the understructure is derived. Proof of the abiding value of his work has been forthcoming for years now in the increasing attention paid to his views by scholars abroad . . . No doubt Jackson was a product of his period, and in not a few respects advancing knowledge has left him behind; his innate modesty never led him to say more of his views than that they were theories and speculations and that some day he would be 'found out'; but he is honoured today by neurology the world over, because of his genius in raising ideas of neural activity to higher planes of thought and in discovering unities and heterogeneous clinical diversities."25 Also in 1935, to commemorate the centenary of Jackson's birth, Foster Kennedy, who as a very young man had seen him at Queen Square, paid a tribute at a meeting of the New York Academy of Medicine on 4th April. He said: "We are still too near the 19th century to be able properly to appraise it but many now are beginning to realize that this century in England represented a Periclean age in which great poets sang and great novelists wrote; in which natural law began to be understood and applied to the material needs

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of man. We have so inherited the amazing mental innovations then instituted—they have become so much the warp and woof of our own mental lives that we are hardly aware of how those men changed the world. We read Darwin's writing and are inclined to think 'this is old stuff'without quite perceiving that, like Aeolus, Darwin caused a new wind to blow through the murk of notions that we inherited from the middle ages. Of the same band of prophets is Hughlings Jackson, who might be called the Father of Neurology; an Arguseyed observer with a passion for detail and a brooding intelligence enabling him to see general law emerging from the details, he represented in himself the spirit of science in medicine. It was said of him that 'Jackson's guess was worth ten men's facts; an epigram which, like all epigrams, was only half true since Jackson did not guess but saw facts he associated with fire and accuracy, and his intelligence like a single horn probed to the heart of the mystery. "In the making of the house of the physiology of the brain he was an adventurous engineer, he gathered the materials for the building, he dug foundations—but even more was he a builder of flying buttresses. His observations by the bedside and in the autopsy room told him where lay the motor areas in our brains. At a time when the function of the basal ganglia was entirely unknown, he rightly knew that in them lay the secret of chorea. "In the most philosophical of his writings, he came to the conclusion that, not only had the nervous system been evolved from the primitive nervous system of the lower vertebrates by the addition of new parts, but he perceived physiological and philogenic differences in the various levels of the nervous system so constructed. "It is proper also to say that this great scientist was also a great doctor. In our days we are being importuned to believe that investigation must be cloistered and that truth can only be found by those who formally devote all of their day to hospital and university work. Hughlings Jackson and his contemporaries were not so closeted; they kept in touch with the adventure of life and out of that adventure they plucked truth for our benefit. On this day one hundred years ago, Hughlings Jackson was born and the World is the better for that birth."26 During a meeting of the Association of British Neurologists from 18th to 20th April 1963 held in Harrogate, Yorkshire, the Members visited the York Medical Society, to which Hughlings Jackson had been elected in January 1858. The Society was housed in the original home of Jackson's first clinical teacher, Dr. William Anderson. On the first day of the meeting, the members of the Association

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of British Neurologists paid a visit to Green Hammerton. The then President, Dr. Macdonald Critchley, unveiled a plaque on an outside wall of Providence Green, where Hughlings Jackson had been born, by permission of Mrs. Knowles, who owned the house at the time. To commemorate the 150th anniversary of Hughlings Jackson's birth, a meeting was held at the London Hospital and the participants re-evaluated his contributions to neurology. Dr. C.W. Wallesch reminded us of the words spoken by Jackson in 1935 by his compatriot, Otfried Foerster: "The doctrines he developed have been and will be forever a guidepost for subsequent research. There is scarcely a single neurological problem which was not illuminated and elucidated by his prophetic ingenuity. Jackson's writings are the bible of neurology, the canon for the votaries of our science."27 An attempt was made, also in 1985, by the Association of British Neurologists, under the presidency of Dr. Peter Robinson, to have a plaque placed in Westminster Abbey in memory of Hughlings Jackson. Dr. Robinson asked the Dean of the Abbey to honour Jackson in this way, but, to date, the request has not been granted. There the story of the life and work of John Hughlings Jackson, "father" of English neurology, ends. "Hitherto", said Dr. A.E. Clark-Kennedy, "neurology had been an accumulation of disjointed facts. Into that chaos Jackson had now injected law and order."28 It remains to be seen whether, after another century, he who was known to his colleagues as "the Sage of Manchester Square"29 will still be remembered as a pioneer in this one aspect of medicine. The upsurge in our technico-scientific knowledge over the last 50 years has simplified much of the practice of clinical neurology. Perhaps our neurological successors will not retain the same affection for our "father" that, even beyond Queen Square—where we are sometimes still accused of ancestor worship—is felt today. It is our hope, however, that, within the history of medicine, Hughlings Jackson will always be recognised alongside such medical giants as Willis, Harvey and Hunter. \ Hazlitt said that no one is truly great who is great only in his lifetime; the test of greatness is the page of history. Yet shall thy name conspicuous and sublime Stand in the spacious firmament of time Fixed as a star. William Wordsworth

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Notes

Chapter 1 1. Some Notes on the Contributions made by Dr. Hughlings Jackson to our Knowledge of Nervous Disease. Anon. The London Hospital Gazette. 8 October 1895. 2. Neurological Fragments. Ed. Taylor, J. London. Oxford University Press. 1926. p. 1. 3. Idem. p. 2. 4. Personal communication.

Chapter 2 1. Neurological Fragments, p. 35. 2. A Short History of Lyme Regis. Fowles, J. Stanbridge, Wimborne, Dorset. The Dovecote Press. 1991. 3. Letter from Ann Pitchforth to The Saints in the Isle of Man. Pub. The Latter-Day Saints', Millenial Star. 15th July 1846. p. 12. 4. Letter from Ann Pitchforth to Mr. John Hughlings. April 1845. Courtesy of Brigham Young University. 5. Advertisement in Nauvoo Neighbour 3.15. 13th August 1845. 6. Deed of Conveyance by John Hughlings to Dolau District Council, dated 4th April 1848. Courtesy of Dolau District Council.

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Chapter 3 1. Letter from John Hughlings Jackson to Thomas Jackson. 28th May 1904. Courtesy of Dr. W.L.H. Jackson. 2. Letter from John Hughlings Jackson to Thomas Jackson. 18th June 1869. Courtesy of Dr. W.L.H. Jackson. 3. Letter from John Hughlings Jackson to Thomas Jackson. February 1876. Courtesy of Dr. W.L.H. Jackson. 4. Letter from John Hughlings Jackson to Mrs. Thomas Jackson. 15th November 1906. Courtesy of Dr. W.L.H. Jackson. 5. Neurological Fragments, p. 2. 6. Selected Writings of John Hughlings Jackson. Ed. Taylor, J. 2 vols. London. Hodder and Stoughton Ltd. 1932. II. p. 269. 7. Jonathan Hutchinson: His Life and Letters. Hutchinson, H. London. Heinemann. 1946. p. 20. 8. Idem. p. 25. 9. Idem. p. 26. 10. The York Medical School. Wetherill, J.H. Med. Hist. 1961. 5. 253-269. 11. Idem. p. 25. 12. Jonathan Hutchinson: His Life and Letters, p. 25. 13. The Late Dr. Hughlings Jackson. Hutchinson, J. B.M.J. 1911. II.

1553.

14. 15. 16. 17. 1854. 18. 19.

Jonathan Hutchinson: His Life and Letters, p. 31. Idem p. 30. Selected Writings of John Hughlings Jackson. II. pp. 334—335. Letter from Samuel Jackson to John Hughlings Jackson. 17th March Courtesy of Brigham Young University. Neurological Fragments, p. 36 Selected Writings of John Hughlings Jackson. II. p. 124.

Chapter 4 1. Neurological Fragments, p. 2. 2. Idem. pp. 29-30. 3. Jonathan Hutchinson: His Life and Letters, p. 38. 4. Idem. p. 29. 5. Notable Names in Medicine and Surgery. Bailey, H. and Bishop, W.J. London. H.K. Lewis & Co. Ltd. 1946. p. 113. 6. Sands of Time. Purves-Stewart, J. London. Hutchinson & Co. Ltd. 1939. p. 42. 7. Neurological Fragments, p. 4. 8. Selected Writings. II. p. 300. 9. Idem. p. 300. 10. Neurological Fragments, p. 5.

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11. Selected Writings. II. p. 301. 12. Selected Writings. I. p. 346n. 13. Neurological Fragments, p. 30.

Chapter 5 1. Jonathan Hutchinson: His Life and Letters, p. 80. 2. The London, A Study in the Voluntary Hospital System. Clark-Kennedy, A.E. 2 vols. London. Pitman Medical Publishing Co. 1963. 3. Idem. p. 78. 4. The First Spasmodic Cholera Epidemic in York. Durey, M. Borthwick Institute. Pamphlet. 1974. 5. The 1832 Cholera Epidemic in York. Barnet, M.C. Med. Hist. XVI. I. p. 31. 6. Idem. p. 34. 7. Idem. p. 37. 8. Neurological Fragments, p. 22.

Chapter 6 1. Neurological Fragments, p. 19. 2. John Hughlings Jackson, 1835-1911. Harris, W. Postgrad. Med. J. 1935. II. 133. 3. Neurological Fragments, p. 40. 4. Suggestions for Studying Diseases of the Nervous System on Professor Owen's Vertebral Theory. Jackson, J. H. 1863. Published privately. 5. Dr. Hughlings Jackson on Mental Disorders. Savage, G. J. Ment. Sci. 1917. LXII. 320. 6. John Hughlings Jackson, M.D., F.R.C.P., F.R.S. B.M.J. 1911. 14.10. 950. 7. Idem. pp. 952-953. 8. Neurological Fragments, pp. 40-41. 9. Contributions of John Hughlings Jackson to Neurology. Walshe, F.M.R. Arch. Neurol. 1961. 5. 28. 10. Letter from John Hughlings Jackson to Thomas Jackson. 18th June 1869. Courtesy of Dr. W.L.H. Jackson. 11. Life and Letters of Jonathan Hutchinson. p. 86. 12. Neurological Fragments, p. 41. 13. Selected Writings. I. p. 99. 14. Idem. pp. 136-137. 15. Idem. p. 77. 16. Selected Writings. I. p. 93. 17. Selected Writings. II. p. 87. 18. Idem. p. 297.

