Archives of neurology and psychiatry from the Pathological Laboratory of the London County Asylums 5.1911

ARCHIBALD CHURCH^
LIBRARY ^,1
NORTHWESTERN UNIVERSITY
MEDICAL SCHOOL ,£

NC RT H W EoT I H N U.: IV t -HJ i J (

MEDICAL CCh'OCL LluHAF.Y

ARCHIVES OF NEUROLOGY

AND PSYCHIATRY

FROM THE

PATHOLOGICAL LABORATORY

OF THE

LONDON COUNTY ASYLUMS.

CLAYBURY, ESSEX.

EDITED HY

FREDERICK WALKER MOTT, M.D., F.R.S., F.R.C.P.,

Director of the Laboratory and Pathologist to the London County Asylums;
Physician to Charing Cross Hospital; Fullerian Professor , Rotjal Institution;
Corresponding Member of the 8oci*ie de Psychiatrie de Paris;

Foreign Associate of the Sociftf Clinique de Mrdecine Mentale.

VOL. V.—1911.

\*X^\

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PREFACE

The publication of this volume has been somewhat delayed
owing to various circumstances, but principally on account of a
printers’ strike; in consequence a considerable amount of patho¬
logical investigation has been published in journals with a wide
circulation in the form of lectures, addresses, and communications
by myself to various learned societies. The Pathological
Laboratory recently issued in the form of a volume a number of
collected papers which had been published in various scientific
journals other than the ‘ Archives ’ of the Laboratory, and it was
intended to issue a second volume of a similar character, but
after consultation with the Pathological Sub-committee it was
decided that it would add to the value of Volume V of the
‘ Archives of Neurology and Psychiatry ’ if it contained the
records of all the work carried out in the Laboratory since the
publication of the last volume; consequently this volume com¬
prises a considerable amount of work which has been already
published. As heretofore, theses for the Doctor of Medicine
Degree by medical officers engaged in the asylum service of the
London County Council and by gentlemen working in the Patho¬
logical Laboratory are contained in this volume. By publishing
these theses and other papers by medical officers in the service in
the ‘Archives of Neurology and Psychiatry,’ it is hoped that the
attention of the authorities may be called to the fact that they
have in their service officers who can find time to pursue clinical
and pathological investigation, and at the same time perform in a
satisfactory manner the routine duties of their office.

In previous volumes the influence of alcohol and syphilis in

IV

Prrfucc.

the production of insanity has been discussed very fully, and this
volume contains the last of a series of contributions on syphilis iii
relation to feeble-mindedness. There is still a good deal of work
to be done in relation to the influence of congenital syphilis to
feeble-mindedness in the light of modern research. It is now
generally and widely recognised that syphilis, both acquired and
congenita], plays a prominent rale in the production of acquired
nervous and mental disease.

Having thus dealt with the two most important acquired
conditions producing insanity there still remained the inborn
factor to be considered. In two lectures dealing with heredity
and insanity the facts deduced from the investigation of over
2400 relatives, who are at the present time, or who have been,
in the London County Asylums, are considered. One very
important fact has been established, and that is the “ Law of
Anticipation or Antedating,” which was predicted by Morel. I
have found, in 420 pairs of parent and offspring, only one
instance in which the first attack occurred in the offspring at a
later age than in the parent. In over 50 per cent, of the instances
the offspring became insane twenty-five years earlier than the*
parent. A considerable proportion therefore of the insane off¬
spring of insane parents are congenital imbeciles or become
insane in adolescence. There is an intensification of the mental
defect, and if Nature were left to itself it would tend spon¬
taneously to eliminate all such weak types, and thus there would
be either a complete destruction of an unsound stock or a
tendency to regression to the normal after three generations’
unless there be consanguinity or introduction of unsound elements
by marriage into an unsound stock. It may be presumed that
there is a tendency of insane germinal determinants to coalesce, or,
metaphorically speaking, to crystallise out of an unsound stock.
This affords an explanation, hypothetical though it may be, why
only one, or perhaps two—seldom more—children of an insane
parent become insane. In insanity, as in bodily disease, there are
always two factors, viz. the soil and the seed, the inborn and the

Preface.

v

acquired environmental. There are individuals born of sound
stocks that no acquired conditions, e. <j. disease, drink, poisons
engendered within the body or taken in from without, head
injuries, emotional shock, distress, and even profound misery and
destitution combined can render insane. There are others, and
these are generally from a neuropathic stock, whose mental
equilibrium may be disturbed by any one of these conditions
or even without any apparent cause, except the physiological
conditions appertaining to the function of the sexual glands at
puberty, the puerperium, and the climacteric period of life.
Between these two extremes are all gradations of mentality from
the congenital imbecile and the insane adolescent at one end of
the scale to the potential sound mind that no combination of
acquired conditions can render permanently insane.

I desire to express my thanks to my assistants, Dr. Candler
and Mr. Mann, for the assistance they have giyen me in correcting
the proofs of this volume.

FREDERICK W. MOTT.

C O N T E N T 8

l’AG E

Congenital Syphilis and Feeble-Mindedness. Bv F. W. Mott, M.D.,

F.R.S., F.R.C.P..1

Microscopic Investigation of a Case of Tabo-paralysis with Ophthalmo¬
plegia Bilateralis. By Pietro Rondoni, M.D.Florence . . .52

Diffuse Cerebro-spinal Syphilis terminating ten years later in Pseudo
General Paralysis. By G. H. Harper-Smith, M.D., B.C.Cantab.,
M.R.C.S., L.R.C.P., and R. W. J. Pearson, L.R.C.P Edin. 07

A Contribution to the Study of Institution Dysentery. By J. P. Candler,

M.A., M.D.Cantab.. D.P.H., and G. Dean, M.B., C M Aberdeen 74

The Psychological Conception of Insanity. By Bernard Hart, M.B.,

M.R.C.S.Lond. .90

Two Cases of “ Washing Hand ” Mania, with some Observations on their

^Etiology. By G. F. Barham, M.D., B.C.Cantab. 101

A Review of the Recent Literature in England and America on Clinical
Psychology and Psycho-pathology. By Ernest Jones, M D., M.R.C.P.

Loud. 120

Dementia Preecox (Thesis for the degree of M.D., Cambridge University).

By G. H. Harper-Smith, M.D., B.C.Cantab., M.R.C.S., L.R.C.P. . 148

The Pathology of Dementia Prsecox, Especially in Relation to the Circulatory
Changes (Thesis for the degree of M.D. Edinburgh University). By
Rae Gibson, M.D., M.R.C.P.E..182

On the Cortex of the Auditory Centre, the Insula and Broca's Convolution
in a case of Deaf-mutism Bv A. B. Droogleever Fortuyn,
Amsterdam ........... 208

A Case of Diffuse Cancer, with Especial Reference to the Changes in the
Brain. By Pietro Ronloni, M.D.Florence, and E. S. Calthrop,

M.B., B.S.Lond.. 218

LIST OF ILLUSTRATIONS

PAOE

Congenital Syphilis and Feeble-minded ness. Figs. 1-5 . . . 31

Microscopic Investigation of a Case of Tabo-paralvsis with Ophthalmoplegia

Bilateralis. Diagram . . ..(33

Diffuse Cerebro-spinal Syphilis terminating ton years later in Pseudo

General Paralysis. Figs. 1-8.70, 72

The Pathology of Dementia Prrecox, especially in relation to the Circulatory

Changes. Plate I. Figs. 1-9 ... 183-185, 189, 192, 194

On the Cortex of the Auditory Centre, the Insula, and Broca’s Convolution

in a Case of Deaf-mutism. Plates I, II. Figs. 1 and 2 . 209, 210. 212

APPENDIX.

The Oliver-Sharpey Lectures on the Cerebro-spinal Fluid. Figs. 1-10

The Huxley Lecture on the Hereditary Aspects of Nervous and Mental
Diseases. Figs. 1-12

Heredity and Insanity. Figs. 1-19

The Comparative Neuropathology of Trypanosome and Spirochsete Infections,
with a Remmt of our Knowledge of Human Trypanosomiasis. Plates I,
II, III and IY, figs. 1-5

Seven Cases of Amaurotic Idiocy (Tay-Sach’s Disease). Plates I and II, figs. 1-18

Motor Localisation in the Brain of the Gibbon, Correlated with a Histological
Examination. Figs. 1-3

APPENDIX OF COLLECTED PAPERS

(1) The Oliver-Sharpey Lectures on The Cerebro-spinal Fluid, l>v F. W. Mott,

M.D., F.R.S., F.R.C.P.

(Reprinted from the ‘ Lancet,’July 2nd and 9th, 1910.)

(2) The Huxley Lecture on The Hereditary Aspects of Nervous and Mental

Diseases, by F. W. Mott, M.D., F.R.S., F.R.C.P.

(Reprinted from the ‘ Lancet,’ October 8th, 1910.)

(3) A Lecture on Heredity and Insanity, Royal Institution, by F. W. Mott,

M.D., F.R.S., F.R.GP.

(Reprinted from the * Lancet,’ May 13th, 1911.)

(4) The Comparative Neuropathology of Trypanosome and Spirochsete Infec¬

tions, with a Uemnnr of our Knowledge of Human Trypanosomiasis, by
F. W. Mott, M.D., F.R.S., F.R.C.P.

(Reprinted from the ‘ Proceedings of the Royal Society of Medicine,’ November,

1910. )

(o) a. The Clinical Study of Amaurotic Idiocy (Tay Sach’s Disease), by H. B.
Carlvll, M.D.Cantab.

b. The Microscopic Examination of the Central Nervous System in

Amaurotic Idiocy, bv F. W. Mott, M.D., F.R.S., F.R.C.P.

c. The Chemical Examination of the Brain in Two Cases of Amaurotic

Idiocy, and Comparison with the Normal Brain, by S. A. Mann.
(Reprinted from the * Proceedings of the Royal Society of Medicine,’ March,

1911. )

(6) Motor Localisation in the Brain of the Gibbon Correlated with a Histological

Examination, by F. W. Mott, M.D., F.R.S., F.R.C.P., E. H. J. Schuster,
M.A., D.Sc., and C. S. Sherrington, M.D., F.R.S.

(Reprinted from the ‘ Proceedings of the Royal Society of Medicine,' b.,

vol. lxxxiv.)

(7) The Incidence of Gall-stones and of Primary Carcinoma of the Gall¬

bladder and Biliary Passages in the Insane, by J. P. Candler, M.A., M.D.
(Cantab.), D.P.H.

(Reprinted from the * Proceedings of the Royal Society of Medicine,'February,

1911.)

Congenital Syphilis and Feeble-mindedness.

By F. W. Mott, M.D., F.R.S., F.R.C.P.

In the evidence which I gave before the Royal Commission on the
Care and Control of the Feeble-Minded, I expressed the opinion that
4t syphilis is an active agent in the production of congenital weakness and
the degeneracy that accompanies it.” Moreover, I was of opinion that
“the measure*of the effects of syphilis in the production of feeble¬
mindedness and epilepsy should not be estimated only by those cases in
which there are visible and characteristic signs of syphilis on the body.”
I gave reasons and cited a number of cases in support of this statement.

It is a very important question to decide whether congenital syphilis is
a cause of arrest of development of the brain (apart from its causing gross
syphilitic lesions) either by the influence of a chemical toxin or £ome
failure of sufficiency of a bio-chemical substance upon the developing
embryo. We know that infantilism and various forms of premature
decay of the nervous system, which Fournier has termed “ parasyphilis,” may
arise in the children of syphilitic parents, and that these children may not
show any gross lesions of a syphilitic nature. The question of the arrest
of development of the most complex and highly differentiated tissue
of the body is difficult to answer by anatomical investigation, and the bio¬
chemical changes which we know occur in the blood and tissues as a result
of the invasion of the body by the syphilitic organism are not yet suffi¬
ciently understood to allow of more than a hypothetical speculation as to
the influence they might exercise upon the development of the cerebral
neurons.

Until the introduction of the Wassermann reaction we were only able to
obtain information as to the existence of a syphilitic taint by statistical
and clinical evidence—a not altogether satisfactory source of knowledge,
for the reason that the u personal equation ” is so frequently biassed and
prejudiced that an over-estimate or under-estimate is arrived at according
to the pre-conceived idea of the investigator. Moreover, a clinical investi-

1

2

Congenital Syphilis and Feeble-mindedness.

gation that is not thorough and accompanied by a personal investigation
of the parents, a careful inquiry concerning the result of conceptions, and
the search for syphilitic signs or symptoms in living offspring other than
the patient, will, as my experience in the investigation of the family
history of a large number of cases of juvenile general paralysis shows,
lead to a very erroneous idea of the effects of the syphilitic taint. I am afraid
that those English authorities who have given such an exceedingly low
percentage of imbeciles with a congenital syphilitic taint have not taken
the same care in investigation, as the German authorities. That the
much higher percentage of the latter is probably correct has recently
received confirmation by the investigation of the blood-serum of the
inmates of imbecile and idiot asylums by the Wassermann method.

Before, however, discussing this subject in extenso I will give a brief
resume of the evolution of our knowledge of congenital syphilis, especially
in relation to diseases of the nervous system.

In the middle ages, soon after syphilis had been introduced into
Europe, Paracelsus asserted that syphilis was in the blood, and a
pathogenic substance was transmitted to the foetus in conception. Con¬
genital syphilis was described by Ambroise Pare, who in 1633 wrote :
“ Souvent on voit sortir les petits enfants hors le ventre de leur mferes
ayaht cette maladie, et tdt aprSs avoir plusieurs pustules sur leur corps;
lesquels estant ainsi infectes baillent la verole a autant de nourrices qui
les allaitent.” Astruc and Boerhaave accepted the existence of here¬
ditary syphilis, but owing to the influence of John Hunter’s teaching this
doctrine fell into disrepute until the facts of hereditary syphilis were
established and placed upon a firm foundation by the works of
v. Barensprung, Wagner, Colles, Virchow, Fournier, Hutchinson, Barlow,
Bury, and others. The two last-named authors state: “It may, indeed,
now be said in contrast to the early views, that nearly every variety of
nervous affection of acquired syphilis has its parallel amongst congenital
examples ; albeit there are indications of a few broad differences which
may be made out as to relative frequency alike of lesions and symptoms
between the two groups.” Curiously'enough, Sir Jonathan Hutchinson,
in his article on “Hereditary Syphilis,” ‘Twentieth Century Practice of Medi¬
cine/ devotes only nine lines to the diseases of the nervous system, and he
states, moreover, “It has never occurred to me in any single instance to
identify the subject of this inheritance in a sufferer from tabes or general
paralysis.” This is remarkable, seeing the enormous number of cases he
must have seen : it differs greatly from the experience of another great

F. IF. Mott.

syphilodologist, Fournier. Tabes is very rare, but 2 per cent, of the cases
of general paralysis dying at Claybury Asylum during the last twelve
years have been of the juvenile form and due to congenital syphilis.

It seems to be proved that syphilis acquired in infancy after birth
may be followed by the same results as its acquisition in utero or its sperm
or germ inheritance. Welander, of Stockholm, records the case of a boy
who had acquired syphilis from his nurse when three months old ; at the
age of thirteen he suffered with interstitial keratitis and nodes; moreover,
the teeth were characteristic. Eudlitz has also recorded a case of a male
child who at the age of two months acquired syphilis from his mother,
who had herself been infected by a nursling; at the age of twenty-three
he was shown at the Paris Society of Dermatology : he was small in stature,
beardless, and with infantile genital development and characteristic teeth.
He had been under Fournier’s care for cerebral syphilis. In an over¬
whelming number of cases of congenital syphilis the transmission of the
disease to the offspring is directly attributable to the father. The woman
in the majority of instances is infected by the man before conception or in
conception, so that the child in such cases may acquire the virus both
from father and mother. This is termed mixed transmission. In such
conditions the offspring is more likely to be infected than when only one
parent is syphilitic. According to Fournier, the transmission of the disease
occurs in 92 per cent., and the mortality of the offspring is 68*5 per
cent.

Colles’s law .—A woman conceives by a syphilitic husband without
becoming herself infected; the foetus is then only syphilitic by the father,
but the mother may subsequently acquire the disease from the syphilitic
embryo choc en retour; this, however, does not necessarily follow, for the
offspring may be syphilitic and the mother escape; moreover, although
she can suckle her syphilitic offspring without acquiring the disease, yet if
a healthy w^et-nurse suckle the child she will acquire syphilis. The
usual explanation of these facts is that the mother, by gradual increased
doses of the toxin from the syphilitic embryo in its development, has
acquired an immunity.

Neisser, however, from his experiments and observations, claims that Colles’s law should
be re-stated as follows : Mothers of congenital syphilitic children are not healthy and
immune, but they are as a rule latent-syphilitic, and in consequence, apparently immune.
He supports this conclusion by the following facts.

1. The researches of Bauer, Engelmann and Rietschl show that all mothers of con¬
genital syphilitic children give a positive Wassermann serum reaction.

2. The researches of Knopfelmacher and Lehndorf show that, those women who have
given birth to congenital syphilitic children within four years react positively in the same.

4

Congenital Syphilis and Feehle-mindedness.

percentage as latent syphilitics. Consequently, in spite of apparent health, the mothers of
congenital syphilitic children are much more frequently syphilitic than has been supposed.

3. The passage of reaction bodies to a healthy mother can only be a passive one, and
the positive reaction would rapidly disappear from the blood of the mother after birth of
the syphilitic child if their source were the syphilitic foetus, but it persists for years.

4. Bauer, Wechselmann and Neisser have shown that there may be a positive serum
reaction in the mother and a negative of the child.

6. A series of cases have been published by Halberstadter, Muller, and Reichel, in
which the child at birth showed a negative reaction, and only gave a positive reaction when
there were definite objective signs of syphilis; in these cases we can exclude passage of the
reaction bodies from the foetus to the mother.

6. The researches of Neisser upon apes afford no support to the occurrence of a true
immunity in syphilis.

Another condition which I have frequently met with is that the father
and mother are at first both healthy and have healthy children ; then,
during a pregnancy or absence from home, the husband goes astray and
acquires syphilis. The result of married life is that there now occur a
series of miscarriages, still-births, dead children, and diseased children.
The following case illustrates this : A man, aged 48 years, a ship's steward,
was married in 1872, and had a healthy male child in 1873. In 1874 he
went away for a voyage and remained away for three and a half years ;
in 1876 he had a hard chancre. He returned home in 1878, and in 1878 and
1879 his wife had three miscarriages; in 1880 a child was born dead; sub¬
sequently four healthy male children were born. Sixteen years after the
primary infection the man developed tabes. So far as the records go these
last four children were healthy, but it is quite probable that an examina¬
tion of the blood by the Wassermann test would have shown that they had
been affected by the parental syphilis. Any one of these might later in
life develop a parasyphilitic affection.

Put under some circumstances it may happen that the woman is
infected while she is already gravid with a healthy embryo; but the syphi¬
litic husband’s sperm does not necessarily infect the developing embryo; the
mother may, however, be infected directly from the primary sore or from
secretions, and in rare cases the child may then be born healthy, but
immune to the disease, for it can be suckled bv the syphilitic mother or
syphilitic wet-nurse without contracting the disease. This is termed the
“law of Pndeta.” Children born of syphilitic parents are said to be always
immune against syphilis ; this, however, is disproved by the fact that con¬
genitally syphilitic subjects occasionally acquire syphilis in later life. I
have seen several instances, one in particular, which 1 got Sir Jonathan
Hutchinson to see. It was the case of a young man admitted to Charing
Cross Hospital ; he had typical notched central incisiors, saddle-shaped

F. W. Mott.

5

nose and rhagades at the corners of the mouth. There was a history of
chancre, and when he came to the hospital he had a well-marked secondary
eruption on the chest and abdomen, which was cured by mercury.

Finger, Ogilvie and others have published exceptions to Colies’s law,
cases where the mother contracted chancre of the nipple by suckling
her syphilitic offspring. But the experimental inoculation of the mothers
of syphilitic children by Finger and Neisser with negative results favours
this law of immunity; moreover, it accords with Fournier’s experience, for
he states that he has never seen a case of exception to Colies’s law.
Moreover, Sir Jonathan Hutchinson says: “My own experience does not
supply me with a single exception to Colies’s law.” From more recent
researches we have seen, however, that Neisser concludes that the mother
is apparently immune in Colles’s law, and the child apparently immune in
the case of Profeta’s law. In both instances it is latent syphilis rather
than immunity.

There is a good deal of evidence to show that infection often takes
place by the semen. Hochsinger records observations on seventy-two
families in which there was paternal syphilis, but the mothers showed no
signs of syphilis during periods of four to nineteen years, although they
were repeatedly examined (fifty cases were under observation for more
than six years). The seventy mothers gave birth to 307 children—110
still-born, 166 syphilitic, and 31 healthy. The healthy children were all the
last born except in four cases. I have met with many cases of undoubted
congenital syphilis with most pronounced and unmistakable stigmata in
which the mother has never suffered in any way, nor did she show any
sign or give any history of infection. It might be argued that these
mothers were really the subjects of latent syphilis. But why should it be
latent in the mother and active in the children? The following is an
extremely interesting example illustrating this fact:

E. H—, aged 34 years, came to Charing Cross Hospital, accompanied
by her elder sister. She complains of pains in the limbs; she is very
deaf, especially on the left side. She has typical Hutchinsonian teeth. Her
sister also has typical notched pegtop-shaped central incisors and old
keratitis. The sister, a married woman, gives the following history :
Her mother had three premature births, then two children born dead,
then one which lived sixteen months. She came next, and the patient,
E. H—, was born a year later. The married sister also informed me that
she herself had had but one child, which was a delicate infant; it had
snuffles and died at the age of six weeks. The patient, E. H—, has been

6

Congenital Syphilis and Feeble-mindedness.

paralysed in the left side since early infancy. It was discovered only by
her not being able to walk or use the hand. When quite an infant she
had a rash on the skin and the eyebrows came out. Later in life it was
noticed she whs deaf in the left ear. The left arm and leg are wasted,
and the bones smaller. She has no contracture. There is a triceps
contraction and marked patellar clonus, but no ankle clonus. This was
undoubtedly a case of congenital syphilitic brain disease causing hemiplegia.
The mother came to see me and said that she had never ailed in any way,
and I could find no evidence of syphilis on the body. The family history
is the specially interesting feature in this case, as showing the effects of
acquired syphilis upon the offspring, and also the possibility of transmission
to the third generation.

Seeing that Levaditi, Bab, and others have seen spirochsetes in the ova,
it is possible that the syphilitic contagion may remain in a resting intra¬
cellular stage; but when the ovum escapes and is fertilised the syphilitic
virus again becomes active, although its virulence is greatly modified and
attenuated. This transmission to a third generation is a mere supposition
unless, however, we can be absolutely certain that the father was not
syphilitic. I could, however, obtain no history of syphilis from the father
in the case above recorded. It is no more physically impossible to admit
infection of the segregated germ-cells of the next generation than
infection of the sperm-cell. It may be observed that Sir Jonathan
Hutchinson is most sceptical of transmission; he says—“ Nor have any facts
been placed upon record which are worthy of much attention as supporting
the belief referred thereto.” An excellent critical summary of cases has
been given by Dr. G. Ogilvie.

In vol. ii. of the ( Archives of Neurology * I pointed out the very much
greater incidence of sterility, miscarriages, still-births, dead and diseased
children in female tabetics and paralytics than occurs when the male is
affected by these diseases. As a general rule when the married woman is
the subject of tabes or general paralysis she has been infected by her
husband, so that the germinal plasm of both parents may be affected by
the virus, but probably this is not so much the cause of the destructive
effects on the offspring as the influence of the syphilised maternal blood
and lymph, and the constant opportunity during pregnancy of the invasion
of the foetal tissues by the specific organism. In fact, the foetal tissues,
judging by the readiuess with which spirochsetes can be found in them as
compared with adult tissues, offer a specially favourable soil for their
development.

F. W. Mott.

7

Table showing the Birth - and Death-rate of Offspring of Male and Female

Tabetics and Taho-paralytics,

- ----—____

Children

alive.

Born alive, but died in
infancy or afterwards.

Born dead.

Miscarriajje.

Twenty-two married females suffering
with tabes or tabo-paralysis; seven
of these were sterile ....

10

10 |

18 31

Fifty-four married males suffering

1

i

with tabes or tabo-paralysis

151

75

!

52

Mendel found that of 252 married female tabetics, 32*9 per cent, were
childless. My inquiries regarding the results of conceptions in syphilitic
parents illustrate the following points. The usual history is either complete
sterility, or miscarriages, abortions, still-births, children dying in infancy
of convulsions, marasmus, meningitis, or hydrocephalus ; then there may
follow children who are apparently healthy, but who in later life develop
syphilis hereditaria tarda , manifested often by interstitial keratitis, nerve-
deafness, bone, skin and visceral lesions. The children may be stunted in
growth and show obvious stigmata of congenital syphilis, in the form of
Hutchinsonian teeth, saddle-shaped nose, and linear scarring around the
angles of the mouth. At puberty it may be noticed that the genital organs
remain infantile in development, and microscopic observations which I have
made on the sexual glands in such cases show atrophy or degeneration of
the germ-cells; in the case of the male organ an absence of the sperma¬
tozoa ; in the case of the female a failure of development of the ova and a
great diminution in numbers. This infantilism is frequently associated
with various grades of idiocy or imbecility. Congenital syphilitic children
presenting those well-determined stigmata may subsequently develop
juvenile general paralysis, tabo-paralysis, tabes, primary optic atrophy,
epilepsy, chorea, hysteria and meningitis. But it is more common to find
apparently healthy children born of syphilitic parents subsequently, about
puberty or adolescence, developing the various nervous affections mentioned
above. It seems as if the virus, as A it becomes attenuated, is delayed in its
destructive effects, and numbers of family histories I can cite show as a
general rule, but by no means invariably, that as the virus becomes
attenuated the conceptions may result eventually in healthy children, who
in later life manifest no visible signs or symptoms of the disease. But, as

8

Congenital Syphilis and Feeble-mindedness.

Fournier remarks, the birth of healthy children is “no free pass” for
future offspring, and the following cases illustrate this fact:

F. C—, aged 11 years, suffering with blindness since he was seven years
old, was brought by his mother to Chariug Cross Hospital ; she said the
child had had snuffles at birth. There was no family history of nervous
disorder or insanity. Three years elapsed after marriage before a seven-
months still-birth occurred, then (1) a girl was born that died with
fits at one year and nine months ; (2) a girl, living, quite healthy ; (3) a
girl, living, quite healthy ; (4) the patient ; (5) bey , aged 9 years , with
paralysis; (6) boy , who suffers with fits. The patient when brought to me
exhibited no external signs of syphilis on the body and no evidence of visceral
disease. There was slight evidence of paresis of the lower face muscles of the
right side, and the tongue on protrusion deviated to the right. There was
optic atrophy in both eyes, also cycloplegia and iridoplegia. The fifth was
a boy, aged 9 years, and I found him to be suffering with left facial nerve
paralysis ; the paralysis came on when he was aged 6 months. The eye
could not be closed, nor the forehead wrinkled; the mouth was drawn to
the right, but not markedly. There was no deafness; he could hear a
watch equally well in either ear and at a normal distance. This was
probably due to a syphilitic affection of the facial nerve. The sight was
now becoming defective in the left eye, the disc being pale with a sharp
edge, and probably he will become blind like his brother. The prac¬
titioner who sent this patient to me treated the mother for acquired syphilis.
The history seems to point to the fact that the treatment by mercury for
some time led to the birth of two healthy children (2 and 3) ; it was then
suspended, and three children, including patient, were then born, all of
whom were seriously affected.

In the following case there was no history of the mother having been
treated for syphilis.

Girl, aged 14 years, was admitted to Claybury Asylum suffering with
juvenile general paralysis, with w r ell-marked signs of congenital syphilis,
viz. notched teeth, rhagades around mouth, saddle-shaped nose. History:
No insanity, direct or collateral. Father died of an accident, aged 40
years. History from mother: Mother^was married at twenty, father at
twenty-two. There were twelve children as follows : (1) dead, 5 months
foetus; (2) dead, 5 or 6 months foetus; (3) dead, 6 or 7 months foetus;
(4) dead, 7 months foetus, lived eight hours ; (o) born alive, very frail and
delicate, ulcers on legs, inflammation of eyes; (6) patient ; (7) girl, living,
well, aged 16 years ; (8) boy, living well, aged 14 years ; (9) boy, living.

F. W. Mott.

9

well, aged 12 years; (10) boy, died of convulsions, aged 11 months;
(11) girl, died at 8 months of brain disease and club foot; (12) boy, living,
well. The patient was an intelligent girl and passed the seventh standard
at twelve years old; developed signs of general paralysis and progressive
demeutia at fourteen and died three years later of this disease. It will be
seen that 7, 8, 9 are living and well, then follow two children with nervous
affections and death. *

As a contrast to the above two cases I may mention the following case.
R. D—, a carpet planner, was admitted into Charing Cross Hospital under
my care, suffering with well-marked signs and symptoms of tabes. He
gave the following history of conceptions following his marriage at twenty-
two, which was just two years after he had contracted syphilis with a
hard chancre, for which he was treated with mercury for only two months.
The first child w r as born within one year of marriage and is alive and
well; he has had six healthy living children, one of whom died, aged 9
years; there were also twins. Why was the wife not infected? Had she
inherited immunity ? These are questions which might well be asked in
respect to this case. Healthy children are occasionally born between
diseased children; as we have seen above this may be sometimes
accounted for by treatment of the mother.

Hoehsinger throws doubts upon a healthy child slipping in between
diseased children. Until the iutroduction of the serum reaction we had no
means of knowing whether a child of syphilitic parents was free from
taint, for although we are unable to see any external signs of disease yet
the internal organs may be extensively diseased, and the following case
illustrates this fact most conclusively.

A. R—, male, aged 22 years, was admitted to Clay bury Asylum. He was
an able-bodied seaman, but had been invalided on account of fits. There
were no external signs of syphilis on the body. There was a history of his
father having died of general paralysis in Banstead Asylum, and of a
brother, a weak-minded imbecile, being at that time in Caterham Asylum.
Whereas the patient, A. R—, presented no external signs of syphilis, his
imbecile brother had the characteristic nose and teeth. A few days after
admission to Claybury he had a succession of epileptiform seizures; his
temperature rose to 108*2° F.; the temperature was reduced by cold
sponging, but he never regained consciousness, although the convulsions
ceased upon the administration of chloral. The case turned out post-
mortem to be a typical case of general paralysis. Although there were no
external signs of syphilis, the liver showed an extraordinary condition.

10 Congenital Syphilis and Feeble-mindedness .

It weighed 1200 grm.; the left lobe consisted almost entirely of
nodules varying in size from a pea to a marble united to one another by
dense bands of fibrous tissue. The right lobe was also nodular in places,
aud the capsule was here and there thickened so that portions of the
organ were partially separated. Microscopic examination showed peri¬
hepatitis and extension of the dense fibrous tissue along the vessels and
bile-ducts. There was nodular fibrosis of the aorta, otherwise no signs
of visceral syphilis was discovered.

Max Nonne believes that it is not impossible for a healthy child
to slip in between two unhealthy ones. He states that within the last few
years a large amount of material precisely controlled and obtained from
the Engel Reimer division of the Hamburg Hospital (St. Georg) has
shown that not infrequently such a thing happens.

I have met with numerous cases in which the mother has had a series
of healthy children, followed by miscarriages, still-births, and children
dying in infancy followed by syphilitic and parasyphilitic children.
These cases often show the necessity of a systematic inquiry of the results
of every conception, for the following case of juvenile general paralysis
and optic atrophy was shown to me as a case in which syphilis could be
excluded as there was a large healthy family and no history of syphilis of
the parents; yet a systematic inquiry showed clearly that the reverse was
the case, and in spite of the denial of the father that he had suffered with
venereal infection, and of the mother that she had ever suffered with any
signs or symptoms which could be associated with acquired syphilis, the
history clearly points to maternal infection after she had had a family.

A. B—, was a bright, intelligent girl, who passed the sixth standard of
the board school and gained several prizes. She left school at thirteen;
her periods never came on, and this was the assigned cause of her com¬
plaint in the notes received from the infirmary, where she was diagnosed
as an imbecile due to congenital brain disease. I took the following
notes on the case; She is now aged over 15 years; she is completely blind
in both eyes, she is quite childish, but will talk and answer questions, but
in the manner of a little girl of six or seven. She has no delusions or
hallucinations, is obedient and now takes her food, although on admission
to the asylum she was noisy, crying and troublesome. She was sent as an
epileptic, but she has had no fits while in the asylum. Apparently, from
what the mother tells me, she had several fits (like fainting attacks) while
in the infirmary. She sits in a chair all day ; the legs are rigid and seini-
flexed, the knee-jerks are not obtainable. She continually fidgets with her

r i i

■ 111

F. W. Mott.

11

Lands. I observe only slight tremor of the lips and tongue. The pupils
are of medium size nnd do not react to light. There is primary optic
atrophy on both sides. She has never complained of headache and there
has been no vomiting. She does not respond to the calls of nature and
passes urine and faeces unheeded. She recognises her friends when they
come to see her and talks to them affectionately. Her palate is high and
narrow ; the teeth show no signs of congenital syphilis, nor were there any
stigmata on the body observed by the medical officer on examination;
syphilis was not therefore suspected. I interviewed the father and
mother. Both said there was no insanity or nervous disease on either
side. The mother informed me that she had had fourteen pregnancies.
The patient was the next to the youngest living child. Prior to the birth
of the patient she had had eight children, all of whom are now alive and
grown up and some were married; then she had two miscarriages followed
by twins bom dead , followed by the patient, who had snuffles and a rash on
the bottom soon after birth, for which she took her to St. George's Hospital
where they gave her grey powders; she did not continue the treatment
long. The dementia and paralysis are progressing. This is in all pro¬
bability one of those cases of the husband acquiring syphilis during the
pregnancy of the wife and subsequently commuuicating the disease to her
with the usual result as regards further conceptions.

Again, a long mercurial treatment of the father, although usually
protecting the offspring from congenital syphilis, does not give a positively
certain voucher of freedom from taint, as the following case shows : Au
intelligent professional man acquired syphilis; was treated by eminent
authorities with mercury for several years; four years after the primary
sore he consulted an eminent specialist as to the advisability of marriage:
he was assured that there was no danger to his wife or offspring. He waited
a year and married, with the following results : The first two children were
born alive but died within a day or two of birth; the third developed
keratitis and otitis with deafness; this child was seen by specialists, who
pronounced the affection to be syphilitic; the fourth developed general
paralysis and died with characteristic lesions at one of the London asylums;
the last two are now bright and healthy children. The microscopic investiga¬
tion of this case was ably carried out in the laboratory by Dr. Rondoni.
The clinical notes and results of this investigation were published in the
* Proceedings of the Royal Society of Medicine.'

As an explanation it may be surmised that either he infected his wife
by his sperm or that this was a case of spermatic infection by the male

12 Congenital Syphilis and Feeble-minded ness.

without the wife being infected. She had no signs or symptoms of syphilis,
but that proves nothing. It is probable that the spirochaete had taken up
its abode in the lymphatics of his testicles and had not been destroyed
in spite of the adequate treatment he had received for several years.

Sir Jonathan Hutchinson asserts that “a large experience on this point
has led to the conclusion that a man rarely becomes the father of a syphilitic
child if an interval of two years has elapsed since the disease was acquired.”
Now we have reason to believe that the specific cause of infection is a
living organism and that the testis is not an unusual location of it; more¬
over, the living organism may remain latent for a long time, consequently
the sperm may be infected long after the primary infection, and this may
explain the case referred to ; likewise if the ovaries are infected it may
explain the fact that although the law of gradual diminution of virulence
and risk of transmission holds good, yet exceptions may occur, as the
following remarkable case reported by Molenes shows: “ A woman, aged
44 years, was married at the age of twenty-one to her first husband, by
whom after the birth of a still living child she was infected by syphilis.
An energetic treatment of husband and wife with mercury and iodide was
adopted. In the course of the following years she had six children who all
died at ages from eighteen to twenty months with symptoms of meningitis.
Six years after the death of the husband she married a healthy widower>
father of two healthy children aged respectively 16 and 19 years. She
now manifested a recurring syphilitic psoriasis for which she received
courses of treatment. Twenty-two years after the primary infection and
by her healthy husband she gave birth to a child. This child, just as the
former ones, died at the age of eighteen months with symptoms of menin¬
gitis (convulsions, vomiting, and coma).” (Max Nonne.)

We may ask the question : Do recent researches and especially the
discovery of the Sjnrochseta pallida and the inoculation of animals enable
us better to understand the cause of congenital syphilitic disease, and
especially the relation of the disease of the parents to imbecility, idiocy,
epilepsy, and parasyphilitic affection of the offspring ? Also, are we^better
able to understand and explain some of the anomalous cases of which I
have given examples ? If it be admitted that the Spirvcheeta pallida
always remains a spiral organism and never undergoes any intra-cellular
modification, then it becomes very difficult to explain spermatic infection
of the ovum, for there is no possibility of the spiroclueta being contained
in the head of the fertilising spermatozoon ; it might, however, be supposed
that the spiroclueta gains entrance to the ovum during fertilisation or

F. W. Mott,

13

subsequently. The researches of Leishman on the spirochaete of tick fever
suggest the possibility of an intra-cellular phase of the spiral organism and
its existence in the form of infective cliromidian granules. Moreover, in
support of this hypothesis I may mention that Neisser in his experimental
investigations on apes has observed that the tissues of infected animals in
which no spirochaetes were demonstrable could nevertheless be used
effectually for inoculation. The spirochaete may be (me form of the
syphilitic organism, but there may be other minuter stages analogous to
the spores of bacilli. Chromidian granules are contained in the Spirochwta
pallida , and in all probability serve a similar function to the nucleus in
more highly developed unicellular organisms; sometimes these chromidian
granules can be seen in enormous numbers in tissues where the spirochaetes
are found. Several observers have seen and described spirochaetes in the
ovum, and it is. improbable that such an infected ovum, even if it were
capable of fertilisation and segmentation, would undergo development to
an embryo. Consequently in those cases where the mother escapes infec¬
tion by the parasitic organism and the offspring alone is infected by it
there are two possible explanations :

(1) The head of the spermatozoon is infected by a hypothetical,
syphilitic chromidian granule which may subsequently multiply and produce
the syphilitic lesions.

(2) That if the specific organism never undergoes any modification or
metamorphosis and only multiplies by longitudinal or transverse fission,
the explanation of infection would be that spirochaetes contained in the
sperm may remain alive in the uterus, and gain ingress to the developing
embryo without infecting the maternal uterus.

It has been proved experimentally that the semen may contain the
syphilitic contagion, for Neisser and Finger have shown that the testicles
of syphilitic monkeys can be used to inoculate the chimpanzee, and a chim¬
panzee was successfully inoculated by Finger with the semen of a man
suffering from secondary syphilis.

In the investigation of the family histories of syphilitic parents I have
been struck with the relatively few cases of children who have survived after
manifesting in infancy symptoms pointing to brain disease; and this
accords with other facts, viz. that although I have been able to collect sixty
fatal cases of juvenile general paralysis and tabo-paralysis, I have only mer
with four fatal cases of coarse syphilitic brain disease due to congenital
syphilis. Moreover, when I was searching for juvenile general paralytics
I visited Darenth Asylum for Idiots, and I was much surprised at the

14 Congenital Syphilis and Feeble-mindedness.

relatively few cases Dr. Taylor, the superintendent, could show me of
imbeciles or idiot children who presented obvious and obtrusive evidence
of congenital syphilis. There were not more than could be counted on the
fingers. It is probable, however, that ophthalmoscopic examination would
have detected some cases of primary optic atrophy and somes case of
choroido-retinitis; moreover, a careful inquiry of the mothers regarding the
ultimate result of conceptions would (as I have found in quite one half
the cases of juvenile general paralysis) have revealed the fact that con¬
genital syphilis may have been a cause of congenital amentia in a certain
number of cases in which there are no obtrusive stigmata.