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Chapter 7 1. Writings of Hughlings Jackson. Mitchell, R.G. Cerebral Palsy Bull. 2. 1. 1960. 34-35. 2. Selected Writings. I. p. 147N. 3. Selected Writings II. p. 40N. 4. Letter from Herbert Spencer to John Hughlings Jackson. 26th November 1866. Courtesy of the late Mrs. Madge Parker. 5. Notes on the Physiology and Pathology of Language. Jackson, J.H. Med. Times & Gazette 1866. i. 659. Repr. Brain xxxviii.47. Repr. Selected Writings. II. pp. 121-128. 6. Letter from Herbert Spencer to John Hughlings Jackson. 8th December 1903. Courtesy of the late Mrs. Madge Parker. 7. An Autobiography. Spencer, H. London. Williams & Norgate. 1904. 8. Life and Letters of Herbert Spencer. Duncan, D. London. Methuen & Co. 1908. p. 227. 9. Selected Writings. II. p. 17. 10. Idem. p. 195. 11. Idem. p. 47 12. Idem. p. 58. 13. Idem. p. 58. 14. Croonian Lectures on Evolution and Dissolution of the Nervous System. Jackson, H.J. B.M.J. 1884 i. 591, 660, 703; Lancet 1884 i. 555, 649, 739; Med. Times & Gazette, i. 411,445,485. Repr. Selected Writings. II. pp. 45-75. 15. Selected Writings. II. p. 84. 16. John Hughlings Jackson and the Mind-Body Relation. Englehardt, H.T. Bull. Hist. Med. 1965. 49. 137-151. 17. Evolution and Dissolution of the Nervous System. Jackson, J.H. Croonian Lectures. B.M.J. 1884, i. 591, 660, 703; Lancet 1884. i. 535, 649, 739; Med. Times & Gazette. 1884. i. 441, 445, 485. Repr. Selected Writings. II. pp. 45-75. 18. The Factors of Insanity. Jackson, J.H. Med. Pract. and Circ. 1894. ii. 615. Repr. Selected Writings. II. pp. 411-421. 19. Remarks on Evolution and Dissolution of the Nervous System. Jackson, J.H. J. Ment. Sci. 1887. xxxiii. 25-48. Repr. Selected Writings. II. p. 79. 20. Selected Writings. II. p. 80. 21. Discussion at the Neurological Society of Dr. Mercier's Paper on "Inhibition." Dr. Hughlings Jackson's Contribution. Brain, xi. 1888. 386. Repr. Selected Writings. II. pp. 477-481. 22. Relations of Different Divisions of the Central Nervous System to One Another and to Parts of the Body (Hughlings Jackson Lecture). Jackson, H.J. Lancet. 1898. i. 79. Repr. Selected Writings. II. pp. 422-443. 23. Hughlings Jackson as Pioneer in Nervous Physiology and Pathology. Broadbent, W. Brain. 1903. 26. 305-359. 24. Hughlings Jackson on Psychiatry. Dewhurst, K. Oxford. Sandford Publications. 1982.

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25. Arch. 26. 27.

Contributions of John Hughlings Jackson to Neurology. Walshe, F.M.R. Neurol. 1961. 5. 120. Idem. p. 130. Idem. p. 130.

Chapter 8 1. On Epilepsy and Epileptiform Seizures. Sieveking, E.H. 1858. London Churchill, p. 10. 2. Idem, p. 4. 3. Selected Writings. I. p. 80. 4. Idem. p. 39. 5. Idem. p. 137. 6. Idem. p. 308. 7. Idem. pp. 101-102. 8. Letter from John Hughlings Jackson to S.A. Kinnier Wilson. 29th April 1908. Courtesy of the Royal College of Physicians of Edinburgh. 9. Selected Writings. II. p. MSN. 10. Jacksonian Epilepsy. Jefferson, G. Postgrad. Med. J. 1935. 11. 150-162. 11. Lecons du mardi a la Salpetriere. Charcot, J.M. Paris. Bureau du Progres Medical. 1887. 12. Selected Writings. I. p. 77. 13. The Functions of the Brain. Ferrier, D. London. Smith, Elder & Co. 1876. 14. Selected Writings. I. p. 278. 15. Idem. p. 190. 16. Positive and Negative Symptoms and Jackson: A Conceptual History. Berrios, G.E. Arch. Gen. Psych. 1985. 42. 95. 17. On the Pathology of Convulsions. Reynolds, J.R. Med. Chir. J. 1858. 2. 1-14. 18. Positive and Negative Symptoms and Jackson: A Conceptual History. 96. 19. Positive and Negative Symptoms in Psychiatry. Trimble, M. B.J. Psych. 1986. 148. 589. 20. Selected Writings. I. p. 386. 21. Idem. p. 388. 22. Idem. p. 387. 23. Idem. p. 389. 24. Idem. p. 309. Chapter 9 1. Epilepsy. Cowers, W.R. London. J.& A. Churchill. 1881. 2. The Falling Sickness. Temkin, O. Baltimore. Johns Hopkins Univ. Press. 1945.

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3. Selected Writings. I. p. 471. 4. The Falling Sickness, p. 327. 5. Idem. p. 334. 6. Idem. p. 388. 7. The Evolution of John Hughlings Jackson's Thoughts on Epilepsy. Eadie, MJ. Clin. Exp. Neur. 1990. 27. 29-41. 8. Selected Writings. I. pp. 8-36. 9. Idem. p. 78. 10. The Evolution of John Hughlings Jackson's Thoughts on Epilepsy. 40. 11. Idem. p. 40. 12. Hughlings Jackson and Epilepsy: An Introduction. Reynolds, E.H. In Hierarchies in Neurology. Kennard, C. and Swash, M. Eds. London. Springer-Verlag. 1989. 13. Physiology of the Cerebral Motor Cortex: The Contribution of Clinical Study. Walshe, F.M.R. B.M.J. 1947. ii. 831.

Chapter 10 1. An Address Delivered at the Opening of the Section of Pathology, at the Annual Meeting of the British Medical Association, in Worcester, August 1882. B.M.J. 1882. ii. 305. Repr. in Selected Writings. II. pp. 334-342. 2. Selected Writings. II. p. 336. 3. Idem. p. 335. 4. Idem. p. 335. 5. Idem. p. 335. 6. Idem. p. 336. 7. Idem. pp. 336-337. 8. Idem. p. 337. 9. Idem. pp. 337-338. 10. Idem. p. 341. 11. Idem. p. 338. 12. Idem. p. 342. 13. Idem. p. 342. 14. The Little Genius. Horder, M. London. Gerald Duckworth & Co. 1966. p. 15.

Chapter 11 1. Report of a Case of Disease of One Lobe of the Cerebrum and Both Lobes of the Cerebellum. Jackson, J.H. Med. Mirror. 1869. i. 126. 2. Case of Tumour of the Middle Lobe of the Cerebellum. Rigidity in CerebellarAttitude—Occasional Tetanus-Like Seizures. Jackson, HJ. B.M.J. 1871. ii. 242, 528. Repr. Brain. 1900. 39. 426. 3. Selected Writings. II. p. 328. 4. On Certain Relations of the Cerebrum and Cerebellum (on rigidity of

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hemiplegia and on paralysis agitans). Jackson, J.H. Brain. 1899. xxii. 621. Repr. Selected Writings II. pp. 452-458. 5. Idem. p. 452. 6. Idem. p. 476. 7. Hierarchies in the Cerebellum. Stein, J.F. In Hierarchies in Neurology. p. 159. 8. On Dr. Hughlings Jackson's Views of the Functions of the Cerebellum as Illustrated by Recent Research. Horsley, V. Brain 1906. 29. 446-466. 9. Idem. p. 446. 10. Idem. p. 456. 11. Idem. p. 460. 12. Idem. p. 462. 13. Idem. p. 465. 14. The Clinical Symptoms ofCerebellar Disease and Their Interpretation. Holmes, G. Lancet. 1922 i. 117, 1231, ii. 59, 111. 15. The Cerebellum of Man. Holmes, G. Brain. 62. 1—30. Repr.in Selected Papers of Gordon Holmes. Ed. Phillips, G.S. Oxford. Oxford University Press. 1979. pp. 248-277. 16. Idem. p. 248. 17. Idem. p. 256. 18. Hierarchies in the Cerebellum. Stein, J.F. In Hierarchies in Neurology. p. 159. 19. Idem. p. 165.

Chapter 12 1. Hemiplegia on the Right Side with Loss of Speech. Jackson, H.J. B.M.J. 1864.J. 572. 2. Letter, Med. Times & Gazette. 1866. ii. 210. 3. Med. Times & Gazette. 1868. ii. 275. Repr. Brain. 1915. 38. 59. 4. Observations on the Physiology of Language. Jackson, J.H. B.M.J. 1868. ii. 259; Med. Times & Gazette, ii. 275; Med. Press & Circ. ii. 237. 5. On the Seat of the Faculty of Articulate Language. Broca, P. B.M.J. 1868. 2. 259.

Chapter 13 1. 2. 3. 4. 5. 6. 7. 8.

Selected Writings. II. p. 121. Idem. p. 123. Selected Writings. I. p. 145. Selected Writings. II. p. 234. Idem. p. 124. Idem. p. 126. Idem. p. 123. Idem. p. 123.

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9. Idem. p. 173. 10. Idem. p. 173. 11. Science of Language. Miiller, P.M. London. Longmans, Green & Co. Ltd. 1861. I. p. 420. 12. Selected Writings. II. p. 188. 13. Notes on the Physiology and Pathology of the Nervous System. Jackson, H.J. Med. Times & Gazette. 1868. ii. 526-602. Repr. Brain. 1915. xxxviii. 66. 14. Selected Writings. II. p. 131. 15. Idem. p. 134. 16. Aphasiology. Critchley, M. London. Edward Arnold (Publishers) Ltd. 1970. Chap. xix. 17. Selected Writings. II. p. 138. 18. Idem. pp. 141-142. 19. Notes on the Physiology and Pathology of Language. Jackson, J.H. Med. Times & Gazette. 1866. i. 659. Repr. Brain xxxviii. 47. Repr. Selected Writings. II. p. 121.

Chapter 14 1. Affections of Speech from Disease of the Brain. Jackson, J.H. Brain. 1878-1879. i. 304. 2. Selected Writings. II. p. 158. 3. Idem. p. 158. 4. Idem. p. 158. 5. Diseases of the Nervous System. Gowers, W. London. J.& A. Churchill. 1892. p. 541N. 6. Selected Writings. II p. 159. 7. Idem. p. 160. 8. Idem. p. 164. 9. Idem. p. 164. 10. Idem. p. 166. 11. Idem. p. 169. 12. Baillarger and Jackson. The Principle of Baittarger-Jackson in Aphasia. Alajouanine, Th. J. Neurol. Neurosurg. Psychiat. 1960. 23. 191. 13. Idem. p. 191. 14. Selected Writings. II. p. 125. 15. Idem. p. 171N. 16. Baillarger and Jackson. The Principle of Baillarger-Jackson in Aphasia. 191-193. 17. Selected Writings. II. p. 173. 18. Idem. pp. 177-178. 19. Idem. p. 191. 20. Idem. p. 191. 21. Idem. p. 197.

Notes 22. 23. 24. 25. 26. 27. 28. 29.

205 Idem. p. 198. Idem. p. 199. Idem. p. 200. Idem. p. 201. Idem. p. 205. Idem. p. 205. Idem. p. 209. Idem. p. 210.

Chapter 15 1. Aphasia. Bateman, F. London. J.& A. Churchill. 1870. p. 240F. 2. On the Various Forms of Loss of Speech in Cerebral Disease. Bastian, H.C. Br. For. Med. Chir. Rev. 1869. xii. pp. 209-236. 3. The Brain as an Organ of Mind. Bastian, H.C. London. C. Kegan Paul & Co. 1880. 4. Aphasia and Other Speech Defects. Bastian, H.C. London. H.K. Lewis. 1898. 5. Idem. p. 269. 6. Idem. 270. 7. Idem. p. 273. 8. Selected Writings. I. 150N. 9. Hughlings Jackson as Pioneer in Nervous Physiology and Pathology. Broadbent, W. Brain. 1903. XXVI. pp. 305-357. 10. Idem. p. 305. 11. Idem. p. 306. 12. Idem. p. 322. 13. Idem. p. 345. 14. Idem. p. 348. 15. Idem. p. 350. 16. Idem. p. 355. 17. Manual of Diseases of the Nervous System. Gowers, W.R. London. J. &A. Churchill. 1892. 18. Zur Auffassung derAphasien. Freud, S. Lepizig. Deuticke. 1891. 19. Sigmund Freud on Aphasia. Stengel, E.. London. Imago Publishing Co. Ltd. 1953. p. xi. 20. Sigmund Freud's Contribution to the Early History ofAphasiology. Bay, E. In Historical Aspects of the Neurosciences, A Festschrift for Macdonald Critchley, ed. Rose, F.C. and Bynum, W.F. New York. Raven Press. 1981. pp. 103-107. 21. Sigmund Freud on Aphasia, p. xi. 22. Idem. p. 61. 23. Idem. pp. 104-105. 24. Die agrammatischen Sprachstorungen. Pick, A. Berlin. Springer. 1913.

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25. Aphasia and Kindred Disorders of Speech. Head, H. Cambridge, Cambridge University Press. 1926. I. p. viii. 26. Hughlings Jackson on Aphasia and Kindred Affections of Speech. Head, H. Brain. 1915. 38. 1-27. 27. Idem. p. 1. 28. Aphasia and Kindred Disorders of Speech. 1. p. 57. 29. Aphasia. An Historical Review. Head, H. Brain. 1920. 30. Aphasia and Kindred Disorders of Speech. Head, H. 1926. 1. pp. 30-31. 31. Henry Head Centenary. Essays and Bibliography. Cross, K.W., Henson, R.A., Critchley, M. and Brain, W.R. London. Macmillan & Co. 1961. 32. An Introduction to the Study of Aphasia. Wilson, S.A.K.W. Lancet. 1921. ii. 1143. 33. Aphasia. Wilson, S.A.K. London. Kegan Paul Trench, Truber & Co. Ltd. 1926. 34. Selected Writings of John Hughlings Jackson, ed. Taylor, J. London. Hodder & S tough ton. 2 vols. 1932. 35. Contributions of John Hughlings Jackson to Neurology. Walshe, F.M.R. Arch. Neurol. 1961. 5. 119-131. 36. Idem. p. 131. 37. History of Neurology. Riese, W. New York. M.D. Publications, Inc. 1959. p. 206. 38. Diseases of the Nervous System. Walshe, F.M.R. Edinburgh and London. E. & S. Livingstone. 1940. 39. Idem. p. 49. 40. Diseases of the Nervous System. Matthews, W.B. and Miller, H. Oxford. Blackwell. 1972. p. 137.

Chapter 16 1. Ramollissement de I'insula gauche, Aphasie, Hemiplegie droite. Marie, P. Bull. Soc. Anat. Paris. 1882. pp. 58-59. 2. Revision de hi question sur I'aphasie: la troisieme circonvolution frontale gauche ne joue aucun role special dans la fonction du langage. Marie, P. Sem. Med. 26. 241-247. 3. Aphasia and Kindred Disorders of Speech. Head, H. 1. p. 67. 4. Paul Broca. Schiller, F. Oxford. Oxford University Press. 1992. p. 208. 5. L'Aphasie de J.M. Charcot a Th. Alajouanine. Llermitte, F. and Signoret, J.L. Rev. Neurol. 1982. 138. 122. 893-919. 6. L'Aphasie et la langage pathologique. Alajouanine, Th. Paris. J.B. Bailliere et Fils. 1968. p. 257. 7. Idem. pp. 259-260. 8. Idem. p. 258. 9. Pierre Marie 1853-1940. Cohen, H. Proc. R. Soc. Med. 1953. 46. 122.1047-1054.

Notes

207

10. L'Aphasie de Broca. Moutier, F. Paris. G. Steinheil. 1908. 11. The Organism. Goldstein, K. New York. American Book Co. 1939. p. 254. 12. The Nervous System and Its Diseases. Mills, C.K. Philadelphia, J.B. Lippincott Co. 1898. p. 115. 13. Idem. p. 115. 14. The Different Theories of Aphasia. Mills, C.K. N.Y. Med. J. 1914. xcix. pp. 861-865. 15. A Study of Aphasia. Weisenburg, T.H. Arch. Neurol. Psych. 1934. 31. 1-33. 16. Aphasia, A Clinical and Psychological Study. Weisenburg, T.H. and McBride, K.E. New York. The Commonwealth Fund. 1935. 17. Idem. p. 11. 18. Idem. p. 16. 19. Idem. p. 19. 20. The Faculty of Speech: A Clinical and Psychological Study of Aphasia. Collins, J. New York. The Macmillan Co. 1898. 21. Aphasia and Associated Speech Problems. Osnato, M. New York. Paul B. Hoeber. 1920. 22. Idem. p. 14. 23. Language and Language Disturbances. Goldstein, K. New York. Grune & Stratton. 1948. 24. Functional Disturbances in Brain Damage. Goldstein, K. In American Handbook of Psychiatry. Ed. Arieti, S. New York. Basic Books. 1959. pp. 772-773. 25. Injuries of Nerves. Mitchell, S.W. Philadelphia, J.B. Lippincott & Co. 1872. 26. Lectures on Diseases of the Nervous System, Especially in Women. Mitchell, S.W. Philadelphia. Henry C. Lea's Son & Co. 1881. 27. The Commonplace Psychiatry of Dr. Adolf Meyer. Lief, A. New York. McGraw-Hill Book Co., Inc. 1948, p. 26. 28. Idem. pp. 27-28. 29. Idem. p. 34. 30. Certain Features of the Work of the Late J. Hughlings Jackson of London. Putnam, J.J. Boston Med. Surg. J. 1913. 169. 73-76. 31. Idem. p. 75. 32. Idem. p. 76. 33. Language, Communication and the Brain. Marus/ewski, M. The Hague. Mouton. 1975. 34. Idem. p. 30N. 35. Selected Writings. II. p. 385. 36. Aphasia and Non-Verbal Disorders of Language. Bay, E. Brain. 1962. 85. 3. 37. Aphasia in Adults. Schuell, H., Jenkins, J.J. and Jimenez-Pab6n, E. New York. Harper & Row. 1964.

208

John Hughlings Jackson

38. Traumatic Aphasia. Luria, A.R. The Hague. Mouton. 1970. p. 100. 39. Idem. p. 168 40. Higher Cortical Functions in Man. Luria, A.R. London. Tavistock Publications. 1966. p. 17. 41. Idem. p. 17. 42. Idem. p. 18. 43. A Review: Traumatic Aphasia. Geschwind, N. Boston Studies in the Philosophy of Science, Vol. XVI. Ed. Cohen, R.S. and Wartofsky, M.W. Dordrecht. D. Reidel Publishing Co. 1974. p. 500. 44. Handbook of Clinical Neurology. Ed. Vinken, PJ. and Bruyn, G.W. Amsterdam. North-Holland Publishing Co. 1969. 4. pp. 84-104. 45. L'Aphasie de J.M. Charcot et Th. Alajouanine. 46. Idem. p. 894. 47. Idem. p. 896. 48. Idem. p. 897. 49. L'aphasie et I'elaboration de la Pensee Explicite. Ombredane, A. Paris. Presses Universitaires de France. 1951. 50. Neurology. Wilson, S.A.K. London. Edward Arnold. 2 vols. 1940. 51. The Neurology of Language. In Speech Disorders. Brain, R. London. Butterworth. 1961. 52. Aphasiology and Other Aspects of Language. Critchley, M. London. Edward Arnold (Publishers) Ltd. 1970. pp. 46-47. Chapter 17 1. Hughlings Jackson on Psychiatry. 2. Neurological Fragments, p. 43. 3. Hughlings Jackson on Psychiatry, p. 118. 4. Disorders of Consciousness in Psychiatry. Ey, H. In Handbook of Clinical Neurology, Vinken, P.J. and Bruyn, G.W. Amsterdam North-Holland Publishing Co. 1969. 3. p. 120. 5. Dr. John Hughlings Jackson. Campbell, A.W. Med. J. Aust. 1935. ii. 344. 6. Idem. p. 347. 7. Idem. p. 347. 8. Idem. p. 347. 9. Idem. p. 347. 10. John Hughlings Jackson 1835-1911. McEachern, D. Arch. Neurol. Psych. 1935. 33. 640. 11. Idem. p. 642. 12. Hierarchies in Neurology. Kennard, C., and Swash, M. London. Springer-Verlag. 1989. 13. The Major Influences on the Early Life and Work of John Hughlings Jackson. Greenblatt, S.H. Bull. Hist. Med. 1965. 39. 346-376. 14. Idem. p. 362.