In the London County asylums I have met with a few fatal cases of
congenital hemiplegia, epilepsy, and epilepsy with imbecility due to
syphilitic endarteritis and softening. I have also met with one case
of endarteritis and gummatous meningitis in a congenital syphilitic girl,
but relatively to juvenile general paralytics and tabo-paralytics with optic
atrophy these cases are very rare. Moreover, I have looked through the
‘ Revue Neurologique* since its commencement seventeen years ago, and I do
not find more than a dozen cases recorded. Max Nonne cites only a few
cases, and Still states that he has seen very few cases, and that they are
rare as compared with juvenile general paralysis. The reason is doubtless
due to the fact that if the Spirochseta pallida gains access to the cerebro¬
spinal cavity the offspring dies either before birth, at birth, or shortly after
or within a year or two, the causes of death being given as convulsions,
hydrocephalus, or meningitis.

The classical works of Fournier, Hochsinger, Barlow, Bury, and others,
have long demonstrated that many serious organic nervous diseases of
children are the result of congenital syphilis, and Jullien was able to
demonstrate that among 162 living children the progeny of forty-three
syphilitic parents (in 206 pregnancies), 50 per cent, were affected with
meningitis and convulsive symptoms. Although in my experience these
conditions are common in congenital syphilitic infants, few of those so
affected survived till puberty or adolescence; it is probable that when the
central nervous system is invaded by the organism there is a general
Spirochsete septiciemia which even the administration of mercury is unable
to overcome sufficiently to prevent a fatal termination. The observations
of Heubner as to the frequency of affection of structures and organs in
congenital syphilis are of interest; according to this eminent authority the
structures are affected in the following order : liver, lungs, spleen, alimen¬
tary canal, heart and blood-vessels, and lastly the nervous system.

F. W. Mott.

15

Rumpf gives the relative frequency of affection of the nervous system as
13 per cent. Gasne studied the spinal cords of thirty foetuses, of which
twenty-six were born of syphilitic parents ; in four cases he found profound
lesions identical to those observed in acquired syphilis, and in seven cases
there were doubtful changes. He also observed that the lesions were pre¬
dominant in the posterior region of the spinal cord.

Ranke, in a very valuable investigation, has studied the brain changes
in congenital syphilis. He has made observations upon sixty brains of
foetuses and infants with a view of determining whether in cases of tabes
and general paralysis due to congenital syphilis the changes in the central
nervous system agree with the lesion of the brain of congenital syphilitic
children, or whether the lesions should be attributed to damage of the
germ-plasm during development. He first points out that it was necessary
to ascertain if the Spirochseta pallida be present in the brains of
congenital syphilitic foetuses and new-born infants, and if this be the case
whether it can be concluded that the lesions are directly due to its
presence. All the organs of the body may show characteristic lesions in
congenital syphilis; they may be found in the specific skin-lesions,
especially the bullae of pemphigus, the lymphatic glands, the pancreas,
liver, spleen, kidneys, lungs (white pneumonia), the bones, and the vascular
system. There are two forms of morbid change in these organs and
tissues—viz. exudative, inflammatory—with which also must be associated
gummatous neoplasms in the organs of syphilitic children. Besides
these changes there is a cell proliferation independent of the vascular dis¬
tribution, and which has been described as occurring especially in the liver
and kidneys. In addition to this evidence of proliferative changes Stroebe,
and particularly Karvonen, have described a progressive arrest of develop
mentin the kidney as shown by a diminution of the normal glomeruli, and
in the presence at the time of birth of pseudo-glomeruli ; also there is an
appearance of necrogenous tracts of tissue in the parenchyma of the kidney
which these observers regard as especially characteristic of congenital
syphilis. Ranke remarks that none of the standard text-books on
children’s diseases deal efficiently with the subject of congenital syphilis
and the nervous system, and no mention is made of changes in the central
nervous system by Rudolf Hecker in his excellent ‘ Beitrage zur Histologie
und Pathologie der Cong. Syphilis/ 1898.

The cerebral gumma generally associated with progressive meningitis
and meningo-enceplmlitis has been most frequently described, but not
infrequently this is associated with disease of the larger cerebral vessels

16

Congenital St/philu and Feeble-minded ness.

which was first found in the brain of a syphilitic child. These cases of
syphilis of the nervous system will be described later when the Symptoms
of infantile syphilis of the nervous system are considered.

But in addition to these reported cases of specific affection of the
nervous tissues in congenital syphilis, which are indistinguishable in their
naked-eye and microscopic characters from similar affections of the adult
due to acquired syphilis, a few cases have been reported of arrest of
development; especially interesting in this respect is a case of Ilberg’s,
in which a child, aged 6 days, the subject of congenital syphilis, was found
at the post-mortem examination to possess a brain exhibiting a remarkable
arrest of development of the centrum ovale, the corpus callosum, and
other commissures, as well as of the pyramidal systems of fibres. There
was also asymmetry of the two halves of the cerebellum and arrest of
development of the optic nerve-fibres. Sibelius has reported changes of a
more delicate character; he found in his researches of the central nervous
system of congenital syphilitics groups or colonies of spinal ganglion cells
exhibiting delayed or abnormal development. In very severe cases of
congenital syphilis he was able to demonstrate such, colonies of abnormal
cells amid typical ganglion cells in abundance and relatively often. He
considers these morbid evidences of delay and arrest of development to be
occasioned by the syphilitic toxin.

Congenital Syphilis and Arrest of Development of the Brain.

In the light of modern investigations, can congenital syphilis be
responsible for the arrest of development of the brain, and the production
of various forms of feeble-mindedness? This is a question of great
practical importance ; the anatomical evidence rests upon far too meagre
reports, and when we fall back on statistical and clinical evidence there is
considerable diversity between the results of investigation by (ierman and
English authorities.

Binswanger, whose statistics have been based upon a large number of
idiots, gives 9*5 per cent, as certain, and 12*2 per cent, probable syphilis
of one of the parents. Similar results were obtained by Wildermuth.
Ziehen gives 10 per cent, demonstrable and a further 17 per cent,
probable. On the other hand, Bourneville holds that congenital syphilis
is an exceedingly rare cause of idiocy. Langdon Down found it in only
2 per cent, of cases, and Shuttleworth, among 1000 idiots at Darenth, only
found 1 per cent, of congenital syphilis. Telford Smith found only eight

l

ii

F. W. Mott.

17

cases with marked evidence of congenital syphilis amongst 580 inmates
of the Royal Albert Asylum. Similarly, Brown, in America, only found
1-1*5 per cent, of syphilitic origin. Seeing how very prevalent syphilis is
among the population, it is impossible to judge how far syphilis on the
father's side should be considered as cause or coincidence. On the other
hand, we should be considerably under the mark if all cases of arrested
development of the brain were omitted that did not exhibit manifest
stigmata of congenital syphilis, e. g. Hutchinsonian teeth, old keratitis,
rlmgades at the angles of the mouth, nerve-deafness, onychia, saddle-
shaped nose, epiphysitis, infantilism, etc. Quite one half of the sixty
cases of juvenile general paralysis which I have notes of showed none of
these obvious stigmata, and yet their history showed that they were
congenital syphilitics.

There can be no doubt that syphilis in the parents may lead to
infantilism in the offspring, and I have seen numerous cases of such in
which there were none of the above-mentioned obtrusive signs of syphilis,
and yet other children of the same parents presented well-marked obtrusive
stigmata; moreover, cases show that one individual of a family of con¬
genital syphilitics may exhibit the characteristic stigmata of congenital
syphilis and another show no external signs, yet the internal organs may-
exhibit post mortem the most marked evidences of the disease. If syphilis
can produce bodily infantilism, including arrest of development of the
reproductive organs—a not infrequent condition in juvenile general
paralysis—surely there is no reason why it should not lead to arrest of
development of the most highly differentiated and specialised tissues of
the body, e.g. the cerebral cortex.

An important piece of evidence has lately been forthcoming in the
examination of the blood-serum of idiots bv the Wassermann reaction, and
I cannot do better than quote the work done by Dr. Dean in the Sero¬
logical Department of the Royal Institute for Infective Diseases, Berlin.
Dr. Dean remarks: “ The examination of the blood-serum of idiots by the
Wassermann reaction has been the subject of several papers. The French
investigators, Ravaut, Breton, Petit, Gayet and Cannae, examined 246 cases,
of which 76 were found to give a positive reaction. Kellner, Clemenz,
Bruckner and Rautenberg examined 216 cases, of which 13 gave a positive
reaction by Stern's method and 9 gave a positive reaction by the original
Wassermann method. Lippmann, working in Wassermann's laboratory,
examined 78 cases at Uchtspringe and obtained a positive reaction in 7 (9
per cent.). An examination of the cases at the Dalldorf Asylum gave a

O

18

Congenital S yphilis a nd Feeble-minded ness.

result of 13*2 per cent. Lippmann also examined 77 cases by clinical
methods and decided that 40*2 per cent, showed signs of congenital
syphilis. Dean, working in the laboratory of Wassermann, examined the
blood-serum of 330 cases from the Wilhelmstift Asylum, Potsdam, and
found that 51 cases gave a positive reaction—15*4 per cent. Among the
330 cases were 9, or including the doubtful cases, were 13 which from
physical signs or symptoms would have justified the diagnosis of congenital
syphilis. Among 13 parents whose serum was examined 9 gave a positive
reaction. Cases have been reported by Plaut and others in which the
husband or wife of a syphilitic who has never shown any signs of syphilis
have nevertheless given a positive reaction. Linser, quoted by Buck, has
examined a series of children of syphilitic parents, and finds that
two thirds give a positive reaction, while only one third show any
other sign of infection. Numerous cases are also on record in which it
has been demonstrated that the apparently healthy mothers of syphilitic
children give a positive reaction, and conversely the serum test has been
positive in apparently healthy children by syphilitic mothers. The
numerous investigations on these lines tend to prove that evidence of
a positive serum reaction may be accepted even in the absence of the
usual signs and symptoms of congenital syphilis. Dean concludes his
interesting and valuable paper with the following apposite remark :
“ It seems to ine reasonable to think that many cases of idiocy should be
classed with that form of syphilis which manifests itself alone by a selec¬
tive toxic action upon the nervous system.”

Probably a number of unsuspected cases might by the Wassermann
reaction show latent syphilis; thus :

Quite recently a female congenital imbecile died in Claybury Asylum,
aged 37 years. The brain weighed only 1140 grm.; there was no obvious
wasting of the cortex and no thickening of the membranes or granulation
of the ventricles. The convolutional pattern was simple. The blood gave
a positive Wassermann reaction, but there were no signs of syphilis on the
body, although the notes state that while in the asylum the hair had been
dropping out. The cerebro-spinal fluid, probably on account of admixture
of blood, gave a proportionally weak reaction ; there was no lymphocytosis.
Remarkable changes in the cortical cells were found, particularly in the
frontal lobes, by Nissl, Cajal and Bielchowsky methods. They were similar
to, but not so marked or universal, as those found in cases of amaurotic
idiocy. Moreover, by Scharla-ch and Sudan III stains a fatty change was
found in these structurally altered cells. Granulation-cells, however, were

F. W. Mott.

19

not met with, nor was there evidence of any marked glia proliferation—
characteristic features of amaurotic idiocy. It is of interest to note that
both the ovaries were small, dense and fibrous, and examination of a
complete series of sections from each showed no evidence of mature or
immature ova. The uterus was small, and there was no evidence of any
inflammatory condition to account for the change in the ovaries. A full
account of this interesting case will be published later.

Dr. Chislett relates an interesting examination of a whole family. The
father, a general paralytic, acknowledged syphilis, and his serum gave a
positive reaction. The mother had never to her knowledge had the sym¬
ptoms of primary or secondary syphilis, but eight years after marriage had
a tertiary ulcer on the left leg. There were ten pregnancies; two children
were prematurely born, and two died in infancy. • The blood-sera of the
remaining six were examined. The eldest, a boy of sixteen, was described
by his mother as very nervous and stupid as a school-boy; his serum reacted
positively although he showed no signs of syphilis. A girl of twelve was deaf
in one ear, but otherwise normal; her serum was also positive. A girl of ten
had a negative serum ; a boy of eight, with rhinitis and conjunctivitis,
had a positive reaction, and the two youngest children of six and four
years respectively had negative sera.

It is probable that syphilis, therefore, plays a more important part in
the production of idiocy and imbecility than is apparent from the English
statistics.

Alcoholism .—The influence of syphilis is frequently combined with
chronic alcoholism, and the latter among the poorer classes, being a more
easily ascertainable cause by those preparing statistics, is assigned as the
cause in the parents of the mental deficiency in their offspring. Both
poisons co-operate in devitalising the tissues of the body, and there is no
reason to suppose that the germ-cells escape from this devitalising
influence. Koenig, in a valuable and interesting paper delivered at the
meeting of the British Medical Association at Oxford, 1904, gave as his
experience atDalldorf Asylum for Imbeciles and Idiots that “ the offspring
of paralytic parents are often imbeciles, idiots, victims of infantile cerebral
paralysis, sufferers from early epilepsy, chorea, meningitis, congenital
syphilis, and various neurotic ailments. There would be a considerably
larger number of these youthful invalids but for the high rate of sterility,
miscarriages, still-born and short-lived offspring. I have recorded 150
absolutely sterile marriages not including those of a more or less long train
of abortions. Among the adult descendants I have noted a fair number

20

Congenital Syphilis and Feeble-mindedness.

of paranoiacs, cases belonging to the dementia prrncox group and other
types of organic and functional disorder. On the other hand a not infre¬
quent record of exclusively sound children could be obtained. In quite a
number of these homologous cases both ascendants and descendants had a
clear history of syphilis.” With this statement my experience entirely
accords. Koenig, moreover, asserts that too much insistence cannot be
laid upon syphilis being the necessary step in the production of general
paralysis. Alcoholism and environment are contributory factors, but a
much greater allowance, however, has to be made for the force of hereditary
predisposition in the production of feeble-mindedness in all its forms.

There are reasons for supposing that general paralysis occurs only in a
community which has acquired a widespread immunity through genera¬
tions to syphilitic infection; it is a true type of acquired mental
derangement.

Beard, in the discussion on heredity, when Koenig read his paper,
said : “ It is a known fact that toxins weaken cells and therefore germ-
cells ; a germ-cell as an adult living organism with a life-cycle must, like
all living cells, feed, grow, reproduce, and exhibit irritability.” Conse¬
quently, we may presume that there is reason for supposing that the two
most potent and prevalent poisons, alcohol and syphilis, may, without killing
the germ-cells, diminish their vita propria , and thus lead to the various
disordered and diseased conditions of the nervous system.

Nevertheless, experience shows that imbecility and idiocy are more
frequently met with in rural populations than urban; it is a fact even in
communities, where purity of living and sobriety are the rule, that
imbecility, idiocy, and certain forms of insanity are almost as common as
among the general population. Again, in the rural districts of Ireland
syphilis is comparatively infrequent and general paralysis is hardly ever
seen, yet the relative percentage to the population of imbecility, idiocy, and
insanity, is very high. Doubtless this fact, as well as the fact that a
greater proportion of cases of congenital amentia pro rata occur among
the inmates of rural than urban asylums,may be accounted for thus: there
has been a constant drain of emigration of the mentally and physically fit
to industrial centres, leaving the unfit to procreate their species.

In the large number of cases of juvenile general paralysis which have
come under my notice, quite one half have been congenital imbeciles who
at puberty or later developed general paralysis. I have not been able to
associate the congenital imbecility with a marked mental deficiency in the
parents, although 1 should say in quite 20 per cent, of the cases I ascei -

F. W. Mott.

21

taiued that the father had died in an asylum of general paralysis. The
subjects of congenital imbecility bore on their bodies well-marked
stigmata of congenital syphilis or exhibited signs of bone or visceral
syphilis at the post-mortem examination more often than those who up to
puberty were bright and intelligent. The examination of the brains of
these congenital imbeciles showed no signs of endarteritis or gross changes
to account for the failure of development of the brain. Moreover, the
majority of these congenital imbeciles were stunted in growth and their
reproductive organs and genitals were infantile. Examination of the
ovaries showed great deficiency of ova in numbers and development. The
testicles generally were very small and showed no spermatozoa. Moreover,
besides the more or less recent degenerative changes in the cortical
pyramidal cells, there were many indications of arrest of development.
I cannot but think, therefore, there is evidence to show that the syphilitic
virus may devitalise the germ-cells and play a more important role than
has been generally ascribed to it in the production of the various forms
of congenital feeble-mindedness. This it may do either by arrest of
development of the functionally more complex neurones of the brain ; or
by inducing a biochemical metabolic instability, it may lay the foundation
of functional neuroses and psychoses. These congenital morbid conditions
are, then, not due to the direct action of the specific organism upon the
brain, but to bio-chemical changes in the developing embryo, changes
which may lead to its subsequent immunity, complete, or partial to the
action of the specific organism. Possibly the existence of a much greater
percentage of imbeciles and idiots which give the Wassermann reaction
than can be shown by physical signs pointing to congenital syphilis may
be explained in this way.

The Existence of Spirociletes in the Central Nervous System.

Several investigators have found the specific organism of syphilis in
great numbers in the central nervous system of infants dying of congenital
syphilis. Drs. Ravaut and Ponselle found spirocha3tes in great numbers
in the vessel wall, in the lumen of the vessels and inHamed pia arachnoid
tissues of a congenital syphilitic infant five weeks old suffering with
meningo-myelitis. Ranke examined twelve cases of congenital syphilis in
which the infant was born dead or died soon after birth, and in nine he
found abundance of spirochmtes in the inflamed pia-arachnoid membranes,
in the walls of the vessels, especially the veins, and in the lumen of the

22

Congenital Syphilis and Feeble •mindedness.

vessels; this was associated with characteristic tissue changes in the
form of lymphocyte and plasma-cell infiltration, endothelial prolifera¬
tion and neuroglia hyperplasia and proliferation. Such a condition
indicates a spirochsete septicemia and is inconsistent with life. If
the central nervous system is invaded by the spirochete during gestation
or in early infancy death takes place either before birth or shortly after,
and if it were not for the fact that invasion of the central nervous system is
soon followed in the majority of cases by death, there would be a much
larger percentage of nervous diseases due to congenital syphilis. Inas¬
much as only 4 to 8 per cent, of adults with acquired syphilis suffer with
diseases of the nervous system, the number of cases dying in early infancy
of the nervous system is proportionately very high, notwithstanding the
fact that there are not very many reported cases with post-mortem exami¬
nation. Ravaut has contributed an important series of observations con¬
ducted upon twenty-eight congenital syphilitic children. He examined
the cerebro-spinal fluid every time nervous symptoms were manifested, and
found that such symptoms were accompanied by lymphocytosis. He
suggests that lymphocytosis of the cerebro-spinal fluid may be used as a
means of diagnosis of congenital syphilis when obvious signs are absent;
moreover, if anti-syphilitic treatment be adopted the lymphocytes will dis¬
appear.

Lesions of the Nervous System due to Congenital Syphilis.

In taking the family histories of a number of cases of juvenile general
paralysis and other affections due to congenital syphilis, I have been
struck by the fact that the mother frequently stated that following mis¬
carriages and children born dead were children who died in infancy of
convulsions, of water on the brain, and of meningitis.

Hydrocephalus .—One of the earliest observers of the relation of con¬
genital syphilis to hydrocephalus and other diseases of the brain producing
mental affections was Mendel. He refers to the fact that Carl Haase in the
year 1828 related the case of a young woman who was infected by her
husband at the age of twenty-two; in consequence she had three pre¬
mature still-born children; a fourth was born at full term living, but died
at the age of seven months of hydrocephalus. He also mentions that Yon
Rosen, in 1862, published several cases in which the hereditary syphilitic
children died of hydrocephalus in early infancy; moreover, Engelberg,
Howitz, Cruveilhier, and v. Riirensprung described cases, and Howitz

F. }V. Mott.

23

ascribed to pachymeningitis and leptomeningitis a fatal hydrocephalus in a
congenital syphilitic child. Similar cases were recorded by Virchow,
v. Barensprung, Fournier and Mendel himself.

Congenital malformations as well as hydrocephalus may arise from
vascular disease in early uterine life. Eisner has described interstitial
inflammation of a specific character affecting the choroid plexus. A case
was recorded by Dr. Ashby in which hydrocephalus began in a syphilitic
infant at the age of three months, and he mentions a case of Heller’s in
which hydrocephalus came on between the fourth and seventh months.
Four cases have been recorded by Sandoz, in which hydrocephalus was
present at nine weeks, at six weeks, a few days after birth, and about
fourteen days after birth; the first three were examined post-mortem and a
thickening and roughening of the ependyma of the lateral ventricles was
discovered; moreover, the choroid plexus had an oedematous appearance
and was gorged with blood.

This condition is not uncommon; Fournier states that he has met
with thirty cases in private practice. Hochsinger has studied 362 cases
of congenital syphilis; of these 34 were hydrocephalic; in the majority
of cases it began within three to eleven months of birth and it was present
six times in foetal life ; nervous symptoms were absent in 11 cases, but in
others the symptoms were restlessness, sleeplessness, chronic vomiting,
contractures and convulsions, increase of tendon reflexes, nystagmus, and
idiocy. It mny therefore in rare cases closely simulate tubercular menin¬
gitis in its symptomatology; in some cases the beneficial effects of treat¬
ment have proved its syphilitic nature ; examination of the cerebro-spinal
fluid would help to determine a diagnosis, also the blood should be sub¬
mitted to the Wassermann test. Hydrocephalus is usually met with in
early life and generally proves fatal when the symptoms are obvious, but
Oppenheim mentions that he once saw a case of well-marked hydrocephalus,
which first developed obvious symptoms at puberty and subsequently
very severe phenomena developed. It is manifest that hydrocephalus is
the result of an accumulation of cerebro-spinal fluid in the lateral
ventricles; all syphilitic conditions, therefore, which prevent the escape of
the fluid from the lateral ventricles, where it is mainly secreted by the
choroid plexus, will occasion its accumulation. Still suggests that con¬
genital malformation might cause blocking of the iter cb tertio, but seeing
that Ranke has shown that true syphilitic specific inflammations of the
membranes and encephalitic foci are common in congenital syphilis, it is
more easy to explain the hydrocephalus by the effect of these lesions inter-

24 Congenital Syphilis and Feeble-mivdedness.

fering with the outflow of cerebro-spinal fluid. Miliary gummata of the
ependyma of the lateral ventricles have been described by Virchow and
Jurgens in cases of syphilitic hydrocephalus. Fournier points out the
practical importance of recognising that hydrocephalus may be a mani¬
festation of congenital syphilis because of the liabilities to infect a
wet-nurse. He cites a remarkable case of M. d*Astros in support of his
arguments. It would therefore be^wise to regard a hydrocephalic infant
as suspect , and in the light of our present knowledge we are able to decide
by the Wassermann reaction of the'blood-serum whether the infant should
be treated for congenital syphilis. The Wassermann reaction might
therefore be tried in all cases of hydrocephalus in which syphilis cannot
with certainty be excluded, or the hydrocephalus accounted for by other
causes.

All the forms of brain syphilis which occur in the adult as the result of
acquired syphilis may occur in infancy, childhood, adolescence, and, in
rare cases, even later in life, as the result of congenital syphilis. This is
as we should expect now that we know that syphilis is due to a specific
organism, which may remain latent in the body for years, to become active
when some depressing influence affects the tissues. As pointed out by
Wilks long ago, the tissue changes of syphilis are the same in the primary,
secondary, and tertiary lesions. The reason that congenital syphilitic
disease of the nervous system is not much more common than it is, is
because invasion of the^ central nervous system is usually fatal to the
developing offspring while in utero , or soon after birth. Another reason
is, that congenital syphilis is usually diagnosed and responds well to mer¬
curial treatment. Hutchinson remarks thereon : “ Some of our most
noteworthy therapetftic triumphs are often obtained when mercury is
judiciously employed for infants who are the subjects of syphilitic cachexia;
they fatten and thrive under it ”; but he also expresses the necessity
of caution not to use mercury too vigorously, for he thinks that its improper
use in infancy is very injurious to the second sets of teeth. However, this
warning need not deter us;, from administering mercury, for the syphilitic
virus is more potent for harm to the enamel germs than mercury.

Syphilitic Lesions of the Nkrvocs System.

True syphilitic diseases of the nervous system in congenital syphilis
are nearly always combined; thus we find a generalised leptomeningitis
and pachymeningitis, small and large gummata, gummatous neuritis and

F. W. Mott.

endarteritis associated in varying degrees. A certain number of such
cases have been recorded, e . g. Sir T. Barlow recorded the case of a male
infant, aged 15 months, who had weakness of facial muscles and
nystagmus. At the post-mortem examination small conical tumours were
found in the fourth, fifth, sixth, seventh, and eighth nerves, at their point
of exit from the brain stem ; these appeared to be of a gummatous nature.
There was an associated endarteritis; the basilar and all the vessels of the
circle of Willis were extensively diseased; these were opaque, dirty-white
in colour, and almost cartilaginous in consistence; the lumen was greatly
narrowed by thickening of the interior, and the small arterioles of the pia
mater were similarly affected. N. Chiari has recorded a case of endo-meso-
and peri-arteritis syphilitica in an infant, aged 15 months, and Bury,
Money, Jurgens, and many others have published similar cases. The
following case, which was published in full detail in the “ Morison
Lectures,” ‘ Archives of Neurology/ vol. iv, is of great interest, for it
illustrates the fact that a typical congenital syphilitic child may attain a
fair degree of intelligence, and then, owing to a latent virus becoming
active, at puberty suffer from a universal and progressive gummatous
meningitis and endarteritis.

E. M. A—, female, aged 16 years, admitted to Clnvbury Asylum
August 30th, 1905, died July 8th, 1906. Her mother had three mis¬
carriages, then five children born alive, of which she was the last. She
was delicate from birth ; she had snuffles and coryza, and was treated
with grey powder; she was undersized, looking about eleven years of age,
and had well-marked Hutchinsonian teeth ; she must have been fairly intelli¬
gent, as she was in the sixth standard at the board school. On admission
she was thought to be a congenital imbecile suffering from mania. Her
conduct had changed, she sang snatches of music-hall songs, and played
with dolls like a child of six. Although easily excited, she was liked and
spoiled by the other patients, who treated her quite as a child. The
diagnosis was juvenile general paralysis. For three months before death
she had stiffness and rigidity of the neck; she became drowsy and helpless,
and there was an internal strabismus of the right eye. At the autopsy a
generalised cerebro-spinal gummatous meningitis and universal peri-
vascularitis and endarteritis were found; all the arteries of the circle of
Willis showed a profound peri-arteritis and obliterative endarteritis; the
peri-vascular and neoplasmic infiltration was universal; it corresponded
entirely in its histological characters with a gummatous meningo¬
encephalitis. At the upper part of the spinal cord the roots were

26

Congenital Syphilis and Feeble-m indedness.

surrounded by an infiltrating exudation quite 3 min. in thickness. The
neoplastic formation consisted of proliferated, branched, and spindle-
shaped connective-tissue cells, and round or oval cells forming all stages
between lymphocytes and plasma-cells; there were also macrophages, but
polymorphonuclears were conspicuous by their absence; large numbers of
the cells were undergoing a granulo-aqueous degeneration. Considering
the universal vascular change and peri-vascular infiltration affecting the
vessels of the brain and spinal cord, including the roots, it was astonishing
how little had been the destruction of nerve-cells and fibres.

Another case of syphilis hereditaria tarda , which occurred at Clay bury,
has been investigated by Dr. Rondoni.

The patient, a girl, was healthy until aged 14 years; she afterwards
became dull and apathetic, suffered with fits (apoplectic), coarse tremor of
arms, nystagmus, exaggeration of knee-jerks, and inequality of the pupils.
The family history obtained was two miscarriages; one boy who lived
only seven months; a boy who lived fifteen months; then the patient, who
died at the age of twenty-three; then came a healthy living girl, and
lastly a girl who lived only sixteen months. Rondoni found an old diffuse,
endarteritis syphilitica with numerous small aneurysmal dilatations,
especially of the arteries of the basal ganglia. The arteritis was evidently
of long standing, for many of the small vessels in the basal ganglia
showed calcareous infiltration and patches of old softening, which can be
correlated with the apoplectic fits. The small veins are also affected.
Rondoni considers this to be a esse of syphilis hereditaria tarda of the
nervous system similar to the cases of Homen and La Chapelle. The
cases of Homen differ only because they were familial (five brothers and
sisters). In Homen’s cases there were diffuse degenerative changes in the
cortical cells without granulation in the ependyma, arterial lesions and
softenings in the basal ganglia, little proliferation of glia, and only a
slight perivascular infiltration. Homen’s cases were as follows: At the
ages of twenty, twelve, and twenty, the disease manifested itself by pheno¬
mena of vertigo, headache, disturbances of general well-being, diminished
intelligence and weakness of memory, diffuse vague pains in the legs,
oscillating gait and difficulty of speech; the intellectual loss proceeded to
an actual dementia; the speech disturbance was rather inability to
initiate than to articulate. Spastic conditions in the legs came on, also in
the arms; in both situations it progressed to actual contractures. Pupil
phenomena and aiuesthesia were absent. In all three sisters a certain
degree of infantilism occurred.

F. W. Mott.

27

Iii both tlie cases I have related the patients showed a marked degree
of infantilism of the generative organs. In view of the results obtained
by Kretschner, who has shown that syphilis hereditaria tarda is associated
with a lymphocytosis of the cerebro-spinal fluid, it would have been
interesting if lumbar puncture had been performed in these cases.

Cases have been recorded of syphilitic disease of the brain, the spinal
cord, their cavities and vessels (Dowse, Siemerling, Bury, Bottiger, Pick,
Hutchinson and others). The nervous disease of the child began in the
case reported by Dowse at the age of ten, Siemerling’s at the age of six,
and Buryis at the age of eight. An especially large single gummatous
tumour situated in the occipital lobe which had led to erosion of the
cranium has been recorded by Hutchinson in a girl of sixteen. Hutchinson
looked upon the case as one of syphilis hereditaria tarda .

As in acquired syphilis so in the congenital form, cases of so-called
syphilitic meningitis or meningo-myelitis are in reality not localised to the
spinal cord, but affect also the base of the brain and its stem; they are
really cases of cerebro-spinal meningitis in which the cerebral symptoms
are slight and the spinal symptoms obtrusive ; consequently it is not
surprising that there are no recorded cases, so far as I can find, of congenital
spinal syphilis, although in all cases of diffuse meningitis and arteritis the
spinal structures participate in the form of disease of arteries and veins, of
circumscribed and diffuse infiltrating gummatous neoplasms, meningitis
and neuritis affecting the anterior, and especially the posterior spinal roots.
In fact all the evidence tends to prove that in congenital syphilitic disease
of the nervous system, multiple combined affections are the rule, and it
seems probable that tissues which are undergoing development afford a
more congenial soil for the specific organism to grow and multiply in;
consequently infection of the central nervous system is especially liable to
lead to severe disturbances and loss of function and early death when it is
not immediately fatal. Moreover, although other aetiological factors, e . g .
alcoholism and mental stress, do not directly play a part, yet it is probable
that alcoholism, and particularly a neuropathic or psychopathic taint in
progenitors, play an important part as contributory factors in the later
development of general paralysis, optic atrophy and tabes, also epilepsy,
hysteria, and other neuroses of congenital syphilitic children.

Syphilitic Encephalitis. —A localised encephalitis, apart from gumma¬
tous meningitis and arteritis, is extremely rare. Little's disease and spastic
hemiplegia have been attributed to an encephalitis of congenital syphilis,
but Oppenheim and Casirer, in their valuable monograph on encephalitis,

28

Congenital Syphilis and Feeble-minded ness.

express the opinion that syphilis plays an unimportant part in the
production of encephalitis. Max Nonne, from his experience, comes to a
similar conclusion, and Sachs, who has had a very large experience regard¬
ing encephalitic paralysis of children, only found two cases of hereditary
syphilis in 200 cases of congenital paralysis. Moreover, the post-mortem
experience of Yon Recklinghausen is to the effect that a true encephalitis
is rare in hereditary syphilis. He found encephalitis only twice in 45 cases
of hereditary syphilis occurring in the post-mortem examination of 1600
children. Possibly, however, had a microscopic investigation been made
as Ranke has done, the results might have been different. Fournier,
Gilles de la Tourette, Charcot, Heubner, Franke and Krienmeyer, on the
contrary, consider congenital syphilis an important cause of Little’s disease.
My own experience would assign congenital syphilis a place inferior to
asphyxia! conditions at birth, head injury, and the infectious diseases of
childhood; not that I disbelieve the important influence of congenital
syphilis in its production of encephalitis, but its relative infrequency I
would explain by the fact that if the living virus gains access to the cranio¬
spinal cavity, in the great majority of cases it proves fatal within a short
time owing to spirillar septicaemia, as Ranke has shown; or the infant, if
born alive, dies of hydrocephalus, meningitis, or convulsions within a
short time after birth.

Congenital Syphilis and Epilkpsy. —Convulsions in early infancy are a
common cause of death of infants the subjects of congenital syphilis; they
may own many causes. Thus a child with syphilitic cachexia may die
from convulsions brought on by improper feeding, teething or infectious
disease, or it may die from convulsions due to meningitis syphilitica. It is
almost impossible in an infant to decide what is the cause of the convul¬
sions ; a post-mortem examination with microscopic investigation could
alone decide whether the convulsions were due to invasion of the central
nervous system or not by the syphilitic organism.

The subjects of congenital syphilis may in later life develop typical
idiopathic epilepsy; unless a careful inquiry be made into the family
history it would be manifestly impossible to assert that an hereditary
neuropathic taint was not the more important cause of the epilepsy than
the congenital syphilis; still, there is reason to believe that acquired
syphilis may be a direct cause in certain instances of the manifestations of
epilepsy in later life, and Fournier went so far as to say that a man who
became first affected with epilepsy after he had reached forty years of age
owed the epilepsy to syphilis acquired a long time previously ; therefore it

F. IF. Mott.

29

is pos-ible that some cases of epilepsy are due to congenital syphilis. In
fact I know of several cases in which congenital syphilis seems to be a
reasonable explanation of the onset of epilepsy in adolescence; one in
particular I have in mind. A young gentleman suffered with epilepsy first
at the age of seventeen. 1 could find no cause in the family history, there
was no evidence of epilepsy or of other neuroses or psychoses in the family.
Examination of the eyes ophthalmoscopically of this apparently healthy,
untainted young man showed a definite choroido-retinitis.

The figures (Figs. 4 and 5) exhibit two well-marked congenital syphilitics,
the subjects of epilepsy and imbecility, and I am sure, from the study of
pedigrees obtained from imbecile asylums, that congenital imbecility and
epilepsy is not a very infrequent result of congenital syphilis. A great
many of these cases, however, which are diagnosed epileptics the subjects
of congenital syphilis, subsequently turn out to be juvenile general
paralytics.

Localised softenings may act as a source of irritation, and give rise to
epilepsy with or without paralytic phenomena. Thus an epileptic, feeble¬
minded woman, an inmate of Clayburv Asylum, told me that she had been
paralysed in her right side from her earliest infancy ; examination of the
eyes showed a well-marked choroido-retinitis indicative of congenital
syphilis; she had, besides, evidence of old interstitial keratitis and squint;
these two latter eye affections she suffered with in early life, and later on
she developed epileptic fits. I have seen many cases of syphilitic brain
disease in adult life followed by softening or gummatous meningitis near
the motor area act as a source of irritation, at first causing unilateral
Jacksonian epilepsy, but the convulsions after a time have become so
generalised that they were indistinguishable from ordinary epilepsy. Such
cases are not so uncommon in asylums. Those persons suffering with
epilepsy due to organic brain disease often have unequal pupils and a
certain amount of dementia, and therefore are sometimes diagnosed as
general paralytics.

Congenital syphilis and symptomatic epilepsy are both fairly common
diseases, consequently because patients show stigmata of congenital
syphilis on the body or the blood gives the Wassermann reaction, it does
not necessarily follow that there is a causal connection between the
epilepsy and the syphilis, unless it can be proved that the syphilitic virus
has so damaged the brain in the neighbourhood of the motor area that the
lesion can act as a source of irritation. In many of the cases of congenital
syphilis and epilepsy ihere is a family history of insanity or epilepsy either

30 Congenital Syphilis and Feeble-minded-nests.

in the direct ascendants or in the collaterals; the syphilis in such cases
may therefore only be a co-efficient in the causation of the epilepsy or
insanity. The following case may be attributed to congenital syphilis :
A. B—, formerly an inmate at Darenth Asylum, was sent to Colnev
Hatch Asylum as a dangerous epileptic. He was scarcely able to speak,
being able only to say a few simple words. He had a low forehead, pro¬
minent development of the lower part of his face, a saddle-shaped
nose, notched peg-shaped teeth, and very marked linear scarring all round
the mouth. He was stunted in growth, but the genital organs were well
developed. He remained for some time in the same condition. The fits
were epileptic in character, the pupils equal and reacted to light and
accommodation ; there was no coarse paralysis (vide Fig. 5).

Some types of congenital feeble-mindedness due to congenital syphilis
are shown in the accompanying photographs.

The important question arises, Can parental syphilis modify the germinal
plasm so as to influence the proper development of its most complex and,
functionally as well as structurally, highly differentiated product—the
cerebral cortex ?

Fournier, Erlenmeyer, Heubner, Fischl and many others have cited
some very remarkable instances of congenital syphilitic children appa¬
rently spontaneously developing epilepsy. The statistics at hand are not
very valuable. According to Veit (Wuhlgarten) the proportion of con¬
genital syphilitics among the epileptics was 7 per cent. Binswanger
asserts that congenital syphilis plays a much more important predisposing
role in the production of epilepsy than is generally imagined. He speaks
of a dyscrasic form of congenital syphilitic epilepsy. I think it would be
a legitimate conclusion to arrive at, that congenital syphilis was the cause
of symptomatic epilepsy if the parents of the syphilitic child both came
from sound stocks in which there was no previous epilepsy, migraine or
insanity.

Without attempting to give any precise data I am of opinion that
syphilis and alcoholism of the parents may influence the germ-plasm and
per se lead to the production of imbecility and symptomatic epilepsy ; but
seeing how very common the combination of syphilis and alcoholism is, the
fact of a child of parents so affected suffering with epilepsy may be only
coincidence. If, as in the case of juvenile general paralysis and optic
atrophy, syphilis were an invariable antecedent in epilepsy, or even if it
were a frequent antecedent, it might be conceded that the syphilitic
poison was epileptogenous; but inasmuch as epilepsy occurs very fre-

i

32

Congenital Syphilis and Fceble-mindednesb.

quently in communities where syphilis is unknown, and among total
abstainers almost as frequently as in drinkers, the causal relationship of
syphilis and alcoholism in the parents with epilepsy in the offspring is
uncertain. What certainly is true is that if there be a neuropathic or
psychopathic taint in the progenitors, alcohol and syphilis will singly or
combined tend to bring out that neuropathic taint—and were it not for
the fact that both these poisons are deadly as well as devitalising, the
effects on humanity would be cumulative and lead to racial annihilation.
Thus, after all, these two scourges of humanity may lead to the survival
of the socially and morally fittest, by killing the progeny of those stocks
which have an inherent lack of judgment and highest control, in this way
counter-balancing to some extent the degeneracy which they produce and
are directly responsible for. Venereal diseases of the parents are much
the most potent factors in the production of sterility, miscarriages, abor¬
tions and infantile deaths, in this respect markedly contrasting with
tuberculosis, in which there is neither sterility nor miscarriages and
abortions. Chronic alcoholics are improvident and have numbers of
children, but do not rear them; generally this is the result of careless
and improper feeding. Venereal disease is so frequently associated with
chronic alcoholism that the progeny of drunkards is greatly diminished in
consequence of their much greater liability to contract these diseases.
Consequently statistics relating to alcohol per se and its causation of
miscarriages, still-births, and children dying in infancy, are open to this
error, that syphilis may be co-operating.