Notes

209

15. Idem. p. 355. 16. Hughlings Jackson's First Encounter with the Work of Paul Broca: The Physiological and Philosophical Background. Greenblatt, S.H. Bull. Hist. Med. 1970. 44. 555-570. 17. The Development of Hughlings Jackson's Approach to Diseases of the Nervous System 1863—1866: Unilateral Seizures, Hemiplegia and Aphasia. Greenblatt, S.H. Bull. Hist. Med. 1977. 51. 412. 18. The Development of Modern Neurological Thinking in the 1860s. Greenblatt, S.H. Persp. Biol. Med. 1991. 35. I. 138. 19. A History of Neurology. Riese, W. New York. M.D. Publications. 1959. 20. Hughlings Jackson's Doctrine of Aphasia and Its Significance Today. Riese, W, J. Nerv. Ment. Dis. 1955. 122. pp. 1-13. 21. Idem. p. 2. 22. The Nature of Psychiatric Research -with Reflections on the Research of Freud and Hughlings Jackson and on the Limitations of Statistics. Levin, M. Am. J. Psych. 1962. 119.5. 404-409. 23. Idem. p. 408. 24. Suggestions for Studying Diseases of the Nervous System on Professor Owen's Vertebral Theory. Jackson, J.H. Published privately. 1863. 25. Letter from John Hughlings Jackson to S.A. Kinnier Wilson, 18th August 1907. Courtesy of The Royal College of Physicians of Edinburgh. 26. Paul Broca. Schiller, F. Oxford University Press. 1992. 27. Language. Sapir, P. New York. Harcourt, Brace & Co., Inc. 1921. p. 10. 28. Idem. p. 211. 29. The National Hospital Queen Square 1860-1948. Holmes, G. Edinburgh. E. & S. Livingstone Ltd. 1954. p. 30. 30. Idem. p. 33. 31. On the Mode of Representation of Movements in the Motor Cortex, with Special Reference to 'Convulsions Beginning Unilaterally (Jackson)'. Walshe, F.M.R. Brain. 1943. 66. 104. Repr. Critical Studies in Neurology. Walshe, F.M.R. Edinburgh. E. & S. Livingstone Ltd. 1948. pp. 149-187. 32. Idem. p. 185. 33. Idem. p. 185. 34. Philosophical Aspects of John Hughlings Jackson's Ideas on Speech Disorders and the Nervous System. Kennedy, P. J. Med. Biog. 5.1. 1977. 17-21. Chapter 18 1. Remarks on the Relations of Different Divisions of the Central Nervous System to One Another and to Parts of the Body. Jackson, J.H. Lancet. 1898. i. 79. 2. Brain. 1906. xxix. 3. Hughlings Jackson and the Cortical Motor Centres in the Light of Physiological Research. Hitzig, E. Brain. 1900. 23. 544.

210

John Hughlings Jackson

4. Hughlings Jackson as Pioneer of Nervous Physiology and Pathology. Broadbent, W. Brain. 1903. 26. 446. 5. The Illustration by Recent Research of Hughlings Jackson's Views on the Functions of the Cerebellum. Horsley, V. Brain. 1906. 29. 446. 6. Special Sense Discharges from Organic Disease. Gowers, W. Brain. 1909. 32. 303. 7. On Aphasia: An Historical Review. Head, H. Brain. 1920. 43. 390. 8. Hughlings Jackson Lecture. Dana, C. Lancet. 1927. ii. 304. B.M.J. 1927. ii. 225. 9. Quantitative Management of Contraction in Lowest Level Coordination. Sherrington, C. Brain. 1931. 54. 1. Chapter 19 1. Hughlings Jackson and His Influence on Neurology. Buzzard, E.F. Lancet. 1934. II. 909. 2. Neurological Fragments, p. 18. 3. Idem. p. 18. 4. Idem. p. 34. 5. Idem. p. 34. 6. John Hughlings Jackson. Buzzard. T. Obituary, B.M.J. 1911. II. 953. 7. Neurological Fragments, p. 16. 8. John Hughlings Jackson 1835—1911. Ferrier, D. Proc. R. Soc. London. 1911-1912. 13. 884. 9. Neurological Fragments, p. 41. 10. Idem. p. 42. 11. Selected Writings. II. p. 360. 12. The Psychology of Joking. Jackson, J.H. Selected Writings. II. pp. 359-364. 13. Idem. p. 362. 14. Idem. p. 360. 15. Idem. p. 363. 16. Neurological Fragments, p. 14. 17. Idem. p. 45. 18. The Late Dr. Hughlings Jackson. Recollections of a Lifelong Friendship. Hutchinson, J. B.M.J. 1911. II. 1553. 19. Neurological Fragments, p. 15. 20. The Late Dr. Hughlings Jackson. Recollections of a Lifelong Friendship. 1553. 21. John Hughlings Jackson, M.D., F.R.C.P., F.R.S. Hutchinson, J. B.M.J. 1911. II. 952. 22. Neurological Fragments, p. 17. 23. John Hughlings Jackson, M.D., F.R.C.P., F.R.S. Gowers, W. B.M.J. 1911. II. 954.

Notes

211

24. Neurological Fragments, p. 43. 25. Idem. p. 42. 26. Idem. p. 43. 27. Idem. p. 42. 28. Dr. John Hughlings Jackson on Mental Disorders. Savage, G. J. Ment. Sci. 1917. LXIII. 316. 29. Neurological Fragments, p. 43. 30. Idem. p. 44. 31. John Hughlings Jackson, 1835-1911. p. xxiii. 32. John Hughlings Jackson, M.D., F.R.C.P., F.R.S. Russell, R. B.M.J. 1911. II. 954. 33. John Hughlings Jackson, M.D., F.R.C.P., F.R.S. Smith, F.J. B.M.J. 1911. II. 954. 34. John Hughlings Jackson, M.D., F.R.C.P., F.R.S. Russell, R. 954. 35. Neurological Fragments, p. 44. 36. Idem. p. 44. 37. John Hughlings Jackson, M.D., F.R.C.P., F.R.S. Russell, R. 954. 38. Jonathan Hutchinson. Foreword by J. Johnston Abraham, p. i. 39. Jonathan Hutchinson. p. 220. 40. Dr. John Hughlings Jackson. Campbell, A.W. p. 347. 41. Aphasia and Kindred Disorders of Speech. I. p. 31. 42. Neurological Fragments, p. 36. 43. Idem. p. 36. 44. Idem. p. 18. 45. Idem. p. 30. 46. Idem. p. 36. 47. John Hughlings Jackson, 1835-1911. Harris, W. p. 133. 48. Neurological Fragments, p. 36. 49. Idem. p. 33. Chapter 20 1. Jonathan Hutchinson. p. 229. 2. The Hughlings Jackson Memorial Lectures. Harris, W. Pamphlet. London. 1932. pp. 6—7. 3. Neurological Fragments, pp. 14—15. 4. Letter from John Hughlings Jackson to Thomas Jackson, l l t h February 1876. Courtesy of Dr. W.L.H. Jackson. 5. Neurological Fragments, p. 36. 6. Die Thrombosen der intrakraniellen Venen und Sinus. Huhn, A. Stuttgart. F.K. Schathauer-Verlag. 1956. 7. Neurological Fragments, p. 36. 8. Idem. p. 15. 9. Jonathan Hutchinson. p. 168.

212

John Hughlings Jackson

10. Personal communication. 11. Hughlings Jackson and His Influence on Neurology. Buzzard, E.F. Lancet. 1934. II. 909-910 12. Idem. p. 910. 13. Idem. p. 910. 14. Idem. p. 910. 15. Idem. p. 910. 16. John Hughlings Jackson, 1835—1911. Ferrier, D. p. xxiv. 17. Neurological Fragments, p. 32. 18. Idem. p. 21. 19. Idem. p. 32. 20. The Hughlings Jackson Tradition at The London Hospital. Henson, R. In Hierarchies in Neurology. Chap. 5. p. 32. 21. Neurological Fragments, p. 20. 22. Idem. pp. 32-33. 23. Idem. p. 20. 24. Idem. p. 20. 25. Jonathan Hutchinson. p. 137. 26. Neurological Fragments, p. 32. 27. Neurological Fragments, pp. 37—38. 28. John Hughlings Jackson, 1835-1911. Harris, W. p. 134. 29. John Hughlings Jackson: A Historical Introduction. In Hierarchies in Neurology. Swash. M. p. 4. 30. Aphasia: Selected Readings. Ed. Sarno, M.T. New York. Meredith Corporation. 1972. 31. John Hughlings Jackson, 1835-1911. Harris, W. p. 134. 32. John Hughlings Jackson. Recollections of a Lifelong Friendship. Hutchinson, J. p. 1522. 33. Hierarchies in Neurology. Chap. 5. Henson, R. p. 32. 34. The Testimonial to Dr.J. HughingsJackson, F.R.S.. The London Hosp. Gazette. Oct. 1895. No. 8. 35. 35. Sands of Time. Purves-Stewart, J. London. Hutchinson & Co. 1939. p. 42. 36. Kinnier Wilson's Notes of Conservations with Hughlings Jackson. Martin, J.P. J. Neurol. Neurosurg. Psych. 1975. 38. 315. 37. John Hughlings Jackson 1835-1911. Harris, W. p. 133. 38. Sands of Time. p. 42. 39. Neurological Fragments, p. 22. 40. The Life of Sir William Osier. Cushing,H. Oxford. Clarendon Press. II. p. 294. 41. John Hughlings Jackson. Recollections of a Lifelong Friendship, p. 1554.