Symptomatology of Congenital Syphilis of the Brain.

The pathological changes in the central nervous system met with in
congenital syphilis are similar in all respects to those found in adults due
to acquired infection. Necessarily, therefore, the symptomatology is very
similar.

(1) Convulsions .— I have already pointed out that infants and young
children born of syphilitic parents very frequently die of convulsions.
Barlow and Bury likewise point out the frequency of early convulsions in
congenital syphilitic children; some of their cases exhibited this symptom
quite early. Their experience is thus summed up : ‘‘ The earliest case of
convulsions with subsequent post-mortem verification of extensive menin¬
geal changes was observed by one of 11 s in a child, aged four months, but
we have notes of several at the age of three months, without post-

F. W. Mott.

Sll

mortem verification, and one of a syphilitic infant, who had ten or twelve fits
daily from the age of fourteen days to seven months.” There is practically
no period after birth up to two years in which convulsions may not occur.
The fits are usually bilateral, consisting of tonic and clonic spasms; in
some there is opisthotonos, spasms with persistent retraction of head and
neck, and laryngismus stridulus not infrequently occurs. These authorities
remark that it is important to note that syphilitic infants simultaneously
or shortly after the appearance of the rash and snuffles may develop
bilateral fits and laryngismus; months or years may then elapse without
fresh symptoms, as if the virus were latent, and then a unilateral spasm
or paralysis may ensue. The following example is given : T. H—, snuffles
at four weeks and probably pemphigus succeeded by bilateral fits, three or
four a month up to one year. The child was unable to sit up till the age
of three, and did not walk till four years of age. At the age of four it
had two right-sided fits within six months followed by right hemiplegia and
dysarthria. She was seen again at ten years of age and exhibited the
usual well-marked stigmata of congenital syphilis. The right eye was
blind and there was extensive detachment of the retina. The left showed
atrophy of the disc and old choroiditis. There was some paresis of the
right upper and lower limbs, but no spasm, and there was a slight arrest
of development (as shown in length and circumference) in the right fore¬
arm as compared with the left. There was no evidence of paralysis of any
cranial nerve. She heard and understood many things which were said to
her, and answered some questions, but could not be trusted in her replies
to questions in testing common sensation and special sense. There was a
slight articulatory defect, as of a young child who had not long learned to
talk. She was docile, but distinctly retarded in her intellectual develop¬
ment for a child nearly eleven. She died of nephritis, and at the post¬
mortem her brain showed remarkable sclerosis of both hemispheres, the
left being more affected than the right, with marked shrinkage in both
transverse and longitudinal measurement. There was also extensive end¬
arteritis of all the arteries of the circle of Willis and their branches.

(2) Headache and irritability .—Headache, worse at night, is a sign of
brain disease due to acquired syphilis, but according to Barlow and Bury
it is also met with in brain disease due to congenital syphilis. Definite
complaints of headache are not made by infants and young children, but
these authorities state that their experience shows that syphilitic infants
sleep badly ; they have screaming fits, and they have known cases of torpor,
paresis, find unilateral convulsions ushered in bv excessive irritability

o

O

34 Congenital Syphilis and Feeble-mindedness.

and stiffness of the neck, either with the head retracted or held to one
side.

(3) Hemiplegia and other motor signs .—A frequent symptom of con¬
genital syphilitic brain disease is hemiplegia; it is usually preceded by
unilateral convulsions, and the convulsions may occur at intervals again on
the paretic side. In some cases there is an onset like an apoplectic fit, and
without any warning the child may fall down unconscious and remain so
for a varying period of time. In other cases the child may be irritable,
restless, and if old enough it may be noticed that it has suffered with head¬
ache and attacks of vomiting; suddenly, or perhaps comparatively suddenly,
and without loss of consciousness, there may be a loss of power on one side
of the body and the speech may become thick and indistinct. Attacks of
drowsy torpor and somnolence, so characteristic of cerebral syphilis in the
adult, may also occur in the child.

(4) Affections of speech .—Speech defects of the nature of dysarthria
or aphasia frequently occur, but as a rule they are more temporary in cases
of congenital syphilitic hemiplegia than when occurring in the adult;
Barlow and Bury state that—“ in many of the initial attacks of hemiplegia
paresis of limbs, so far as its gross indications are concerned, clears up to
a great extent, and the paresis of the face to a marked extent. The only
vestige may be that the child does not use the arm and hand which have
been affected quite as freely as those of the opposite limb.” But as in the
adult form, so in the congenital, there is a great proneness to subsequent
attacks, after which a spastic condition may supervene; following an attack
affecting one side of the body there is a marked liability to affection of the
opposite side. In such cases an endarteritis may be suspected. In the
hemiplegic condition of children, speech affections are, as a rule, much
more transient than in hemiplegias of adults. Some interesting cases are
recorded by the above-mentioned authors.

(5) Affections of cranial nerves .—Any one, or several of the cranial
nerves, may be affected, apart from evidence of disease of the brain or
definite meningitic symptoms; the nerve affection may be unilateral, or
both sides may be affected, or several pairs of nerves; again, separate
portions of the third and fifth nerves may be paralysed; occasionally, but
rarely, the facial nerve is affected ( vide case, p. 8).

Affections of the third and sixth nerves are not uncommon, giving rise
to strabismus, and Hutchinson has recorded two cases of ophthalmoplegia
externa in congenital syphilis. Nerve-deafness is not uncommon, and I
have met with instances in the asylums : it is, however, rare as compared

F. W. Mott.

35

with primary optic atrophy. The deafness comes on mostly between the
periods of five years before and five years after puberty; it is bilateral,
painless, and unattended by otorrhoea. In a number of the cases bone-
conduction is absent. The following case, among others, may be cited :
A young woman, aged 18 years, was admitted to Colney Hatch Asylum
suffering with imbecility and impulsive conduct, amounting to a mild form
of mania. She was absolutely deaf, but she was able to talk. She began
to lose her hearing at eight, and in two or three years had become stone
deaf. There were signs of old keratitis and notched teeth, but she was
not undersized. She was soon discharged as recovered.

According to Gray, many authorities consider that congenital deaf-
mutism is often due to inherited syphilis, and on this account the following
case is of interest: A congenital deaf-mute was admitted to Clay bury at
the age of nineteen, and after being in the asylum for some time was
discharged. He was, however, readmitted on account of suicidal impulses
and mania : he died at the age of thirty-nine. The cerebro-spinal fluid
gave the Wassermann reaction. The fourth ventricle was slightly granular,
but the microscopic examination of the brain showed no signs of general
paralysis. Very frequently the nerve-deafness of congenital syphilis is
accompanied by interstitial keratitis, but the notes do not point to this
condition, nor to any syphilitic stigmata on the body, so it. is doubtful.
Still, the positive Wassermann reaction and the granular ventricles suggest
the existence of latent or active syphilis, and it will be interesting to know
what morphological changes Mr. Sydney Scott finds in the internal ears.
As he made special examination of the patient’s ears during life the
temporal bones were removed and forwarded to him. This case suggests the
desirability of a systematic examination of deaf-mutes by the Wassermann
test.

Parasyphilitic (Metasyphilitic) Affections of the Nervous System due

to Congenital Syphilis.

The diseases which are generally recognised as such are general
paralysis, tabo-paralysis, tabes dorsalis, and optic atrophy. These diseases
are really a single morbid entity owning the same cause, insidious in onset,
progressive in character, and uninfluenced as a rule by anti-syphilitic
remedies. These various clinical types of parasyphilitic disease are the
result of a primary neuronic dystrophy; they have a similar pathogenesis,
and may occur simultaneously or successively in the same individual.
Congenital syphilis may result in any of these forms of parasyphilis, but

36

Congenital Syphilis and Fceble-rnindedness .

general paralysis and optic atrophy are the most commonly met with.
Undoubtedly some of the cases of optic atrophy are of a truly syphilitic
nature and may be subsequently followed by parasvphilis in the form of
general paralysis. General paralysis as the result of congenital syphilis is
not, however, common, for the reasons before mentioned : it may begin at
any age; the youngest I have known commenced at eight years, and death
occurred at sixteen, the eldest occurring at twenty-eight years with death
at thirty-one. In 500 post-mortem examinations made at Claybury
Asylum on general paralytics, there were ten cases of the juvenile form,
and of these five were males and five were females. The sexes were
affected equally as might be expected. Professor Clouston in 1877
described a case of general paralysis in a boy, aged 16 years, and he
pointed out that clinically and pathologically the disease that affected his
patient in no way differed essentially from the adult form : he termed it
developmental general paralysis, and it was looked upon by him as an
extremely rare condition. Since then a great number of cases have been
recorded, and important papers have been published on the subject by
Regis, Alzheimer, and others. The disease formed the subject of a paper
by myself on twenty-two cases in the ‘Archives of Neurology/ vol. i, and
a second paper by Dr. Watson in vol. ii, and I claimed that these juvenile
cases, having been proved to occur in the great majority of instances in
the subjects of congenital syphilis, supported the contention of Fournier
that syphilis was essentially the fons et ongo of general paralysis, for the
other aetiological factors which had been claimed to cause general para¬
lysis, viz. sexual excess, mental stress, injury, and particularly alcohol, can
in the majority of these juvenile forms be eliminated. Moreover, I have
shown that a psychopathic heredity as a rule plays little or no part in this
acquired disease. Numbers of cases have occurred in the asylums since the
publication of these investigations which have confirmed the results I then
obtained; it will therefore be unnecessary to do more than summarise
the principal facts concerning the parasyphilitic affections resulting from
congenital syphilis, illustrating the same with a few typical cases. The
majority of cases admitted to asylums, unless they present well-marked
stigmata of congenital syphilis, are diagnosed as imbeciles or epileptic
imbeciles, yet careful inquiry from the parents of a considerable number,
shows that until puberty these children were up to the average standard
in intelligence, for they usually attained the sixth standard in the board
schools ; others, however, were feeble-minded and backward from birth ;
as a rule the signs of active degeneration commenced about the time

F. IV. Mott.

37

of puberty. It is not uncommon to find children admitted to the schools
for the blind with optic atrophy coming on before puberty in early
or later childhood. Some of these cases are feeble-minded, and some are
intelligent and capable of training. At puberty or early adolescence
various signs of cerebral decay, e . g. changes in the habits and disposition,
inability to learn, weakness of memory, etc., may be noticed, or the patient
may have a fit, followed by other fits. Sooner or later the signs of mental
disorder are sufficiently pronounced to necessitate the removal of the
patient to an asylum. Thus two brothers, sons of a dissolute father, were
admitted to one of the London County Asylums; both had become blind
before puberty and at about the same age. The mother had had mis¬
carriages, followed by the birth of these two boys ; they were good-looking
and presented no obvious signs of congenital syphilis, and they were
intellectually capable boys before they commenced to have fits (vide fig. 2).
They were sent to the asylum as epileptic imbeciles, and died there some
years after admission.

These cases of optic atrophy associated with juvenile general paralysis
are frequently accompanied by changes in the spinal cord of a tabetic
character. Ataxy of the limbs in these congenital cases is not common.
I have met with three definite cases, one in which there was a spontaneous
fracture of the femur and two other cases. Perhaps the most interesting
of these two was that of a young man, aged 18 years, in whom the disease
terminated fatally within four months of the onset of pronounced symptoms.
The history obtained from the mother was briefly as follows: Her husband
drank, but always remained in employment. She had had three children,
all alive and healthy, then two were born dead ; the sixth died at seven
months and the seventh is the patient. The husband was not a steady
man and went with other women. There was no insanity or fits in the
family on either side. The patient, she said, was a bright, intelligent lad,
although weakly and delicate. He was an excellent musician and was
always sober and steady. For some time he had complained of pains in his
legs and a feeling as if they were giving way under him. Then he had
the delusion that someone was coming to rob the house and kill his mother.
His speech became affected, and he was removed to University College
Hospital and subsequently transferred to Colney Hatch Asylum. On
admission I noted that the pupils were small and reacted slightly to
accommodation but not to light. The speech was tremulous; there was
elision of syllables and slurring of words. There was tremor in his writing
and a marked tremor of the tongue and lips. There was slight rotatory

38

Congenita l Syph ills and Feeble-mindedness.

nystagmus but no squint. The fundi were normal, and there was no con¬
centric limitation of the field of vision. He stood with a wide base and
swayed a good deal on closing the eyes. The knee-jerks were absent, but
the muscles responded to faradism. There were linear cicatrices at the
angles of the mouth ; the teeth were decayed and the incisors were
cupulated and peg-shaped. He had a semi-imbecile paretic expression of
foolish contentment and his conversation was incoherent, but he exhibited
no delusions while in the asylum. He became progressively more paretic
and demented, and died within four months of the onset of symptoms.
This is the most rapid case I have seen; probably excessive masturbation,
which he practised after the mental symptoms developed, hastened the
progress of the mental decay. At the post-mortem the typical lesions of
general paralysis were found in the brain, together with a naked-eye
sclerosis of the posterior columns. The liver showed pericapsular, peri¬
vascular, and pericellular fibrosis, characteristics of congenital syphilis.

A considerable number of cases of juvenile general paralysis are sent to
the imbecile asylums of the Metropolitan Asylums Board, and if they are
troublesome, necessitating more care and attention than can be given,
they are transferred to the London County Asylums— e. <j. D. McD—, aged
18 years, was admitted, October 28th, 1907, to Bexley Asylum, having
been transferred from Tooting Bee, where he had been sent certified as an
imbecile. He is said, however, to have reached the seventh standard
in the board school when aged fourteen, and up to sixteen was able to
earn his living. There is a history of a fall from a ladder, injuring his
head when he was aged twelve. The notes state that he was undersized and
that he had carious, syphilitic teeth, the genital organs were undeveloped,
and he was only 4 ft. 9^ in. in stature. There was a slight ptosis of the left
eye ; the pupils were unequal, outline irregular, the left larger than
the right, with both inactive to light. The knee-jerks were present. There
was no control of the sphincters. His mental state was thus described :
The attention is obtained with difficulty, and he is unable to comprehend
what is said to him. He has little or no knowledge of his surroundings,
and calls everybody “ father ” or “mate.” He is too demented to test his
orientation of time and place ; there is no evidence of hallucinations or
delusions. He is noisy, restless, resistive, and destructive. His speech
is markedly tremulous. Xo history of syphilis was obtainable, but I
ascertained that the father died in Guy’s Hospital, and information obtained
from the registrar points to the fact that he had syphilis; moreover, a
brother of the patient has been admitted to the asylum suffering with

F. W. Mott .

39

general paralysis, aged twenty-nine. The notes state that he has had
acquired syphilis. The patient died after a residence of six months of
double lobar pneumonia. The post-mortem examination showed the
following changes in the brain :

The brain was forwarded to the Pathological Laboratory for examina¬
tion : Weight, 1175 grm.; right hemisphere, 510 grm.; left hemisphere,
478 grm.; pons, etc., 187 grm. All the convolutions are small, not much
wasting, no local wasting. Adhesions along middle line of the two hemi¬
spheres in front. Convolutional pattern complex. Calcarine fissure in left
hemisphere comes a long way round on the external surface. Calcarine in
right hemisphere ends in the vertical fissure of Seitz at the pole.. There is
comparative to the right hemisphere, an obvious failure in development of
the parietal lobe in the left hemisphere. The Sylvian fissure is horizontal
in both hemispheres. Lateral and fourth ventricles granular. Spinal cord
shows apparent degeneration in posterior columns, and the grey matter
looks more vascular than normal, and the cord generally is smaller than
natural. There is nothing further noteworthy in the post-mortem notes
except that death occurred from double lobar pneumonia (red hepatisation
in both lungs) of about four or five days’ duration.

The microscopic examination of the brain and cord exhibited the
following points of interest: The cortex of Broca’s convolution showed
more pronounced changes than the top of the ascending frontal convolu¬
tion, but in both situations the same changes were observed. There was
increased vascularity; many of the vessels showed an infiltration of their
lymphatic sheaths with lymphocytes and plasma-cells. The endothelial cells
lining the vessels and forming the walls of the capillaries were swollen;
the nuclei, instead of staining deeply, were swollen and pale in coloration.
Rod-cells were met with occasionally in sections of Broca’s convolution;
also a few sprouting capillaries were to be found. The neuroglia cells
were not found in any numbers in the grey matter of the cortex, but they
were very numerous in the white matter. There was some sub-pial felting
of glia, and the leptomeninges in places exhibited a lymphocyte and plasma¬
cell infiltration. The vascular and glia changes were not, however, marked.
The cells were well shaped in the majority of instances, and there was no
marked distortion of Meynert’s columns in the ascending frontal convolu¬
tion; the cell changes were more pronounced in Broca’s convolution. The
cells showed a large clear nucleus; the processes in many instances
appeared broken off or absent, and many of the cells were crumbling at
the borders. Occasionally two nuclei or a nucleus dividing could be seen

40

Congenital Syphilis and Feeble-minded nests.

in the ganglion-cells. All the cells examined by the Nissl method showed
a diffuse uniform purple staining, with absence of Nissl granules—an
appearance that is consistent with prolonged high fever. The notes do
not say so, but it is probable that during the last twenty-four hours of life,
when he lay in a comatose condition, he had hyperpyrexia. All the
central nervous system, including the spinal cord, showed this change in
the ganglion-cells. The spinal cord showed very marked changes, the
leptomeninges and the vessels showed infiltration with lymphocytes and
plasma-cells; there was well-marked sub-pial felting indicative of chronic
change. There was glia-cell proliferation most marked in the posterior
columns and around the central canal, which was obliterated and filled up
by proliferation of the cells of the ependyma and neuroglia. By the silver
Cajal method the cells showed the fibril structure in the majority of
instances fairly well, especially in the deeper structures of the grey matter
of the cortex. The small and medium-sized pyramidal cells were con¬
siderably diminished in numbers; also the cells of the deep polymorphic
layer. The molecular layer was almost absent and replaced by glia tissue.

The microscopic appearances suggest that this lad was a feeble-minded
boy in whom the brain had participated in the general bodily deficiency;
the pattern was fairly good and very complex, but all the convolutions,
especially of the parieto-occipital and frontal regions, were very small—
almost a microgyria. There was a progressive dementia in this case, but
there was also a condition of amentia or arrest of development proportional
to the. general bodily arrest of development, and possibly associated
particularly with the infantile reproductive organs. * He never had fits, or
hallucinations or delusious; probably this may be associated with the fact
that there was comparatively little vascular and glia change. The whole
nervous system, including the spinal cord, was affected. The changes in the
nerve-cells were partly due to arrest of development and partly to a pro¬
gressive primary decay, together with a universal affection of the cells of
the whole nervous system of a bio-chemical nature, as revealed by uniform
dull purple staining with absence of Nissl granules, due to the effects of
toxeemia and hyperpyrexia, and not related, therefore, to the mental
symptoms that characterised the disease.

Juvenile genera! paralytics diagnosed as epileptics .—Some of the
cases of juvenile general paralysis are sent from epileptic colonies or Dr.
Barnardo’s Homes. The following case of a feeble-minded boy who was
sent to Barnardo’s Home is also of interest, because the first sign of the
disease was manifested at the age of eight, when he had a fit. F. J— at

F. W. Mott.

41

the age of nine, was brought to Charing Cross Hospital suffering with
epiphysitis. He had typical Hutchinsonian teeth, rhagades all round the
mouth, choroido-retinitis, internal strabismus of the left eye. Under
mercurial treatment the epiphysitis healed completely. The mother stated
that prior to his birth she had had several miscarriages and two still-born
children. She herself has, however, never suffered in any way. The next
child is a girl; she presented no symptoms of syphilis, except internal
strabismus of the left eye. After attending nearly a year, his mother
came and thus described several fits which he had had at school. He went
to school all right, but while there he passed a motion unconsciously.
He was brought home, cleansed, and returned to school, “ more to get him
out of the way than for what he learnt;” he was quite an infant in mind.
At eleven o’clock he was again brought home in a fit; be was quite
unconscious, there were no clonic spasms, but he remained unconscious
for one hour. The teeth were clenched, but he did not bite his tongue.
The mother said that two years previously he had had a similar fit. On
another occasion he was observed by the master to act strangely, for
he kept rubbing out and writing the same word automatically. He was
quite unconscious of what he had been doing. Later he was sent to
Dr. Barnardo’s Home, and I lost sight of him for four or five years
until he was admitted to Colney Hatch Asylum. His appearance was
but little changed: he looked about ten years of age although he was
fifteen. The tongue was tremulous and jerky, likewise there was a well-
marked tremor of the lips; the speech was muttering, hesitant, tremulous
and incoherent. He seemed to understand only partially what was said
to him, and although he did not recognise me, he knew his mother.
The knee-jerks were absent on both sides; the pupils were unequal,
dilated, and irregular, reacting sluggishly on convergence, but not to
light. He did not respond to the calls of nature. There was no hair
on the pubes, and the genital organs were quite infantile. The dementia
and paresis progressed rapidly, but he manifested no evidence of delusions
or hallucinations. Death occurred two months after admission from
exhaustion. The brain, macroscopically and microscopically examined,
presented all the characters of general paralysis; the arteries showed no
syphilitic affection, therefore the fits at the age of eight were not due to a
true syphilitic brain disease, but were the first sign of paralytic dementia.
There was a scar of an old gumma on the liver, and both this organ and
the kidneys showed the characteristic changes of congenital syphilis.
The testicles showed no spermatozoa.

42

Congenital Syphilis and Feeble-mindedness.

General paralysis in parents and offspring .—In about 20 per cent, of
the cases of juvenile general paralysis I have found that the father has
died in an asylum of general paralysis; seeing that there are a large
number of female paralytics (the proportion in the asylums being three males
to one female), it is rather remarkable that in sixty cases of juvenile general
paralysis I have not met with an instance in which the mother has died
of general paralysis. In the statistics of relatives which I have been
engaged in collecting, and which are dealt with fully in the Huxley
Lecture (Appendix), it has been shown that relatively few cases of
parents and offspring occur in which general paralysis is the disease
affecting either or both. Yet we see that similarity of the mental disease
occurs in 20 per cent, of the instances, and according to my experience
the father is the parent invariably affected. In other forms of insanity
due to the neuropathic taint the mother transmits twice as frequently as
the father, and daughters are affected twice as frequently as sons. The
difference is this—that general paralysis is an acquired disease due to the
late effects of the syphilitic virus, and hereditary neuropathic tendency
plays little or no part in the production of this organic brain disease.
Now while I do not say that instances may not occur of the mother suffer¬
ing with general paralysis, and one or more offspring dying later of the
same disease, I am of the opinion that as I have not met with them they
must be very rare indeed. How can this extreme rarity be accounted for ?
Clearly neuropathic tendency cannot play an all-important part, otherwise
we should expect to have had instances of female paralytics with paralytic
offspring; juvenile paralysis occurs with equal frequency in the two sexes
as might be expected, seeing that there is a comparative numerical balance
of the sexes, and the essential cause is syphilis; unlike the conditions met
with in the adult form, the syphilitic virus is liable to affect both sexes
equally. The fact that women acquire syphilis much less frequently than
men would not account for the fact that I have found no instances of
mothers with general paralysis having paralytic offspring. How can the
fact be accounted for ? Most of the mothers of paralytic offspring have
not apparently suffered with any severe symptoms; they have been im¬
munised. Again, a large number of the paralytic women in asylums have
undoubtedly been prostitutes, and have therefore become sterile; in connec¬
tion with this it may be mentioned that 50 per cent, of the female paralytics
dying at Claybury Asylum were found, post-mortem, to have suffered
with old salpingitis. Moreover, a woman who had been infected and after¬
wards suffered with general paralysis is less liable to have living offspring.

F. IF. Mott.

43

Congenital syphilis and general paralysis in later life. —In my Croonian
Lectures upon the “ Degeneration of the Neurone ” (1900), I remarked
that it is very probable that some of the cases occurring in adults, in which
acquired syphilis can be excluded with certainty, may still owe the
disease to congenital syphilis. It is not even necessary, as quite one half
of the cases show, that they should exhibit any external signs of congenital
syphilis, for many juvenile cases can be proved beyond doubt, as the
following cases I have collected show, to have been born of syphilitic
parents; although manifesting themselves no external signs of syphilis, yet
the history of miscarriages, still-births, and children dying in infancy of
meningitis, hydrocephalus, or of brothers and sisters with well-marked
stigmata or evidence of syphilis hereditaria tarda , disclosed the necessary
proof of the congenital taint. Sometimes no history may be obtainable
and there may be no signs of syphilis on the body; even in some of these
cases a definite proof of the possibility of congenital syphilis may be forth¬
coming by a little investigation. Thus I was asked to see a case at Cane
Hill Asylum, who was suffering from advanced general paralysis. He was
almost speechless, had great difficulty of swallowing, his saliva dribbled
from the angles of the mouth, all four limbs were in a condition of spastic
contracture, and there was loss of control of the sphincters. There were
no signs of syphilis on the body, and the only information obtainable was that
he had had a fit at the age of eigthteen, he had married when young, and
his wife had given birth to a dead child, and had left him because of
his “ strange” conduct. He had more fits, and became slowly and insidiously
more demented, and died at the age of twenty-eight. At the autopsy the
most advanced condition of paralytic brain degeneration was found. I
subsequently found that his father had died eight years previously of
general paralysis in Claybury Asylum. I have once or twice met with
instances of father and son being in the asylum together suffering with
general paralysis. The case above referred to was one of juvenile general
paralysis, commencing in adolescense, but running a slow course. Doubt¬
less the fit at eighteen was the commencement of the brain decay, and had
lumbar puncture been performed and the cerebro spinal fluid been examined,
a lymphocytosis and probably a positive Wassermaun reaction would have
been obtained. Just as in the cases of acquired syphilis the onset of
general paralysis may in rare cases be greatly delayed, so in the juvenile
form there may be great delay in the onset of the parasyphilitic affection.
Thus a case of general paralysis died at Banstead Asylum which had
previously been under Dr. Percy Smith at Bethlehem Hospital. This

44

Con yen it a l Syphilis a ml Feeble-min (lain ass.

woman had characteristic signs of congenital syphilis, but she did not
manifest symptoms of paralytic dementia until she was thirty. She Vvasan
unmarried woman, and there was no evidence to show that she could have
acquired the disease. Recently Christian Muller has put forward the same
hypothesis to explain parasyphilitic disease affecting patients in whom no
history of acquired syphilis can be obtained. He described two cases of
women (virgins) who were the subjects of well-marked signs of congenital
syphilis, and who died of general paralysis at the ages of forty-two and
forty-three years. The symptoms were not noticeable until a year or two
before death.

Tabo-paralysis and optic atrophy .—The following case of tabo-paralysis
is of interest, as gastric crises at the age of nine were the first symptoms
that brought the patient under observation.

P. C—, aged 9 years, was admitted to Charing Cross Hospital suffering
with attacks of vomiting and occasionally diarrhoea. She had well-
marked obtrusive stigmata of congenital syphilis, in the form of
Hutchinsonian teeth and rhagades. I ascertained that the father had
died some years previously at Banstead Asylum of general paralysis; his
notes gave no history or signs of syphilis, although the fact of his having
had syphilis was clearly demonstrated in his offspring—a not unusual
occurrence. The mother had not suffered with any sign or symptoms, but
prior to the birth of the patient she had had one miscarriage and two
children born dead. The paroxysmal attacks of vomiting had commenced
at seven years of age. She had become progressively enfeebled mentally,
and was sent to Darenth, where I again saw her. She still suffered with
vomiting and lightning pains; the pupils were unequal, inactive to light
and accommodation ; the knee-jerks were absent. Both eyes showed well-
marked choroido-retinitis and optic atrophy. There was anaesthesia of the
chest to light tactile impressions from the third to the sixth rib inclusive.
Beyond childish mental enfeeblement there was nothing in her mental
condition. There were no delusions, illusions, or hallucinations. Later
she suffered with a sudden painless swelling of one knee, and a dorsal
dislocation of the head of the right femur. There were no teeth in the
lower jaw, and the alveolus was so much absorbed as to resemble the jaw
of an old woman. Then she began to have fits and lapses of uncon¬
sciousness, sometimes biting her tongue and passing her urine and fie cos
under her. She died after some years’ residence in the asylum of tabo-
paralysis, the brain and spinal cord presenting the usual appearances met
with in that condition.

F. W. Mott.

45

According to my experience o])tic atrophy in juvenile general paralysis
is commoner than in the adult form. A certain proportion of these cases
are probably not true optic atrophy, but are the result of syphilitic brain
disease.

Congenital syphilis and amentia terminating later in paralytic
dementia. —As already remarked, in a large proportion (quite 50 per
cent.) the syphilitic virus has led to a congenital amentia or feeble¬
mindedness from birth ; this is shown by an absence of a large number of
cells in the cerebral cortex as compared with the normal; by an imperfect
development of the convolutions of the hemispheres, microgyria, and a
comparative deficiency of weight of the cerebrum as compared with the
weight of the cerebellum, pons and medulla, a deficiency which cannot be
accounted for by the loss of substance due to the more acute degenerative
process which has led to the superadded paresis and dementia. The
mental symptoms in such cases are two-fold * those due to the arrest of
development, viz. (1) imbecility or feeble-mindedness of varying grades,
and (2) decay due to the primary decay and death of the neurones
associated with acute destructive changes the result of congestive stasis
and auto-intoxications.

Symptomatology of juvenile general paralysis. —I have shown that there
is hardly any age at which para-syphilitic affections may not come on as a
result of congenital syphilis, but the majority of cases show symptoms just
about puberty; a fit occurs as the first warning, and the child is thought to
be an epileptic. The child’s character changes: if it is already feeble¬
minded it becomes more mentally deficient, that is to* say, it begins to lose
the little mind it possessed in its totality; if the child has shown itself
possessed of a fair intelligence, the first signs of the disease may be a
strange and unusual behaviour followed by a progressive loss of mind in
its affective, cognitive, and conative aspects. The mother will tell you that
her child, for no reason she knows of, is becoming childish and silly,
sometimes bad-tempered and morose, whereas previously it was good-
tempered, happv, and cheerful; while formerly careful and tidy in habit,
it had become forgetful, careless, and untidy, given to doing strange
things, showing less affection for the parents, giving up occupation for no
apparent reason, and sometimes wandering from home. This pre-paralytic
stage is often overlooked, but as the change of character and the dementia
become more pronounced the facial expression alters either to one of
depressive apathy or to one of foolish contentment, so that there is no art
to find the mind’s complexion in the face. Tremors of the face and tongue

46

Congenital Syphilis and Feeble-minded ness

with characteristic affections of the speech and hand-writing, as a rule,
now become manifest, differing in no way from that of the adult form, the
result of acquired syphilis. Since the more youthful patients are, as a
rule, not anti-social, for they seldom have grandiose delusions or delusions
of persecution, it may not be until they have had many serious convulsive
seizures, become wet and dirty in their habits and obviously demented,
that the parents of the lower classes consult a doctor; then a history
such as I have given is frequently elicited from the parents. The constant
symptoms in juvenile general paralysis are progressive dementia and
paresis; grandiose delusions are rarely met with. When the disease does
not become pronounced until some years after puberty there is often a
history of masturbation, but, although this undoubtedly aggravates the
course of the disease, it has not necessarily a causal relationship, but is
rather an effect of the dementia.

Delusions of a sexual nature and grandiose delusions of wealth,
strength and power coloured by the events of the period may occur just as
in the adult form, but only according to my experience when the disease
commences after puberty, the reason being that ambition for wealth and
power and the sexual passion do not become an habitual incitation to con¬
duct until some time after puberty; consequently, if the mental decay has
set in before that period, these cannot become a revivable content of
consciousness. The following case which; I have recently seen illustrates
this. A young woman, aged 21 years, the subject of well-marked
stigmata of congenital syphilis, who commenced to suffer with fits two years
previously, was admitted to Long Grove Asylum. The notes on her
mental condition are as follows: She is restless, very talkative and
expansive; she is going to give me medals, a carriage and four horses;
everything in connection with her is fine and beautiful; the feeling of bivn
itre is marked with an irresponsible sense of altruism. She is fairly
orientated in time and place, though not knowing where she now is;
amnesia is not noticeable.

After puberty consciously and subconsciously these desires are in one
form or another always forming a part of the content of consciousness;
there maybe no outward manifestation thereof, for social amenities compel
the normal individual to control, repress, and silence the inmost thoughts
which nevertheless in their nakedness and crudity form the chief content
of consciousness, or are ever on its threshold. But the neural structures,
which are the last to be developed, are the first to go (Hughlings Jackson),
and as the higher controlling centres decay and the auto-critical sense is

F. W. Mott.

47

lost, then by the slightest suggestion, or even apparently without it, what is
left of the psychic content bubbles forth, and what is left will be that which
has by constant repetition become most fixed; now grossly exaggerated
and coloured by associations, they come to resemble the fantastic tabula¬
tions which characterise many dreams.

Diagnosis .—There may be some difficulty in differentiating a case of
juvenile general paralysis from dementia praecox, especially if there are no
stigmata of congenital syphilis to warn one of the possibility of this rare
disease. The characteristic signs and symptoms of paralytic dementia may
be absent in the early stages, and in the absence of signs of congenital
syphilis the case may be thought to be one of hysteria, epilepsy with
imbecility, dementia praecox, or disseminated sclerosis. The hebephrenic
or maniacal form of dementia praecox owing to the fact that it occurs in
adolescence may be confounded with juvenile general paralysis. Of course
it is possible for dementia praecox to occur in a congenital syphilitic, but
if there are obvious stigmata one’s suspicions would naturally be aroused
that the case might eventually turn out to be paralytic dementia. The
mental state of dementia praecox is, however, different to that of general
paralysis; in the former it is the affective side of the mind which especially
suffers and leads to strange conduct; the cognitive side of the mind, as
shown by the patient’s memory and intelligence, is relatively much less
affected. In general paralysis, on the contrary, it is the cognitive side of
the mind that is especially damaged, while the affective side, as shown by
the emotional reactions of the physiognomy, is less affected. Whereas in
general paralysis, on the one hand, the countenance often changes from
one of depression to one of radial joy and exaltation; in dementia praecox,
on the other hand, there may be no emotional reaction and the countenance
retains a continuous stolid indifference. As a rule in dementia praecox there
are auditory hallucinations, which are not usually present in paralytic
dementia. Certain cases of general paralysis may have a mask-like
expression of emotional indifference indicating that the affective side of the
mind is profoundly affected, and therefore it is necessary for a correct
diagnosis to look for the characteristic physical signs of general paralysis,
which are seldom if ever wanting, and if there is still any doubt, lumbar
puncture and examination of the cerebro-spinal fluid can be made.

Hysteria , hystero-epilepsy , and epilepsy. —Again, not a few cases in
females may be regarded as hysterical in the pre-paralytic stage, or if
there be fits, as epilepsy or hystero-epilepsy. The existence of dementia
accompanied by pupil phenomena will lead to suspicions which can in most

48

Congenital Syphilis and Ftadda-minded ness.

oases be verified or negatived by lumbar puncture and examination of the
cerebro-spinal fluid.

Disseminated sclerosis. —Some cases of juvenile paralysis have been
diagnosed as disseminated sclerosis, but the intentional tremor of dis¬
seminated sclerosis is coarser and affects the large muscles of the limbs;
the speech is affected, but it is scanning rather than hesitant, syllabic, and
tremulous. There is frequently Babinski sign, which is very rare in para¬
lytic dementia, likewise aukle clonus. The bien etre expression, or air de
beatitude of Charcot, gives a superficial facial resemblance to the expression
of foolish contentment of paralytic dementia, especially when, as often
happens, there is a mental enfeeblement. But the dementia is never so
marked nor is it so steadily progressive in disseminated sclerosis; there is
not a progressive paresis, but the remissions and attacks point to coarse
foci of disease.

Neurasthenia cerebri. —Characterised by headache, loss of memory,
weariness on mental or bodily exertion, loss of will-power, indecision of
character in a young person the subject of congenital syphilis, may well
make one think of the neurasthenic pre-paralytic stage of general paralysis.
When there is a doubt about the diagnosis, examination of the blood and
cerebro-spinal fluid by the Wassermann reaction and the latter for lympho¬
cytes will help to clear up the diagnosis.

Duration and course. —I have seen cases which, like the adult form,
may be galloping in their course—one terminated in four months from the
onset ( ride p. 37); as a rule, however, the disease runs a longer and
slower course than in the adult; thus it proceeds to a more complete
dementia and paralysis. The patient in the terminal stage is absolutely
indifferent to his surroundings, speechless, and even swallowing with
difficulty the minced food with which he has to be fed; there is marked
wasting and contracture of the limbs, he passes his urine and faces under
him, and dies eventually either from broncho-pneumonia, tuberculosis, septi¬
caemia, which may result from bed-sores, or suppurative nephritis, secondary
to cystitis, and if not dying from one of these secondary or terminal
microbial infections, he eventually and gradually succumbs to marasmus
and asthenia.

Prognosis in disease of the nervous system due to congenital syphilis .—
As in adult diseases of the nervous system due to acquired syphilis, so
in the congenital form prompt, active anti-syphilitic treatment may be
attended with remarkably favourable results. The first point, how¬
ever, to attend to before giving a prognosis in nervous disease arising in

F. W. Mott.

49

later childhood or early adolescence in a subject of congenital syphilis, is to
determine whether the symptoms indicate syphilis or para-syphilis of the
nervous system or are merely coincident; this can be done by attention to
the symptoms, their inode of onset and progress, and their response to anti¬
syphilitic treatment. Moreover, the greatest help can be obtained by the
examination of the blood and cerebro-spinal fluid by microscopic and bio¬
chemical methods. A cerebro-spinal fluid that gives a Wassermann reaction
points generally, though not necessarily, to parasyphilis. Parasyphilitic
affections are invariably progressive; when the brain is affected they are
usually fatal within four or five years of the onset of definite symptoms of
dementia and paresis, and they are uninfluenced by treatment. In other
parasyphilitic affections, for example, optic atrophy and tabes, the pro¬
gnosis, although not so bad as regards duration of life, yet offer an outlook
most unfavourable, for many of the cases end in dementia paralytica
and others terminate eventually in complete helplessness from blindness,
imbecility, or other causes. In cases of epilepsy and feeble-mindedness
the result of congenital syphilis, the prognosis is always bad, for the
possibility of improvement of the mind or arrest of the fits is remote ; more¬
over, there is the probability that the case may terminate at puberty or
adolescence in dementia paralytica.

In the case of nerve-deafness it is seldom that treatment does any good
and the patient will become stone deaf. If, however, the child has learnt to
speak and read for some years, as is usually the case, then, in spite of the
deafness, it retains its speech faculties.

In cases of vascular and meningeal syphilitic inflammatory conditions
the prognosis is more hopeful than in parasyphilitic affections, for they
improve remarkably under treatment, but post-mortem investigation shows
again and again the existence of widespread morbid processes which have
left their scars if they are not even still active or capable of reactivation.
If the disease can be treated in the early irritative stage, when convulsions
occur and paralyses have not yet taken place, the prognosis is much more
hopeful, for there can be no question that mercury and iodide, energeti¬
cally but judiciously administered, will stay further progress and lead to a
disappearance of symptoms. When, however, there is hemiplegia, it means
destruction by softening occasioned by thrombotic sclerosis of vessels, and
not only is the chance of relief by treatment less, but the probability of
other vessels being similarly affected much greater.

Psychical symptoms, whether mania and motor restlessness or somno¬
lence and drowsy stupor, are of grave omen, for the tendency is to dementia

4

50

Congenital Syphilis and Feeble-mindedness.

Many cases of affection of the nervous system arising later in life
might never have occurred if the congenitally syphilitic infants had been
treated judiciously with mercury for a year or two instead of a month or
two. Again, I have found in my experience how many cases of congenital
syphilis which have developed such symptoms as keratitis, and nerve-deaf¬
ness in later life have not been adequately treated. Mercury should be
given in all cases of syphilis hereditaria tarda, and continued with periodic
remissions for several years. An examination of the blood by the Wasser-
mann method and if necessary an examination of the cerebro-spinal fluid
should be made periodically. A negative reaction of the serum may lead
one to remit the treatment, and according to my experience, if the blood-
serum gives a negative result the cerebro-spinal fluid will also be negative
and therefore lumbar puncture is not necessary. Should, however, the
blood-serum give a positive reaction, examination of the cerebro-spinal
fluid will afford very valuable information; a positive reaction points to a
parasyphilitic affection, especially general paralysis. In juvenile para-
syphilitic affections I have seldom seen any benefit derived from anti¬
syphilitic treatment; it may be given a trial in some selected cases, but
disappointment at the result must not be felt if it is without benefit.
There is little more to be done for parasyphilitic affections due to con¬
genital syphilis than for the similar affections in adults.

Bibliography.

A full bibliography of the earlier writers mentioned is given by Mendel, “ Ueber
hereditare Syphilis in ihrer Einwirkung auf Entwickelung von Geisteskrankheiten,” ‘ Archiv
f. Psychiatric/ i, 1868.

Alzheimer.— “ Die Paralyse progressive der Entwickelungsjahre/’ ‘Neurol. Centralbl./
October 15th, 1894: “ Die Fruhform der progressive Paralyse/* ‘ Allgem. Zeitsehr. f. Psych./
lii, f. 3, 1895.

Ashby.— ‘ Brit. Med. Journ./ October 15th, 1898.

Astruc.—‘ De morbis venereis libri no vein.’ English translation, 1756.

Bab. — “ Beitrag zur Bakteriologie der Congenitalen Syphilis,” ‘ Munch, med.
Woehensehr./ No. 46, November 12th, 1907.

Barlow. —‘ Path. Soc. Trans./ vol. xxviii.

Barlow and Bury. —“Syphilitic (Hereditary) Disease of the Nervous System,”
‘ Dictionary of Psychological Medicine/ Hack Tuke.

Ibid. — Loc. cit.

Beach and Shuttle worth.- —Article, “ Idiocy and Imbecility,” ‘ Dictionary of Psycho¬
logical Medicine/ Hack Tuke.

Binswanger. —“ Die Epilepsie,” * Nothnagel’s System/

Binswanger, Wildermuth, Ziehen, Bouuneville. —Quoted from Kanke, loc. cit.

Chislett. —Meeting of the Medico-Psychological Association, Edinburgh, 1910.

F. W. Mott.

51

Clouston. —" A Case of General Paralysis at the age of sixteen,” ‘ Journ. Ment. Sci /
October, 1877, p. 419; 'The Neuroses of Development/ 1891.

Dean. - " An Examination of the Blood-serum of Idiots by the Wassermann Reaction,”
* Proc. Roy. Soc. Med./ July, 1910.

Finger and Neisber.— Quoted from Max Nonne.

Fournier. —‘ Les affections parasyphilitiques.*

Ibid. —‘ La syphilis hereditaire tardive*, 1886.

Ibid. —' Les families heredo-syphilitiques.*

Ibid. —‘ Les affections parasyphilitiques.*

Gasne. —“ Localization de la Syphilis hereditaire/* ‘ Nouv. Iconographie de la Sal-
petriere/ No. 5, 1896.

Hochsinger.— ' Studien iiber heriditare Syphilis/ 1898.

Hunter. —'Treatise on Venereal Disease.* Edited by Adams, 1810.

Hutchinson.— "Hereditary Syphilis/* ; Twentieth Century Practice of Medicine.’

Ibid. —■“ Syphilitic Disease of Occipital Lobe with Perforation of Cranium/* ' Brit.
Med. Journ./ vol. i.

Ibid .—' Diseases of the Eye and Ear in connection with Inherited Taint/ 18(54?.

Ilberg.— " Beschreibung des Zentralnervensysteins eines 6 tiigigen syphilit. Kindes,”
' Westphal’s Archiv./ Bd. xxxiv. Heft 1.

Jullien. —" Heredo-Syphilis/* 'Arch. gen. de med./ tome v, 1901.

Karvonen.— ' Die Nierensyphilis/ Berlin, 1901.

Koenig. —" The Problem of Heredity from the Psychiatrical Aspect/*' Brit. Med. Journ.,
1904, vol. ii, p. 966.

Kretschner. —"Lymphocytose, etc./* ‘ Deutsch. med. Wochenschr./ November 14tli,
1907, p. 1901.

Max Nonne. — ' Syphilis und Nervensystem.*

Mendel. —“ Ueber hereditare Syphilis,” * Westphal’s Archiv/ Bd. i, 186.3 ; * Neurologi-
sches Centralblatt/ 1888.

Nkisser.—' Beitrage zur Pathologie und Therapie der Syphilis/ 1911.

Ogilvie, G.— 4 Brit. Journ. of Derm./ 1897.

Ranke. —" Ueber Geliirnveriinderungen bei der angeborenen Syphilis/* 'Zcitschr. fur die
Erforschung und Behandlung des jugendlichen Schwachsinns/ herausgegeben von Dr. H.
Vogt und Dr. W. Weygandt, Zweiter Band, Zweiter Heft

Ravaut. —*'Le liquide cephalo-rachidien des lieredo-syphilitiques,” ‘ Ann. de Derm, et
de Syph./ 1907.

Ravaut et Ponselle. —"Contribution k l’etude clinique et bacteriologique des lesions
encephalo-meninges chez les nouveau-nes syphilitiques/* ‘Bull, de la Soc. med. des Hopit.
de Paris/ January 12th, 1906.

Regis. —"Note sur la paralysie generate premature,” 'l’Encephale/ 1883; " Un cas de
paralysie generate k Page de 17 ans,” ' l’Encephale/ 1885.

Rondoni. —"On Some Hereditary Syphilitic Affections of the Nervous System,” ‘Proc.
Roy. Soc. Med./ February, 1909.

Shuttleworth. —“ Idiocy and Imbecility due to Inherited Syphilis/* ' Amer. Journ. of
Insanity/ 1888.

Sibelius.— " Zur Kenntniss der Entwicklungslosungen der Spinalganglienzellen bei
hereditar-lusteschen, etc.,” 'Deutsche Zeitschr. f. Nervenheilk./ xx.

Still. —' System of Syphilis/ Power and Murphy, vol. ii, ‘‘Congenital Syphilis.”

Strobe. —“ Zur Histologie der kongenitalen Nieren- und Lungensyphilis,” ‘ Zentralblatt
f. allg. Path./ ii, 1891.

Telford Smith. —'Brit. Med. Journ./ October 15th, 1898.

Microscopic Investigation of a Case of Tabo-Paralysis with
Ophthalmoplegia Bilateralis.

By Pietko Rondoni, M.D. Florence.

(From the Pathological Laboratoi'y of the London County Asylums , Claybury.)

Through the kindness of Dr. Mott I have had tlie opportunity of
undertaking the histological examination of the following case of tabo-
paralysis, which presents some interesting features, especially as regards
the correlation of the anatomical changes with the clinical symptoms, the
details of which were obtained from the London County Asylum at Long
Grove, where the patient was an inmate. The following are the most
important points regarding the clinical history of the patient kindly
furnished by Dr. Bond : .

J. R—, admitted May 22nd, 1908, aged 37 years, married. Occupa¬
tion, cricket-ball maker.

Condition on admission .—The patient is described as a man of poor
general bodily condition. Temperature, 97*4° F. Old scars on shin and
abdomen ; small scar on wrist. Skin sallow, slight icteric tinge. Expres¬
sion of face dull and confused; marked transverse furrows on forehead ;
eyebrows raised; lack of tonicity of the other facial muscles, but no
paresis.

Marked external strabismus, neither eye can be moved towards the
middle line, and only slightly upward.

Marked ptosis, more on left side than on right. There is, therefore,
paralysis or paresis of both internal and superior recti, inferior obliques
and levatorcs palpebrarum. In respect to the last-named muscles, the one
on the left side is more affected than that on the right.

There is complete paralysis of the sphincter of the pupils, which react
neither to light nor to accommodation.

The pupils, though not reacting, are regular and equal; size, 45 mm.
'.^te st^Llit'crf Ihtr right eye is moderately good, but the left is very defec¬
tive. The heafing'V not impaired, and his articulation of words is normal.

Pietro Rondoni.

53

There is no obvious inco-ordination of the limbs and the gait is normal;
Romberg’s sign is not present. There is no tremor; the knee-jerks are
sometimes not obtainable; sometimes they are present, but are obtained
with difficulty; there is no ankle clonus. The superficial reflexes are
normal. There is a zone of light tactile anaesthesia involving the lower part
of the chest and extending completely round the body; also a true girdle-
anaesthesia. There seems also to be some general analgesia.

The patient cannot distinguish between the point and the head of a
pin, denying that either gives him any pain. There is a moderate degree
of anaemia, and there is some thickening of the radial artery. The heart
is apparently normal, as are also the digestive and respiratory systems.
There is a small scar on the inner surface of the prepuce ; there is no
enlargement of the inguinal or other lymphatic glands.

Mental state .—The patient generally lies quietly in bed, but unless
watched he will occasionally get out and wander aimlessly about. On the
day following admission, while lying iu bed on the veranda, he suddenly
attempted to escape in his night-shirt. He willingly enters into conversa¬
tion ; there is no defect of immediate comprehension, and his answers to
questions are prompt and relevant. He is able to read and write, and
performs mental arithmetic with average rapidity and accuracy. He is able
to carry on an intelligent and coherent conversation, fully describing his
work as a cricket-ball maker. Orientation in time and space are defective;
he names the month and the year correctly, but says he has been here four
months, and that it is Lambeth Workhouse. His statements vary from
time to time, and he has no accurate memory of recent events. The gaps
are filled with confabulations which are extremely susceptible to sugges¬
tion. By suggesting a few points to him, it is possible to induce him to
relate a fabulous pseudo-history of yesterday's doing of any kind desired.
The ideas mentioned in the certificate concerning the brother's imaginary
defalcations are probably of this nature. It is significant that he now adds
that he was successful in his summons at the courts for the return of his
money, all of which is imaginary. Otherwise there are no delusions or
hallucinations. The affective state seems to be one of placidity, and he
professes to be perfectly contented. Apart from the restless wandering
mentioned above he gives no trouble. He is clean in his habits, but does
not attempt to occupy himself in any way.

Previous history (chiefly from wife).—Nothing unusual in childhood;
suffered with chorea in boyhood. He is a steady and temperate man. He
was infected with syphilis ten years previously. He was married in 1901,

54 Microscopic Investigation of a Case of Tabo-Parah/sis.

and has one healthy child. In 1894 he was in St. Thomas's Hospital for
an operation on the nose (previous to the syphilitic infection). In 1905 he
was in some hospital because “ his sight became queer/' and he remained
an out-patient till July, 1907. He suffered also for some time from
diarrhoea and tenesmus. From 1907 “ his eyes seem to turn" : he accused
his brother of stealing things from him which he never possessed. He
would “ go off in a swoon" lasting half-an-hour, and said his inside felt
“ as if on fire." The doctor said he was suffering from vertigo and
diplopia. He became rather better after three months but was bad again
at Christmas. His family history is not kuown to his wife.

Progress of case .—The patient became more dull and confused. The
knee-jerks disappeared completely. Sometimes he showed a liability to
impulsive and foolish actions: he was very restless and often fell and
bruised himself. In October a slight thickening of articulation was noticed.
On October 28th a partial dislocation of the knee-joint occurred; and on
November 9th a fracture of the femur, about six inches above the knee-
joint, was recognised ; but it was not possible to ascertain how this injury
was produced, and whether a fall had occurred.

The patient became weaker daily, and bed-sores developed over the
sacrum; finally he became comatose and died on November 15th.

Summary of autopsy .—There is commencing gangrene of the skin of
the sacral region. Fracture of the lower portion of the left femur; the two
fragments of the femur are atrophied and rarefied. The knee-joint is full 5
of a blood-stained fluid, with a quantity of fibrinous material. The lungs
and the bronchi contain a considerable quantity of nqjco-purulent fluid, and
there is generalised broncho-pneumonia. The brain is very congested ;
the weight is 1420 grm. There is some slight decortication on stripping
the pia, which is a little thickened in the fronto-parietal region.
Cortex rather atrophic in the frontal region. Fourth ventricle is
granular.

Histological i\ruminatio)i and discussion of the case .—I shall relate
only the most important points and the peculiar features of the case. In
the cortex of the brain I have found all the characteristic changes of
general paralysis of the insane.

There was a marked lymphocyte and plasma-cell infiltration of the
perivascular pial and adventitial sheaths of the vessels which exhibited
proliferation and sprouting of capillaries. This was generalised in the
tissue of the cortex, and there was no evidence of a gummatous wedge-
shaped formation, extending from the pia-arachnoid inwards, as occurs in

Pietro Random.

55

meningoencephalitis syphilitica; moreover, there was a predominance of
plasma-cells over lymphocytes in the perivascular infiltration, which is
more significant of general paralysis than syphilitic meningo-encephalitis
in which the lymphocytes usually predominate. Some granular cells were
present; in the pia there was proliferation of the fixed cell elements, with
formation of large protoplasmic fibroblasts. Rod-cells (Stabchenzellen,
Alzheimer) were also present in the nervous tissue of the cortex. All the
well-known changes in the neurons indicative of extensive decay of the
nerve-cells and fibres were present, as well as typical changes in the glia
tissue. To demonstrate the neuroglia proliferation and hyperplasia
sections were stained by Heidenhain iron-haematoxylin and Ranked
method. The morbid histological changes were observed most markedly
in the frontal lobes ; the parietal lobes were affected, but to a less degree,
although distinct morbid changes were observable. The left hemisphere
appeared to be more affected than the right; the occipital lobes showed
no distinct histological change; I found, however, very marked changes
in the hippocampal region both in the grey and in the white matter. The
most noticeable feature was an abundant infiltration around the vessels of
almost similar intensity as was found in the frontal lobes; the right cornu
ammonis seemed to be preferred, especially in the anterior part (uncus).
The basal ganglia were scarcely affected; in the thalamus, however, there
was some slight infiltration, chiefly in the central part. The cerebellum
exhibited fairly well-marked typical changes, which I do not propose to
describe here. I shall later describe the changes found in the mesen¬
cephalon and rhombencephalon ; but I may now remark that in the spinal
cord a typical tabetic degeneration of the posterior columns was found
with exclusive involvement of the exogenous system of fibres and integrity
of the endogenous systems. As the spinal cord was not so well preserved
as the brain I was not able to follow the differences in degree and distribu¬
tion of the degeneration in the whole length of the cord, but this principal
and important feature was quite evident in preparations stained by the
Weigert and Weigert-Pal methods. The Nissl method revealed a fairly
diffuse chromatolysis and pigmentary degeneration of the majority of the
large cells of the anterior horns, without great variations in degree in the
different regions of the cord, but no vascular changes or infiltrations
were noticed. Some proliferation of the ependymal cells was observed.
All these changes have been described fully in previous volumes of the
* Archives of Neurology/ Moreover, both Mott and Watson have called
attention to the proliferation of the ependymal cells, which change, how-

56 Microscopic Investigation of a Case of Tabo-Paralysis.

ever, Mott has found in old non-tabetic people and in other spinal affec¬
tions. Many authors have dealt with the changes in the cells of the
anterior horns in general paralysis and tabes. Berger showed degenera¬
tive changes in the cells in 83 per cent, of his paralytics. The atrophy of
the muscles often found in these patients and believed to be due only to
inactivity or cachexia might be correlated with these changes, which do
not indicate necessarily a degenerative electric reaction. Wyrnbow,
Schaffer, Alzheimer, and Mott likewise mention them. Mott describes
completely all the features of this lesion, and concludes that there are two
possible explanations for them: either there is a superadded primary
degeneration of the anterior horn-cells, or an extreme atrophy of the
sensory neurons and abolition of the incidental stimuli necessary for the
vital activity of those cells leads in process of time to a secondary neuronic
atrophy. He considers that the second opinion is more likely to be true,
because the changes in the radicular cells appear after the endogenous
system of the posterior columns has been destroyed—that is, after abolition
of every possible means of stimuli being carried to the cells. In the case
1 am describing the endogenous systems were not degenerated, yet there
were degenerative changes in the cells of the anterior horns. In several
cases of juvenile general paralysis which I have studied in this laboratory
(an account of which was published in the ‘ Proceedings of the Royal
Society of Medicine '), I described in one case a diffuse proliferation of
glia in the anterior horns of the spinal cord in sections stained by Ranke's
method. I have observed a similar proliferation in the anterior horns in
this case of fabo-paralysis. It is probable that there is, then, a primary
degenerative atrophy of the neurons of the anterior horns with secondary
neuroglia growth similar to the primary degeneration of the cortical
neurons (Schmaus and Sacki, Watson). This primary atrophy may be
the result of the general toxic action of the syphilitic virus and occurs
without inflammatory change.

The diagnosis of tabo-paralysis when the patient was admitted to the
asylum was by no means certain. The fact that ten years had elapsed
since infection supported this diagnosis, but the symptoms presented by
the patient were not typical. The pupil phenomena and the ophthalmo¬
plegia interna and externa were unlike the ordinary symptoms met with
in tabo-paralysis; in fact Dr. Mott advised mercurial treatment in the
belief that it was most probably a basic syphilitic gummatous process that
was causing the ophthalmoplegia associated with alcoholism and a general
endarteritis syphilitica to account for the mental symptoms, which in many

Pietro Rondoni.

57

respects resembled Korsakow’s psychosis rather than general paralysis. It
might well have happened that tabes was combined with Korsakow's
psychosis.

Histological changes in the fibres of the cortex .—The brains of many
tabetic patients may show some atrophy of the tangential systems of
fibres without any other change, and the question might be asked, Are
these cases mild forms of tabo-paralysis ? But an atrophy of the tangential
fibres and other systems of fibres of the cortex does not necessarily denote
the existence of general paralysis, for it may occur in other forms of
dementia. I may add that Kaes has found a normal diminution of
myelinated fibres in the cortex from forty to forty-five years of age, and
that arterio-sclerosis, beginning early in syphilitics, may quicken this
involution. There remain the cases of tabes with true paralysis or tabo-
paralysis, concerning the onset of which I think it is unnecessary for me
to speak, as it has already been treated in a masterly manner by Mott in
the ‘ Archives of Neurology/ vol. ii. Regarding his first class of tabetic
cases, with anatomically normal brains, not affected with general paralysis,
but which manifested during life psychic disturbances, they correspond
with Dieulafoy’s “ psychose tabetique.” Again, Marie mentions moral and
intellectual disturbances in tabetics.

Mott mentions different forms of mania and dementia in tabetics
differing in the clinical characters from those of general paralysis.
Alzheimer, too, points out that not every case of tabes with dementia is a
general paralytic, and it is interesting to remember that in one case of his
(case 21), in an old tabetic, there was a form of insanity very much like
Korsakow's psychosis, but differing from my case in that no paralytic
change was found in the cortex. Moreover, it is not of rare occurrence
to meet with severe forms of neurasthenia in tabetics due to the effect of
the combination of worry, pain, and syphilis. A consideration of these
facts throws a light on the difficulty experienced in the correct diagnosis
of such a case.

The pathology of tabes'and general paralysis shows the unity of both
diseases, there being a single morbid process with different localisations
and features; thus there may occur simple tabes, i.e. tabes without
paralytic dementia or other psychic disturbances, tabes with true paralytic
symptoms and dementia in all gradations and in different combinations.

The lack of ataxia in this case is a feature which is often found in
tabes when complicated by paralysis (Mott) ; if the ataxia exists already
in such cases, the development of the cerebral affection seems to attenuate

58 Microscopic Investigation of a Case of Tabo-Paralysis.

it, by excluding “ overaction ” (Mott) of physiological compensations
which plays a large part in the origin of ataxia. Vertigo is mentioned as
a symptom in this case and is possibly due to the diplopia.

Having come to the conclusion that this is clinically and histologically
a case of tabo-paralysis, we may now pass to the study of the ophthalmo¬
plegia and of the changes in the brain which may be associated with it.

Method of investigation .—The pons and all the mesencephalon were
fixed in formol, then treated for a long time with Muller’s fluid, embedded
in celloidin, and cut in series. On account of the friability of the material
I was not able to get a complete series without gaps, but the sections
permit of the study of the lesions at different levels. The sections were
stained by Weigert-Pal aud carmine, thionin, and Van Gieson stains.
Some sections were also made from the medulla oblongata. In the latter
I found the descending root of the fifth nerve and the nuclei of Goll and
Burdach to be quite normal. The constant integrity of the second sensory
neurons in tabes and tabo-paralysis is a point to which Mott has already
called attention. The structures in the pons seemed to be normal, except in
the upper portion, where I found some small haemorrhages in the grey
matter of the floor of the fourth ventricle, and some dilatation of the
vessels and a slight haemorrhagic infiltration around some of them in the
nucleus of the left fourth nerve.

Histological Changes in the Mesencephalon.

I will now pass to a consideration of the condition of the nervous
structures in the mesencephalon. The medial and lateral lemniscus,
as well as the pyramidal tracts, were quite normal. Between the
commencing decussation of the anterior cerebellar peduncles and the
here rather thin fasciculus longitudinalis posterior were scattered some
cells, rather large and well preserved. I believe them to belong to
the nucleus centralis superior mentioned by Obersteiner. At this level,
that is, before the appearance of the nucleus of the fourth, my attention
was directed to the appearance of the cells in the grey matter between the
aqueduct and the fasciculus longitudinalis. There were some large
cells which formed a central group in the middle and two other
groups laterally : these last two soon disappeared, but the central group
became more and more scattered and indistinct and became at last
fused in the general appearance of the periventricular grey matter or
“ centrales Grau.” Following the series upwards the nucleus of the

Pirtro Romloni.

59

fourth appears enclosed in a dorsal furrow of the fasciculus longitudinalis
posterior, and its features were so characteristic that it was not possible
to confound it with other structures. The characters given by Tsuchida
for distinguishing the caudal pole of the third from the fourth are very
definite ; the fourth has a sharper contour and it is limited from the
central grey matter by a thin ridge or border of myelinated fibres;
the fasciculus longitudinalis shows a deep depression for receiving the
nucleus of the fourth,.which is not the case for the third. Moreover, the
two nuclei of the fourth are separated from each other by a greater
distance than the nuclei of the third, which in the caudal pole are nearer to
the middle line. Tsuchida mentions also the caudal decussation of fibres
of the third as not continuing as far as the level of the fourth. All these
observations are confirmed by my specimens; also the “central decussa¬
tion ” (Siemerling) or “medial root ” (Tsuchida) of the fourth, which
Tsuchida seems to consider rather rare, having found it only in a foetus of
six months and in a child of three weeks. I could make out this root
very well in preparations of normal and pathological brains which I have
studied. This root is formed by the fibres of the fourth, which, instead of
going laterally, as happens in the majority of cases, proceeds medially
along the back of the fasciculus longitudinalis perpendicularis to the
bundles of the latter; near the middle line in every section can be
observed a few small bundles which represent this “ medial root.” These
fibres form probably a central connection between the nuclei of the two
sides, that is, they should have the same significance as the caudal decussa¬
tion of the third. Siemerling seems to admit even a direct continuation
between the decussation of the third and that of the fourth. It is certain
that the appearances of the medial root of the fourth are very peculiar
and quite different from the decussation at the level of the third; the latter,
according to Tsuchida, is more a “ Durchflechtung ” than a decussation of
thin fibres, which are, therefore, commissural rather than radicular. The
medial root of the fourth is not constant, and according to the same author
does not decussate. In my specimens it shows no decussation, and conse¬
quently I am of the opinion of Tsuchida that it goes to the fasciculus
praedorsalis of the same side ; its further course is not known. Dorsally
from the true nucleus of the fourth, beneath the aqiueductus Sylvii, the
grey matter shows some groups of fairly large cells, chiefly two, one on
each side above and lateral to the “ nucleus trochlearis ”; these cells
I believe to form that group, which Siemerling in his first work believed
to be the nucleus of the fourth, but now he and all the authorities agree

60 Microscopic Investigation of a Case of Tabo-Paralysis.

that the fourth nucleus lies in the previously mentioned furrow of the fasci¬
culus longitudinalis; therefore the significance of these groups is unknown.
Perhaps they are not always present to the same extent owing to indi¬
vidual variations, which according to v. Monakow often occur in all the
nuclei of this region. I should be inclined to consider this particular
supra-trochlear group of cells as association neurons, connecting a part of
the nuclear column of the third with the nucleus of the fourth, perhaps
co-ordinating the action of the rectus inferior (third) with that of the
obliquus superior (fourth).

I will now pass on to a description of the nucleus of the oculo-motor or
third, which shows very severe lesions. All the structures hitherto
examined were normal with the exception of some small haemorrhages in
the nucleus of the sixth, which gave rise to no clinical signs during life,
the recti ex tern i having shown no impairment in their function. Before
reaching the caudal pole of the third, there were one or two sections very
poor in cells; I do not think this is the result of cell atrophy, but rather
the normal interval which seems to exist (Tsucliida) between the caudal
pole of the third and the frontal pole of the fourth. The nucleus of the
third, however, soon appears in an undoubted form in the caudal portion.
The two lateral principal nuclei with their dorsal and ventral groups of cells
and some elements in the middle line, which are perhaps to be referred to the
posterior part of the median nucleus of Perlia, can be recognised; the cells
at this level were pretty well preserved, although some destruction was
evident chiefly in the dorsal group of the left lateral principal nucleus'.
At this level the Pal preparations show well the caudal decussation
already mentioned. The network of myelinated fibres is fairly well pre¬
served in the more ventral part of the nucleus ; also the “ fibrae recta? '*
are seen in the middle; more dorsally the rarefaction of the network was
very marked. The more we proceed in the frontal direction the more the
degenerative changes were marked, the middle and the anterior part of
the nuclear columns were almost destroyed, only in the ventral group some
small degenei’ated cells were still to be seen. The nuclei of Westphall-
Edinger were not seen at all; the bundles of fibres which should cross
the fasciculus longitudinalis to form the roots of the oculo-motor were
either attenuated or quite absent; also at the base medially from the pes
pedunculi, only a very few small atrophied bundles of degenerated fibres
representing the roots of the third were present. Another feature is of
interest ; the vessels in this region were sometimes thickened, although
no profound changes were seen, not even infiltrations. They are full of

Pietro Rontloni.

61

blood, and very often small haemorrhages have taken place. It is chiefly
in the middle segment of the nuclear column that this haemorrhagic
tendency was marked, and here consists not only of capillary haemorrhages
but also of larger ones. There is, therefore, in this case a degeneration of
the middle and anterior part of the nuclear column of the oculo-motor, in
the middle part haemorrhagic changes predominating over simple atrophy.
In the posterior or caudal part there were some changes observed but less
severe in degree. The dorsal groups were more affected and the ventral
better preserved. In the frontal sections I have not been able to find any
trace of the nucleus of Darkschewitsch, which I suppose must be atrophied
completely. It is nowadays considered as independent from the nucleus
of the third ; perhaps it gives origin to some part of the fasciculus
longitudinalis (Edinger).

The bundles of fibres in connection with the corpora mammillaria were
normal, and the fasciculus retroflexus of Meynert was well developed. In
spite of the atrophy of the nuclear column of the third cells lying in the
so-called grey wedge of the fasciculus longitudinalis (grauer Keil des
hinteren Strangsbundels v. Monakow) were well preserved, as well as those
scattered between the bundles of the fasciculus longitudinalis (Buchtzellen
of v. Monakow). These two groups of cells have a different function and
significance from the cells of the nuclear column. The opinions of many
authors on ophthalmoplegia in tabes and general paralysis do not agree on
every point. Siemerling considers the changes in the nuclei of the nerves
concerned as a primary degenerative process, whilst Buzzard lays more
stress on inflammatory changes. Alzheimer says that the appearances
found histologically must depend upon the stage of the process; in one
case he has found the same characters as in the wasted parts of the cortex,
which means an actual atrophy subsequent to active inflammatory and
degenerative changes. It is not even certain whether the lesion attacks
the root first or the nuclei, whether the palsy is in the earlier stage
fascicular and the nuclei are secondarily affected or vice cerxa . Strumpell
accounts for the transitory palsies by a radicular neuritis and a nuclear
atrophy for the permanent forms. Dieulafoy, Kahler, and Dejerine are uf
the same opinion. Mingazzini concludes that the morbid process attacks
the whole neuron, and that here, as in many other cases, the conception
of the “ neurone unit ” is of incontestable usefulness for neuro-pathology.
The nature of the changes, which are certainly nuclear in the case I am
describing, is that of a chronic atrophy, probably primarily degenerative.
As in Siemerling’s cases, the haemorrhages may be due to changes in the

62 Microscopic Investigation of a Case of Tabo-Paralysis.

vessel walls of the nature of arterio-sclerosis. I do not think that the
changes began as an acute or subacute process comparable to those found
in the cortex. I think the changes in the mesencephalon are more
like those found in the anterior horns of the spinal cord.

Mott’s comparative analysis of a large number of asylum and hospital
cases of tabic ophthalmoplegia showed a greater number of permanent
forms in his hospital cases. This was doubtless due, as he explains, to a
number of cases being sent to him from the adjacent ophthalmic hospital.
Garbini, in the asylum of Rome, under Mingazzini’s direction, investigated
this matter and found that ocular paralyses often precede paralytic dementia.
According to Mott, Mobius, Swanzy, Leyden, aud Goldscheider, the muscle
most frequently attacked is the rectus externus; according to Charcot, and
Dieulafoy, the muscles innervated by the third are generally more affected;
at any rate ptosis seems to be very frequent (Iwal, Dercum). Symmetrical
affection of the two eyes as in this case is comparatively rare; the common
type is an ophthalmoplegia hilateralis partialis insequalis utriusque oculi .
It is rare to find bilateral complete paralysis of the sphincter pupilla?,
which is accounted for in this case by the lesions described, which also
account for the bilateral paralysis of the external muscles supplied by the
motor oculi. The ptosis was more marked on the left side. The lesion
seemed to be a little more marked in the left nucleus, but this is only evi¬
dent in the caudal part of the nucleus, and we know that the centre for
the levator palpebrm seems to be rather anterior (according to Bernheimer,
Maiano, Cassierer, Schiff, Mingazzini, and Dejerine; v. Monakow, Tsuchida
and Panegrossi hold a contrary opinion), and that just in the caudal part
the chief decussation of radicular fibres takes place, so that slight
differences in the lesions *are difficult to correlate with clinical phenomena.
The function of the rectus inferior was in this case the best preserved, and
the part of the nucleus best preserved was caudal, which rather sub¬
stantiates the opinion of Bernheimer, who puts the group of cells for the
rectus inferior in the caudal sections, than that of Bach, Scliwabe,
Panegrossi, Tsuchida, who place this centre in the anterior part. It seems
that the centre of the rectus inferior would be more likely to be as near as
possible to that of the obliquus superior (fourth), that is, in the caudal
pole, as we know that these two muscles generally work together in the
downward movement of the eyeball, and that there are diffusely scattered
cells in the nuclear column of the oculo-motor for co-ordinating movements.
The downward movement of the eyeball is performed by the two mentioned
muscles. It is very probable that the whole representation of this

Pietro Rondoni.

63

movement lies caudal in the nucleus of the fourth and the nearest parts of
the nucleus of the third, and that the groups of cells found in the peri¬
ventricular grey matter above the trochlear nucleus contain the association

Scheme op Pupillary Reflexes (simplified from v. Monakow).

Pupillary sphincter.

✓ Retina.

-Corpus geniculatuin

externum.

Occipital

cortex.

Optic

radiations.

Ciliary

ganglion

-- - -. Anterior quadrigeminal body.

Aqueduct of Sylvius.

Nuclear column of the oculo-motor nerve.

Paths (not well known) con¬
veying the stimuli for the
accommodation from upper
centres (cortex) to the
centres for pupils and for
ciliary muscle in the nuclear
column of the oculo-motor

A lesion in the Ilnd neuron (of the four, 1st, Ilnd, Illrd, and IVth, forming the reflex arc
for light) must prevent reflex to light, whereas the reflex for accommodation and the
accommodation itself remain undamaged. A lesion from the nuclear column downward
(Illrd, IVth) brings suppression of every movement of the pupil. The first gives the
typical Argyll-Robertson pupil; the second realises the condition of our case.

neurons responsible for the synergic action of these muscles. Concerning
the innervation of the internal muscles there is a great deal of discussion
amongst the principal authorities. This case throws no new light upon
the subject. I can only say that the fasciculus pnedorsalis and Meynert’s

64 Microscopic Investigation of a Case of Tabo-Parahjsis.

commissure did not seem to be degenerated, which fact does not support
the ideas of Maiano on the centres and paths of the reflex to light.

The complete palsy of the sphincter pupillae points to a large destruc¬
tion of the nucleus of the oculo-motor; the motor cells for this muscle
(which send their axons to the ciliary ganglion, from which the fibres for
the sphincter arise) are very likely scattered over a relatively large area
along the nuclear column, perhaps more abundant in the anterior part
(v. Monakow). In the usual cases of tabes or paralysis where the oculo¬
motor nucleus is not affected, or only slightly affected, there remain
always cells enough to control the sphincter, which is not paralysed, as the
reaction to accommodation shows; the lack of reaction to light is due to a
lesion of the reflex arc in front of the nuclear neuron, very likely in the
neuron intercalated between the termination of the optic fibres in the
superficial white and grey matter of the anterior quadrigeminal body
of the nuclear neuron itself; this intercalated neuron should be repre¬
sented by elements scattered between the deep layers of the anterior
quadrigeminal body and nuclear column (v. Monakow); and lesions in
this region are fairly frequent in tabes and general paralysis (Cramer
and others), and might account for the typical Argyll-Robertson sign
without real paralysis of the pupil, whereas in my case the diffuse
pupillar centre ought to be destroyed in the nuclear columns, unless lesions
of the nerves and ciliary ganglion were present, which, of course, would
offer another explanation (vide diagram).

The fasciculus longitudinalis was well preserved; it was poorer in
bundles in the region of the nucleus of the third, more developed at
the level of the fourth, but such a condition is quite normal (Tsuchida).
The fibres taking origin from the nucleus of the oculo-motor do not form
the greater part of the fasciculus, and they seem to come, not from the
radicular cells (true motor elements, corresponding to the large cells of
the anterior horns), but from the small association elements (Schnitzellen)
of the nucleus (v. Monakow, Tsuchida), which are perhaps more resistant
and not completely destroyed. Altogether it is not strange that the
fasciculus longitudinalis shows no important changes and looks almost
normal, whilst the nucleus of the third is deeply degenerated.

Conclusions.

We have a case of tabo-paralvsis, the peculiar features of which are :

(a) Clinical .— A symptomatology very much like a Korsakow’s
psychosis, at least in its early stages.

Pirfro Rnmloui .

G5

An ocuhir palsy, nil tin* external muscles moved by the tliird being
affected with the exception of the recti inferiores on both sides (almost
symmetrically) ; complete palsy of the sphincter of the pupils.

(n) Au(i!nmir<il. — Abundant infiltration and other paralytic changes
well marked in the hippocampal region almost as much as in the frontal
cortex.

Degeneration of the cells of the anterior horns of the spinal cord;
the characteristic degeneration of the posterior roots and exogenous
systems of the posterior columns with integrity of the endogenous
systems.

Degeneration of the nuclear columns of the oculo-motor nerve, chiefly
in the middle and anterior part, with some haemorrhages; atrophy of
the roots of this nerve. In the less damaged posterior part of the
nucleus is supposed to lie the centre for the rectus inferior. The de¬
generation of the nucleus of the oculo-motor as well as of the cells of the
anterior horns are supposed to be primary and without true inflammatory
changes.

A well-developed te medial root” of the fourth was found.

Bibliography.

Alzheimer. — ‘ Histologischo Studien zur Differentialdiagnose der Progressive!!
Paralyse,’ 1904.

Aschkrson. —“On Some Aspects of the Mental State in Alcoholism: with Special
Reference to Korsakow’s Disease,” * Arch, of Neurol.,’ vol. iii, 1907.

Berger.— “ Degenerationen del* Vorderhornzellen des RiickenmArks hei Dementia
paralytica,” ‘ Monatschrift f. Psychiatric und Neurol.,’ Bd. iii.

Bernheimer.— “ Zur Kenntniss dor Lokalisation ini Kerngebiefce des Oculoinotorius,”
•Wien. klin. Wochensehr.,’ 1895, No. 5.

Ibid. —“ Innervation dor AugcnmuskMn.,” ‘ Deutsche mxl. Wochenschr.,’ 1897, Vereins-
Inulage, No. 22.

Ibid. —“ Experimentaluntorsuehungen ueber die inneren und a(i9seren Muskeln des
Auges, die vom Oculoinotorius innerwiert werden,” ‘ Neurol. Centralblatt.,* 15, ii, 1899.

Cassierkr und Schiff. —“ Beitriige zur Pathol, der Chronischen Bill bare rkrank ungen,”
Obersteiner’s Arbeiten, H. 4, Leipzig-Wien, 1890.

Dercum. —In the book of Campell, Posey and Spiller: ‘The Eye and the Nervous
System,’ Oh. xii.

Dieulafoy. —* Manuel de Pathologic interne,’ 1901, Paris.

Edinger. —‘ Vorlesungen ueber den Bail der nervosen Centralorgane,* Bd. i, Auflage 7,
1901.

Epstein.— “ Ueber den Fasernschwund in der grossliirnrinde bei Tabes und Paralyse,”
‘ Monatschrift f. Psychiatric und Neurol,’ Bd. iv, 189S.

Kaes. —* Die Grossliirnrinde des Menschen,’ Jena, Fischer, 1907.

Leyden und Goldscheidkr. —‘Die Erkrankunges des Ruckenmarks,* Wien, 1897.

Maiano. —“ Ueber Ursprung und Verlauf des Nervus Oculoinotorius im Mittelhirne,”
‘ Monatschrift f. Psychiatric und Neurol,’ Bd. xiii, 19011.

0

66 Microscopic Investigation of ai Case of Tabo-Paralysis.

Masoin et D’Hollandbr. —“ Psychose tabetique,” ‘ Gand. Vanderblagen,' 1908. Review
in the * Archives des Neurologic/ Janvier, 1909.

Mingazzini. —‘Lezioni di Anatomia Clinica dei centri nervosi/ 1908.

v. Monakow. —* Gehirnpathologie/ Auflage 2, 1905.

Mott.— “ Tabes in Asylum and Hospital Practice,” 1 Arch, of Neurol./ vol. ii, 1905;
“ Syphilis of the Nervous System,” vol. iv, ‘ System of Syphilis,' Oxford Press, 1910.

Oberstbiner.— ‘ Anleitung beim Studium des Baues der nervosen Centralorgane,' 1890.

Panegrossi. —“ Contrib. alio Studio anat-fisiol. dei centri dei nervi oculomotor! doll'
uomo/' f Laboratorio anat-patol. del Manicomio di Roma/ 1898.

Ibid. — f Monatschrift f. Psych, und Neurol./ Bd. xvi, 1904.

Schaffer. —“ Das Verhalten der Spinalganglienzellen bei Tabes auf Grund Nissl's
Kiirbung/' "Nourolog. Centralblatt,' 1898, No. 1.

Schmaus und Sacki.— In the * Ergebnisse der allgemeinen Pathologie,' 1898.

S6glas. —‘ Lemons cliniques sur le maladies mentales,' Paris, 1895.

Siemerling und Boedeker. Chronische fortschreitende Augenmuskelliihmungen
und Progressive Paralyse/' * Archiv fiir Psychiatric,' Bd. xxix.

Tsuchida.— “ Ueber die Ursprungskerne der Augenbewegungsnerven,'' * Arbeit aus der
Himanatomischen Institut in Ziirich/ Bergmann Wiesbaden, 1906.

Watson. —“The Pathology and Morbid Histology of Juvenile General Paralysis,”
‘ Arch, of Neurol./ vol. ii, 1903.