Notes

213

Chapter 21 1. On Special Senses Discharges from Organic Disease. Cowers, W.R. Brain. 1909. 32. 303. 2. Neurological Fragments, p. 25. 3. Idem. pp. 25—26. 4. Letter from John Hughlings Jackson to Thomas Jackson, 24th May 1904. Courtesy of Dr. W.L.H. Jackson. 5. John Hughlings Jackson, 1835-1911. Harris, W. p. 134. 6. John Hughlings Jackson. Obituary. B.M.J. II. 1911. 952. 7. Idem. pp. 952-953. 8. Idem. p. 953. 9. Idem. p. 953. 10. Neurological Fragments, p. 40. 11. John Hughlings Jackson. Russell, R. B.M.J. II. 1911. 953-954. 12. Kinnier Wilson's Notes of Conversations -with Hughlings Jackson. 316. 13. John Hughlings Jackson. Cowers, W. B.M.J. II. 1911. 954. 14. John Hughlings Jackson, 1835—1911. Ferrier, D. p. xxv. 15. John Hughlings Jackson. Smith, F.J. B.M.J. II. 1911. 954. 16. The National Hospital, Queen Square. 1860-1948. Holmes, G. Edinburgh. E&S Livingstone Ltd. 1954. p. 32. 17. Idem. pp. 33-34. 18. Great Doctors of the 19th Century. Hale-White, Sir W. London. Edward Arnold & Co. 1935. p. 275. 19. Idem. p. 277. 20. Hughlings Jackson Centenary. Wilson. S.A.K. B.M.J. I. 1935. 769. 21. Idem. p. 769. 22. Idem. p. 769. 23. Idem. p. 769. 24. Idem. p. 770. 25. The Hughlings Jackson Centenary. Wilson, S.A.K. Lancet. 1935. I. 882-883. 26. John Hughlings Jackson. Kennedy, F. Bull. N.Y. Acad. Med. 1935. II. 479-480. 27. Hughlings Jackson and European Neurology. In Hierarchies in Neurology. Wallesch, C.W. p. 21. 28. The London: A Study in the Voluntary Hospital System. ClarkKennedy, A.E. London. Pitman Medical Publishing Co. Ltd. II. p. 82. 29. John Hughlings Jackson, 1835-1911. Ferrier, D. p. xxiv.

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Index

Aberdeen, University of, 151 Abiogenesis, 119 Academy of Aphasia, 151 Academy of Medicine, Paris, 108 Aeolus, 193 Ackroyd, P., 25 Acland, H. (Sir Henry), 181 "A Day at Uncle Ben's", 173 Addison, T., 36, 150 Adrian, E. (Lord Adrian), 160 Agnosia, 127, 144, 145. See also Imperception Alajouanine, Th., 109, 133, 143, 144 letter from Pierre Marie 133 Alalia, 94 Alcoholic poisoning, 57 Ali-Rodoham, 74 Allbutt, C. (Sir Clifford), 39 Allerton Mauleverer, 3, 4 Alogia, 94 Alvarenga prize essay, 136 American College of Physicians, 136 American Handbook of Psychiatry, 137 American Neurological Association, 159, 184 Amnesia, 94 Amsterdam, University of, 192 Ancestor worship, 155, 195 Anderson, T., 25, 194 Anderson, W., 25, 42, 194 Andral, G., 41 Ansell, T., 32 Anthropologie, Socie'te, 91 Aphasia, 51, 53, 56, 57, 91-95, 97-104, 105-15, 117-18, 121-22, 123, 124-25, 126, 127, 129, 131-46, 148,

152-3, 154, 155, 156, 159, 179 abstract attitude, 137 affection of speech, 106 asemasia, 106 available speech, 92 Baillarger-Jackson principle, 109 barrel-organisms, 50, 112 classification, 107, 126 dysphasia, 106 emotionally-charged words, 93, 98, 100-101, 111-12, 143 gold is yellow, 101 jargon, 98, 111-12 lame in his thinking, 103 motor aphasia, 123, 127, 145 occasional utterance, 98—99, 101, 103, 107, 110, 118 negative and positive, 107, 139 perseveration, 112 propositionizing, 93, 102, 103, 109, 110, 111, 113, 115, 126, 137, 143 rags and tatters of speech, 100-101, 109 recurring utterance, 50, 101, 107, 109, 110-11, 112, 118, 122 sensory aphasia, 121, 123, 127, 145 sole utterance, 50, 98 stock phrase, 101, 109, 111 swearing, 93, 99-100, superior and inferior levels of speech, 93, 110 symbolic thinking and expression, 126 syphilitic aphasia, 51 transcortical sensory aphasia, 127

216 Aphasia, (Continued) traumatic aphasia, 51 yes and no, 92, 93, 98, 102, 103, 109-10, 111, 113, 123 Aphemia, 94, 95, 99, 101, 106, 121 Aphonia, 99 Apothecaries, Worshipful Society of, 32 Apprenticeship, 25. See also. Medical education Apraxia, 97, 103-104, 127, 143, 144, 145 Arbitrary images, 115 Aretaeus, 74 Aristotle, 1, Arnott, J., 32 Articulation, ataxy of, 99 imperfect, 94, 99 movement of, 99 suppressed, 99 Association of British Neurologists, 194-95 Auburtin, E., 91 Austen, J., 176 Autopsies. See Post-mortems Babinski, J., 133, 160 Bailey, H., 37 Baillarger, J., 108, 109, 143 Baillarger-Jackson principle, 109, 153 Bain, A., 99, 151, 164 Barlow, T. (Sir Thomas), 192 Barnes, S., ix, 45, Barrel organisms, 50, 112 Bastian, H.C., 105, 114, 117, 118-19, 122, 125, 131, 134, 135, 140, 145, 149, 157, 158, 162, 180 Bateman, J., 93, 95,,117, 118 Battle of Sedgemoor, 10 Baumler, Prof., 181 Bay, E., 123, 141, 144 Bazire, V, 180 Beale, L.S., 39 Bedford Place, 172 Belgrave Hospital, 69 Bennett, H., 158 Berrios, G.E., 68 Bethlem Asylum, 28, 167

Index Bicetre. See H6pital Bicetre Binswanger, O., 148 Bishop, W.J., 37 Bleuler, E., 67 Bologna, University of, 169 Bouillaud, J., 91, 151 Bouman, K., 192 Boumann, L., 138 Bowman Lecture, 39 Brain, 45, 85, 105, 125, 136, 153, 157-58, 178 Brain, boycotted, 82 duality of, 102, 103, 108, 111, 128 nervous system of the nervous system, 97 organ of mind, 97 softening of, 51, 56 Brain, W.R. (Lord Brain), 144, 145-46, 160 Bramwell, B. (Sir Byrom), 159 Bramwell, E., ix, 193 Brassavola, 74 Bravais, L., 64, 65, 67, 74 Bravais-Jacksonian epilepsy, 65 Brenner, S., 160 Bright, R., 36, 74 Bright's disease, 81 Brissaud, E., 134 Bristowe, J.S., 105, 157 British Association for the Advancement of Science, 46, 93-95, 97, 137-38, 154 British Medical Association, Worcester Meeting, 79-82 British Medical Journal, 45, 92, 159 Broadbent,W. (Sir William), 60, 105, 117, 119-21, 131, 134, 136, 151, 157, 159, 181, 184 Broadbent's hypothesis, 47, 119, 121 Broca, P., 91, 92, 93, 94, 98, 99, 105, 108, 115, 118, 122, 128, 132, 133, 134, 135, 136, 137-38, 140, 142, 151, 152, 154 Broca's area, 92, 94, 98, 114, 121, 132, 133, 154 Brouwer, B., 160 Brown, J., 180, 182 Brown, M., 8

Index Brown, P.L., 162 Browne, J.Crichton (Sir James), 28, 105, 157 Brown-Sequard, E., 37, 38, 62, 99, 151, 193 Bruce, N., 145 Brussels, University of, 144 Bruyn, G., 143 Bucknill, J., 157 Bust of Jackson, unveiling, 181 theft of, 182 replacement, 182 Buzzard, Miss, 175 Buzzard, E.F. (Sir Farquhar), 153, 174, 192 Buzzard, Mrs. F., 154 Buzzard family, Jackson's visits to, 174-75 Buzzard, T., 48, 149, 159, 163, Calkin, L. 181, 188 Cambridge, University of, 39 Campbell, A.W., 148-49, 169 Carlyle, T., 148, 192 Carus, L., 101 Censor, Royal College of Physicians, 184 Centre du langage, Paris, 144 Cerebellar disease, symptoms of, 85, 87 influx, 87 paralysis, 83, 84, 85, 86 tumour, 83-84 Cerebellum, 83-89, 159 Cerebral lesions permit symptoms, 51 Cerebrovascular disorders, 53, 57 Cezanne, 165 Chance, B., 39 Charing Cross Hospital, 167 Charles II, King, 10, Charcot, J-M., 64-65, 74, 80, 117, 120, 131, 136, 144, 152, 184 Cheyne, W., 184 Cholera in London, 41—43 in York, 42-43 Chorea, 53, 194 Churchill, J., 36 Clark, A. (Sir Andrew), 162-63, 164

217 Clarke, R.H., 87 Clark-Kennedy, A.E., 42, 195 Classification of disease, 51, 60 of the epilepsies. See Epilepsy Clinico-Pathological Club, 80 Clotted mass of innumerable movements, 62 Clotted mass of spasm, 50 Coats, J., 68 Cohen, H. (Lord Cohen), 133, 134 Cole, M.C., 134 Cole, M.F., 134 Coleridge, S., 69 Collier, J., ix Colman, W., 45, 158 Collins, J., 136 Compound sequence of spreading, 57, 65—66. See also Epilepsy Consciousness, 147, 148, 152, 154, 164 anatomical substrata, 59 defect of, 66 double consciousness, 164 loss of, 50, 67, 70. See also Epilepsy over-consciousness, 69. See also Epilepsy super-consciousness, 70. See also Epilepsy Cranial vertebrae, 47 Critchley, M., 134, 144, 160, 193, 194 Cromwell, R., 16 Cromwell, O., 10, 16 Croonian Lectures, 56, 58, 64, 66, 87 Crude sensations, 75. See also Epilepsy Cumings, J., 160 Curnow, J., 106 Cushing, H., 159 Dade, E. See Elizabeth Jackson Dade, M.S. See Mary Smith Jackson Dana, C., 159 Darwin, C., 1, 54, 154, 194 Davis, J.N., 160 Dawson, B., (Lord Dawson), 160 Dax, pere etfils, 105, 108 Deaf-mutes, 108, 113

218 Decerebrate rigidity, 84 Deja-vu experiences, 69, 70. See also Epilepsy Dejerine, J., 117, 125, 132, 133, 134, 136, 144, 159 Denny-Brown, D., 193 Descartes, R., 101 Descending incongruity, 164 Detonating commas, 50, 100 Devonshire, Duke of, 184 Dewhurst, K., 60, 69, 147-48 Dickens, C., 25, 69, 163, 175, 176 Dirt in the brain, 51 Dissolution. See Evolution and Dissolution Doctrine of concomitance, 58 Donders Festival, Utrecht, 169 Donne, Rev. J., 13 Douglas, A., 192 Dovinctus, 74 Doyle, A. (Sir Arthur Conan), 185 Dreamy states, 68, 69, 70-71, 147. See also Epilepsy Dunn, R., 93, 94 Dysphasia, 106. See also Aphasia

Index definition of, 63 deja-vu sensations, 69, 70 dreamy states, 68-69, 70-71, 147 epigastric aura, 70 epileptic hallucinations, 75 epileptiform seizures, 59, 64, 65 epilepto-hemiplegia, 64 experiments on the brain, 66 falling sickness, 73, 74, 76 flower of a noxious weed, 61 hemiplegic, 64, 67 idiopathic, 63, 67 intellectual aura, 69 investigation of, 65 Jacksonian, 2, 62, 64, 65, 66, 67, 74, 75, 77, 120, 150, 153, 155-56, 173, 193 localized loss of power, 63-64 nosologists, of, 63 over-consciousness, 69 paralysis, temporary (Todd's paralysis), 64 positive and negative symptoms, 67-68 post-epileptic automatism, 57, 59, 70-71

Eadie, M.J., 74, 76 Eccles, J. (Sir John), 88 Edinburgh, University of, 28, 32, 184 Edinger, L. 87, 137, 152 Edward VII, King, 183 Elgar, E. (Sir Edward), 184 Ellis, H., 37 Elphinstone College, Bombay, 19 Empire Hospital for Officers, 124 Emprosthotonos, 86 Englehardt, H.T., 58 Epicurus, 101 Epilepsy, 14, 50, 51, 53, 57, 59, 61-71, 73-77, 80, 113, 120, 152, 154, 167, 185 aura, 63, 69, 70 authorities, of, 63 bemazement, 68—69 Bravais-Jacksonian fits, 65 classification of, 67 compound sequence, 65 cortical, 114 crude sensations, 75

post-epileptiform paralysis, 86 presque-vu sensations, 70 psychomotor, 68 reminiscences, 68 sacred disease, 61 super-consciousness, 70 tasteless taste, 70 tonic seizures, 88 temporal lobe, 68 treatment, 73—74, uncinate, 69-70, 71 voluminous mental states, 68 warnings, 71 Erb, W., 184 Evolution and dissolution, 5, 51, 53-59, 82, 106, 112, 120, 128, 138-39, 156 Experiments caused by disease 66, 81, 120 Ey, H., 148 Falling sickness, 73, 74, 76. See also Epilepsy

Index Falret, ]., 69 Faventius, 74 Felling, A., ix Feminine oaths, 50. See also Speech Fe>6, C., 63 Ferrier, D. (Sir David), 66, 105, 120, 157, 158, 159, 163, 167, 175, 178, 190 Ferrier's motor region, 57 Finkelnburg, F.C., 146 Finsbury Circus, 36, 38 Flexibility of defects, 153 Flourens, M., 66, 87 Foerster, O., 160, 195 Four factors of the insanities, 58—59 Freud, S., 67, 117, 122-24, 134, 140, 148 Fritsch, H., 66 Frontal lobe lesion, 91, 92 Fulton,}., 88, 159 Functional, use of the term, 85 Gairdner, W.T., 50, 105, 112 Galen, C., 74 Gall, F.J., 66 Gallon, F., 158 Gautier, J-C., 143 George V, King, 181 Geschwind, N., 143 Gladstone, Mrs. W.E., 42 Glasgow, University of, 19, 184 Godlee, R., 38, 75 Gold is yellow, 102, 115. See also Aphasia; Propositionizing Gold medal, Hughlings Jackson Lecturers, 159-60 Goldstein, K. 134, 136-38, 142, 144, 152 Golla, F.L., ix Goltz, F., 139 Goulstonian Lectures, 39, 49, 73 Cowers, W. (Sir William), 25, 26, 59, 73, 74, 106, 117, 122, 139, 148, 149, 159, 165, 181, 187, 190 Grant, L., (Sir Ludovic), 185 Green, J.H., 32 Greenblatt, S., 47, 60, 150-52, 165

219

Greenfield, J., 160 Green Hammerton, 3, 4, 5, 8, 23, 171, 172, 178, 194 Independent Chapel, 5, 6, 7, 8, 172 Greenwood, Mr. and Mrs., 23-24 Gruenbaiim, A., 138 Guillain, G., 160 Gull, F.J., 36 Guy's Hospital, 28, 36, 74, 150, 167, 191 Hagbarth, K-E., 160 Hale-White, W, (Sir William), 191-92 Halifax, 5, 8, 17, 19, 20, 21, 22, 24 Hall, M., 28 Hallpike, C., 160 Hamilton, D., 106 Hammond, W, 152 Hampton, H., 181 Handedness, 92 Harewood, Earl of, 184 "Harris, Mr.", 163 Harris, W. (Sir Wilfred), ix, 46, 159, 161, 170, 172, 177, 182, 188, 192 Harveian Society, 67 Harvey, W, 195 Hawkins, C., 32 Hazlitt, W, 25, 195 Head, H. (Sir Henry), 60, 100, 102, 117, 124-26, 127, 128, 132, 135, 136, 137, 138, 144, 145, 159, 169, 176, 180, 189 Centenary Meeting, 126 Headache, 47, 53, 83. See also Migraine Heilbronner, K., 138 Helmholtz, H.L.F. von, 39 Henson, R., 180 Herder,]., 56, 101 Herpin, Th., 69, 74, 75 Hewling, B., 10-11 Hewling, H., 10-11 Hewling, W, 10-11 Hierarchies, 53, 57, 59, 76, 86, 89, 139 Highgate Cemetery, 173, 188

220 Highest, middle and lowest levels, 57, 58, 59, 89, 120, 128 Hippocrates, 76 Hitzig, J., 66, 119, 120, 136, 158, 181 Hodgson, J. 32 Hodder-Williams, E. (Sir Ernest), 46 Hole in the brain, 51, 82 Hollier, B., 74 Holmes, G. (Sir Gordon), ix, 56, 87-88, 120, 127, 155, 159, 160, 183, 191 Hopital Bicetre, 92, 105, 131, 134, 157, Hopital Salpetriere, 109, 131, 143, 144 Horder, T. (Lord Horder), 160 Horsley, V. (Sir Victor), 75, 86, 87, 149, 159 Horsley Lecture, 76 House of Lords, 177 Hughlings, Ann, (Mrs. Solomon Pitchforth), 17-19 Hughlings, Ann (n6e Williams), 15-16, 20-21 Hughlings, Edward, 12—13 Hughlings, Elizabeth, 20 Hughlings, Hannah (n6e Jones), 12-13 Hughlings, Henry (Harry), 5, 20, 21, 22 Hughlings, John The First, 11-12, The Second, 12—13, The Third, 12-15 The Fourth, 5, 8, 14-22, 79 Hughlings, Mrs. John, IV. See Ann Lewis Hughlings, John Powell, 19-20, 22 Hughlings, John Powell, junior, 19 Hughlings, Mary (Mrs. Donne), 13 Hughlings, Sarah (Mrs. Samuel Jackson), ix, x, 5, 6, 7, 8, 9, 10, 20, 21, 22 Hughlings, Sarah (ne'e Powell), 13-15 Hughlings Jackson Lecture, 59, 60, 86, 87, 119, 125, 145, 157, 158, 159, 160

Index Hughlings, William, 20 Huhn,A. 173 Humphry, Dr., 95 Hunter,]., 195 Hutchinson, H., 168 Hutchinson, J. (Sir Jonathan), 25, 26, 27, 28, 32, 35, 36, 37, 38, 39, 40, 41, 49, 62, 148, 150, 158, 162-63, 165, 167, 168, 169, 172, 173, 174, 176, 177, 180, 183, 184, 193 Huxley, T, 46, 138 Hyphen, the inconsistent, 177—79, 181 Idea centre, 121 Imperception, 144, 145. See also Agnosia; Word-deafness; Ingall, Mr., 162 Insanities, four factors of, 58-59 Insanity, 56, 75, 167 Institute of Neurology, 181 Ireland, Dr., 105 Iron in treatment, 74 Isle of Man, 17 Isserlin, M. 144 Ito, H., 88 Ivy Cottage, 8 Jackson, Andrew, 5, 172 Jackson, Ann (Mrs. William Langdale), 5, 8, 31, 49 Jackson, Charles, 188 Jackson, Elizabeth (Mrs. Thomas Jackson), 171-72 Jackson, Elizabeth Dade (Mrs. John Hughlings Jackson), 172-74, 178, 188 Jackson, George, 3—4 Jackson, George Lumley, 4 Jackson, George William, 188 Jackson, Isabella, 4 Jackson, The Rev. James, 4, 5, 6, 7, 172 Jackson, John Hughlings, absent-mindedness, 167 accent, 168—9. See also voice acknowledgement of others' help, 161-62

Index anniversary of birth, 149, 183, 192-94 anniversary, 150th, 88, 149-50, 195 appearance, 177, 180, 191 apprenticeship, 25—26, 29. See also medical student argus-eyed observer, 194 Bedlamite theorist, 168 Bell's palsy, 37 bible of neurology, 195 birth, 7 Bologna University, 169 books abuse of, 31, 176-77 borrower of, 177 reader of, 170, 176 Boswellized, 170, 192 Bowman Lecturer, 39 Brain, joint-editor of, 157 editorial board, 45, 105, 178 bust, 181-82 carriage rides, 175, 182-83, 188, 192 children, love of, 175, 180 cholera epidemics, 41—43 clinician, 148, 153-54 clothes, 30-31 cold, impervious to, 169 committees, dislike of, 162 courtesy, 191 deafness, 2, 155, 159, 162, 180, 183, 188 death, 188 death of wife, 173 destiny, sense of, 165 discomfort at suffering, 166 doctorate, 33 education, 23—5, 32. See also Apprenticeship; Medical Student emmetropia, 188 exercise, dislike of, 169—70, 189 father of English neurology, 1, 190, 194, 195 foreign travel, dislike of, 169 generosity, 170 gold watch, 43