Wtrnbow.— “ Ueber Ruckenmarksveriindorungen bei der Progrossiven Paralyse,”
"Neurol. Centralblatt/ 18.

Diffuse Cerebro-Spinal Syphilis terminating ten years later in
Pseudo-General Paralysis.

By G. H. Harper-Smith, M.A., B.C.Cantab., M.R.C.S., L.R.C.P., and
R, W. J. Pearson, L.R.C.P.Ed.

A man, aged 34 years, a horse-breaker, was admitted to Clay bury
Asylum, July 3rd, 1908; died July 17th, 1908. Dr. Mott obtained the
following history from his wife: They had been married eight years; she
had no children and no miscarriages. About eighteen months after
marriage he had a fit, fell down unconscious, foamed at the mouth, and
passed water. He continued on and off to have fits, sometimes slight, but
occasionally severe. After some months he complained of headache, worse
at night; there was drooping of the left eyelid. Then he used to complain
of a numbness in his right hand and arm and weakness, which would pass
off; his mouth became drawn and his speech thick; he became irritable in
temper; his memory failed him ; he did foolish things in consequence. He
was unable to follow his business, and was admitted to the London
Hospital, November 10th, 1901, under Dr. Henry Head, who kindly sent
Dr. Mott the following abstract of the notes of the case: “ The man
contracted syphilis when he was twenty-four, and according to the father’s
account he had severe symptoms. Speech thick, no aphasia, no word-
deafness, no headache now, but before admission he had headache in the
back of the head, no vomiting, no loss of motor power, or of co-ordination.

“ He is a very muscular man, both knee-jerks brisk and equal, no ankle
clonus; the left great toe shows a definite tendency to extension ; the right
goes definitely down. There is no ptosis or ocular paralysis, no nystagmus ;
the face is normal; the tongue is not tremulous. Optic discs and fundi
normal. Sphincters: He passed water in the bed on admission, but
rapidly improved as soon as the mental state cleared up.

“Mental state .—On admission he was semi-comatose, and when aroused
he became violent. He was always more restless at night; there are no
hallucinations, no illusions, no obvious emotional disturbance. His
memory has been bad lately, and has been entirely destroyed for the whole

G8

Diffuse Crrebro-Spinal Syphilis.

of the present illness. He does not remember coming into the hospital ;
he remembers trying to get out.

“ A few days after admission the delirious state with purposeless motile
restlessness began to clear, and his memory for recent events improved, so
much that at the end of a week the notes state—'he answered questions
quite sensibly, and his mental state seemed to have cleared up.’ He was
discharged on December 12th, 1901.

“Diagnosis and summary .—Syphilitic cerebral endarteritis. Comatose
on admission. On discharge no physical signs. He attended as an out¬
patient for some time, and after two months, as he improved so much, he
neglected to go any more. The wife informed me that for the last six
months he has been a changed man ; he complained of severe headache,
worse at night; there was no vomiting; waking irritable, restless states,
alternated with sleepy drowsy states. For years he has been unable to do
any proper work; he took no interest in anything; he had no delusions.
He was a kind, affectionate husband, and up to three months ago the
sexual relations were normal; since then he has been impotent. She has
been married to him eight years and has had good health. Since he came
out of the hospital six years ago he had been having fits; he did not lose
consciousness, ‘ but saliva dripped from the mouth, and he lost his speech. ,
He was worse after a fit. He was again admitted to the London Hospital,
transferred after a few days to the infirmary, and sent from the infirmary
to the asylum.”

His state on admission to the asylum was thus described in the notes.
Heart and lungs apparently healthy. Pupils irregular and react slug¬
gishly to light. The knee-jerks are exaggerated, ankle clonus and
Ihibinski sign obtained. “ Speech slurred and at times like a general
paralytic. He is extremely confused, no idea of time, nor has he any idea
of where he is or how long he has been here. lie is incoherent and
rambling. ? Cerebral tumour.” A week later the case was diagnosed as
epileptic dementia on account of the fits he was having.

July 9th, 1908.—The notes state he has marked rigidity of the left arm,
leg, and side of body, with weakness of muscles of right side of face and
difficulty of swallowing. No rise of temperature.

July Kith, 1908.—“ He is, if anything, worse this morning; his respira¬
tions at times are slow and regular, at others quick and laboured, and
Chevne-Stokes breathing is no doubt indicated here. The next dav
he died.”

The following is an abstract of the notes of the post-mortem examination

G. H. Harper-Smith and R. W. J. Pearson.

69

by Dr. Mott: “ At the autopsy old basic syphilitic meningitis with
universal syphilitic endarteritis cerebri was found. The whole of the
cerebral vessels were affected by an endarteritis. All the arteries forming
the circle of Willis show nodular or general thickening of their walls, the
small arterial branches universally have the feeling and appearance of
fiddle-strings, and when cut their walls are obviously so much thickened
as to partially or completely obliterate the lumen. The pia-arachnoid
about the base of the brain is obviously thickened, due to old meningitis.
There is recent softening in both hemispheres, affecting especially the
upper portion of the prefrontal and frontal regions, and corresponding to
the distribution of the anterior cerebral arteries, which are thickened and
occluded by endarteritis and thrombosis. The weight of the brain is
1385 grm., but the pons, cerebellum and medulla weigh together only 145 grin,
instead of 175-180 grm.; no doubt this loss of weight can be accounted for
by the basic meningitis and arteritis which the patient suffered with six
years previously. The fourth ventricle was granular throughout. The
aorta was free from atheroma except for an elongated pearly fibrous
plaque just above the bifurcation.”

Histological examination of the tissues .—Sections of the spinal cord at
various levels were hardened in Formol-Muller fluid, fixed and cut in
celloidin, and stained by the Weigert and Weigert-Pal methods.

Sections of the brain were taken from the following situations: The
top of the ascending frontal, parietal, the first frontal convolutions, the
basal ganglia, the pons and medulla; these sections were hardened in the
same fluid as those of the spinal cord, fixed and cut in celloidin, and stained
by the Weigert, Weigert-Pal, Van Gieson, and Nissl methods.

Histological changes .—The arachnoid and pia mater of the convexity
are thickened owing to an infiltration of lymphocytes and plasma-cells;
this infiltration extends along the septa into the substance of the brain,
and is most marked in the perivascular lymphatics (see Fig. 2).

There is also a diffuse lepto-meningitis at the base of the brain, most
marked in the interpeduncular space, and about the optic chiasma.

The meninges of the spinal cord show the same changes, the infiltration
extending along the septa and sheaths of the small vessels (see Fig. 4).

The arteries of the brain and cord are extensively diseased; in nearly
all the vessels the lumen is partially and in some cases wholly obliterated
by the thickened endarterium.

In the small arteries this thickening is uniform ; in the larger arteries the
wall presents a nodular thickening showing on section a lialf-moon shape.

G. H. Harper-Sm ith and T\. W. J. Pearson.

71

All the arteries of the circle of Willis are markedly affected, this
thickening being due to a hyperplasia in the non-vascular layer, which lies
between the lining endothelium and the fenestrated membrane.

Around the vasa vasorum are lymphocytes and plasma-cells; the
muscular coat shows but slight changes, the nuclei do not stain deeply, and
are not well differentiated (see Fig. 7).

No gummatous tumours were found in the meninges or in the substance
of the brain.

In the brain there are several softenings situated in the frontal and
prefrontal areas, and a large softening in the basal ganglia in the region
of the lenticular nucleus of the right hemisphere (see Fig. 8).

These softenings are due to occlusion of vessels.

A section through the ascending frontal convolution stained by Nissl
method shows a great increase of neuroglia with degeneration of the
ganglion cells, and collection of plasma-cells round the vessels.

A section through the basal ganglia in the region of the lenticular
nucleus of the right hemisphere shows increased formation of neuroglia,
with destruction of nerve-fibres.

The ganglion cells of the motor area show some degeneration ; in a
large number of cells the nucleus is eccentric, and in some has disappeared,
the Nissl granules are not distinct, and in most of the cells there is a
chromatolysis.

The degeneration in these cells is not so marked as in those of the
frontal and prefrontal areas.

There is a variable degree of damage to the medullated fibres; and
there are several small haemorrhages throughout the substance of the
brain.

The sections of the top of the ascending frontal and parietal convolu¬
tions, stained by Weigert’s method show no universal destruction of the
tangential fibres (see Fig. 1); but in some of the sections there is a
distinct destruction of these fibres, the membranes over these parts of the
cortex being very markedly thickened, and infiltrated with small round-
cells (see Fig. 2).

Fig. 1 . —Motor cortex showing tangential fibres. Weigert-Pal method. Magnification

250.

Fio. 2 —Motor cortex showing thickening of meninges, and softening of the base of
the section; it also shows absence of tangential fibres. Van Gieson. Magnification 85.

Fig. 3. —Section of spinal cord showing annular sclerosis - old-standing lesion. Weigert-
Pal. Magnification 80.

Fig. 4 —Spinal cord showing recent small round-cell infiltration in meninges extending
along the septum; it also shows old-standing sclerosis. Magnification 215.

G. II. Ilarper-Smith and It. W. J. Pearson.

73

Tlio annular sclerosis of the cord is due to an increase of the glial
tissue, with a corresponding destruction of the nerve-fibres. This sclerosis
was caused by the attack of syphilitic eerebro-spinal meningitis which
lie had six years before his death; it was a long-standing chronic
condition. The sclerosis is most marked on the lateral surfaces of
the cord, including the outer parts of the direct cerebellar, crossed
pyramidal, and antero-lateral descending tracts (see Figs. 5 and 6).
The primary degeneration of the descending tracts is owing to the
old-standing sclerosis of the cortex. The columns of Goll and Burdacli
are almost unaffected, this being due to the fact that the thickening
of the meninges and small round-celled infiltration is a much more
recent development than the old-standing sclerosis of the cortex ; more¬
over the cells of the posterior spinal ganglia, the trophic centres of the
exogenous fibres of the posterior columns were not affected. This
roundrcelled infiltration shows that the old syphilitic disease had again
lit up and super-added the meningitis and infiltration to the sclerosis of
the brain and cord of six years before.

In conclusion, we would express our indebtedness to Dr. Mott for his
direction, help and kindly interest; and to Mr. Charles Geary for his advice
on histological methods and producing the micro-photographs.

Figs, 3, 6 .—Spinal cords, dorsal and fcervical regions showing old-standing annular
sclerosis and recent thickening of meninges.

Fig. 7 .—Artery on medulla showing endarteritis and periarteritis. Magnification 30.

Fig. 8 .— Motor cortex showing softening. Magnification 15.

A Contribution to the Study of Institutional Dysentery.

By J. P. Candlek, M.A., M.D.Cantab., D.P.H., afid Professor Georg e
Dean, M.A., M.B., C.M.Aberdeen.

Institutional or asylum dysentery in this country has formed the
subject of several important papers, the most noticeable being the report
furnished by Dr. Mott to the Asylums Committee of the London County
Council.

A further criticism on this subject was published by one of us (J. P. C.)
in the 1 Archives of Neurology/ vol. iii, in which evidence was produced
in support of the infectivity of the disease and of its similarity to the types
of acute bacillary dysentery of warm climates. The close association
between these two types has been proved bacteriologically by the isolation
of one or other of the types of j Bacillus dysenteric from the stools of cases
suffering from institutional dysentery both at home and abroad.

In this country Eyre in 1904 examined the faeces of five acute cases in
the London County Asylum of Clayburyand isolated Shiga’s bacillus in four.
He also isolated Shiga’s bacillus in two out of four cases examined post¬
mortem. The serum of the acute cases was found to agglutinate Shiga’s
bacillus, but to have no effect upon that of Flexner. Further, Eyre found
the Flexner bacillus in six out of nine of the acute cases above mentioned,
and in fifteen out of thirty-five chronic cases. At that time lie regarded
the latter organism as of doubtful importance.

In 1906 one of us (J. P. C.), at the suggestion of Dr. Mott, investigated
the faeces of six cases at Claybury suspected to be suffering from the acute
form of the disease. In five out of the six cases the motions at the time
of examination consisted of mucus and blood only; and in each case an
organism resembling the Flexner type was isolated and submitted to the
usual tests. In the sixth case fiecal matter was mixed with mucus and
blood, and from this case no organisms of the dysentery type could be
isolated. This case died later and was found to be suffering from
pulmonary and intestinal tuberculosis. The cultures were sent to Dr.
Boycott, who was kind enough to examine them and control the results.

J. P. Candler and George Dean.

75

No organism of the Shiga type was isolated in this series. The material
used for obtaining plate cultures from the fasces was the Drigalski-Conradi
medium.

In 1908 a paper by Aveline, Boycott, and Macdonald was published, in
which they recorded the results of a bacteriological investigation of cases
of asylum dysentery. They found the B. dysenterix of Flexner in the
stools of seventeen out of nineteen cases of asylum dysentery. In one
fatal case the spleen and mesenteric glands were alone available, B.
dysenterix being found in both. There was no evidence of the presence of
an organism of the Shiga type in any of the cases examined.

Before relating our own findings it is necessary to refer to the work of
Ur. H. de R. Morgan at the Lister Institute upon the bacteriology of
summer diarrhoea in children in this country. He found (1906-07) that
the B. dysenterix is not responsible for the summer diarrhoea of children in
London, though it has been found associated with this condition in America
and elsewhere. Dr. Morgan found, however, that a certain bacillus—
Morgan’s No. 1 bacillus—occupied a prominent position among the non¬
lactose fermenting organisms in the excreta of patients suffering from
summer diarrhoea. From selected cases it could be isolated in as many as
63 per cent, of the cases. The organism was found to be pathogenic to
experimental animals; rats and monkeys were susceptible to infection by
feeding, and after a period of diarrhoea succumbed. Dr. Morgan states
that “the group to which it belongs, i. e. the non-maunite, non-liquefying
group, is an extremely small one. The only known pathogenic member
of this group is the dysentery bacillus of Shiga, which, of course, is
readily distinguishable from Morgan’s bacillus by at least three important
characteristics, viz. absence of motility, absence of indol formation, and
gas production.”

From a small percentage of cases Morgan also isolated a bacillus which
resembled the bacillus of Flexner with the exception that it produced acid
with sorbite. From the small percentage of cases iu which this paradysentery
bacillus was found he concluded that there is no evidence that dysentery
or pseudo-dysentery bacilli have any significance in the aetiology of summer
diarrhoea as it is met with in London.

Details of the Investigation of Cases of Dysentery occurring at Clayhury

Asylum.

The material for our investigation was obtained from sixteen cases, some
of which showed evidence of dysenteric lesions of the intestine after death,

76 A Contribution to the Study of Institutional Dysentery.

while the other remaining cases were affected with dysenteric symptoms
during life.

In the case of post mortem material scrapings from the intestine and
small pieces of the spleen were carefully emulsified in sterile broth tubes,
and a few drops of the resulting emulsion were sown on to plates contain¬
ing MacConkey’s bile-salt lactose agar. A few drops of blood and bile
from the same body were ;»lso smeared over the MacConkey plates. In all
c.ises strict precautions were taken to obtain the material under sterile
conditions.

In the case of stools obtained from living patients, those which consisted
of mucus with more or less admixture with blood were treated by insemi¬
nating a small portion directly on the surface of the nutrient medium. In
cases where the amount of faecal material rendered it impossible to recognise
any particles of mucous material, a small portion of the stool was emulsified in
a broth tube and a few drops smeared over the surface of several plates in the
usual manner. The stools were in every case taken and used for examina¬
tion as soon after evacuation as possible. At the end of forty-eight hours’
incubation, colonies which showed absence of lactose fermentation were
picked off and sown on to agar tubes. The subsequent identification of these
colonies by cultural and other methods was conducted by one of us (G. D.)
at the Lister Institute. The cultures were examined without reference
to the numbers affixed to the tubes for identification, and in many cases
it was found on tabulating the results that cultures with different numbers
had originated from the same case. This method of examination, which was
entirely uninfluenced by other knowledge, considerably increases the value
of the results obtained, and is confirmatory of the accuracy of the methods
employed.

Examination of post-mortem cases .—The following is a brief account of
the cases examined and the bacteriological findings :

Case 1 : B—, female, aged 68 years. Recurrent melancholia. Large
intestine showed acute ulcerative dysentery with evidence of previous
chronic dysentery. The patient had suffered from symptoms of severe
dysentery for over a month prior to death.

Culture tubes were inoculated from intestine, blood, bile, spleen.

Result .—Bacillus No. 1 Morgan from the intestine.

Case 2: N—, male, aged 69 years. Senile melancholia. Acute ulcerative
dysentery. This case was one of the severest types of dysentery. The
whole of the large intestine was the seat of extensive dysenteric ulceration
with necrosis extending into the muscular tissue. The small intestine was

J. P. Candler and George Dean .

77

extremely congested in parts, but there was no ulceration. It is interesting
to note that a week prior to death this patient ceased to pass dysenteric
stools and the disease was thought to have been controlled.

Culture tubes were inoculated from spleen, mesenteric gland, blood,
cerebro-spinal fluid, intestine.

Result .—Bacillus No. 3 Morgan from the blood. (The cultures from the
intestine in this case unfortunately died out before they could be sub¬
cultivated.)

Case 3 : P—, female, aged 60 years. Dementia. The intestine showed
jost mortem no evidences of catarrhal or ulcerative dysentery, but the
patient was transferred to the infirmary three weeks prior to death as she
was passing blood and mucus by the bowel.

Culture tubes were inoculated from the blood, bile, spleen, and
intestine.

Result .—Bacillus No. 1 Morgan from the intestine.

Case 4: E—, female. Chronic mania. This patient, one month prior to
death, was noted as suffering from pyorrhoea alveolaris. One week before
death she suffered from profuse diarrhoea, of an ordinary character without
evidence of blood or mucus in the stool.

Post mortem : The serous surface of the intestine was covered with
lymph; about one ounce of turbid, foul smelling fluid was found in the
most dependent part of the pelvis. The large intestine showed intense
congestion. There was a ragged ulcer invading the muscular tissue
about two feet below the ileo-cmcal valve. The last eight feet of the small
intestine showed intense congestion, with marked infiltration of the
mucous and submucous tissue, and in places ulceration.

Culture tubes were inoculated from large and small intestine, blood,
spleen, mesenteric glands, and bile.

Result. —Non-lactose fermenting organisms absent from all the cultures
examined.

Probably this was not a case of ordinary dysentery, but the intestinal
lesions may have resulted from infection from the gums.

Case 5: H—, male, aged 59 years. Dementia. The mucous membrane
for the distance of three inches from the anal margin presented a very
marked ragged and pitted appearance, areas of ulceration being found
bridged across with strands of infiltrated and oedematous mucous membrane.
The condition was one of long standing. The large intestine from two to
three feet above the lesion showed marked congestion of the mucous
membrane. The patient never had any attacks of diarrhoea.

78 A Contribution to the Study of Institutional Dysentery.

Culture tubes were inoculated from the ulcerated areas and from the
congested mucous membrane above it.

Result. —Bacillus No. 3 Morgan in the congested area above the
ulceration.

Cask 6: F—, male, aged 36 years. The whole of the large intestine
was the seat of very acute ulceration. The last three feet of the small
intestine were congested, with ulceration in the last six inches of its length.
The patient is noted as having been subject to slight attacks of diarrhoea
a short time before death.

Culture tubes were inoculated from intestine, bile, blood, liver, spleen.

Result .—Bacillus No. 1 Morgan from the spleen and bile.

Case 7 : female, aged .74 years. Senile mania. This patient was sent
to the infirmary about five weeks before death, suffering from dysentery.
One stool was examined five days prior to death. This was scant in
character, had been passed on to the sheet and consisted of mucus tinged
with blood.

Post mortem .—There was slight congestion and roughening of the
mucous membrane of the lower part of the large intestine; no ulceration.

Culture tubes were inoculated from stool during life, and intestine,
blood, and bile post-mortem.

Remit. —From stool during life, Bacillus No. 1 Morgan; from spleen
and bile, Bacillus No. 1 Morgan.

Case 8: R—, female, aged 64 years. Melancholia. Transferred to
infirmary seven days before death for slight diarrhoea. Character of
stool, pea-soup consistency, seini-solid, greenish-brown, very offensive. No
blood, no mucus. Two days before death only one stool was passed in the
day, which was fluid, contained some mucus and blood, and was very foul¬
smelling. Intestine distended.

Post mortem .—The last two feet of the large intestine showed the mucous
membrane to be replaced by a greenish-yellow membrane which could only
be removed with difficulty from the underlying tissue. The removal of
this membranous slough laid bare the muscular coat of the intestine in
several places. The condition could be best described as an acute
membranous inflammation of the lower bowel.

Cultures were prepared from the stools during life, and from the intes¬
tine, cerebro-spinal fluid, blood, bile, and spleen post mortem. From these
situations cultures were obtained of a bacillus which could not be classified.
It resembled the hog cholera bacillus of McFadyean, blit did not produce
any indol. No organisms of the dysentery type were found.

J. P. Candler and George Dean.

79

Case 9 : T—, female, aged 79 years. Mania. Two months before death
passed two or three stools, scant in amount, mustard-yellow colour, con¬
sisting of mucus with very faint streak of blood. Stools became solid
within a week (not noted as diarrhoea or dysentery).

Culture from stools: Bacillus No. 1 Morgan.

The intestines were found to be natural at the autopsy, and no cultures
were taken.

Case 10: N—, male attendant. Contracted very acute diarrhoea with
rise of temperature; severe intestinal pains and vomiting. Stools light
brown in colour, of thin pea-soup consistency, consisting of blood, mucus
and liquid fecal matter, becoming in the course of a few days greenish-
brown, later assuming a solid form and being very offensive throughout.
Patient recovered.

Cultures from the stools.

Result .—Bacillus No. 1 Morgan.

Case 11: R—transferred to infirmary for dysentery. Stools at first
fluid, consisting of mucus streaked with blood, fairly copious, containing a
little fecal matter. In two or three days had become formed and clay-
coloured; the surface streaked in places with a little blood-stained mucus.

Culture from stools: Bacillus No. 3 Morgan.

Case 12 : W. M —, noted as suffering with an attack of dysentery, from
which he recovered in three weeks. Stools: Blood and mucus only at
first; no faecal matter.

Culture from stools : Bacillus No. 3 Morgan.

Care 13: G—, male. Character of stools. Amount moderate, consis¬
tence mainly mucus with one or two small solid fecal lumps and some
streaks of blood. Stools regained normal character within three or four days.

Culture from stools: Bacillus No. 3 Morgan.

Case 14: E —, female, aged 38 years. Admitted 1898, died 1907. Had
an attack of colitis in 1898. Transferred to isolation hospital in October,
1907, with temperature of 100°F., diarrhoea with passage of blood and
mucus. Patient died within a fortnight from symptoms of toxaemia due to
djsentery. The stools at the onset of the attack were scanty in character,
consisting of blood and mucus only. Later they became dark yellow in
colour, of pea-soup consistency, and very foul smelling. The traces of
blood disappeared, but there was still some mucus.

Post-mortem .—Extensive acute pulmonary tuberculosis, with old chronic
phthisis. Tuberculous ulceration in the small intestine and acute ulcerative
dysentery of the lower part of the large intestine.

80 A Contribution to the Study of Institutional Dysentery.

Cultures of non-lactose fermenting bacilli were obtained from stools
during life, and post-mortem from intestine, blood, bile, liver, spleen.

The cultures from this case (C. 115, C. 110, C. 118) approached closely
in fermentations, etc., to the members of the dysentery group. The agglut¬
inative relations will be dealt with in the general discussion of the
bacteriological findings.

Case 15 : T—, female, aged 50 years. Put to bed on account of
diarrhoea and influenza.

Stools examined, moderate in amount; one or two flakes of blood
and mucus.

Result on culture of stool: No organisms of dysentery type found/

Case 16 : It—, female, aged 71 years. Transferred to infirmary as she
had been passing blood per rectum . Stool received following day.
Character very scant; consisted of a mass of gelatinous material mixed
with blood. No further stools of dysenteric character passed. Patient
died five months later.

Post-mortem. —Intestines normal; uterine fibroids, haemorrhoids.

Cultures from stools: Non-lactose fermenters absent.

In summarising the clinical and pathological features of the sixteen
cases described; it is doubtful if all of them can be regarded as cases of
true dysentery.

In connection with certain of the cases there are points worthy of note.

In Case No. 4 the patient had been suffering from severe pyorrhoea
alveolaris, and the localised ulcerations found near the ileo-caecal valve may
have been due to septic infection from the gums and mouth.

As to Cases 15 and 16 considerable doubt must be entertained as to
the nature of the condition, as the stools contained blood from a doubtful
source, and in the absence of definite evidence to the contrary they have
been grouped with the dysentery cases.

Case No. 8 is of considerable interest. Post-mortem : The last 2 ft.
of the large intestine showed an acute inflammatory condition of the
mucous membrane with the formation of a membrane firmly attached
to the underlying tissue, and leaving a granular roughened surface on
removal. It will be seen from the notes on the case that the patient was
sent to the infirmary for slight diarrlnea seven days before diath, and in
the interval the number of stools passed per diem was never excessive,
though those which were passed were very foul.

No organism of the dysentery group could be isolated, but a. bacillus
bearing several characteristics of the hog cholera bacillus described by

J. P. Candler and Georye Dean. 81

McFadyean was found in the stools, the intestine, cerebro-spinal fluid,
and spleen.

Control eases .—In twelve cases in which there was no previous history
of diarrhoea or dysentery, scrapings were taken from the mucous membrane
of the large intestine post-mortem and plates inseminated. In no single
instance were organisms found which had any connection with the
dysentery group or with Morgan's types.

Further, the stools of several cases selected at random were also investi¬
gated, and in each case the result was negative.

The Diagnosis of Asylum Dysentery.

The diagnosis of institutional dysentery rests upon the symptoms
exhibited during the attack and upon the discovery of organisms of the
dysentery type in the stools.

In simple cases the diagnosis by either method is comparatively easy ;
in difficult cases both methods may fail, and a true diagnosis may only be
reached if the patient succumbs.

Bacteriological evidence .—The routine method for examining the faeces
of a suspected case is to inseminate some of the material passed, upon the
surface of several plates in succession of MacConkey's bile-salt lactose
agar, using for the series the same glass rod bent into an L shape, the
instrument being carried from plate to plate without being sterilised.
When the stool of a patient suffering from dysentery consists of mucus and
blood only, there appear on the surface of the plates in the course of
twelve to twenty-four hours delicate transparent colonies showing no
tendency to redden the medium on which they are growing, as is the case
with the lactose-fermenting organisms.

At the end of twenty-four to forty-eight hours these colonies can be
picked off and sub-cultivated on to ordinary agar-agar and be subjected to
the various cultural tests, including their reaction on sugar media. As, how¬
ever, this method takes some days to complete, the blood-serum of the
patient may be tested for its agglutinating properties towards the strain of
organisms isolated from the stool, or towards a culture of the Flexnor or
Shiga bacillus. This method in the hands of one of us( J. P. C.) has been
applied in the cases occurring at Claybury, but the results obtained were
not sufficiently definite to allow an accurate diagnosis by this method.
Aveline, Boycott and Macdonald have recently drawn attention to the
following method of testing for agglutination, by which they claim that a

0

82 A Contribution to /he Study of Institutional Dysentery .

reasonably certain diagnosis may be arrived at in twenty-four hours, and
afterwards confirmed by culture. For agglutinating purposes special
horse-serum prepared for therapeutic use with a number of strains of
dysentery bacilli was employed. The strains of dysentery bacilli included
the types of Shiga, Kruse, and Flexner, those isolated by Eyre from
asylum dysentery, and several from cases of infantile diarrhoea in
America. This serum agglutinated the homologous organisms of the
Flexner and Shiga type up to a dilution of 1 in 10,000, and was generally
used diluted 1 in 1000; observations were made at room temperature.

For the actual test any suspicious colonies appearing on the MacConkey
plates are picked off, cultivated in broth for four to six hours, examined
for presence or absence of motility, and tested for agglutination by means
of the specific horse-serum.

As an early diagnosis is desirable in all cases of dysentery, and as the
various cultural tests take some days to perform, we should follow this
method of Boycott in future investigations with the addition of adding the
bacilli of Morgan to the strains used for horse immunisation.

From practical experience it was found that when the stool of a dysentery
case consisted of mucus and blood only a very free growth of colonies of
the non-lactose fermenting type took place to the almost complete exclusion
of the acid formers, so that within twenty-four to forty-eight hours a very
typical appearance was obtained on the MacConkey’s plates which in the
absence of the possibility of typhoid could lead practically to a diagnosis
of dysentery. So regularly did this occur that in the absence of growth
of non-lactose fermenters, from a stool consisting of mucus, or mucus
and blood only, it appeared almost safe to assume that the patient was not
suffering from dysentery.

The cases, then, which are most suitable bacteriologically for diagnosis,
are those which present the best clinical picture of the disease, and which
can easily be diagnosed without the assistance of the bacteriologist.
There are, however, mild cases of dysentery unassociated with a rise of
temperature or abdominal discomfort (or in which the transitory rise of
temperature has been missed) in which bacteriological confirmation would
be of great assistance to the clinician as an aid to diagnosis.

Such a case is seen in No. 9, an old lady who passed two or three
stools, scanty in amount, and of a mustard-yellow colour, containing some
mucus with a faint streak of blood. There was no constitutional
disturbance, and the stools regained their normal character within a week,
and remained so until she died two months later. The case was not

J. P. Candler and George Dean .

83

considered to he one of dysentery, but Morgan’s bacillus No 1 was recovered
from the stools. Post mortem the intestines appeared natural.

The following are instances in which a clinical suspicion of dysentery was
negatived by the bacteriological findings.

Case 1 : An old lady (Case 16), was warded because she had been
passing blood per rectum . One stool was examined bacteriologically.
No colonies of the dysentery group were found on the MacConkey plates.
The patient died five months later.

Post mortem .—No evidence of dysentery was found in the intestine,
but there were internal haemorrhoids and uterine fibroids.

Case 2 : A female was sent to the infirmary as a case of dysentery.
She was stated to be passing blood and mucus by the bowel. Organisms
of the dysentery group were not found. At the autopsy a few
days later the intestine was found to be quite healthy, but the vagina
contained a large amount of muco-purulent material caused by the
presence of a large pedunculated uterine fibroid which was found
protruding through the cervix.

In both these cases circumstances had prevented a thorough examination
of the rectum and vagina to determine the cause and source of the discharge.

Case 3 : G—, female, aged 56 years. Recurrent mania. Five weeks
before death she was stated to have suffered from diarrhoea. This
continued more or less till death. Stools passed in the early stage were
scanty in amount, mustard colour, grumous, no blood, slight amount of
mucus. Culture of stools. No evidence of dysenteric organisms.

Post mortem .—Extensive pulmonary and intestinal tuberculosis.

Case 4 : C—, female, aged 53 years. Sent to the infirmary for an attack
of dysentery. Stools relaxed, consisting of liquid material with a small
quantity of faecal matter; dark brown in colour, very offensive; a little
mucus and one or two streaks of bright blood.

Six months later she vomited up some dark-coloured blood on three
occasions. At the autopsy the intestines were found to be natural.
Scrapings from the raucous membrane were taken, but no organisms of
the dysentery group were obtained by culture. The patient died from
haemorrhage from an old gastric ulcer.

Case 5 : A. M—, female. Character of stools: Liquid contained
faecal material and a little mucus. No naked-eye evidence of blood.
MacConkey’s plates : All acid colonies. Tubercle bacilli were found in a
film of the faeces. The case was one of pulmonary tuberculosis with
diarrhoea.

84 A Contribution to the Study of Institutional Dysentery .

Cask 6 : E. M—, female, aged 53 years. Character of stools : Liquid,
contained fecal material broken up; a little mucus and shreds of intestinal
mucous membrane. The case was suspected to be dysentery. MaeConkey’s
plates : All acid colonies.

Po$t mortem. —Cause of death : Acute peritonitis from obstruction by a
mesenteric band; perforation of small gut at point of constriction one foot
above ileo-cmcal valve. Prolapse of rectum. The large intestine was free
from congestion. The small intestine showed ulcerated surface close to
perforation and congestion of the surrounding mucous membrane. No
organisms of the dysentery group were isolated from scrapings from the
mucous membrane either of the large or small intestine.

Cases similar to those above described must occasionally occur in every
asylum, and it is in such instances that a negative report as regards the
presence of organisms of the dysentery class might assist the clinician, and
lead to the discovery of the nature of the lesion producing the change in
the character of the evacuations.

The "Limitations of the Method for Detecting Dysentery Organisms in the

Evacuations.

As has been previously stated, the type of stool most suitable for
bacteriological examination is one consisting of mucus or mucus mixed
with blood. Directly the character of the stool changes and fecal material
becomes intermixed the greater the number of lactose-fermenting organisms
which appear on the plate to the ultimate exclusion of the non-lactose
fermenters. Herein unfortunately lie the limitations of the method. For
in those cases in which the clinical symptoms of dysentery are somewhat
obscure, and in which the motions have from the very first consisted
mainly of fecal material, the isolation of non-lactose fermenters may com¬
pletely fail.

Further, the difficulty of isolating organisms of the dysentery group
from the formed fecal evacuations of convalescent dysentery cases and
from grumous stools of chronic recurring cases, prevents to a great extent
the detection of the infective and carrier cases, the proper control of which
would materially diminish the incidence of the disease, fof the failure to
find the organisms in these cases does not exclude the probability that
these organisms are still present in the mucous membrane and submucous
tissues of the intestine, and only await a favourable opportunity to again
light up the disease in the same patient or to become disseminated amongst
others.

J. P. Candlrr and Grorg<> 1)ran.

85

We have found that we have been unable to recover these organisms
with any degree of certainty when the stools of acute cases have become
grumous from admixture with foul-smelling faecal contents; and likewise
we have failed to isolate them from the formed faecal evacuations of
recovered cases. We have also failed to find them in the stools of
apparently normal cases taken as controls.

This is comparable with the experience of Aveline, Boycott, and
MacDonald, who examined the stools of five positive cases during con¬
valescence with the following results. One was negative 8 and 30 days
after, one negative 14 days, and two negative 25 days later.

One case also was examined as a natural control two days before the
onset of dysenteric symptoms with the negative result, yet on the third day
of illness!?. dysenteric was found in large numbers.

In three acute cases the stools failed to reveal dysentery bacilli during
the acute phase; but later they were found in one of these cases during
convalescence.

These observers also failed to find 13. dysenteric in twenty-seven control
cases, though five of these had diarrhoea without clinical symptoms of
dysentery.

Discussion of the Bacteriological Results obtained in the above Cases.

Several points of interest arise in connection with the results of the
bacteriological examination of the cases dealt with above.

The most important is that out of sixteen cases which had symptoms of
dysentery during life, or in which lesions of a dysenteric character were
found after death, five yielded a group of organisms known as Morgan’s
bacillus No. 1, and four yielded bacilli giving the fermentations of the
bacillus spoken of for convenience as Morgan's bacillus No. 3, i. e. a per¬
centage of 31 percent, of Morgan's bacillus No. 1, and a percentage of 25
per cent, of Morgan's bacillus No. 3.

It must be remarked that in the case of Morgan's bacillus No. 1 slight
variations were found in the fermentations of cultures even from the same
case, e. g. one culture would produce acid and gas in eight days, whereas
another strain would produce acid and gas within two days. On the
whole, however, there was a wonderful uniformity in the fermentations.
As has already been stated, these observations were made without know¬
ledge of the source of the culture, the numbers employed for cultures from
the same case being frequently not in series. It was only in the final

86 A Contribution to the Stiuly of Institutional Dysentery .

tabulation that the relation of these numbers was ascertained. Such a
method adds considerably to the value of the results.

In regard to the agglutination of Morgan’s bacillus No. 1, Morgan found
that the serum prepared from one strain agglutinated only a certain
number of other strains. In view of this no agglutination tests have been
carried out with this bacillus in the present research.

Morgan ( loc . cit.). Eyre and Minett (1909) have found Bacillus No. 1 in
a certain number of apparently healthy children, e. g . Eyre found it in 6
per cent, of a series of 60 cases. Two views may be taken in regard to
this —either that the 6 per cent, represent “ carrier ” cases, or that Bacillus
No. 1 is an inhabitant of the normal alimentary canal occurring in small
numbers under normal conditions, but assuming an undue prominence in
the intestinal flora when the conditions are made favourable by alterations
occurring during diarrhoea from whatever cause.

An analogy to the latter view may be found in the occurrence of
Bacillus suipestifcr in small numbers in the alimentary canal of the healthy
pig, whereas in the animal suffering from swine plague it is so abundant as
to have been erroneously regarded for many years as the cause of the
disease which in recent years has been proved to be due to a filter-passing
organism. This illustration may serve to indicate how important it is not
to draw definite conclusions as to the causal relationship in the case of the
alimentary canal bacilli where the evidence rests chiefly on frequent
asssociation of the bacillus with the pathological condition.

Two of the other cases have bacilli closely allied to the Bacillus No. 3,
but which differed in certain biological characters. These two bacilli,
C. 116 from Case 14 and C. 88 from Case 5, prove to be of considerable
interest. They produced no indol, gave the chief fermentations of the
typhoid bacillus, produced acid in milk slowly, but, unlike the typhoid
bacillus, were found to clot milk on the fifteenth day. They were rather
readily agglutinable by anti-typhoid serum, and also in higher dilutions
than usual by normal serum. They were, however, non-motile.

The first idea that occurred to us was that these might be a non-motile
variety of the typhoid bacillus, but further agglutination tests have made
it necessary to modify this view. Both agglutinated in 1 to 2000 “ Flexner ”
serum, and in 1 to 20,000 “ Y ” serum, and in 1 to 800 by “ Strong ” serum.
These two bacilli do not absorb* ‘Flexner” or “ Y ” agglutinins from the
respective sera.*

* We wish to express our thanks to Dr. J. 0. G. Ledingham for his help in connection
with these agglutination results.

J. P. Candler and George Bean.

87

In view of the enormous variability of the dysentery bacillus (Shiga,
[1908] holds that there are at least fifteen varieties as shown by Dr. Ohno)
we must regard these as probably true dysentery bacilli. The fermentations
of these two bacilli and the other dysentery bacilli, Morgan's No. 3, are
shown on the table.

The bacilli from Cases 11 and 12 were not agglutinated by “Flexner”
nor “ Y ” nor “ Strong ” serum. A second race from Case 12 was agglutin¬
ated by “ Y ” serum in a dilution of 1 in 200. The two strains from Case
12 were agglutinated by serum prepared from C. 81 from Case 11, but
were not absorbed by C. 81 agglutinins.

The failure to obtain cultures of a bacillus giving all the characters of
the true Shiga or Flexner bacilli in any of the above cases is noteworthy
and difficult of explanation.

It must, however, be stated that whereas in some of the cases the
majority of the colonies which appeared on the MacConkey plates were
non-lactose fermenters, and a large number of which were picked off and
transplanted on to slopes of agar-agar, some of these unfortunately died
out before they could be examined fully. It is possible, therefore, that
some of these more delicate colonies may have been those of the true Shiga
or Flexner bacilli. In many of the cases, however, we are quite certain
that no colonies of the true “Flexner” variety appeared on the plates.

It is particularly interesting to note that within the last few years the
uumber of cases of dysentery in the asylum at Claybury and the severity of
the attacks have markedly decreased, and owing to the preventive measures
taken an outbreak of dysentery is rare, and the number of cases found
with dysenteric lesions at autopsy has considerably decreased. This change
was already in evidence when the above investigations were conducted.
It is possible, therefore, that the “Flexner” type of organism has died out
pari passu with the more acute form of the disease, and that its place has
been taken by the organism described by Dr. Morgan, and which he has
shown to be associated with summer diarrhoea in children. At any rate,
in the light of our own researches we venture to suggest that the two types
of organisms described by Morgan must be added to the group of organisms
associated with, and possibly responsible for, some of the cases of dysentery
met with in asylums.