221 Goulstonian Lecturer, 39, 49 handwriting, 49, 173 "Harris, Mr.", 163 health, 173, 180, 187-88, 189. See also Deafness; Myopia holidays, 169 honorary degrees, 169, 184-85 house physicians, 49, 84, 126, 149, 153, 162, 166, 168, 169, 182, 188, 192 humour, sense of, 162—63, 168, 174, 192 hyphen in name, 177—79, 181 impatience, 162, 175 initials, symbol for, 179 insane patients, dislike of, 167 Jacksonian epilepsy, 2, 62, 64, 65, 66, 67, 74, 75, 77, 120, 150, 153, 155-56, 173, 193. See also Epilepsy kindness, 165 lecture, Hughlings Jackson, 59, 60, 86, 87, 119, 125, 145, 157, 158, 159, 160 gold medal, 159-160 lecturer, ability as, 167—68 legacy from grandfather, 22 letters from father, 29-31, 177 to brother, 5, 24, 49, 159, 173, 188 to William Osier, 187 from Herbert Spencer, 54—55 to Kinnier Wilson, 64, 154 London Hospital assistant physician to, 40, 167 lecturer on pathology to, 37 presentation, 178-79, 181 physician to, 40 Manchester Square, 69, 172, 174, 178, 179-80, 188 Sage of Manchester Square, 195 marriage, 171—174 medical reporter, 36 Medical Society of London, annual oration, 38 medical student, 26-31, 35, 150. See also apprenticeship "memorial", the, 175

222 Jackson, John Hughlings, (Continued) memory, erratic, 166 mental diplopia, 164 migraine, 67, 192 modesty, 125, 126, 143, 151, 161, 165, 180, 193 Moorfields, clinical assistant to, 38 morbid anatomist, 79—82 mourning, 173—175 Moxon gold medal, 184 music, 30, 175 myopia, 188. See also short-sightedness National Hospital, assistant physician to, 38 physician to, 38, 182 Nestor of English neurology, 136, 185 Neurological Fragments, 46, 47 neurologist's neurologist, 193 neuro-ophthalmology, 38—39 non-smoker, 176 philosopher, 2, 36, 53-56, 65, 75, 125, 139, 147, 149, 191, 192, 193, 194 plaque, 195 plain speaking, 165 poetry, 177 politeness, 166 politics, 177 portrait, 178, 181, 188 precision, 165 qualified in medicine, 8, 31—32, 150 recluse, 174 rectitude, 167 reiteration of ideas, 51 religious beliefs, 177 restlesssness, 162, 175 Royal College of Physicians, Censor to, 184 on council of, 184 fellowship of, 39 membership of, 39 Royal London Ophthalmic Hospital, clinical assistant to, 187 Royal Society, fellow of, 40 Selected Writings, 127 self-effacement, 164

Index short-sightedness, 175. See also myopia shyness, 174, 180, 183 simplicity, 166 shooting, dislike of, 169-70 society, dislike of, 162 Spencer, Herbert, influence of, 53-56, 65, 75, 125, 139, 152 State recognition, no, 2, 183, 190, 191 syndrome, 193 teacher, 168 textbook, requests to write, 46, 187 tributes after death Thomas Buzzard, 189 David Ferrier, 190 William Cowers, 190 Henry Head, 189 William Hale-White, 191-92 Gordon Holmes, 191 Charles Mercier, 189 Risien Russell, 190 RJ. Smith, 190 tributes at anniversary celebrations K.H. Bouman, 192 Edwin Bramwell, 192 Farquhar Buzzard, 192 A.M. Douglas, 192 Wilfred Harris, 192 James Taylor, 192 Kinnier Wilson, 192 G.W. Wallesch, 195 truthfulness, 165, 166 vertigo, 155, 188 voice, 168—69. See also accent walking, 169-70, 174 Will, 6, 178, 188 words, careful choice of, 165 writer, 45-46 the "memorial", 175 writing style, 47-51, 60, 76, 122, 125, 128, 146, 148, 153, 155, 156, 191 Jackson, Mary Smith, 171-72 Jackson, Richard, 3 Jackson, Samuel (grandfather of Hughlings Jackson), 3, 4 Jackson, Samuel (father of Hughlings Jackson), 4, 5, 8, 29-31, 177

Index Jackson, Samuel (brother of Hughlings Jackson), 6, 49, 179 Jackson, Sarah (ne'e Hughlings, mother of Hughlings Jackson), ix, x, 5, 6, 7, 8, 9, 10, 20, 21, 22 Jackson, Thomas (uncle of Hughlings Jackson), 4, 171-72 Jackson, Thomas (brother of Hughlings Jackson), 5, 7, 23, 24, 25, 49, 159, 171, 172, 173, 174, 179, 188 Jackson, William, 3 Jackson, William (brother of Hughlings Jackson), 6—7, 49 Jackson, William (uncle of Hughlings Jackson), 4 Jackson, Dr. W.L.H., 7, 8, 23, 179 Jakobson, R., 156 Janet, P., 148 Jefferson, G. (Sir Geoffrey), 56, 65, 160 Jeliffe, Smith Ely, 160 Jenkins, J., 141 Jenner, W. (Sir William), 173 Jim6nez-Pabon, E., 141 Johns Hopkins Hospital, 150 Joking, psychology of, 163—64 Jones, E., 12 Jones, Hannah (Mrs. John Hughlings I), 12-13 Jones, Sarah (ne'e Hughlings), 15 Jones, S., 11 Keats, J., 177 Kennedy, R, ix, 160, 193-94 Kennedy, P., 156 Kiffin, W, 10 Kinaesthesia, 118 King's College Hospital, 185 Klippel, M., 132-33 Knowles, Mrs., 195 Kolk, Schroeder van der, 63 Kussmaul, A., 105, 117, 122, 131, 136, 146 Lamarck, J. 54 Lame in his thinking, 103. See also Aphasia

223 Lancet, The, 39-40, 45, 46, 51, 127, 159, 193 Langdale, Ann (ne'e Hughlings), 5—6, 21, 31, 49 Langdale, Annie, 5—6 Langdale, Dr. Henry, 5 Langdale, William, 5, 6 Language, faculty of, 92, 98, 99, 135, 154 like baking and brewing, 50 origin of, 145 Lawrence, W., 32 Laycock, T., 26, 28, 32, 42, 43, 47, 49, 100, 150, 151, 193 Leading parts, 64 Leborgne, M., 91, 132 Leeds, University of, 184-85 Leibnitz's two-clock theory, 58 Lelong, M., 92 Lelut, M., 109 Levin, M., 60, 150-53 Lewes, G. 151 Lewis, Ann (Mrs. John Hughlings IV), 21, 22 Lhermitte, R, 43, 143, 144, 145 Lhermitte, J., 134 Liepmann, H., 104, 135 Linguistics, 156 Lister, J. (Lord Lister), 181 Llandegley, 13, 14, 22 Llanfihangel Rhydithon, ix, x, 11, 12, 13, 14, 21 Localization, 60, 75, 77, 81, 94, 98, 117-18, 123, 125, 126, 127, 129, 134, 136, 140, 141, 142, 144, 152, 154. See also Speech; Aphasia London Hospital Gazette, The, 181 London Hospital, The, 23, 36, 40, 41-43, 88, 124, 126, 134, 149, 162, 167, 170, 177-79, 181, 183, 188, 195 London Hospital Reports, The, 177 Longfield School, 23—24 Lotmar, R, 138 Louis, P., 150 Luciani, L., 87 Luke, J., 32 Luria, A., 137, 141-43

224 Macaulay, Lord, 10, 177 McBride, E., 135, 136 McEachern, D., 149 Macewan, W., 75 Mackenzie, S., 84 Macmillan's Magazine, 164 Manchester Square, 69, 172, 174, 178, 179-80, 188 Sage of, 195 Marie, P., 131-34, 135, 138, 140, 143, 144, 160, 181 Marr, D., 88 Marsh, S., 69 Maruszewski, M., 140-41 Matthews, W., 129 Mead, Miss, 180 Meadows, S., 193 Medical Times &• Gazette, 36, 45, 49, 55, 93, 166 Medical Society of London, 119, 163 Mental centre, 59 Mental diplopia, 164 Mercier, C., 46, 48, 50, 59, 148, 163, 166-67, 189-90 Meredith, Ann, 19 Merritt, H., 152 Metcalfe, P., 160 Metropolitan Free Hospital, 37, 40 Meyer, A., 138-39 Meyers, A.T. ("Dr. Z."), 68. See also Quaerens Meynert, T., 184 Migraine, 67, 192. See also Headache Miller, H., 129 Mills, C.K., 134-135 C.K. Mills Lecture, 135 Milton, J., 9 Minnesota Graduate School of Medicine, 141 Mitchell, R., 53 Mitchell, S. Weir, 46, 138, 187 Monakow, C. von, 138, 140, 144 Monmouth, Duke of, 10 Montreal Neurological Institute, 149, 182 Moore, N. (Sir Norman), 82 Moorfields, 38 Morbid anatomy, 29, 75, 79-82, 133, 136, 146

Index Morley, Jane, 8 Moruzzi, G., 88 Mott, R, 158 Mourge, R., 144 Moutier, R, 117, 134 Moxon, W., 36, 105 Moxon gold medal, 184 Muller, M., 101 Musee Dupuytren, 132 National Hospital, Queen Square, ix, 38, 61, 73, 114, 118, 126, 139, 151, 155, 158, 168, 169, 178, 180, 181, 182, 183, 191, 192, 193 Nauvoo, 18 Nervous arrangements, 156 Nervous system of the nervous system, 50, 97. See also Brain Nestor of English Neurology, 136, 185 Neurological Fragments, 46, 47 Neurological Society, The, 59, 85, 120, 126, 157, 158, 185, 192 Neuro-ophthalmology, 38-39 Newsom-Davis, J., 160 Newton, I. (Sir Isaac), 1 Neuropathophysiology, 53 Neuropsychiatry, 137 Neuropsychology, 136 Neurosurgery, 67, 71, 77 Neurosyphilis, 51, 53 New South Wales Medical Association, 148 New York Academy of Medicine, 193 Niedermeyer, E., 62 North, S., 26, 28, 35, 80 Northowram, 5, 21 Norwich Meeting, 93-95, 97, 137-38, 154. See also British Association for the Advancement of Science Not-knowing, 50 Noxious weed, the fit as the flower of, 61. See also Epilepsy Occasional utterance, 98—99. See also Aphasia Occipital lobes, 58-59