Conclusion .—The object of this paper is to report the presence in
certain cases of intestinal dysentery at the London County Asylum at
Claybury of types of organisms which have been associated by Dr.
Morgan with the summer diarrhoea of children.

88 A Contribution to the Study of Institutional Dysentery .

Some of the difficulties and conditions leading to error in the clinical
and bacteriological diagnosis of institutional dysentery have been indicated,
and attention drawn to the usefulness to the clinician of bacteriological
methods. The limitations in practice of such bacteriological methods are
discussed in the light of our experience.

Tahir Showing the Fermentations , etc., of the Chief Groups of Organisms
Isolated and of the Well-known Types to which they are Related .

liacilhis.

Motility.

_

Arabinose.

..

Glucose.

i

o

£

4»

ill

O

O

X

"5

35

9

*2

aj

«

£

ce

&

O

o

8S

Jl

Lactose. ^

6

X

e

x

«

Imilin.

Dextrin.

Salicin.

.

£

c

V

6

X

CO

Mannite.

Dulcite.

1

Milk. |

iL *

> w i

H W

£

Dy sen tery (S1 1 i ga)

J

!

~i

A

A

A

—

—

—

—

AS

—

A S

—

Aik

-

— .

Dysentery (Flex-

i

!

ner) .

— '

A !

A

A

A

A

-

AS

—

A

—

—

—

A —

A l

Aik

+

Morgan I

-i-

—

AG

AG AG

—

-

—

—

—

-

—

— -

—

— J

Aik

+

Morgan III.

—

A

A

A

A j A

_

_

_

A

—

—

A

A —

A

A

T

B. Hog - cholera

1

(McFadyean) .

+

AG

AG

AG AGjAG

—

—

AG

—

—

—

— 1 —

A

A

+

, Case 3 (six

1 strains) .

+

—

AG

AGiAGj —

_

—

—

_

—

—

—

— , —

—

Aik

+ 1

j Case 10 (four

!

strains) .

+

—

AG AG AG

—

—

—

—

—

—

—

—

—

— 1 —

—

—

1

■ Case 7 (seven

|

strains)

+

AG AG AG

j —

—

—

—

—

_

—

— —

—

—

! Case (i (two

!

strains) .

+

—

AG

i AG AG

—

—

—

—

_

—

j —

- -

—

—

' Case l J (one

1

i

l

strain)

+

—

AG

AG

AG

—

—

_

— ,

—

—

—

—

- ,-

—

Case 8 (four

i

'

1

1

i |

strains) .

+

—

AG

, A

AG

—

—

—

_i

—

—

! —

— -

A

A

! Case* 13 (three

|

i

i

1 strains)

—

—

1 A

1 A

A

—

| _

. —

— i

—

_

—

—

A

A

SA

—

.Case 3 (one

strain)

A

1 A

A

A

A

—

—

— 1

—

—

't —

—■

A

' — -

SA

—

+

Case 11 (t w o

|

i

i i

i strains) .

—

—

A

A A

A

—

—

1 —

—

—

1 —

, A

i A

A

—

1 +

Case 13 (one

1

,

i

i

' strain)

—

—

A

! A

A

A

■ _

_

—

—

_

—

i

A

A ! -

AS

—

+

j Case H (t h r v e

j

1

1

1

1

;

i

strains)

—

A

A

A

A

AS —

1_

1 —

-

—

—

—

A 1 -

A and C

i —

Case 14 (three

1

strains) .

-

i A

A

A

A

A

1 -

—

—

—

—

—

—

A and C

—

A - Acid. G =

Gas.

S

- Slight.

_

_ ;

No recognised

change

in medium

. When

particular tests not carried out, as under sorbite, a blank is left. Aik — Alkaline. C = Clot.

•/. P. Candler and Georje Dean.

89

Bibliography.

Morgan, H. de R.—"Upon the Bacteriology of the Summer Diarrhiea of Infants,”
4 Brit. Med. Journ./ July 6th, 1907, vol. ii, p. 16.

Morgan, H. de R., and Lkdingham, J. C. G.—" The Bacteriology of Summer Diarrluea,”
‘ Proc. Royal Soc. Med./ March, 1909, Epidemiological Section, p. 133.

Avelink, Boycott, and Macdonald. —“ Bacillus Dysenterix of Flexner in Relation to
Asylum Dysentery,” ‘ Journ. of Hygiene/ vol. viii, June, 1908, p. 309.

Eyre, J. W.—‘Brit. Med. Journ./ April 30th, 1904, vol. i, p. 1002.

Mott and Durham.— ‘ Report on Dysentery in the London County Asylums/ 1900.

Mott, F. W.—‘ Arch, of Neurology/ vol. ii, p. 761, 1905.

Shiga, K. (1908).—"Ty pen der Dysenteric bazillen, ihr Epidemiologisclies Verhalten
und serotherapeutische Studien,” 4 Zeitschr. f. Hygiene/ Bd. lx, S. 75.

Amako, T. (1908).—“ Dysenterie Epidemien und Bazillentypen,” ibid., Bd. lx, S. 93.

Eyre, J. W. H., and Minett, E. P. (1909).—"The Incidence of Morgan’s Bacillus No. 1
in the Normal Faeces of Young Children,” ‘ Brit. Med. Journ./ 1909, vol. i, p. 1227.

The Psychological Conception of Insanity.

By Bernard Hart, M.B., M.R.C.S.,

Lecturer in Psychiatry, University College Hospital Medical School; Assistant Medical Officer ,

Long Grove Asylum, Epsom.

Psychiatry has been throughout its history the victim of innumerable
conflicts of opinion. These conflicts have related not only to questions of
fact and theory, but to the very groundwork of the science—the material
with which it deals, and the proper methods of research by which it should
be approached. A science constructed upon a shifting basis can have no
stability or permanence—and therefore psychiatry has had but little
share in the triumphal progress of its sister sciences.

If we glauce through the history of psychiatry we see a succession of
revolutions—the rapid replacement of one mode of conception by another,
and the abandonment of almost every result to which the former
mode had led. We see the singularly enlightened conceptions of the
Greeks replaced by the theological conceptions of the middle ages, and
the development of the view that the symptoms of insanity are the
manifestations of an evil spirit lodged in the body of the patient. Such
a conception led logically to suitable methods of diagnosis, the procedures
of the witch trials, and to suitable therapeutics, the exorcising of the
offending devil, or the burning of the witch.

This hopeless confusion of the categories, of the material and super¬
natural, the psychological and moral, was obviously incapable of yielding
any satisfactory results, and men turned expectantly to that new method
which was revolutionising human knowledge, the method of the natural
sciences. But this method had hitherto only concerned itself with the
material world, and the endeavour to bring psychiatry within the pale led
to the postulate that the basis of mind is brain, and that insanity is a
disease of the brain. Around this postulate arose the physiological
conception of insanity, a conception of the utmost historical importance,
and one which has, until within recent years, dominated almost the whole
field of psychiatry. Even at the present day many authorities are
convinced that any attempt to deal with the problem of insanity from the

Bernard Hart.

91

point of view of psychology is doomed to failure, and that the therapeutics
of the future will be inevitably limited to the methods of physiology and
physiological chemistry. Some even deny that psychology can form a
portion of science, that it deals with material which can be treated by the
scientific method, and they insist that mental processes must first be
translated into physiological terms before we can attain to any exact
knowledge of their laws and causation. This school has been aptly
described by Hoffding as virtually wishing to abolish psychology in
order to make it into a science.

Notwithstanding this destructive criticism the psychological conception
of insanity persisted in asserting its vitality. It has passed through a long
sterile period, dominated by the introspective psychology of former days,
a period whose meagre results justified to a large extent the contempt of
the practically minded physiologist. It was thought that the methods
of the natural sciences were not applicable to psychology, and these
were therefore replaced by armchair speculation which bore no resemblance
to the procedure adopted in other branches of knowledge. And yet the
futility of an attempt to understand dementia praecox by means of
analogies from introspection hardly requires demonstration.

In recent years, however, psychological psychiatry has made gigantic
strides—it has discovered that the mind can be treated as a phenomenon,
and can, therefore, be rendered amenable to the method by which we study
all other phenomena—the method of science. The recognition of this
simple fact has led on the one hand to the introduction of experimental
psychology, and on the other to the immensely important work of Janet,
Freud, and Jung. The psychological conception of insanity has acquired
a new life, and now offers, we believe, the most fruitful method of modern
psychiatry.

It is not difficult to trace to its roots the dogmatic assertion of certain
authorities that the physiology of the brain is the only profitable method
in psychiatry. It rests upon a crude and naive conception of the nature
of reality and of science. Reality is regarded as something extended,
tangible, and visible, and science is assumed to be concerned with
measurement, and, therefore, only applicable to the material world. The
brain constitutes a part of reality, something which really exists and is
causally effective, whereas psychological research is concerned with
flimsy unrealities. Science cannot deal with unrealities, and must,
therefore, limit itself to an external “real ” world of “things in themselves,”
composed of extended objects arranged in an infinite space. This is the

92

The Psychological Conception of Insanity.

doctrine that aroused Mach’s gibe that “ The majority of natural scientists
tend to embrace a materialism some hundred and fifty years old, whose
insufficiency has long been obvious, not only to the philosophers proper,
but to all those accustomed to think philosophically.” (1)

This crude theory of the physiological dogmatist extended in former
days over the whole field of science. Scientists had concerned themselves
solely with the search for knowledge and did not consider the foundations
upon which they were building. During the nineteenth century, however,
a school of critical philosophy arose devoted to an investigation of the
bases and nature of science. Owing to the labours of Clerk-Maxwell (2),
Ostwald(3), Mach (4), Karl Pearson (5), and other members of this school
the method of science has now been precisely formulated. The nature of
this method has been most perfectly described in Pearson’s classical
c Grammar of Science.’ Limits of space prevent more than a short
summary of the principal conclusions reached therein—for the
demonstration of their validity the reader must be referred to the
original work. These conclusions may be stated as follows: Science
is characterised solely by its method, not by its material. It is,
therefore, applicable to the whole field of human experience. It
deals with phenomena , not with “ things in themselves,” “ matter,”
or other metaphysical abstractions. Its method is, firstly, to classify
phenomena into sequences; secondly, to find some general law which
will enable us to resume these sequences in a short and convenient
formula. These laws are constructions of the mind and form no part of
phenomenal experience—in other words, they are conceptual in character.
The justification of a scientific law consists solely in the fact that it enables
us to resume and predict our experience. Thus, in order to explain the
phenomena of chemistry, we construct the conceptual atomic theory. The
scientist may bo compelled, not only to construct the law, but to invent
the objects between which the law is conceived to hold. Atoms have not
been seen, or heard, or touched; they are not phenomena, they have been
invented by the chemist. The chemist has, in fact, constructed a conceptual
model of the universe: his claim is merely that by the aid of this model
he can deduce certain results, and that these results will be found to agree
with the phenomena actually occurring in nature. The physicist has
adopted a precisely similar method, and makes a precisely similar claim
with regard to the phenomena of light and the theory of ether waves. The
conceptual models of the scientists are not only non-phenomenal; they
may even contain elements which contradict all phenomenal experience—

Bernard Hart.

93

for example, the weightless frictionless ether. The method of science,
therefore, consists in (1) the observation and classification of phenomena,
(2) the construction, by the aid of the disciplined imagination, of a
conceptual model designed to resume these phenomena, (3) the comparison
of the results deduced from this model with the facts of actual experience.
The last step establishes the validity of the conception ; if this test is not
satisfied the conception is merely a useless phantasy.

Underlying all these principles is the distinction between the pheno¬
menal and conceptual, and it is of fundamental importance that this
distinction should be clearly understood. Our actual experience is pheno¬
menal, and every fact of experience is regarded by science as a phenomenon.
A conception, on the other hand, is a construction of the human mind, and
it forms no part of phenomenal experience. Thus colour is a phenomenon,
the ether and its waves are conceptions. Similarly, chemical substances,
moving bodies, and nerve-fibres are phenomena—atoms, force, aud nerve-
currents are conceptions. The modern scientist no longer imagines that
atoms and ether waves are phenomenal realities ; he will at once acknow¬
ledge that he has invented them in order to explain his phenomenal
experience.

Now, if science is concerned with the whole field of human experience,
it must be applicable to mental phenomena, for surely the mental is as
much a portion of human experience as the material. And if science aims
at the construction of a conceptual model designed to resume our experi¬
ence, it cannot be synonymous with measurement—measurement must be
merely one of the means by which this aim is attained.

Let us next consider how science deals with this problem of the
physical and mental. If we inquire of the physicist where he places
mental phenomena in his scheme of the universe, he replies that he does
not place them anywhere, and that their introduction into his chain of
cause and effect would altogether vitiate his conceptions. He insists that
the physical world must be regarded as a closed series in which the
psychical plays no part whatever. If we turn to the physiologist we are no
better off : he is willing to deal with psychical phenomena if we will allow
him to translate them into complicated interactions of nerve-cells and fibres,
but with the psychical in itself he has no concern. Are we, then, to
conclude that the psychical is a mere epiphenoinenon, something which
has no place in the universe of the scientist ? Surely not, for if the
psychical is a portion of human experience it must be amenable to the
method of science. The difficulty is solved by the introduction, as a

94

The Psychological Conception of Insanity .

working hypothesis, of the doctrine of parallelism. The psychical and the
material form two series; within each the law of causation is effective, but
between the two there is no causal relation. Ideas may be causally
related to other ideas, and molecules may be causally related to other
molecules, but an idea cannot cause a molecule, nor a molecule an idea.

Science is compelled to make this assumption because it cannot
construct useful concepts unless the physical and psychical series are
kept rigidly apart. It does not need to establish parallelism as an abso¬
lute truth, nor need it concern itself with metaphysical problems
concerning the relation of mind and body. Human experience may be
regarded from two aspects: from the psychical point of view it is a
chain,of phenomena conceived as forming part of a consciousness; from
the physical point of view it is a chain of phenomena conceived as occurring
in space, and forming part of a physical universe. In other words we
may say that the physicist resumes his experience by means of a conceptual
model involving space and time, whereas the psychologist regards it as the
chain of mental factors constituting a consciousness.' The ultimate goal of
the physicist is a complete description of the universe in terms of motion
or mechanism ; the ultimate goal of the psychologist is " personality.”

Science is compelled to treat the physical and psychical series rigidly
apart because, as we have seen, the doctrine of parallelism demands that
no causal relation between elements of the two series shall be postulated.
This principle has long been realised by the physiologist. He refuses to
introduce psychical conceptions into his chain of cause and effect—his aim
is to construct a conceptual model composed entirely of physiological
elements. The psychologist, however, rarely grasps the full significance
of the principle of parallelism, and he is often content to fill up the gaps
in the psychical series with cells and nerve-currents. It is this confusion
of the categories which has so retarded the progress of psychology in
comparison with that of its sister sciences. So long as this confusion is
not realised psychology cannot proceed to that second step which we have
described in our preliminary exposition of the method of science. It will
remain a mere description and classification of phenomena, and will be
unable to attempt the construction of a conceptual model designed to
resume those phenomena.

The principle of parallelism demands, therefore, that psychology should
be excluded from physiology, and as a necessary corollary that physiology
should be excluded from psychology. The psychologist must refrain from
introducing physical terms into his chain of cause and effect. Now this

Bernard Hart.

95

proposal immediately arouses considerable practical difficulties—and it
certainly requires some qualification. It will be objected, for example,
that the clinical method largely depends upon this alleged confusion of the
categories. We know that if we give a quantity of alcohol to a certain
individual he will develop a certain mental state characterised by a
peculiar clouding of consciousness, etc. Are we, then, talking nonsense
when we say that the alcohol causes this mental effect ? The solution of
this apparent dilemma lies in the ambiguous use of the word “ causation.”

Hoffding states that “ the causal concept appears under two aspects:
under a provisional elementary form, with which we are often compelled
to be contented; and under an ideal aspect which all research and all
theories strive after. The elementary causal concept presents only an
unconditional succession; if the phenomenon A appears, then B inevitably
follows, and B only appears when A has preceded it. The ideal causal
concept goes a step further and sees in the phenomenon which we call the
consequence the continuation of that phenomenon which we call
the cause or its equivalent in a new form.” (6) Thus, when we say
that the tubercle bacillus is the cause of phthisis we mean that the
bacillus is an invariable antecedent of the disease—this is an example of
the first or empirical type of causation. When, on the other hand, we
say that heat is the cause of motion, we mean that motion is the equivalent
of heat in a new form. Heat is conceived as being the vibration of
particles, and hence motion can be regarded as a continuation of the same
phenomenon. This is an example of the second or ideal type of causation.

It will be found that this second or ideal causation is only met with
upon the conceptual plane, never upon the phenomenal. Upon the
phenomenal plane we experience only a succession of phenomena—hence
it is that mere observation of the facts of experience will only yield us
that form of knowledge which we term “ empirical.” Empirical know¬
ledge is, in fact, the result obtained by the application to our experience
of the elementary causal concept; it is that observation and classification
of sequences of phenomena which we found to be the first step in the
method of science. Such knowledge is rightly regarded as merely
preliminary in character, and science is not satisfied until it has proceeded
to the ideal concept of causation. Thus when Kepler demonstrated the
fact that a planet would be in a certain position at a certain time because
it moved round the sun in an ellipse, he was employing the elementary
causal concept. Newton, however, went further, and succeeding in
explaining the same fact by means of his conceptual model of particles

96

The Psychological Conception of Insanity .

attracted towards each other by the force of gravity, thereby employing,
of course, the ideal concept of causation. It is this ideal concept which
constitutes the “ why ” of science, whereas the unconditional succession of
phenomena is merely the “ how.”

This ideal concept of causation is only to be found upon the conceptual
plane, and it is only by means of a conceptual model that we can ever
“ explain ” our experience. That aspect of continuation, of equivalence in
a new form, is never found upon the plane of our phenomenal experience ;
it is a result only to be achieved by the efforts of our constructive
imagination.

Our final conclusion is, therefore, that while in our preliminary
classification of phenomena it is admissiblo to employ terms from both the
physical and psychical series, such a procedure is altogether inadmissible
when we proceed to the second step of the method of science, the
construction of a conceptual model designed to explain the phenomena.
The terms of a scientific conception must always be taken from one or the
other series, never from both. For otherwise it would be obviously
impossible to obtain a “ continuation ” and “ equivalence in a new form.”
Thus the physiologist is prepared to accept as a first approximation our
statement that the idea of a good dinner causes our mouths to water.
But when he proceeds to the construction of his conceptual model our
statement will be discarded, and he will produce only a picture of cells
and fibres, traversed by nerve-currents, and obeying only physiological
laws.

We are now in a position to return to our original dilemma concerning
alcohol and mental confusion. When we say that alcohol causes mental
confusion it is obvious that we are employing the term “cause” in its
empirical sense; we are merely registering the fact of observation that
administration of alcohol is followed by the phenomenon of mental
confusion. The second phenomenon cannot be regarded as the equivalent
of the first—it is altogether impossible even to conceive mental confusion
as the equivalent of alcohol in a new form.

It must be clearly understood, of course, that empirical knowledge of
this kind is far from useless. It is a very valuable first approximation,
not only useful in itself, but serving to indicate the lines along which
further research may be profitably undertaken.

We may therefore qualify our original statement as follows: The
psychologist is at liberty to introduce physiological terms into his subject
so long as he makes no effort to proceed beyond the limits of a merely

Bernard Hart.

97

descriptive science. Hut if lie desires to brim* psychology into line with
the natural sciences he will be compelled to introduce the conceptual
method. He must then clearly understand that the introduction of
physiological elements into conceptual psychology is inadmissible, and that
lie must altogether confine himself to the psychical series.

Let us now endeavour to apply these principles to the study of
psychiatry from the standpoint of psychology. Firstly, the phenomena
must be accurately observed and classified. This necessary first step was
in former days rendered impossible by the predominance in psychology of
the introspective method, for introspection was obviously inapplicable to
the mental processes of the insane. It was only with the introduction
of an objective psychology that the facts of insanity could be rendered
amenable to scientific observation. Objective psychology depends upon
that process of deduction from analogy which we customarily employ
in everyday life. We have no immediate knowledge of any consciousness
but our own ; we deduce the consciousness of others in one of two ways—
either directly from what they tell us by means of speech, or indirectly
from certain actions they exhibit, actions which are invariably connected
in ourselves with certain conscious states. By these modes of observa¬
tions we are enabled to describe and classify the sequences of mental
phenomena which occur in the mind of another person. In precisely
the same way we can describe and classify the sequences of mental
phenomena which occur in the mind of a lunatic. It must be admitted,
of course, that in this second case the sequences may be more frag¬
mentary, because we are frequently compelled to depend mainly upon
our deductions from the actions of the patient, and only to a small extent
upon his verbal communications.

As a result of work conducted along these lines a considerable body of
psychological material has been collected, and this material has been to
some extent classified. The process has been carried out in the sphere of
both normal and abnormal psychology. As an example of such observa¬
tion and classification in the latter sphere we may cite the dissociations of
consciousness demonstrated by the French school during the latter half of
the nineteenth century, in particular the work of Janet upon the sub¬
conscious phenomena of hysteria. Further research has revealed the fact
that the operation of dissociation can be traced throughout the whole range
of the normal and abnormal mind—from the “ habits v of everyday life to
the hallucinated voices of the paranoiac.

The minute analysis of the phenomena of the mind formerly occupied

7

98

The Psychol oy lad Conception of Instmity .

the psychologist to the exclusion of every other aim, owing, we believe, to
the erroneous view that no conceptual psychology was possible until the
mental phenomena had been dissected into their ultimate elements. It is
not disputed that accurate observation and classification of facts are a
necessary preliminary to the employment of the conceptual method, but the
complete analysis of each phenomenon into its structural constituents is by
no means essential. Thus Newton formulated the laws which govern the
interactions between particles at a period when the analysis of these
particles into their chemical elements was in its infancy.

We may now proceed to inquire what use psychology has hitherto made
of this conceptual method, what progress is at present taking place in this
direction, and therefore to what extent psychology has now advanced
beyond the standpoint of a descriptive science. A cursory examination of
the facts will at once convince us that conceptualisation of a simple
unsystematised type has been employed by the human mind from the very
beginning of its history. iC Memory,” for example, is such a concept. We
are only actually cognisant of the fact that a certain mental event is liable
to recur at some subsequent time. In order to satisfy our demand for
continuity we assume that this mental process must somehow have existed
during the interval, and we construct the concept of “memory” in order
to explain this continued existence. Similar simple concepts can be found
throughout the whole range of popular psychology. Nineteenth century
physiological dogmatism refused to admit that these conceptions had any
claim to be incorporated into science. It insisted that the mental process
had no psychical existence during the interval in which it. was not being
actually experienced, and that “ memory ” was for science nothing but the
persistence of physiological traces in the brain. This view involves that
confusion of the phenomenal and conceptual and that confusion between
the physiological and psychological series which we have already seen to
be destructive of all coherent science. Firstly, the physiological brain-trace
is not a phenomenon—it is made up of such conceptual constructions as
“ nervous energy ” and “ permeability of paths,” and is therefore itself a
conception, and not a fact of experience. Secondly such a physiological
conception, while admirably adapted to explain the connection between two
successively appearing brain facts, is altogether unadapted to explain the
connection between two mental events. We cannot conceive one mental
event as continuously passing over into the other if the intermediate links
are composed of such disparate stiilT as nerve-cells and fibres. But it is
just this “continuous passing over” which we achieve by the construction

Bernard Ilart.

90

of our psychological conception of "memory.” Once it is definitely
realised that the physiological " brain-trace ” is as much a conceptual
abstraction as the psychological "memory,” and that neither are to be
regarded as phenomena, the superior claims of the latter, when we are
speaking of psychical events and not of physiological events become
immediately obvious.

We owe to Professor Freud (7), of Vienna, the first consistent attempt
to construct a conceptual psychology on lines similar to those which have
proved so successful in other sciences. He devised the conception of the
" unconscious,” and endeavoured to explain our actual conscious experi¬
ences as the result of mental processes of which we are altogether unaware.*
This conception has been systematically developed both by its original
author and by the school of which he has been the founder. Whatever
view one may take of certain of Freud’s developments, it must now be
admitted, we believe, that the essential groundwork of his theory has been
definitely established.

A description of these methods and theories does not, of course, lie
within the scope of this paper. Our purpose is merely to indicate the broad
lines of their historical development, and the importance which they have
now acquired in modern psychology. Freud’s investigations were primarily
directed to the study of the neuroses, and in particular to the psychological
aspects of hysteria. By the employment of his method of " psycho¬
analysis ” he found that the symptoms of hysteria could all be explained as
the result of an emotional conflict. A certain system of ideas, which was
for some reason incompatible with the personality, was repressed into the
unconscious, and the patient became henceforth unaware of its existence.
It continued, however, to exert in various indirect ways an effect upon the
personal consciousness—these indirect effects constituted the symptoms of
hysteria. The laws by which the hysterical processes proceeded were
foupd to be identical with those governing the processes of normal life.
Dr. C. (t. Jung (8), of Zurich, continued the work of investigation. In his
well-known f Diagnostische Assoziationsstudien ’ he confirmed Freud’s

# Hartmann’s original conception of the “ unconscious mind,” though similar in form,
was constructed on lines opposed to the method of science. It endeavoured to explain
everything, and therefore succeeded in explaining nothing: its relation to Freud’s
theory is merely one of superficial resemblance. See two articles by the present author,
“ A Philosophy of Psychiatry,” ‘ Journal of Mental Science,’ July, 1908; and “ The Conception
of the Subconscious,” ‘Journal of Abnormal Psychology,’ 1910. These contain a more
complete discussion of the general principles constituting the scientific basis of psychiatry,
and the reader is referred thereto should the descriptions contained in the present paper
not be sufficiently clear.

100 The Psychological Conception of Insanity .

results, and demonstrated that the labour of psycho-analysis could be con¬
siderably shortened by the use of preliminary association experiments.
He also extended Freud’s method to the study of dementia prmcox from
the psychological aspect, and showed that the same essential mechanisms
were to be found here as in the case of hysteria.

Considering the short period during which these investigations have
been in progress the results have been astonishingly fruitful, and we are
now within measurable distance of a psychological conception of insanity.
Much work is still needed, but the future is bright, and we may reasonably
look forward to the establishment of a psychiatry worthy of the name of
Science.

Bibliography,

(1) Mach. —‘ Erkenntniss und Irrtum/ Leipzig, 1905, p. 4.

(2) Clerk-Maxwell.—‘ Scientific Papers/ Cambridge, 1890.

(3) Ostwald. —‘ Naturphilosophie/ Leipzig, 1902; * Die Uberwindung des wissensehaft-
liclien Materialisinus/ 1905.

(4) Mach. —‘Die Mechanik in ihrer Entwicklung/ Leipzig, 1883; ‘Die Analyse der
Empfindung/ Jena, 1892 ; “ De la Physique et de la Psychologie/’ ‘ I/Annee Psyehologique/
1906.

(5) Pearson, Karl. —‘Grammar of Science/ London, 1892.

(fi) Hoffdino.— ‘ The Problems of Philosophy/ New York, 1905, p. 0(5.

(7) Freud. —‘ Die Traumdcutung/ ‘ Kleine Schriften zur Neurosenlehre/ ‘ Der Witz/
and numerous other works, mostly published by Deuticke, Leipzig and Vienna.

(8) Jung. —“ Diagnostische Assoziationsstudien,” ‘ Die Psychologie der Dementia
Piweox/ Halle, etc.

Two Cases of “ Washing-Hand ” Mania, with some Observations on

their Etiology.

By G. F. Barham, M.D., B.C.Cantab.,

Senior Medical Officer, Long Grove Asylum.

In the progress of our knowledge of psychiatry no more important
advance has been made than that which depends upon the realisation that
the phenomena of mental diseases are subject to the same laws as those
which govern the processes of. the normal mind, and that the disease
syndromes which are so familiar under the various labels of an ever-changing
nomenclature are really the outcome of the gradual influence of certain
morbid factors upon the whole development of the personality. The two
cases of obsession-impulsion described below will, I think, emphasize these
points, and in the study of their evolution appears to lie the principal
indication of their efciolosrv.

Caroline M—, single, aged 31 years, was admitted into the asylum in
November, 1908. She was suffering from mental depression together
with ideas of unworthiness, and an uncontrollable impulse to wash
her hands. Prior to her birth her mother had been in a very weak
state of health. Her previous history revealed the fact that she
had been backward and slow in development ; at school she attained
to the sixth standard, and she was then brought up to domestic
service. She has been in several good situations, and appears to have
possessed ordinary intelligence and ability. In early life she suffered much
from ereutophobia. She was peculiarly timid and sensitive in disposition,
and although she was aware of her practical usefulness in her own sphere
of work, she was nevertheless over-ready to disparage herself, and frequently
experienced a feeling of incapacity, especially when placed in unusual
circumstances. She was extremely conscientious, but lacked self-confi¬
dence. Her inability to make up her mind and act with decision caused
her to depend unduly upon the direction of others. She was retiring and
reserved, and made no very intimate friends. Unambitious and simple in
her ideas and desires, she gave much thought to religion, and was unduly

102

Tiro Cases of “ Wii-shiinj-Hand” Mania.

impressed with the idea that her normal sexual feeling was something to
be ashamed of and suppressed. While her earlier life had not been
unhappy, it was nevertheless colourless and devoid of satisfaction, and she
grew up to be self-centred and secretly discontented. No serious love
affair appears to have ever disturbed the monotony of her life. Her
attention was expended in matters of small consequence, and in an
exaggerated punctiliousness.

Five years previously, when in service, curiosity respecting the nozzle of
a douching apparatus belonging to her mistress led her to give way to
experiments upon herself, which developed the. habit of masturbation. In
the course of time, however, remorse and disgust at herself enabled her to
overcome this practice, the painful memory of which she more or less suc¬
ceeded in putting away from her mind. Nevertheless, in the process of
this suppression she experienced feelings of profound shame and personal
unworthiuess, an experience which left an indelible mark on her personality.

At her last situation (June, 1908) she was suffering from menorrhagia.
Her linen was much stained, and this incident worried her excessively
because she thought that her fellow-servants would remark on it. She
was habitually clean in her habits, and the opposing idea of uncleanness,
as I hope to demonstrate, already exercised a morbid influence on her
personality. At this time there occurred a case of infectious illness in the
household, and it was part of her duty to handle a quantity of soiled and
infected linen. This was an additional source of anxiety to her; it was
something unusual which she was called upon to cope with, and instead of
reacting to this fresh call upon her energy the feeling of incompetence
inherent in her disposition was accentuated. The next step was the
insidious growth in her mind of doubts and questionings about her
personal cleanliness, and she reacted by making unusual efforts to wash
herself on every possible occasion. This habit became an impulsion over
which she was less and less able to exercise any control.

Her habit of observing and discussing with herself each little detail
of her methods led her into interminable self examinations: thus, having
washed some article w ith great care, she w ould then wash her hands, and
after drying them with a towel, she would commence questioning herself
as to whether anyone else had used the towel, and if so, whether her hands
were not again soiled. She would then laboriously repeat the washing pro¬
cess, and having at length temporarily sat isfied her mind, doubts would arise
as to whether perchance she had or had not contaminated the towel, and if
so, might it not come about that someone else would use this towel and so

G. F. Barham

103

become infected through her. She developed a dread of touching any
object of wearing apparel, and was gradually ‘reduced to such a helpless
state of hesitation and doubt that she was quite unfit for her work, and
voluntarily came to the asylum.

She was a woman of small stature, somewhat ungainly in build, with
rather heavy features and a coarse skin. There was a growth of hair on
the upper lip. Her general health and condition was fairly good and the
reflexes and sensation were normal. No history of neuropathic heredity
was obtained. She was very quiet in manner; her expression was
as a rule calm, but her eyes were red as with weeping and she was
over-readily emotional. She replied at once to my questions and willingly
gave a very good history of herself; there was no appreciable retardation.
She appeared ‘well orientated and quite realised her position and circum¬
stances ; her memory was unimpaired. She conversed intelligently and
rationally on such topics as she was interested in and which did not
awaken any morbid affect in her mind; but the attention was generally
centred upon the depressing content of her thoughts, of which after some
preliminary hesitation she spoke openly. There was a strongly subjective
feeling of incapacity and incompleteness. She was morbidly cognisant of
her own timid and retiring disposition, and told me that she had always
experienced a difficulty in making a decision where her own interests were
concerned, and that she was seldom free from the consciousness of effort in
her daily life. There was no generalised or marked depression, she
occasionally smiled in speaking of her past life, and could be distracted
from the influence of the distressing thoughts which tended to dominate her
mind; she told me that she felt wicked and unworthy and that she must
be guilty of sin. She was unable to rid her mind of the idea that she was
unclean ; this idea dominated her attention and was the theme of an
unending argument or rumination, which only ceased when she obtained
sleep, but the feeling of anxiety and doubt recommenced on waking.
Sleep was broken and seldom brought her complete mental rest.

She complained of her inability to stop washing her hands and that she
could not get rid of the idea that they were dirty; this idea forced itself
upon her but she retained her power of forming a sane judgment upon it
and recognised that it was something abnormal in herself and that her action
in washing her hands in this way was irrational. The continued contest
that was carried on with this obsessive idea absorbed the greater part of
her mental energy. There was a prevailing affect of anxiety with feelings
of incapacity and of dissatisfaction. She would reproach herself in

104

Tim Cases of “ Washiinj-Hand ” Mania.

everything she* had done or left undone ; the idea of personal wickedness
was out of all proportion with the facts of her history, and this, on
argument, she admitted to. Finally she confessed to her former habit of
masturbation.

She would constantly revert to disparaging thoughts concerning her
work and maintain that such work as she did accomplish was badly done
and this despite all evidence to the contrary. She was in this way
morbidly.critical about herself; nevertheless she was not without insight
into her condition, which she recognised as strange and abnormal; but
unless forcibly held in conversation or driven to employment she would lose
all practical grasp of reality. Left to herself she became restless and
agitated or had definite though mild crises of diffuse anxiety which she was
unable to control. She has frequently sought assurance in the doubts bred
in her mind by renewed presentment of the obsessing ideas ; thus at one
time on waking in the morning she could not rid her thoughts of the* idea
that she might have masturbated during the night. She confessed to
having no recollection of having done so and assured me she had quite
given up the practice ; still she was obsessed with the idea that she
might have done it u without knowing.” She would feel compelled to lie
in bed and argue with herself as to whether or no she had really done this,
and if so, her hands being soiled and unclean how was she to get out of
bed and without touching something, how could she wash her
hands before* getting out of bed, etc.? Under these circumstances
it was necessary to reassure her that her fears were unfounded and
that she might confidently get up. On another occasion she came to me
in a sad dilemma concerning a box of clothing she had left at home ; she
was unable to rid her mind of a doubt- as to w hether a piece of rubber
tubing (douche) might or might not be in this box. She sought mv
advice as .to whether, in case her fear was warranted, J thought all her
clothes would be contaminated, and if so would it be sufficient to have
them washed thoroughly or should she have them all destroyed ? She
always washed herself scrupulously and continued doing so until the nurse
told her to desist. She informed me that she preferred that the nurse should
be there as a witness who could reassure her later on in the day that she
really had thoroughly cleaned her hands. She continued for many months
to have attacks of anxiety associated with these* obsessive ideas and rumina¬
tions. It will be* observed that the* idea of masturbation or some associated
idea was frequently present in her thoughts ; but this ide*a was less repressed
in the later pe*rioels of her illness, principally,] think, on account of our free

G. I<\ Barham,

105

discussions of her case, in which attempts were made to give her a deeper
insight into the factors conditioning her trouble. She made considerable
progress, and had much greater control over herself when she was
transferred to another asylum.

The second case has many points of interest which may be compared
with the foregoing one.

Elizabeth D—, aged 89 years, married, was first admitted to the
asylum in June, 1907, suffering from depression of mind and an impulse
to wash her hands.

Particulars of the early life and development of this case are scanty,
and contain nothing of special interest. She is a moderately well-educated
woman, and was formerly capable in household affairs. She was married
at the age of twenty-three. In disposition she was reserved, retiring, and
very timid in society. She suffered from ereutophobia, and was described as
being of a very nervous temperament. She was much disposed to trivial
worries and anxiety, and was afraid of any conditions strange or unusual
to her habitually quiet existence. The first year or two of marriage appear
to have been uneventful. She was simple in her aims and wants and was
fairly happy and contented. The first confinement was prolonged and
difficult, and this experience caused her to wish to have no more children.
From this time preventive measures were successfully employed and she
was never again pregnant. The ensuing years showed the gradual
development of morbid symptoms culminating in the neurosis from which
she is now suffering. Her predisposition to worry became more noticeable,
a state of disquietude gradually became habitual with her, and she suffered
frequently from vague anxiety. Self-criticism and a feeling of incompe¬
tence and indecision accentuated a natural tendency to seek sympathy and
affection, and to rely more than ever upon the guidance of her husband.
Now the advent of these symptoms in the wife was followed by a change
in the husband, in whom there developed a growing coldness of manner;
gradually in the course of the following years.the conjugal relationship
became more and more strained ; associated with this change there
developed an increasing tendency to sexual indifference. In 1897, when
she was twenty-nine years old, she nursed her husband through a serious
illness, during which he seemed to turn against her, and she was constantly
troubled by the idea that they were drifting apart. Five years later her
husband was again ill, and she again nursed him under very trying circum¬
stances, for he became more and more disngeeable, and at times it seemed
to her that he could not bear her presence near him. One day subsequently

106

Two Caws of “ Washiny-Hand ” Mania .

to these events she observed her child nt play with another child who was
suffering from ringworm; many years before this her baby had had this
disease; recovery had taken place in due course, and nt the time no undue
importance was attached to the incident. Now, however, she displayed
extreme anxiety fearing that infection might have again taken place, and
long after there was any possibility of this having occurred she continued
to have unreasoning fears, which she was unable to control. She persisted
in taking every precaution she could think of to protect the child from
further infection, and maintained a constant and anxious observation of
her scalp and skin ; actuated by the idea that infection might have already
occurred she made use of every sanitary precaution against the possibility
of conveying tlie disease or getting the house and clothing contaminated.
The fear of infection constantly forced itself upon her, incapacitating her
from her usual occupations, and compelling prolonged and profitless
ruminations. This state of mind continued with remissions for the next
few years, the attacks always returning with increasing severity, and
leaving her more and more aboulic. In these crises of anxiety and doubt
she sought relief in a prolonged washing of hands. This habit became
more and more uncontrollable and developed into the impulsion which
brought her to the asylum.

She is a woman of medium build and is well nourished. On admission
there were chilblains on the hands, the skin of which was red, glazed, and
exfoliating in patches. There were signs of a well-compensated mitral
cardiac lesion, but she was otherwise in good health; the reflexes were
normal and sensation unimpaired.

One maternal aunt was known to have been insane.

Her manner was quiet, and she appeared calm and self-possessed except
for an expectant and slightly anxious expression. She replied willingly,
the attention being well maintained and the reaction not delayed. She
gave a good account of herself and her memory was unimpaired; orientation
was normal. The prevailing affective tone was one of mild depression and
anxiety. She spoke and reasoned intelligently and with self-control. She
showed much insight into her condition and circumstances, and quite
realised her position. She complained that she was unable to prevent
herself from persistently washing her hands. She realised that it was
something abnormal in herself which she desired to be cured of, and she
recognised that she was in the asylum on account of this abnormality.
She told me all the details of the ringworm and of her obsessive ideas and
fears, but she made no mention of her relations with her husband.

G. F. Barham.

107

There was a marked feeling of self-insufficiency. She informed me
that she had always been nervous and timid, and that for many years she
had felt strangely anxious, had lost all confidence in herself, and that she
had been subject to fears and anxiety about her child, which quite in¬
capacitated her from her usual occupation. After a week or so a rapid
improvement set in, she felt herself again, and the impulsion entirely
disappeared. She returned apparently quite willingly to her husband, and
seemed to have entirely recovered.

In March, 1909, she was readmitted. It transpired that the return to
her old environment had been associated with a recurrence of anxiety
and unrest; gradually the same fear of infection took hold of her mind,
and with it the impulsion returned. Although she was able to control
these symptoms to a certain extent, she had been in an almost constant
state of doubt and self-interrogation. The anxiety she had formerly
experienced concerning her child now appeared in a more generalised
form; thus, if she chanced to meet a child in the street, she was liable to
begin arguing with herself as to the possibility of that child being
infected with some disease, and in order to avoid a meeting she would
turn back and reach home by a long detour and then subject herself to
prolonged ablutions. On one occasion, seeing the baker approaching the
house, she observed that he stopped and spoke to a child, she at once
became very uneasy and alarmed, and refused to take in the bread which
he brought. She was only reassured by her husband’s promise that they
would employ a different baker. At times her anxiety associated with
this idea of contamination spread to the house generally, and on one
occasion she cleaned everything with paraffin, including the inside of the
piano, pouring this fluid about instead of using it upon a cloth, because,
as she argued, the cloth might possibly contain some germ of infection.
The idea of infection was at this time less defined, and not particularly
associated with ringworm, but her child was always the special object of
her concern. There was a strong feeling of personal contamination which
compelled her to wash after touching any object.

When she returned to the asylum she was at once more self-possessed,
and her mental state was very similar to that already described. She
now for the first time confided to me that her husband had not been kind
to her, that she was unhappy at home on this account, and that he was
the cause of her relapse. She rapidly became well again, and in the
following October was again discharged as recovered. She stayed awhile
with her sister, and then returned to her husband. After a few weeks

108

Two Canes of “ Wa-shing-Hand” Mania.

she became unhappy and restless. She began her ruminations again, and
was unable to sleep. The fear of a return of her trouble caused her to
write to me for advice; she complained of a return of her feeling, of
anxiety and loss of self-confidence, ami said that she relied entirely upon
me, and would return to the asylum if I thought it best for her. After
six weeks* absence she was again admitted. She was despondent and
resigned, and was suffering from the same washing impulsion; there was,
however, no dominant idea in her mind associated with the action, which
now appeared more automatic. She seemed relieved to be back again.
This attack was more persistent, and was marked by the same feelings of
incompetence and the same want of self-confidence. She has always
retained a perfectly sane judgment in the matter of her impulsion. She
improved slowly, and is now almost free from her trouble, but for a long
time there was always a feeling of apprehension when the question of her
discharge was raised. She often showed anxiety and indecision in respect
to her relations with her husband. It was now for the first time that she
made a full confession of these relations in reference to which there is
always evident in her mind the conflict between opposing trends : thus
she would maintain that he had treated her shamefully, that he was the
cause of all her trouble and that she would never live with him again, yet
she never seemed to relinquish the hope that he would be unable to live
without her. She continued to receive visits from him, though he often
seemed unsympathetic and unkind to her, and when quite recently he
became dangerously ill, she showed the greatest concern and anxiety to be
with him and care for his wants.

There are certain features which are common to these two cases.

(1) General temperament: Both these patients were timid and reserved
in disposition, they were subject to ereutophobia, shrank from publicity,
and showed a general want of self-reliance. They were self-critical and
particularly scrupulous in the less important affairs of life. There was a
ready tendency to become discouraged, and they were frequently subject
to feelings of effort and of incapacity.

(2) The liability to states of anxiety.

(3) The tendency towards hesitations, doubts, self-examination, and
endless questionings (ruminations).

(d) A resulting inability to arrive at a decision or action, particularly
in matters which concerned themselves (abulia).

(o) Phobias, of infection, of contamination, of contact.

(0) Obsessions of personal uncleanliness.

G. F. Barham .

109

(7) Compulsive actions, e. g. constant washing of lumds.

All these symptoms have been frequently described by various writers;
formerly, however, they were regarded as belonging to a number of
distinct diseases, e. g. “folio da doutr” “obsessional insanity,” “impulsive
insanity,” etc.

Now Janet, in his great work on * Los Obsessions et la Psychasthenic,’
published in 1903, pointed out a common form of reaction underlying
certain mental states; these included, besides those already mentioned,
the mental “ manias,” various states of anxiety, phobias, and diverse forms
of agitation and tics. These he collected together, and showed, in an
exhaustive study, that they shared a common basis and that they could be
interpreted by reference to a single theory. To this group he gave the
name of “ psychastlienia.”

In this reaction he observed a disorder in the functioning of the mind
presenting the same essential characters independently of the particular
function involved; the function reacts in a nfanner which is not only
exaggerated, but inefficient and beyond the proper control of the subject.
There is no complete paralysis of the mental processes, but they are liable
to be checked or insufficient; thus there is a failure in the attainment of
certainty and of belief in thought, and in action the execution is incomplete.
This failure is accentuated in the presence of others, or as the mere result of a
subjective effort of attention ; moreover, even when the functioning appears
complete, there is a subjective feeling of incompleteness accompanied by
feelings of incapacity, uneasiness and anxiety. When placed in circum¬
stances demanding action or decision, the consciousness of this incapacity
tends to promote crises of agitation and diffuse anxiety. The mind,
incapable of complete action, thought or feeling, becomes conscious of
having forced upon it doubts and questionings, and is liable to forced
ruminations and reveries, or to a variety of forms of “ manias,” e. g . of
precision, of counting, or of explanations, precautions, etc. In this state
of mind the essential disorder appears to have reference to an absence of
decision and of the power of resolution, to an absence of belief and of
attention, and to an inability to realise an exact perception of the present
moment. In order more readily to resume these various troubles in a
single conception, Janet propounded the idea of a special function of mind,
which he named “La fonction du rit'l ” (1). On the quality of this function
depends the individual’s power of apprehending reality whether in percep¬
tion or in action. “ To understand a perception or an idea with a feeling
that it is reality, this is to co-ordinate round that perception all our

110

Tiro Cases nf “ Washing-Hand ” Mania .

tendencies, all our activities; it is the complete accomplishment of the
attention” (*2).

The loss of this function is that feature above all others which charac¬
terises the phenomena of psvehasthenia. It is exemplified in the feelings
of incompleteness of automatism and of being in a dream. The psychas¬
thenic often complains that he is only half alive or that his soul is
separated from his body ; he experiences feelings of strangeness as if he
were in another world; his environment seems changed and unreal.
In the abstract in imagination and in affairs which have little importance
or barely touch on reality he is able to act without difficulty ; but when
action becomes important, when the social environment becomes difficult,
or when there is question of reacting on concrete reality, lie fails.

Hence it comes about, then, that while in states of psychasthenia there
is a deficiency in those phenomena of mind upon which depends the exact
adaptation of the personality to the present situation, the power of
attention, the faculty of belief, the feeling of reality, and the power of
completely assirnulating new perceptions—in short, the qualities of a mind
of the highest level of efficiency—in these same states we find preserved or
exaggerated those mental phenomena to which the personality attaches
little interest or importance, phenomena of a simple kind exacting no
complicated or new co-ordination of ideas, and no strain upon the attention,
phenomena to which the mind is already well accustomed, and which have
little bearing on reality or relation to an immediate and new set of
circumstances. Xow the functioning of the normal mind is subject to
oscillations of its level of efficiency; it is influenced by fatigue, by sleep,
and by emotions, it has a definite relation to age, experience, and
education. These oscillations may be observed also in a number of
diseased mental states, in which they undoubtedly plav an important but
subsidiary part. The psychasthenic mind, however, is essentially charac¬
terised by an instability of its level of efficiency, by its inability to maintain
a high level, and by the readiness with which under various influences it
tends to become rapidly lowered.

This lowering of the mental level (alndssment <1u niveau mental) Janet
has explained by the conception of a variation in the mental tension
(la tension pstiehnhujiyw). The degree 4 of this tension is dependent on the
number, richness, and complexity of the elements in consciousness, together
with their unification and concentration in a new synthesis. The lowering
of the mental tension, therefore, would render difficult or impossible the
conscious realisation of those higher phenomena of mind connoted in

CL F. Barham.

Ill

Janet’s “fonduni du r< : d” viz. the consciousness of personality and the
feeling of freedom in voluntary action, the perception of reality, belief
and certainty, and tho faculty of realising satisfaction in the reaction of
the present moment. The consciousness of this deficiency and mental void
is expressed by the subject in all manner of feelings of incompleteness.
The psychasthenic is always comparing his present incapacity with the
best achievements of his previous experience; he possesses ideals of a
perfection impossible to him; hence the feeling of insufficiency and the
resulting abulia, ruminations, and self-criticism. From these are derived
the various “manias” of precision, explanation, etc., and ultimately the
obsessive ideas. “An obsession is the final result of the lowering of the
mental level; it is a sort of interpretation which presents itself perpetually
to the mind, so long as the fundamental disorder which underlies it
persists” (J).

The obsessive ideas of psychasthenia are, as Janet has pointed out,
always critical in nature and derogatory towards the actions and thoughts
of the subject; they have, moreover, a particular reference to their persons,
ideas, and actions, or to their bodies. He, therefore, regards them as
endogenous in origin, and contrasts them with the exogenous fixed ideas
of hysteria. A feeling of incompleteness always precedes or accompanies
the psycholeptic crisis, and a vague anxiety drives the sufferer to seek
some form of excitation. The reaction to this stimulus, usually some
symbolic action, is passionately pursued, and brings with its accomplishment
a certain amount of temporary relief. The impulsion thus set up tends to
persist because the abulic mind is incapable of conceiving an alternative
remedy; it continues so long as the feeling of anxiety remains. In a paper
on “The Pathogenesis of some Impulsions” (4) Janet has emphasised these
points, and shows how these excitations are satisfied by actions which are
normally exciting to everybody ; even the impulsion to inflict pain upon
oneself (as in observation 5) can be traced to the need of courageously
bearing pain. The central idea of the obsession is the expression of an
explanation which the patient arrives at in the interpretation of his own
mental state ; it is his own theory of the transformation, of which he is
painfully conscious in himself. Thus, Caroline M—, though she recognised
her own scrupulously moral character, came, through feelings of anxiety,
doubt, of suspicion and shame, to interpret the change in herself by an
obsession of uncleanness and sin. In the psycholeptic crisis these ideas
form the content of ruminations and are forced on a mind which constantly
experiences a need for precision, for explanation, and for some symbolic

112

Tiro Cnsrs of “ IVnsIriiKj-Ihrml ” Minna.

expression of its feelings of incompleteness and psychic insufficiency ; they
have, moreover, reference to actions and thoughts of a painful nature
which the patient would not desire to accomplish; they constitute, in fact, a
delirium of auto-aecusation, and are developed in the mind of the subject
as a confession of a state of impotence in which the process of thought
cannot be carried to its logical conclusion, and which perpetuates a state
of doubt regarding his actions and beliefs. The obsession is then regarded
by Janet as a further manifestation of that lowering of the mental tension
by which he has interpreted the phenomena of psychasthenia in general.

Amongst the associated causal factors concerned in the abnormal
oscillations of the mental level we must again refer to the influence of
states of fatigue and of bodily illness, but especially to the influence of
emotions. These latter, as Janet has shown, are associated both with the
rise and the fall of the mental tension, and he remarks that they are often
both the occasion of and the feeling experienced in marked changes in the
mental level. He holds the view that emotions, while they are frequently
important associated factors, still, cannot be held to offer an adequate
explanation of the phenomena. The psychasthenic often shows a tendency
to a'feeling of indifference; but this is not the indifference of apathy, it is
an indifference which he constantly criticises and deplores, his great
trouble in his incapacity to feel a real and complete emotion over
anything.

To explain the phenomena which he has shown to depend on variations
in the mental level and also his conception of a deficient mental tension,
Janet has put forward his hypothesis of a failure in mental synthesis; this
latter process he describes as “an operation which unites in one single and
new composition the elements furnished at each moment of life by the
senses and by the memory” (5). Further, he conceived the mind of these
patients to be in a state of molecular disintegration, in which condition all
the sensations, ideas and memories were assumed to be loosely bound
together. It is instructive to turn for a moment to compare this conception
with that suggested by Janet to explain the phenomena of hysteria; here
he conceived the idea of a molar disintegration to account for the splitting
and contraction of the field of consciousness. In this latter condition the
ideas, memories, etc., are assumed to be compactly associated, but liable to
be split off in lumps as it were. The dominance of certain associated
systems of ideas would then lead, by exclusion of others, to the narrowing
of the field of consciousness, but within this narrowed field the functioning
of the mind may appear normal.

G. F. Barham.

113

We have, then, in this far-reaching interpretation of Janet's, to the
magnitude of which the limits of a short paper render it hopeless to do
adequate justice, the practical conception of a form of reaction which is
invaluable in its application to clinical phenomena as well as in the
intelligent understanding of the problems they present. Both Caroline
M— and Elizabeth D— are examples of this reaction; the former case
belongs to the constitutional variety of psychasthenia; the latter should
perhaps be regarded as an acquired form, the earlier history being incon¬
clusive. The occurrence of obsession-impulsions in these cases is only in
accordance with innumerable observations, particularly by Janet. Bianchi
observes, “ I have never seen a subject suffering from obsessions who was
not uncertain and hesitating in most of the actions of his life” (6). As
regards the aetiology of obsessions this writer holds that indispensable
conditions are (1) an excessive emotivity, and (2) congenital or acquired
weakness of the mental organism.

Storring also lays stress on the importance of emotions, and particularly
of anxiety. In the latter half of the nineteenth century there were two
opposing theories to explain the origin of obsessions. There was the
intellectual theory, supported by Grriesinger, Westphal, Hack Tuke, and
Magnan amongst others; with certain individual modifications, it advanced
the conception that the essential factor was a disorder of the intellect, and
that all other symptoms were subsidiary. On the other hand, there was
the theory advanced by Morel, and supported by Legrand du Saulle,
Wernicke, Fere, and by Pitres and Regis, which held that the intellectual
phenomena were secondary to a disorder and disturbance in the affective
life. Until recent times this latter theory was generally accepted by the
majority of observers. Janet, however, pointed out that neither of these
theories offered an adequate explanation of the phenomena. He sought a
wider interpretation, and regarded the emotional factor as also subsidiary.
Janet based his conclusions on innumerable observations on the
evolution of morbid states of mind, which enabled him to place these
syndromes in large groups exhibiting similar reactions. It is note¬
worthy that he constantly observed the modification or exaggeration of
normal psychic processes underlying the phenomena of disense. He
regards the obsession as the reproduction of a former event or idea which
at the moment of its appearance was not the cause of any trouble, but
which becomes pathological at the instance of a new emotion.

As regards the form of the impulsion, Storring (7) has insisted on the
importance of “ strain-sensations ” or muscular hallucinations as playing

8

114

Two Case* of “ Washing-Hand” Mania

an essential part in the development of the action. In reference to this it
may be noted that Janet observes that the subjects of impulsions have
representative images in their mind which harmonise with the execution
of the desired act, and he has remarked on the exhibition of more or less
involuntary little muscular movements which are like the beginnings
of these acts; hence the patient frequently says he feels urged to perform
the action.

Although Janet’s interpretation can be applied to explain the evolution
of the two cases of obsession-impulsion described above, nevertheless it fails
to take account of certain points which appear fundamentally important
to a more complete understanding of the morbid factors at work. The
elucidation of these points we owe to the work of Prof. Freud.

The latter interpreted the phenomena of the psycho-neuroses, firstly by
his conception of the unconscious mind, and secondly, by constructing a
conceptual mechanism designed to explain the morbid phenomena observed
in these neuroses. He justified his theories by demonstrating that they
satisfactorily account for the phenomena, and this he has been able to prove
by his method of psycho-analysis and by the success of his psycho-therapy.
For the present purpose only a brief reference is made to certain essential
points of Freud’s theory; a more detailed explanation is beyond the limits
of this paper, and the reader is referred to several articles on the subject
recently published by Bernard Hart (8) and Ernest Jones (9).

Inquiry into the intimate experiences and history of patients frequently
brings to light the existence of a mental conflict between, on the one hand,
the personality, and, on the other, a complex* of a painful nature and with
which it is out of harmony. Under these circumstances the mind endeavours
to rid itself of the complex and to forget its existence. The process by
which this is effected is known as "repression”; “ the effect of repres¬
sion,” to quote a recent paper by Bernard Hart (8), "is to prevent the
complex exerting its normal action upon the flow of consciousness; that is
to say, the complex can no longer cause its constituent ideas to emerge
without resistance into consciousness, and it can no longer cause the flow
of thought and action to proceed in the direction of its own conative trend.
Bepression means, therefore, that a certain resistance is opposed to the

* The word “complex ” first used by Jung lias now come into general use. A complex
presents those aspects: (1) Intellectual elements; (2) the affective tone appertaining to
these elements, (:0 certain definite conativo tendencies (Hart) (8). In a recent paper by
E. Jones a complex is held “to indicate the whole group of mental processes relating to a
given set of experiences that have become invested with a strung feeling tone, usually of a
painful nature ** (1< >).

G. F. Barham .

115

complex which prevents tlie latter affecting consciousness in its normal
manner.” To this resistance Freud has given the name of “censure”
(Zensur).

“ In spite of repression and the censure, however, the complex preserves
an autonomous existence” in the unconscious (Freud), “and continues to
influence the flow of phenomenal consciousness, but the influence is now
distorted and indirect.”

By this mechanism Freud claims to explain many of the obsessions; an
obsession is an idea in consciousness that has become overweighted, due to
the fact that there has become attached to it the affect originally belonging
to a repressed complex. The obsessive idea is frequently, though not
necessarily, the opposite of the one repressed, and often stands in a symbolic
relationship to it.

In the case of Caroline M— there is unquestionable evidence of a con¬
flict between her naturally scrupulous and moral personality and the ideas
associated with a morally objectionable and repulsive habit. She succeeded
in overcoming this habit, but the complex remained in her mind. An
examination of the clinical evidence justifies the assumption that the
components of this complex would for the main part consist of—(1) ideas
associated with masturbation ; (2) the desire to obtain gratification by
resorting to this practice. Opposed to this would be the conative trend of
the personality towards a moral life, depending on her early education and
environment. Between these opposing complexes a conflict must inevitably
arise, and this conflict would express itself in feelings of remorse, disgust,
• self-reproach, and anxiety. In order to avoid the conflict the process of
“ repression” would come into play. That this masturbation complex had
been more or less successfully repressed there is, I think, sufficient evidence
in the patient's attitude towards her onanism when I first examined her.
She voluntarily came to the asylum because she realised her morbid state
and sought relief. Her complaint was her impulsion to wash, and the
uncontrollable idea that she was contaminated and wicked. She did not
admit or recognise any causal relationship between these symptoms and
the onanism, which when questioned she sadly confessed to as a regrettable
incident in her life. She, however, obviously did not attach any importance
to this episode, which held no disproportionate place in her conscious
thought. In this ignoring of the real significance of the masturbation we
have evidence of the partial repression of this complex. In the second
place there is evidence of the exaggerated conative trend of the personality
which appeared in an increased tendency to scrupulousness in her manner

1! 6

Tiro Canes of “ Washing-Hand” Mania.

of life, especially in the direction of an excessive personal cleanliness and
in the desire to be regarded as scrupulously clean and proper in her person.
The incident of the stained and soiled linen presented an idea opposed to
this trend and unconsciously stimulated the repressed complex ; hence
feelings of anxiety and suspicion arose in her mind respecting the opinion
of her fellows. Thirdly, we have the complex expressing itself symbolically
in the idea of uncleanness and leading to the symbolical action of washing
the hands.

The personality would not tolerate the avowal of the real occasion for
its feeling of uncleanness; the repressed complex could only elude the
censure by an indirect and distorted expression not essentially repugnant to
the mind. But owing to the fact that the irritant cause, i . e. the offending
complex, remains repressed and undispersed, the morbid affects thus
symbolically expressed tend to persist, and the obsessive idea and
impulsion continue to force themselves on the mind in a manner which is
subjectively recognised as entirely unbalanced by facts and as wholly
irrational.

The exercise of the censure constantly detracts from the available
mental energy and thus renders the mind abulic.

By this interpretation of the mechanism of obsessions Freud has
rendered intelligible the content of certain clinical phenomena which
frequently appear wholly haphazard and unaccountable. Although lie
differs from the interpretation given by Janet, the recognition of the
intrinsic meaning of psychasthenia, i. e. the grouping of a mass of clinical
material presenting a certain form of reaction, broadens the basis of our
knowledge of the psycho-neuroses, and paves the way to a realisation of the
significance of Freud’s theories.

Briefly to summarise the principal factors in the case of Caroline M—
we have—

(1) A constitutional predisposition—a certain type of reaction charac¬
terised by psychic self-insufficiency, tendencies to abulia, etc., symptoms
frequently observed as here, in association with imperative ideas and actions,
and which we may conveniently recognise under the name “psychasthenia.”

(2) The incidence of a painful experience affecting the sexual life.

(•») The conflict between mutually incompatible feelings and conative
trends and the barring from consciousness of the offending complex.

(4) The inevitable tendency of the repressed complex to influence and
disorganise the mental life of its host.

(o) The evolution, resulting from these forces, of a psycho-neurosis.

G. F. Barham .

117

Turning next to the case of Elizabeth D—, the problems presented
are considerably more complicated and scarcely permit of more than a
simple review of the facts. The application of the method of psycho¬
analysis to this case would probably reveal many factors elucidating the
development of the clinical symptoms. Still, recognising this deficiency,
the case appears to have considerable interest, both in comparison with the
other comparatively simple case described above and also in reference to
these questions of aetiology and of interpretation. The repognition of
Freud’s mechanism enables us to gain a far deeper insight into the problems
presented in our daily clinical observations, both in respect of a more
scientific classification of material and also in reference to the questions of
prognosis and treatment. This recognition obtains especially in the
practice which deals with large numbers of cases, where the more complete
methods of analysis are impracticable.

In this second case an examination of the principal factors reveals a
closely similar mechanism to that in operation in Caroline M—. This
woman was naturally dependent, and felt the need of domination, sympathy,
and affection. These she found in her husband, and married life started
favourably. Then came an important factor—the interference with the
normal conjugal relationship and the practice of prevention, which in this
case took the form known as “ coitus interruptus.” Freud (11) has called
attention to the evil effect of a frustration of the normal somatic
and psychic satisfaction, and has observed the frequent incidence of this
form of sexual trauma in the histories of patients suffering from anxiety
neuroses. He goes so far as to hold the view that in this factor is to be
found the principal cause of the neurosis. I will only record the observa¬
tion that the abnormal state of anxiety in this case bears a chronological
relationship to the practice which was carried on for some years, and that
her morbid emotivity was followed by the development of vague fears
relative to conjugal estrangement, to the health of the child, and to the
possibility of infection from ringworm.

Pari pawn there was the development of a real sexual indifference,
chiefly on the husband’s side. The patient was constantly distressed bv
the idea that her husband cared less for her, and came to realise the full
import of this fact in the repulsion he showed during his illness. Thus
the whole trend of events evolved in her mind certain painful complexes
at conflict with all her natural tendencies.

The ideas associated with her husband’s indifference and unkindness
towards her were clothed with feelings of a painful nature, of regret, self-

118

Tiro Cases of “ Washing-Hand ” Mania.

reproach, and anxiety for the future, and the conative trend of this
complex tended in the direction of resentment and antagonism towards
him, a feeling that has frequently shown itself since, often in association
with contrasting feelings showing her real affection (e. g . as in his latest
illness). The very nature of this complex at conflict with the personality
(her affection for her husband, her desire to look after and care for him,
her dependence on him and the idea of her home, and all that this meant
to her) necessitated concealment in the social environment where she had
no intimate friends and only unsympathetic relatives. The offending
complex was too painful to be suffered to occupy her thoughts and was
therefore persistently ignored and repressed. In this connection it may
be recalled that for a long while after she came under my care she
concealed these facts from me, although freely giving me her confidence
in other matters.

Her natural conative trend showed itself in her efforts to care for and
nurse her husband, in face of his repulsion of her—in persistent tendencies
to actions in justification of her desires, aud when checked in this direction
she showed an exaggerated development of maternal affection. The
conflicts in this patient’s mind are certainly extensive and complicated, and
there is evidence of other complexes, e . g. such emotional disturbances as
may be assumed to be associated with sexual frustration and the interference
with sexual and maternal instincts, which could not be brought to light
by the ordinary method of examination. An attempt is only made here
to demonstrate the fact of the occurrence of conflicting states of mind and
of the repression of painful ideas.

In conclusion, we may, therefore, again emphasise the practical
significance of the recognition of Freud’s mechanism in the interpretation
of the evolution of these abnormal mental states, the aetiology of which
may, in this way, be found in a study of the whole development of the
personality and in the vicious influence exerted by the social environment
upon the normal functioning of the mind.

Bibliography.

(1) Janet. —‘ Les Obsessions et la Psychasthenic,’ tome i, p. 487.

*2) Ibid. — Idem., tome i, p. 488.

(3» Ibid .—‘ Los Nevroses/ p. 366.

(4) Ibid .—‘Journal of Abnormal Psychology/ April, 1906.

(•”>) Ibid .—‘ Les Obsessions et la Psychasthenic/ tome i> p. oOl.

(Oi Bianchi.— ‘ Text-book of Psychiatry ’ (translated by MacDonald), p. 626.

(}. F. Barham.

119

(7) Sto wring. —‘Mental Pathology and Normal Psychology ’(translated by Loveday),
p. 197.

(S) Hart.— “The Psychology of Freud and his School/' ‘Journal of Mental Science/
vol. lvi, p. 431.

(9i Jones. —" Freud’s Psychology,” ‘ Psychological Bulletin/ vol. xvii, p. 109.

(10) Ibid .—“ The Practical Value of the word Association Method in the Treatment of
the Psycho-neuroses,” * Review of Neurology and Psychiatry/ vol. viii/ p. 6-18.

(11) FreCd. —“ Obsessions et Phobics,” ‘ Revue Neurologique ’ 1895 ; ‘ Kleine Schriften
zur Neurosenlehre/ 190*3, p. 92.

A Review of the Recent Literature in England and America on
Clinical Psychology and Psycho-Pathology.*

By Eknkst Jones, M.D.Lond.,

Demonstrator of Psychiatry, University of Toronto , Canada.

I. Introduction.

Thkkk have been four distinct movements in clinical psychology and
psycho-pathology in Anglo-Saxon countries. The two that originated in
England are practically dead so far as further progress is concerned : the
American two are at the height of their vigour. At the head of these
movements stand the names of Braid, F. W. H. Meyers, Morton Prince,
and Adolf Meyer respectively. Associated with the first of these, Braid,
the names of his predecessors Elliotson and Esdaile should especially
be mentioned; with the second those of Gurney, Podmore, William James,
and Hyslop; with the third Boris Sidis, Putnam, Coriat, Courtney,
Linenthal, and Taylor; and with the fourth August Hoch and Macfie
Campbell.

To the first of these movements, which may be dated 1840, we directly
owe most of our modern knowledge of hypnotism. Braid’s work was the
inspiration for Azam, Broca and Velpeau, and to some extent indirectly
for Liebault, from whom the Nancy and practically all other present-day
European schools of hypnotism have sprung. Little, however, has been
added to Braid’s work. Hypnotism is still looked askance at by the medical
profession in England, and even more so in America, though there are
many physicians in the former country, notably Milne Brainwell, Lloyd
Tuckey, Woods, and Kingsbury, and some in the latter, including
Quackenbos and others, who devote themselves to the practice of it.

The second movement, which flourished most in the eighties, first in
England and then in America, was productive of a mass of valuable experi¬
mental work on post-hvpnotic suggestion, hallucinations, automatic writing,
crystal-vision, etc. This is practically all published in the 'Proceedings of

* Written December, 1SHJ9, for the ‘Jahrbueh fur psychoanalytische und psychopatho-
logische Forsch unveil/ in Bd. ii, of which a German translation appeared.

Ernrst Jours.

121

the Societies for Psychical Research.’ From the first, however, much
interest was manifested in such subjects as clairvoyance, telepathy, table-
rapping, etc., and of late years the spiritistic aspects have dominated all
others. The pronounced tendency of the members to spiritism did a
great deal to discredit their work on other subjects, and is one of many
causes why clinical and practical psychology is still coldly received in
England.

The third movement was initiated by Morton Prince about twenty years
ago, but most of the published work is less than half-a-dozen years old, and
it is only within this time that he has achieved any considerable following.
Though it has many independent features, it owes much of its inspiration
on the one hand to the experimental and non-spiritistic work of the
second movement mentioned above, and on the other to the investigations
of the Paris school, particularly those of Pierre Janet.

The fourth movement is of still more recent date, and traces more direct
connections with the continent, particularly to the Freud school. It is
chiefly concerned with the psycho-pathological problems of psychiatry.

The present review refers chiefly to the publications of the past three
years. A great number of articles, frequently of no value whatever,
have appeared in this time, aud in the list given above references are given
to only about a tenth of the publications; it is hoped that the list includes
all the best work on the subject. Many excellent articles by foreign
writers, notably by Bechterew, Claparede, Janet, Jung, Pick, Sollier, and
Soukhanoff, have been published in Anglo-Saxon journals in this period,
but these are not included as they do not originate in any Anglo-Saxon
school. Works on the subjects of hypnotism, sexology, religious
psychology and social psychology are also excluded, so as to economise
space. Much of the best work done anywhere on the latter two subjects
has been American; a review by Pratt of the recent American work
in religious psychology, in the ‘Zeitschrift fur Religionspsychologie/ 1909,
Bd. iii, H. 3, may be referred to. The leading Anglo-Saxon writer on
sexology is Havelock Ellis, whose works are better known in Germany
than elsewhere.

A word may be said as to the attitude towards clinical psychology
prevalent in Anglo-Saxon scientific circles. This is quite different in
England and America. In the former country the subject is viewed with
a cold antipathy, and, so far as the present writer is aware, no scientific
investigation whatever is being carried out on it ; less than a tenth of the
articles here referred to were published in English journals. In America,

122

Clinical Psychology and Psycho-Pathology.

on the other hand, there is a widespread cordiality towards the subject,
though the value of this is largely counter-balanced by the superficial and
uncritical views that, except in a comparatively small circle, generally
prevail. Readiness to accept a psychogenetic origin of certain maladies is
much more widespread in the American medical profession than in the
English, and there is also in that country a very general interest taken in
the problems by the laity, as is evidenced by the popularity of such books
as Addington Bruce’s “The Riddle of Personality,” Hudson’s “Psychic
Phenomena,” and Waldsteiu’s “The Subconscious Self,” etc.

Those who propose personally investigating any of the writings here
referred to should be explicitly reminded that, as the account of them
given in this review is based on the present writer’s individual judgment,
it is not likely to be quite impartial, though every attempt will be made so
far as possible to make it so. The descriptions will further necessarily be
incomplete and condensed, so that the danger of distorting the authors
views is especially hard always to avoid.

II. Casuistic, Symptomatology, Diagnosis and Treatment.

In the symptomatology of hysteria valuable contributions have been
made on the subject of blindness and other visual abnormalities by Baird
(5), Diller (40), Gradle (59), Onuf (114), and Parker (116), on that of
hysterical affections of the ear by Holmes (70) and McBride (96), and
cases have been recorded of hysterical mutism by Hudson-Makuen (72),
J. K. Mitchell (109), and Oettinger (113), and of aphasia by Le Kerr (93).
It is held that hemianopsia never occurs in hysteria, a view also subscribed
to by Mills (106). Studies of Ganser’s Syndrome have been published by
Diller and Wright (41), Frost (54), and Ruggles (143); the first named
(42) and Woodman (191) have also contributed useful clinical discussions
on hysterical insanity. It is generally thought that Ganser’s Syndrome is
not pathognomonic of hysteria, and that hysteria is comparatively rarely
found in asylum cases. Detailed reviews on the subject of hysteria in
children, with many illustrative cases, have been published by Hecht (63)
and Thomas (166) ; it is dealt with from a purely clinical point of view.
Hoover’s (71) sign of hysterical paraplegia consists in the absence of the
normal downward pressure of the heel when the patient raises from the
bed the opposite limb. The present writer has published (77) a case of
hysteria showing at four different stages in its evolution true tactile
aphasia (in Claparede’s sense), asymboly, Tastlahmung , and anaesthesia.
He has also shown (81) that the current belief that hysterical hemiplegia

El'Urst Jours.

123

affects by preference tlie left side is founded solely on Briquet’s opinion ;
in the cases published since 1880 the two sides are affected with equal
frequency. In two further papers (78, 80) it is pointed out that allo-
ehiria is a pathognomonic symptom of hysteria; in the past it has been
confounded with other troubles that may occur in organic disease.
Dyschiria is an affection of sidedness, of which there are three forms; (1)
achiria, in which the patient has no knowledge of the side of a stimulus ;
(2) allochiria, in which lie refers it to the exactly corresponding point on
the opposite side; and (3) synchiria, in which he refers it to both sides.

Deaver (36) and Williams (182) point out the importance of the mental
factors in cases of gastric neurosis , and Cannon (16) deals with the same
subject from the physiologist’s point of view, relating the work of Pavlow
and others on psychic influences in relation to gastric secretion.

Weir Mitchell (111) has published a case under the title “Motor
Ataxy,” and Scripture (152) one under the title “ Penmanship Stuttering,”
which are evidently instances of Angsthysterie.

Janet’s conception of psych-asthenia has a great vogue in America, and
the nosological status of the condition is generally accepted. Orthodox
expositions of the subject have been given by Blumer (7), Collins (22),
Courtney (31) and Donley (49). Of these Courtney’s description is the
fullest and most precise. Donley (43, 45) has published some cases of what
Prince in 1891 described under the term “association-neurosis.” By this
is meant a syndrome, which may occur in various maladies, where the
symptom ( e.g . fear) is reproduced whenever the patient lives through an
experience that is associated with the occasion on which the symptom first
occurred. For instance, a patient who lias once been frightened in a
churchyard may experience fright whenever he meets anything associated
with a church. The patient is usually relieved when he fully recalls and
talks over the initial experience.

A meeting of the Neurological Section of the Royal Society of Medicine,
London, on January 30th, 1908, at which Buzzard, Collier, Guthrie, Harris,
Head and Ormerod spoke, was devoted to a discussion of tic. It followed
the lines laid down by Cruchet, Meige and Feindel, and nothing new was
brought out. Prince (125) has described a severe case of multiple tic, and
expresses the view that the symptom is the manifestation of a dissociated
automatism, due to the functioning of some subconscious mental process ;
the nature of this he could not determine.

Spiller (162) has an interesting article ou the subject of pyschasthenic
attacks, of the type described especially by Oppenheim, and discusses the

124

Cliwical Psychology and Psycho-Pathology.

diagnosis between them and narcoleptic attacks. In relation to this the
present writer described a case (79) in which it was possible, by studying
the subconscious memories related to the attack, to establish the diagnosis
of hysteria; he contrasts the “ massive ” disaggregation of hysteria with
the “ molecular ” disaggrega t ion of psychasthenia. Putnam and Waterman
(139) have also discussed the differential diagnosis between epileptic and
hysterical attacks from a psychological point of view, and Camp (10),
Hetcli ((54) and Taylor (163) have described other conditions of chronic
narcolepsy. Coriat (25, 27) has been able to trace a relation between
nocturnal paralysis (Weir Mitchell’s syndrome), and repressed unconscious
memories of painful experiences; he has described five cases of it, and
advances good reasons for considering it a psychical manifestation, a
“ recurrent mental state.”

Great interest was aroused in America in the subject of multiple
personality by Prince’s study of a case of this nature published in great
detail in 1906 (126). It is certainly the best observed case of the kind
that has been recorded, and is so well known that description of it here is
not necessary. The book is purely descriptive in character, and is to be
followed in 1910 by another volume in which the theoretical aspects of
the subject will be dealt with. In a book that will presently be again
referred to (154), Sidis published a case of double personality, and a.
number of like cases have since been recorded by Angell (3), Coriat (26),
Dewey (39), Fox (53), Gaver (5G), Gordon (57), Hyslop (73), and others.
Hyslop’s case showed a subconscious fabrication of Martian language
similar to that invented by Mddle. Helene Smith, and probably founded
on the knowledge of Flournoy’s book. Studies on cases of ambulatory
automatism have been published by Courtney (30), Lloyd (95) and
Patrick (117) ; in the first mentioned article Courtney discusses the
differential diagnosis between the various maladies in which this condition
may arise.

The number of articles published on psi/chotherapy is very great, and
the quality of many of them is decidedly poor. Practically all the
European schools are represented in America. Thus Barker (6) advocates
Dejerine’s method of isolation, etc., Jelliffe (75, 76) advocates Dubois’
“persuasion” method, Williams (170, 187, etc.) that of Babinski, etc.
Prince and Coriat (132) hold that there is no distinction between persuasion
and suggestion. They rely in treatment especially on tracing back as far
as possible the origin of the symptom, particularly in hypnosis, on divesting
it of its unpleasant associations (Janet’s device), and substituting a fresh

125

Ernest Jones.

group of pleasant associations. Hypnotism is, in general, not regarded
with favour in America. Putnam (134, 135) advocates-wliafc he terms the
“skle-tracking” method, by means of which the patient’s interest for
healthy and useful mental pursuits is strongly aroused. He has inaugurated
an interesting “ Social Service” department in the Massachusetts General
Hospital, so that patients may as far as possible be brought into a
healthier and more stimulating environment. Emphasis is laid on the
relation of psychotherapeutic treatment to the “ social consciousness ” i>y
Putman (137), Schwab (149) and others. Another and more original
psychotherapeutic method is that devised by Sidis (159), and termed
by him “ Hypnoidization ”; it has been extensively employed by Donley
(47) and others. It will be discussed in the next section in connection with
Sidis’ other work. Miinsterberg (112) has published a very interesting and
useful book of a general character, but does not discuss individual methods
in detail. On May (3th, 1909, the American Therapeutic Society held a
symposium on psychotherapy. The papers read there have been published
in book form under the title of ‘ Psychotherapeutics’; this includes, besides
the articles above numbered 49, 84, 131, 159, 1(35, 172, one by Gerrish on
“The Therapeutic Value of Hypnotic Suggestion,” and one by Putnam on
“ The Relation of Character Formation to Psychotherapy.”

The Emmanuel and other religious movements of psychotherapy have
evoked a great deal of discussion in medical circles; their medical
encroachments have been energetically opposed by Collins (23), Farrar
(52), and Witmer (190). The relation between religious and medical
efforts in this direction has been defined by Putman (138) and others.
Tn this connection an interesting essay may be mentioned by Waddle (170)
on miracles of healing.

Just now it is fashionable in America for patients to publish auto¬
biographies describing their illnesses in great detail; such are : “ My Life
as a Dissociated Personality” by 13. C. A., ‘Journ. of Aim. Psychol.,’
October and December, 1908, ‘The Maniac : A realistic Study of Madness
from the Maniac’s Point of View,’ 1909, 4 The Autobiography of a
Xeurasthene ’ (really a case of hebephrenia), by Margaret Cleaves, M.D.,
1909, “The Mind that Found Itself,” by Clifford Beers, 1908. It need
hardly be said that most of such writings are of little scientific interest,
as the essential points are never mentioned. Beer’s book has been of
considerable public service in drawing attention to a number of asylum
abuses.

12(3

Clinical l\s;fcl(ohxfif and rsjfcho-Pathohuftf.

III. General Psychopathology.

We may begin with some of the work of Morton Prince, who is
unquestionably the leading Anglo-Saxon on “abnormal psychology.” His
first book, ‘ Nature of Mind and Human Automatism/ published in 1885,
was devoted to developing a panpsychic theory. He lias retained his
interest for similar problems, and his latest work (130) is mainly concerned
with the relation of conscious to subconscious mentation, and of both to
unconscious cerebration. As was mentioned above, he has made a very
great number of interesting observations on cases of multiple personality,
and it is chiefly in the light of such cases that he formulates his conclusions
on subconscious processes. For the study of them he makes use of direct
observation, hypnosis, automatic writing, crystal gazing, and various
specially devised and experimental tests.