Index Ocular palsy, 39, 53 Offensive missiles, 50. See also Speech Ogle, J., 105 Ogle, W., 105, 140 Ombredane, A., 142, 143, 144-45 Ophthalmological Society of the United Kingdom, 39 Ophthalmoscope, 39, 166 Ophthalmoscopy, 97 Opisthotonos, 85, 86 Optic disc, 50 Optic neuritis, 39, 53, 84 Organ of mind, 56, 97. See also Brain Orford, Earl of, 13 Osier, W. (Sir William), 41, 46, 181, 183, 187 Osnato, M., 136-37 Owen, R., 46 Owen's vertebral theory, 47, 83, 154 Paget, J. (Sir James), 31, 150, 181, 193 Pannal, 2, 3 Pantomime, 102, 106, 113, 115, 134 Paralysis agitans, 57, 85, 86 Paralysis of the will, 82 Paris Anthropological Society, 91 Paris, Faculty of Medicine of, 151 Paris, University of, 148 Parry, H. (Sir Hubert), 184 Paton, L., ix, 46, 159 Patrick, H., 160 Pavlov, L., 141 Pembroke College, Oxford, 19 Philadelphia Neurological Society, 135 Phillips, C., 160 Phillips,]., 16 Pick, A., 124, 135, 138, 142, 144, 145 Pitchforth, Ann (ne'e Hughlings), 17-19 Pitchforth, Solomon, 17, 19 Poland, A., 38 Post-mortem Club, 32 Post-mortems, 29, 69, 74, 79, 80, 82, 85, 91, 94 Powell, Elizabeth, 14

225 Powell, Evan, 14, 15 Powell, Hugh, 14 Powell, Sarah (Mrs. John Hughlings III), 13-15 Preconception before action, 112—13 Presque-vu sensations, 70. See also Epilepsy Presteigne, 17, 21, 22 Preverbitum, 103 Prince of Wales, 173 Private practice, 80 Proctor, W, 26, 27-28 Progressive muscular atrophy, 57 Proposition of images, 107 Propositionizing. See Aphasia Providence Green, 3, 4, 5, 6, 7, 8, 35, 178, 179, 195 Psalms of David, to abstract, 148 Pseudo-knowing, 50 Psychiatry, 28, 60, 68, 75, 138, 139, 147, 153, 166-67 Psychological Association, 49 Punning, 164 Purves-Stewart, J., ix, 37, 74, 159, 181, 182-83 Putnam, J., 46, 138-39, 187 Quaerens (The Seeker), 68—69. See also "Dr.Z." Queen Square, vi, ix, 38, 149, 172, 182, 183, 192, 193, 195. See also The National Hospital Rags and tatters of speech, 100-101, 109. See also Aphasia Rainhill Asylum, 148 Ramskill, J., 38 Recurring decimals. 50 See also Aphasia Represent, re-represent and re-re-rerepresent different levels in the brain, 57, 142 Reynolds, E., 76 Reynolds, R., 38, 68 Richardson, B. (Sir Benjamin), 181 Riese, W, 60, 128, 150, 152 Right-brain hurry, 50, 111 Rigidity in hemiplegia, 85 Ripon, Marquess of, 184

226 Roberts, W. (Sir William), 181 Robertson, A., 64, 105 Robertson, Argyll, 162 Robinson, P., 195 Rockefeller Library, vi, 181 Romanes, G., 158 Romberg, M. 152 Royal College of Physicians, 32, 39, 49, 73, 87, 173, 184, 188 Royal College of Surgeons, 32 Royal Earlswood Institution, 167 Royal London Ophthalmic Hospital, 38 Royal Medical and Chirurgical Society, The, 158 Royal Medico-Psychological Society, The, 167 Royal Society, The, 40, 67 Royal Society of Medicine, The, 158, 159, 192 Russell,}. Risien, 46, 149, 158, 168, 190 Sachs, B., 160 Sacred disease, 61. See also Epilepsy St. Andrews University, 33 St. Bartholomew's Hospital, 31, 36, 150 St. Mary's Hospital, 38, 61 St. Tecla, 14 Salpetriere. See Hopital Salpetriere Sanderson, B., 181 Sapir, E., 154 Sarno, M., 178 Savage, G. (Sir George), 28, 47, 166-67 Schafer, E., 158 Schiller, F., 132, 154 Schuell, H., 141 Sechenov, I., 141 Senile dementia, 59 Shann, G., 28, 80 Shattuck, R, 183 Sherrington, C. (Sir Charles), 84, 153, 160 Sieveking, E., 38, 61 Sign-language, 108 Signoret, J., 144 Singer, D., 46 Skey, R, 32

Index Smith, R, 168, 190 Society de Neurologie, 132, 144 South, J.R, 32 Speech, 140. See also Aphasia; Localization articulation, 94, 99, 102, 107, 114, 117, 121 automatic, 102, 103, 108, 117, 121, 134, 145 available, 92 centres, 92, 117, 118, 122, 121, 122, 127, 132, 134, 135, 140, 141, 152, 153, 154 fragments of, 92 idea of, the, 99 inferior and superior, 93, 110 interjections, 50, 100, 101, 102, 107, 110 iterations of, 50 internal and external, 101, 102, 107, 113, 114, 151 origin of, 94, 101 Pooh-pooh theory, 101 preverbitum, 103, 135 rags and tatters of, 100-101 terminology, 94 therapy, 156 verbalising, 99, 103, 113-14 words referring to one another, 101 yellow spot for, 98 Spencer, Herbert, x, 53-56, 67, 119, 138, 139, 148, 164, 181 correspondence with Hughlings Jackson, 54-55 Jackson's debt to Spencer, 39, 53-56, 75, 139 letter to Youmans, 55 Spencerian ideas, 39, 53, 56, 65, 67, 75, 118, 125, 139, 151, 152 Spillane, J., 160 Spooner, W., I l l spoonerisms, 50, 111 Sprigge, S. (Sir Squire), 46 Stanley, E., 32 Stein, J., 86, 88-89 Stengel, E., 123, 148 Stewart, G. (Sir Grainger), 181 Still-born proposition, 50 Storch, A., 138

227

Index Super-positive elements, 57. See also Epilepsy Suppressed articulation, 99. See also Speech Sutton, H., 36 Swearing, 93, 99-100, 192. See also Aphasia Sylvius, 74 Symbolic thinking, 50, 113, 115, 126 arbitrary images, 115 non-verbal symbols in mentation, 114-115 symbols of symbols, 50 Symonds, C. (Sir Charles), 160 Symptomatology of nervous disease, 56 Symptoms permitted by cerebral lesions, 51, 56 Syphilis, 150 Tasteless taste, 70. See also Epilepsy Taylor, D., 69 Taylor, James, ix, 4, 5, 23, 24, 35, 39, 43, 47, 127, 159, 162, 163, 164, 169, 172-73, 174, 176-77, 183, 187, 188, 190, 192 Taylor,]., 17, 18 Temkin, O., 74-76 Tennyson, A. (Lord Alfred), 69 Thackeray, W., 176 Third frontal gyrus, lesion of, 92, 133. See also Broca's area Thomas, A., 160 Thomas, P.K., 160 Tilney, R, 136 Tissot, R., 144 Todd, R. Bentley, 63 Todd's paralysis, 64 Trallianus, A., 74 Travers, B., 32 Trimble, M., 68, 182 Trollope, A., 176 Trousseau, A., 69, 92, 106, 109, 110, 136 Twig of a gouty family tree, 81 Tuke, D., 28, 101 Tuke, S., 42 Turner, A., ix

Uncinate attacks, 69—71. See also Epilepsy Unilateral convulsions, See Epilepsy Universalisation, 141 Utrecht, 169 Vaco, 101 Valery, P., 144 Vertigo, 53 Victoria, Queen, 173, 181, 183 Vigotsky, L., 141 Vinken, P., 143 Voisin, A., 69 Wakefield Asylum, 157 Wallesch, C., 195 Walshe, F.M.R. (Sir Francis), 48, 60, 76, 127-28, 155, 160 Warsaw, University of, 140 Walton, J. (Lord Walton), 160 Watson, T., 105 Watteville, A. de, 157-58 Webster, H., 8 Weisenburg, Th., 135-36, 160 Weiskrantz, L., 160 Wells, F.S. (Sir Spencer), 36, 181 Wernicke, K., 105, 118, 122, 123, 128, 131, 132, 135, 136, 137, 140 Wernicke's area, 132 Wernicke-Lichtheim hypothesis, 141 Westminster Abbey, 195 Westminster Hospital, 167 Westphal, A., 184 West Riding Asylum, 28 West Riding Lunatic Asylum Reports, 50, 51, 157 Wilde, O., 183 Wilks, S. (Sir Samuel), 36, 105, 150, 157 Willis, T., 1, 195 William III, King, 2 Williams, Ann (Mrs. John Hughlings, IV), 15-16, 20-21 Williams, D., 147 Williams, W, 15-16 Wilson, S.A. Kinnier, ix, 64, 126—27, 145, 154, 159, 181, 183, 192, 193 Woerkom, W. von, 138, 144

228 Word-blindness, 113, 118, 120, 121, 127, 145 Word-deafness, 105, 113, 114, 118, 120, 121, 127, 145 Wordsworth, W., 177, 195 Wyllie, J., 134 Yes and no. See Aphasia York, Archbishop of, 184 York County Hospital, 27

Index York Dispensary, 27, 28, 32, 61, 80 York General Hospital, 35 York Medical School, 26-29, 32, 42 York Medical Society, 32, 194 York Minster, 164 Yorkshire to London, 35-36 Youmans, E., 55 Young, J.Z., 160 Z. Dr. (Dr. A. Meyers), 69