Prince’s work on the subconscious may be considered in conjunction with
that of other writers ; his views are developed especially in a series of articles
on the unconscious (130), and in a review of a symposium on the sub¬
conscious published in the ‘ Journ. of Abn. Psychol./ April and June, 1907.
In the preface to this symposium lie defines the six main connotations in
which the term subconscious has at different times been employed :
(1) the marginal region of diminished attention which at any given
moment is outside the focus of consciousness; (2) active dissociated ideas
of which the subject is quite unaware; (3) synthetised, self-conscious
states, dissociated from the main consciousness, and forming a considerable
part of every normal and abnormal mind; (4) all potential memories,
including both the active dissociated states mentioned in the second
definition and all past conscious experiences, which are now inactive, and
which may or may not be capable of revival at a given moment; (5) a
“ subliminal” reservoir comprising the main consciousness, out of which the
personal consciousness flows as a subordinate stream(6) unconscious
cerebration. The fourth definition is that adopted by Sidis, the fifth that
adopted by F. W. H. Meyers. In the present symposium Miinsterberg
calls the third, second and sixth definitions given above the layman’s, the
physician’s and the psychologist’s respectively; he supports the last-
named, and maintains that all the facts invoked in favour of the conception
of the subconscious are adequately and more simply to be interpreted on
the physiological hypothesis. Pibot, in a short contribution, also inclines
to the same view. Jastrow, both in this symposium and in a book (74)

Ernest Jones.

127

specially devoted to the subject, seems to maintain a similar position, but
owing to the obscurity of the language in which it is couched the present
writer is unable to understand and thus to present his point of view.
Janet restricts the term subconscious to the second connotation given
above, and regards all disaggregation as abnormal. Prince sharply
divides the phenomena usually called subconscious, for instance as the
term is used by Sidis, and also those included in Freud’s Unhetcusute, into
two fundamentally different groups, which he terms co-conscious and
unconscious respectively. Co-conscious ideas are synonymous with Janet’s
#nhcornclent , and are mental states dissociated from the main personality.
The subject is often not aware of their presence, but sometimes is, as in
the case of an obsession. Thus for Prince not lack of awareness is the
true criterion of co-consciousness, but independence and automatic activity
that cannot be controlled by the subject. Further, “ consciousness may
be so rudimentary that it contains nothing of awareness, of self, of
intelligence, or of volition.” He stoutly maintains, as against Munsterberg
and Ribot, the psychical nature of these states, and supports this view by a
series of most convincing arguments and ingenious experiments (129, 130,
133, and ‘Journ. of Abn. Psychol./June, 1907). Unconscious processes
on the other hand, are not psychical, but physiological. They are divided
into sub-groups: (a) cerebral neural organisations and residua the func¬
tioning of which is manifested as consciousness ; (b) spinal and ganglionic
organisations and residua the functioning of which is manifested as
physiological memories; there is however no sharp line to be drawn
between these two. “ Purely physiological processes may manifest them¬
selves in acts of quite as intelligent a character as those exhibited by the
conscious processes.” Prince uses the term dormant consciousness to
denote those physiological residua into which mental complexes pass when
out of mind. “ It is the unconscious, rather than the conscious, which is
the important factor in personality and intelligence. The unconscious is
the storehouse of our minds. The secret of our moods, our impulses,
our intelligence, our acquisitions, our attitudes, our judgments, our
capacities, is to be found in its conserved dispositions/’ These dormant
memories may or may not be capable of voluntary recall; if not they may
be capable of being recalled through the use of special technique
(hypnotism, etc.). Again “dissociated dormant complexes that cannot
by any means be awakened to a conscious memory may be aroused into
activity as an independent co-conscious idea,” “ If the term Unbneus#te
is not restricted to co-conscious great confusion arises, and this very

128

Clinical Psycholoyy and Psycho-Pa thuloyy.

confusion underlies the psycho-pathology of the Freud and Zurich schools.”
Prince warmly criticises Freud and Jung for being so “ vague” about the
difference between co-conseious aud unconscious functioning: “ Freud’s
theories are severely impaired by defects which would seem to have
followed from his entire disregard or unfamiliarity with the methods and
results of experimental psychology. If we are to establish sound principles
underlying the mechanism of the mind, we must correlate the findings of
all methods of research, experimental as well as clinical, and give due
consideration to the results obtained by all competent investigators.”
His criticisms, in which he chiefly cites Jung, are not easy to follow,
especially ns he uses the term “complex” in a special and personal sense.
The main criticism seems to be of Freud's conception of the functioning of
the TJnhtnmnsste . Prince holds that Freud's facts may be explained in two
ways without invoking this conception. On the one hand the stimulation
of an unconscious complex ( e.g ., in the word association test) may cause
this to function as a co-conseious idea, in which case there is no uncon¬
scious and purely physiological cerebration, as he thinks Freud believes in.
On the other baud a given complex that is being stimulated may have
become split, so that the emotion has become secondarily attached to an
indifferent idea. Thus a given test-word may evoke a painful emotion,
not because the underlying complex is stimulated to functional activity,
but because the emotion originally connected with the complex has become
secondarily attached to* an associated idea, which is represented by the
test-word. In this case the underlying complex does not function, and
is not concerned in the manifestation of the emotion, though it may
historically have been concerned with the genesis of it.

Prince seems to accept as proven the activity of co-conscious ideas
only when these can be experimentally demonstrated, and he has published
a large number of instances in which he has done this by means of auto¬
matic writing, crystal gazing, and other methods. The principles of
dissociation and of automatism of dissociated ideas are the two on which
he lays most stress in psycho-pathology (124). He has, however, not eluci¬
dated any of the actual mechanisms by means of which these dissociated
ideas function. On the subject of multiple personality he has recently
written, besides the book referred to above (12b), a very interesting paper
(128) comparing ordinary hysteria with this condition. He regards all
cases of hysteria as a fur me frusta of multiple personality, and insists that
in neither case is any amnesia necessarily present. The paper contains a
tabulated summary of twenty of the best recorded cases of multiple

Ernest Jones.

129

personality, and it is pointed out tliat in some of these (e. g. Felida X) the
new condition that appeared was wrongly thought to signify the develop¬
ment of a new and superior personality, whereas really it signified the
synthesis of two halves of the personality, one of which had previously
been in abeyance from childhood.

Sidis* first book, ‘The Psychology of Suggestion * 1897, was also con¬
cerned with the question of the subconscious, which he defines in the fourth:
sense given above ; it contains many original and interesting ideas, which
however cannot here be considered. His second book, ‘ Psycho-patholo¬
gical Researches in Mental Dissociation/ 1902, is an account of experimental
observations on amnesias, anaesthesias, “ recurrent mental states,”’
disaggregation, motor automatisms, etc.; it is shown that the attacks in-
psychic epilepsy are the manifestation of dissociated mental states. Sidis
has recently contributed a series of extensive articles on the subjects of
perception and hallucination. In one of these (157) he maintains that
ideational and perceptual processes are fundamentally different in their
nature; a percept differs from an image in having intensity, in bearing
the mark of externality, in being immediate experience, and in that recall
of it is independent of the will. He divides the elements of a percept
into two, primary and secondary sensory elements; the former arise from
direct stimulation of a sense organ from the outside, the latter from
irradiation of this physiological process on to other sense structures.
1'hus when one looks at a table one sees the colour, form, etc. (primary
sensory elements), but one also sees the hardness, weight, etc. (secondary
sensory elements). In this article and in a previous one (153) he main¬
tains that hallucinations are purely sensory in nature and differ from
normal percepts in that the primary sensory elements are dissociated, and
so are not apprehended in consciousness, while the secondary sensory
elements constitute the hallucination; all hallucinations are due to
peripheral stimuli acting on a subject with a tendency to mental dissocia¬
tion. The “hallucinations” suggested during hypnosis, on the other hand,
are, according to Sidis (155), totally different from true hallucinations ;
tluw are not percepts but images, and should more correctly be called
delusions. In another series of articles (158) Sidis deals with the subject
of sleep. Dividing the explanations into physiological, pathological,
histological, psychological, and biological he strongly supports the last
named, and agrees with Claparede in regarding sleep as an active pro¬
tective instinct. He relates a number of experiments carried out on lower
animals (frogs, guinea-pigs and dogs) and infants by means of monotonous

9

130

Clinical Psychology and Psycho-Pathology.

stimulation, limitation of movement and inhibition of external impressions.
He sees in a certain half-waking state, which he terms “ hypnoidal,” the
primordial biological state out of which both sleep, aud hypnosis have later
developed. The hypnoidal state, which does not seem to differ from
Bremaud’s etnt de fascination and Forel’s Hypotaxie, is intermediate
between the waking state on the one hand and sleep and hypnosis on the
other. It is induced by the application of monotonous stimulation ( e . g.
the sound of a metronome) while the subject is in a condition of relaxation,
and is an unstable, fleeting condition. In the hypnoidal state it is deter¬
mined whether sleep or hypnosis will ensue. Sleep differs from hypnosis
essentially in that the psycho-motor thresholds are higher th in in the
normal ( i . e. psycho-motor activities are less excitable), whereas in hypnosis
they are lower ; iu the hypnoidal state a redistribution of thresholds
occurs.

Sidis’ recent work iu psycho-pathology is presented in his third book
(154), and in a series of papers entitled “ Studies in Psycho-pathology”
(156). He uses very special language in the exposition of this, such as
“ fading moments,” “ recurrent psycliomotor states,” “ moment conscious*-
ness,” and refers to various different states as hypnoid, hypnoidic,
hypnoidal, hypnagogic, hypnoleptic, hypnapagogic,hypnonergie, etc. The
book contains a valuable collection of instances of multiple personality,
and includes, amongst others personally observed, an account of the
celebrated Hanna case. This was a patient with profound and total
retrograde amnesia, even for the meaning of everyday objects such as
articles of diet and clothing, and Sidis gives an interesting account of
the order in which the resurrected memories flashed back and gradually
became synthetised. To this he adds a number of considerations on the
theoretical aspects of the condition and of the various abnormal mental
states. Sidis has had a great experience in the study of psychical
amnesias, anaesthesias, synthesias, and other types of dissociation.
Dissociated mental activities sum up for him a great part of psycho¬
pathology, but in considering the genesis of them he rests content with
such factors as psychic trauma, emotion, impression, etc.; the wish side of
the phenomena is hardly considered. Similarly he has not brought out
any of the mechanisms by which these dissociated activities manifest them¬
selves. Recurrent motor states is the name he gives to the symptoms of
the Ztvangsneurose and psychic epilepsy; these he traces to the manifesta¬
tions of subconscious activities (he uses “subconscious ” in about the same
sense as Freud’s Unhewusstc.)

Ernest Jones .

131

Sidis attaches great therapeutic importance to the use of the hypnoidal
state (154,156,159). In this state the patient obtains access to subconscious
memories that are otherwise difficult to reach, but Sidis maintains that the
mere making conscious of these is in itself inefficacious. The action of the
hypnoidal state lies rather in the release it permits of stores of potential
subconscious energy; this released energy brings about a synthesis of the
previously dissociated mental states that now come to the surface.

In an article written in common with Prince and Linenthal (161) Sidis
deals with the pathology of hysteria in the light of a given case. It is shown,
by Janet's methods, that the hysteric anaesthesia is really only a psychical
anaesthesia, and that subconsciously hyperaesthesia is present. Hemi-
epileptiform attacks were in hypnosis traced to their first occurrence on
the occasion of a severe fright, though no explanation is given as to why
this particular symptom should have followed. When the patient was able
to remember that in the attacks he was again living through the fright
experience they ceased. It is concluded that hysteric symptoms are the
manifestation of the automatic activity of a subconscious group of ideas,
the dissociation having in this case been brought about by the fright.
“Dissociation and automatism are the two fundamental processes in
hysteria;”

Coriat (24, 28) relates several cases in which he has been able, by
experimental methods, to bring back the memories lost in alcoholic amnesia
and other conditions ; in discussing the mechanism of amnesia he does not
consider the process of Verdrdngung . Verrall (169) has given an excellent
account of automatic writing as developed in herself. In a number of
papers (80, 86, 89) the present writer discusses the pathology of dyschiria
in general, and allochiria in particular. In the common form of hysteric
anaesthesia only the incoming sensations are dissociated ; in the rarer form
(depersonalisation) there is in addition an amnesia for the past memories
of the part of the body in question. If the latter are dissociated and not
the former, a rare occurrence which the author calls “ paradoxical type of
cleavage,” then dyschiria results, at first in its simplest form, achiria.
Sensations evoked by stimulation of such a part have six characteristic
features, which the author groups under the term “ phrictopathic ” (83).
Allochiria is a secondary result, and a teleological hypothesis is advanced
explaining its occurrence as an erroneous association that subserves the
function of enabling the lost bodily memories once more to be apprehended
in consciousness. A detailed study of two cases is related (86), which is
held to disprove Janet’s “image hypothesis” of allochiria.

132

Clinical Psychology and Psycho-Pathology.

Several writers have discussed the pathology of hysteria. Woodman
(191) expounds Janet's views in the light of twenty-six personally recorded
cases. Williams (175, 176, 179, 180, 183, 184, 187, 189) is an ardent
supporter of Babinski's views, and has expounded them in a number of
short articles. Mills (108) supports many of Babinski's views, which he
considers to be very fruitful, but does not think that they contradict Janet's
dissociation theory. He holds that physical trauma and emotion are
operative as well as suggestion, and believes that vaso-motor symptoms
may result from hysteria, as does Edgeworth (51). Dercum (37) throughout
opposes Babinski's views, and explains hysteria as a retraction of neuronic
processes. Dana (34) regards hysteric symptoms as indicating a “ wearing
out of the psychic machinery, due to some metabolic cell degeneration
produced by a teratological defect." Savill (147), who is the leading
authority in London on the psycho-neuroses, holds that hysteria is a disease
of the sympathetic nervous system.

Several attempts have been made at a re-classification of the -psycho-
neuroses. Dana (33) restricts the term hysteria to the severe cases with
pronounced bodily symptoms, and divides the psycho-neuroses into—
1, Neurasthenia; 2, Abortive types of the major psychoses (e.g., manic-
depressive insanity) ; 3, Phrenasthenia, including (a) Hysteria major,
(/>) Hypochondriacal Psychasthenia (usually diagnosed as hysteria),
(c) Obsessive Psychasthenia. Dercum (37) divides them into—1, Neuras¬
thenia ; 2, Neurasthenoid conditions; 3, Symptomatic neurasthenia;
4, Hysteria; 5, Hypochondria. Walton (171) groups all cases of tic,
hypochondria, neurasthenia, hysteria minor, folic dc doute , and mild manic-
depressive tendencies under the term “ obsessive psychosis," considering
the obsessive feature to be the fundamental one.

Stress is laid on the mental side of neurasthenia by Donley (44),
Drummond (49), Lane (91), J. K. Mitchell (110) and others. Lane considers
that some depressing emotion, and not overwork, is the cause of neuras¬
thenia. Savill (145) attributes neurasthenia to toxins absorbed from the
teeth and intestines. Courtney (31) regards psychasthenia as a forme,
fruste of petit mat, and closely allied to epilepsy. It need hardly be said
that the sexual genesis is not referred to by any writer. Booth (8) contends
that coitus interruptus is an important cause of psycho-neurosis, but draws
no clear picture of the symptoms that result.

The first of Adolf Meyer's papers referred to (99) is a long and
sympathetic review of Bleuler’s Afi’ectivitat, Suggestibility und Paranoia ;
he opposes any over-dogmatic separation of the emotional and intellectual

Enn j st Jour. s\

133

functions. In this, as in his other papers, Meyer uses his influence power¬
fully and consistently in support of the importance of the psychogenetic
point of view. Two matters, however, make it difficult to review his work
or to convey a just appreciation of its significance, first, in that his influence
has been mainly exerted in personal teaching or in society discussions,
and, secondly, in that his publications on the subject include no indepen¬
dent papers, but are comprised either of comments on various German
writings, in the form of a review, or of abbreviated accounts of papers
read before societies. His writings are very general in character and do
not deal technically with the actual mechanisms of psychogenesis. Anyone,
therefore, who knew only of his writings would be liable to under-estimate
the value of his influence. The main theses he develops are: the great
importance of adopting a general biological point of view, especially in
contrast with the histological one, and of testing abnormal manifestations
as different forms of reaction to the environment. Speaking of dementia
pr&cox he says (101) : “ The symptoms appear as perfectly natural results,
not of abstract and so far undemonstrated auto-intoxications, or supported
merely by fragments of histological knowledge, but of habits of function
and mental activity which may in part open a chance for correction. . .

The general principle is that many individuals cannot afford to count on
unlimited elasticity in the habitual use of certain habits of adjustment;
that instincts will be undermined by persistent misapplication, and the
delicate balance of mental adjustment and of its material substratum must
largely depend on a maintenance of sound instinct and reaction-type.
. . . At first, perhaps, there is merely an excess of substitutive

reactions, such as occur also in the normal, a shirking and scattered and
distracted slurring over of the difficulties, secretiveness, instead of a frank
ventilation and correction by joining the activities of the normal, a habit
of excusing carelessness and lack of determination by hypochondriacal
complaints or fault-finding with others, or the habit of passing over diffi¬
culties by imaginative thoughts, or mere praying, or pondering, or other
expedients which as a rule help successively over an individual disappoint¬
ment, etc.” He joins issue with Bleuler (105), who, he says, agrees with
Kraepelin in regarding general paralysis as the obligatory paradigma of
the psychoses; the aetiology of dementia prjecox he sums up as a conflict
of instincts and habits. In psycho-pathology he lays especial stress on
“ abnormal ways of dealing with the situations of life, and on the tendency
towards false adjustments,” and (105) describes six reaction-types of dis¬
order : (1) The reactions of organic disorders; (2) Delirious states with

134

Clinical Psychology and Psycho-Pathology.

dream-like imaginative experiences, hallucinations, especially of sight,
with deficient orientation; (3) The essentially affective reactions;

(4) Paranoic developments, of six grades; (5) Substitutive disorders of
the type of hysteria and psycliasthenia; (6) Types of defect and

deterioration.

Macfie Campbell, an assistant of Meyer's, has in a very clear article (15)
expounded Meyer’s views of dementia praecox, and gives an account of
five cases. The psychosis is “ the culmination of a long-continued period of
unhealthy biological adjustments in individuals who constitutionally are
apt to meet their difficulties in an inadequate manner.” August Hoch
(67, 68) also lays great stress on psychogenesis in the psychoses. In
dementia praecox (69) he states that in 50 per cent, of the cases he has
discovered evidence of a peculiar “shutness” in the personal reactions
before the outbreak of the malady. Kicksher (141) has applied Stern’s
Aussage methods in dementia praecox, and finds that the ability to repro¬
duce the stimuli depends directly on the ability to concentrate the
attention.

Campbell (15), Donley (46), Hart (62), Meyer (99, 103, 104, 105), and
Putnam (136) deal with the relation of philosophic conceptions to psychiatry.
Meyer (104) defines mind as “ a sufficiently organized living being in
action.” Hart’s paper is especially lucid and penetrating.. He develops
the point of view represented by Ostwald, Mach, and particularly by Karl
Pearson, and distinguishes clearly between the empiric conceptions of
scientific idealism and the absolutist view of various schools of metaphysics.
His remarks on the practical application of these principles to the problems
of research in psychiatry, and his criticism of the materialistic views
current in psychiatric circles, especially deserve to be read. Peterson (121)
argues that the corpus striatum is the seat of consciousness.

Finally, an essay of Chamberlain’s (18) should be mentioned, in which
is contained an interesting collection of the beliefs and superstitions about
night in folk-psychology.

IV. —Psycho-Analysis.

In the English literature I have been able to find only one reference to
Freud’s work, and none to Jung’s. In America, on the other hand, a con¬
siderable number of articles on the subject have appeared. Psycho-analysis
is discussed in most articles on psychotherapy, though in two recent
extensive reviews of the subject, by Mills (106) and Miinsterberg (112), it

Ernest Jones .

135

is not mentioned. The writings may be divided into three groups according
as they support Freud's views, adopt an attitude of suspended judgment or
of indifference, or oppose it.

To the first of these groups* belong those of A. A. Brill and the present
writer. Four papers have been published, one by Brill (12), and three by
the present writer (84, 88, 90), expounding Freud's views. They contain
nothing that is not familiar to readers of the Jahrbuch. In a paper on the
psycho-pathology of everyday life (11) Brill records an interesting collection
of some twenty instances illustrating Freudian principles. One of them
may be quoted. On thinking of a certain patient in whom he had been
very interested, and with whose case he had spent a gre;it deal of time,
Brill found himself unable to recall the patient’s name, and decided to
make a self-analysis to test the method. The case had beeu an unusual
one, and after taking great pains he had written an account of it for
publication.* Just when this was ready, his chief informed him that he
wished to publish the case himself at a society meeting, which he
did, to Brill's considerable disappointment. The chief was, however,
at the last moment prevented from personally reading the paper.
In five hours' analysis Brill filled over two dozen sheets with a record
of the free associations that occurred to him, but at first in vain. He
then observed that two thoughts, apparently unconnected with the subject,
kept on recurring to him. The first one, which came back to him
twenty-eight times more often than any other, was a vivid memory
of an actual scene in which his chief had shot at a rabbit but
missed it. While he was ruminating on this memory the patient's name
that was being sought suddenly flashed up. It was Lapin (rabbit). The
scene had symbolically expressed his chief's failure to “bpg the rabbit."
The other thought that kept recurring was the name of another patient,
Appenzeller, who was suffering from the same malady as the first one, and
the first part of whose name phonetically closely resembles the French word
Lapin. In a short paper (82), which was read at the Salzburg Congress,
the present writer gives an account of the mechanisms of rationalisation
and evasion, by which a subject invents a plausible explanation for a given
belief or action that has really been determined by some unconscious process.

• Since this date a considerable number of favourable articles have appeared. See
‘ Journ. of Abnormal Psychology/ vol. iv, Nos. 5, 6, vol. v, Nos. 2, 3, 4; ‘ Amer. Journ. of
Psychology/ January and April, 1910; * Psychol. Bulletin/ April, 1910; ‘ Amer. Journ. of
Insanity/ July, 1910 ; 'Journ. of Nerv. and Ment. Dis./ May, 1910; ‘ New York Med. Journ./
April, 1910; 'Interstate Med. Journ./ July, 1910; ‘Maryland Med. Journ./ June, 1910;
ete., etc.

136

Clinical Psyclwloyy and Psycho-Pathology .

Psycho-analytic accounts of four cases have been published, two by
Brill and two by the present writer. The former two were cases of
dementia praecox, which had been investigated at Burgholzli. The first of
these (9) occurred in a bank clerk of thirty-nine, in whom the first outbreak
of insanity had taken place some nine months previously. He had had two
acute crises, lasting three days and a week respectively, of the delirious
confusional, dreamlike type. The intervening and succeeding periods
were marked by great restlessness, delusions and hallucinations. Brill
relates the reactions to fifty-six association test-words, and gives a short
analysis of each of these ; of the responses twenty-two concerned erotic
complexes and seven religious ones. The patient’s father was very
religious, the patient was an atheist. The religious influences of childhood
expressed themselves in the crises by the patient feeling himself forced
by a magnetic power to kneel and repeat “Our Father” hundreds of
times, identifying himself with Christ and his father with God. He also
felt himself under the power of Isis and Osiris, Osiris being the name of
a wealthy banker who had recently died and from whom he expected
money. The general psychogenesis of other manifestations is also described.
The second case (10) was that of a law student and promising journalist,
aged 20 years, who had, after a short period of depression arising from
disappointment in a love affair, attempted to commit suicide. He fired
five shots at himself, but hit only a picture of Ibsen and a candle. He
then passed into a delirious condition and repeatedly murmured to himself,
“Where are the white horses?” After a period of dulness, apathy and
somnolence, he recovered. Brill gives the analyses of a number of
association reactions, which indicated that the love affair had not played
the significant role in the outbreak of the psychosis that it had seemed to;
for years before he had suffered from hypochondriacal ideas and self-
accusation. The analysis of the attempt at suicide is especially interesting.
The shots were symbolic actions, and were intended to kill the part of
himself that he loathed. The candle was associated with a masturbation
complex, and Ibsen, with whom he had unconsciously identified himself,
with an egocentric complex. The cry, “Where are the white horses?”
was of course taken from Rosrnersholm, where they presage the hero’s
death. Brill adds a number of apposite remarks concerning the apparent
senselessness of the manifestations of dementia pnecox.

The first of the present writer’s cases referred to (85) was one of
hysteria that occurred in a man, aged thirty, who on his arrival in a
Toronto hospital could give no account of himself, or tell us his name, his

Ernest Jones .

137

country, or anything of his past life. The only name he could give was
Bert Wilson, though he did not think this was his own. When his memory
was brought back it was learnt that he had been a sea-cook for many years,
but had recently settled down in New York State, where he now had a
wife and child. Two months before he had lost his work and had left
home to find another situation, leaving his wife with only a little money.
He did not succeed, had to tramp long distances and do without food, and
on reaching Buffalo he saw a navigation advertisement and took a boat
crossing the lake to Toronto. In his despair he unconsciously identified
himself with Bert Wilson, who was his senior (a sea-cook) on his first
voyage, whom he had formerly envied, who had run away to sea as the
patient did when a boy, whose wife maintained herself by keeping a
lodging-house, so that he had no anxiety about her when away, who had
once deserted and changed his name to escape detection, and finally, whose
name nearly resembled the patient’s own (Bert Williams). The symptoms
illustrated a great number of the unconscious mechanisms in hysteria
which are described. An instance of Venvendung desselben Materials- and
Umkehrung may be quoted. When asked the street in which the New
York Station is situate (42nd Street), the patient answered first 24,
then 28 (24 -I- 4), then 32 (24 + 4 -1- 4), and finally 26 (24 + 2); his street
number in New York was 4. A short discussion of the nature of amnesias
is added. The second case (87) was one of manic-depressive insanity in a
woman aged 39 years. Erotic and religious complexes revealed them¬
selves in various delusions, symbolic actions and flights of ideas. For her
childlessness she blamed her husband, partly on account of his relative
impotence, partly on account of a gonorrhoeal salpingitis from which she
had long suffered. She had had illicit relations with other men that had
caused her much remorse. Keligious appeals to forsake her evil ways and
lead a new life she interpreted as a revelation indicating the error of her
past sexual life and advocating a new form; this new way, for various
reasons, she imagined to be the fellatorism perversion. She then
identified the Holy Communion with fellatorism, and obtained sexual
gratification from going through imaginary performances of this ceremony.
The other symptoms, such as delusions of being poisoned, refusal to take
food, intense excitement, etc., are analysed and traced to the same group
of complexes. In one delusion, concerning a watch, she identified this
with the uterus because “ it has works inside that keep regular time (s)
and it needs a key to wind it up.”

In the second group may be counted five articles. These include a

138

Clinical Psjfchohnjjf a ml Psi/cho-Patholoyt/.

short account by Collins (21) of psycho-analytic treatment, in which no
opinion is expressed as to its merits, a general account of complexes by
White (173), an article by Peterson (122) in which a page is given to a
description of Freud’s views on psycho-apalysis, dreams, insanity and
everyday life, and two articles by Putman* (135) andLinenthal and Taylor
(94) respectively, in which is given an account of attempts to apply psycho¬
analysis. The latter two papers are on the whole sympathetic, and several
cases are recorded, in which, however, the psycho-analysis is of a very
elementary kind.

The third group is the largest.t The accounts given of psycho-analysis
are very brief, usually taking up less than a page, and are often distorted,
as for instance in Collins’ article (21) where it is said that Freud (there
throughout called Freund) relies on hypnotism, or in Scott’s (150) where it
is said that “ the normal reaction of an emotion is converted into voluntary
movements of defence, which may then survive as habit spasms.” The
adverse criticisms are rarely written in a personal tone, and are evidently
based on ignorance of the subject. Prince’s criticism of Freud’s views of
the Unhewm»te have been mentioned above: he denies (131) that the
therapeutic successes of psycho-analysis are due to the making conscious
of repressed mental processes, for “if nothing more were done the
patient would still not tolerate them and would push them out again.”
The results are due to the general re-education, to the introducing of new
ideasandfeelingsintothecoinplexes. PierceClark (19) says “Freud’smethod
is of great benefit in hysterics, but it is not widely applicable in general
disorders of the minor neuroses until the sexual idea is eliminated.” Allen
(1) sums up in exactly the same words, evidently copied from Clark ; in
describing the method he explains that “ the physician should be a man of
morality, yet (sic) a man of the world.” Courtney (32) says that Freud
has an idr.v fuvv on the subject of sex ; he adds: “the theory applies only
to a certain unwholesome type in whom any unusal accident in the sexual
sphere may lead to hysteria. There are extremely few cases in which
education and environment, coupled with the individual’s own power of
inhibition, do not shield him from the dangers which may accompany the
externalization of the instinct in any of its forms.” Edes (50) says that
“ Freud’s method invites an attitude of confidential trust evoked by long-

# In later papers Putnam has expressed his cordial agreement with Freud’s views, as
have Adolf Meyer, August Hoch, Macfie Campbell, and others.

t As this review was written for the Jahrbueh, whose readers are familiar with psycho¬
analysis, the adverse criticisms are here quoted in their naked absurdity, without any
comment; they are throughout based on an entire ignorance of .the subject.

Ernest Jones .

139

continued and careful questioning. This tedious questioning is almost
certain to implant and vivify ideas of the very kind *which it is desirable
to get rid of.” Schwab (149) says that Freud’s treatment is useless,
because it is doubtful if there is such a thing as subconscious activity.
Ring (142) writes of psycho-analysis as the method of Janet and Freud,
and objects to Freud’s theories that they do not take account of the
emotions of fear and anger, fear being the most important setiological
factor in the psycho-neuroses. The most inept criticisms, however, are
those by Dercum (38), Savill (147) and Scott (150). Dercum, referring to
Freud’s theory of obsessions, writes: “Others than myself have dwelt
upon the glaring inconsistency of the sexual immaturity of children and
the intrinsic biological improbability of this theory. Perhaps Freud has
himself been impressed by this fact, for of late years it would appear that
he has retreated to the age of puberty, attempting to save the situation,
however, by saying that the memory of these sexual events is projected
from puberty into the period of childhood .... Next is the all-
important factor that Freud’s explanation leaves out of consideration all
the obsessions which obviously and clearly have a non-sexual origin.
What shall we say, for instance, of the obsessions present in the cases of
the traumatic neuroses, which in this country may be fairly said to greatly
outnumber all others ? What shall we say as to cases of the special fears
the origin of which can be clearly traced to occurrences non-sexual in
character ? What shall we say of the obsessional states which make their
appearance in middle life or toward old age,? By what possibility can
these be ascribed to infantile sexual aggressions ? Like Edes, Ring, and
many others, Dercum imagines that Freud’s method consists in the
questioning of patients about their sexual lives. “ Such questioning must
be persistent and insistent, and, aside from the doubtful value of the
results obtained, must be painful and offensive alike both to the physician
and patient. Certainly, in persons of high social and moral make up, such
a stance , if at all possible, must be intensely disagreeable, and if the
truth be known the rehearsal of sexual details, repulsive and revolting
probably does harm and not good.” Savill (147) makes on the same page
these two sets of statements, which may profitably be compared with each
other. “ Freud’s investigations have a tendency towards the revival of
long-forgotten sexual incidents. It appears to me that there is a good
deal of danger both to the patient and to the physician in undertaking such
investigations .... I cannot but regard it as a most undesirable
thing for any medical person, and particularly for one of the opposite sex,

140

Cl in ical Psychology a ml Psych o-Pa th ology.

to make investigations into the dead memories of a sexual past. To my
mind such a procedure would be hazardous, harmful, and wholly unjustifi¬
able. M “ Freud states that with a normal vita sexualis a neurosis is
impossible. This does not accord with my experience, now somewhat
considerable, of these neuroses. I have seen scores of neurasthenics and
hysterics whose sexual life-history and constitution were absolutely normal.”
Scott (150), Professor of Psychology in the North-Western University,
considers that the success of psycho-analysis is obtained by suggestion, and
that those who use this method have by their ignorance of this fact been
“ hampered in their treatment, and have taken longer time for their cures
than otherwise would have been necessary.” On one occasion he demon¬
strated himself the truth of this opinion by applying “ psycho-analysis ”
to a case. This is his account of it. “The patient was told (sic) that she
had been guilty of sexual irregularities, that she had had sexual
experiences which had undermined her health, and that her perfect cure
was delayed by the fact that they had never been confessed. She
seemed to believe this implicitly, her confession disclosed all the factors
which even Freud would expect to find in a case of extreme phobia
(distressing sexual experiences of youth, sexual perversion, sexual excess,
as well as periods of sexual anaesthesia). At the conclusion of the
confession she fell back into a condition of relief, which was the condition

needed for the most perfect possible working of suggestion.

As an antidote to the rehashing of all this sexual filth the patient was
hypnotized and total amnesia w'as suggested for all the ideas which had
had a casual part in the history of the disease.”

Jung’s work is more widely known in America than Freud’s and is
more generally accepted there ; in fact, it has met with practically no
adverse criticism. Among the favourable reviews of it may be mentioned
those by Meyer (‘ Psycho. Bull.,’ 1905, p. 241; 1906, p. 275; 1907,

p. 196; 1908, p. 273); Kirby {ibid., 1907, p. 197; 1908, p. 270); Hoch
(‘ J. Ab. P.,’ June, 1906, p. 95) ; Coriat (ibid., June, 1908, p. 137J ; Karpas
(ibid., December, 1908, p. 366), and Hart (* Journ. of Ment. Sci.,’ 1908).
The works of Bleuler, Riklin, Wehrlin, and Binswanger are also included
here. Demonstrations and expositions of his association methods have
been published by Bailey (4), Henke and Eddy (65), Scripture (151),
Town (168), and Yerkes and Berry (191), all of whom confirm his findings
and conclusions. Peterson, both independently (119, 120), and in con¬
junction with Scripture (123), has given demonstrations of the psycho¬
galvanic method. Prince and Peterson (129, 133) have used this method

Ernest Jones.

141

to prove the existence of co-conscious ideas in a case of multiple
personality. Sidis and Kalmus (160), in two articles that are not
primarily concerned with psychological problems, have given an account
of experiments which they maintain show that the psycho-galvanic reflex
is the result, not of any change in the bodily resistance, but of independent
currents set up by the emotional disturbance. Prince (130) accepts their
results. Coriat (29) finds that the emotional disturbances are more readily
detected in association work by an increase of frequency in the pulse-rate,
best observed while the patient is in the hypnoidal state.

Two events of the past six months should also be mentioned in the
present connection, namely, the lectures* delivered by Freud and Jung last
autumn at Clark University, Worcester, Mass., and the publication of
some of Freud’s papers, and of Jung’s ‘ Psychology of Dementia Praecox,’
in translations made by Brill ( f Journ. of Nerv. and Ment. Dis.’; Mono¬
graph Series).

Bibliography.

For the sake of space the following abbreviations are made use ofA. J. I.*, 1 Ameri¬
can Journal of Insanity *; ‘ A. J. M. S./ * The American Journal of the Medical Sciences *;

‘ Bost. J./ ‘ The Boston Medical and Surgical Journal *; ‘ B. M. J./ ‘ British Medical
Journal *; Disc., Discussion; ‘ J. A. M. A., ‘ The Journal of the American Medical Association*;
‘ J. Ab. P./ ‘Journal of Abnormal Psychology/ ‘J. N. M. D./ ‘Journal of Nervous and
Mental Disease ’; ‘ L./ ‘ Lancet*; ‘ N. Y. M. J.,’ ‘New York Medical Journal.’

(1) Allen. —“ Psychotherapy/* ‘ Univ. of Penna. Med. Bull./ May, 1908, p. 76.

(2) Angell. — “ Hypesthesia and Hypalgesia and their Significance in Functional
Nervous Disturbances.” Amer. Med. Assoc., June, 1905. ‘ J. N. M. D./ May, 1906, p. 324.

(3) Ibid .—“A Case of double Consciousness —amnesic Type, with Fabrication of
Memory/* ' J. Ab. P./ October, 1906, p. 155.

(4) Bailey, Pearce. —“ The practical Value of the Association Test,” ‘ A. J. M. S./
September, 1909, p. 402.

(5) Baird. -“The Contraction of the Color Zones in Hysteria and Neurasthenia,*’
‘ Psychol. Bull./ August, 1906, p. 249.

(6) Barker. — “ Some Experience with the simpler Methods of Psycho-therapy and
Re-education/* ‘A. J. M. S./ October, 1906, p. 499.

(7) Blumer. —“The Coming of Psychasthenia,” Boston Soc. of Psychiatr., December
2nd, 1905. ‘ J. N. M. D./ May, 1906, p. 356.

(8) Booth. —“ Coitus interruptus and Coitus reservatus as Causes of profound Neuroses
and Psychoses/* ‘Alienist and Neurologist/ November, 1906, p. 397.

(9) Brill, A. A.—“Psychological Factors in Dementia Pnecox, an Analysis,” ‘ J. Ab.
P./ October, 19u8, p. 219.

(10) Ibid . —“ A Case of Schizophrenia (Dementia Praecox)/' ‘ A. J. I./ July, 1909, p. 53.

(11) Ibid .—“A Contribution to the Psychopathology of Everyday Life,” ‘Psycho¬
therapy/ 1909, Art. ix.

(12) Ibid. —“Freud’s Conception of the Psycho-neuroses,” N. Y. Academy of Med.,

(Section of Neurology and Psychiatry), October 11th, 1909. ‘ Med. Record,’ December 25th,

1909.

(13> Burgess. —“A Case of Neurasthenia complicated with ‘Vasovagal Attacks/”
‘L./ December 12th, 1908, p. 1743.

# Published in the ‘ American Journ. of Psychology,’ April, 1910.

142

Clinical Psychology and Psych a-Pathology.

(14) Camp. — 44 Morbid Sleepiness, with a Report of a Case of Narcolepsy and a Review
of some recent Theories of Sleep,” 4 J. Ab. P./ April, 1907, p. 9.

(15) Campbell, Macfib. — 44 A Modern Conception of Dementia Praecox, with five illus¬
trative Cases,” 4 Rev. of Neur. and Psychiatr./ October, 1909, p. 623.

(16) Cannon. — 44 The Influence of Emotional States on the Functions of the Alimentary
Canal,” 4 A. J. M. S./ April, 1909, p. 480.

(17) Carr.— 44 Unusual Illusions occurring in Psycholeptic Attacks of Hysterical Origin,”
4 J. Ab. P./ February, 1908, p. 260.

(18) Chamberlain. — 44 Notes on some Aspects of the Folk-Psychology of Night.” ‘Atuer.
Journ. of Psychol./ January, 1908, p. 19.

(19) Clark, Pierce. — 44 Freud's Method of Psychotherapy,” N. Y. Neur. Soc., January

7th, 1908. 4 Med. Record/ March 21st, p. 481. 4 J. N. M. D./ June, p. 391.

(20) Cleghorn. —“Notes on Six Thousand Cases of Neurasthenia,” 4 Med. Record/
April 27th, 1907, p. 681.

(21) Collins. — 44 Some Fundamental Principles in the Treatment of Functional Nervous
Diseases, with especial Reference to Psychotherapy,” 4 A. J. M. S./ February 1908, p. 168.

(22) Ibid .— 44 Psychasthenia,” 4 N. Y. M. J./ February 15th, 1908, p. 297

(23) Ibid. — 44 The General Practitioner and Functional Nervous Diseases,” 4 J. A. M. A./
January 9th, 1909, p. 87.

(24) Coriat.— 44 The Experimental Synthesis of the Dissociated Memories in Alcoholic
Amnesia,” 4 J. Ab. P./ August. 1906, p. 109.

(25) Ibid .— 44 Nocturnal Paralysis,” 4 Bost. J./ July 11th, 1907, p. 47.

(26) Ibid .— 44 The Lowell Case of Amnesia,” 4 J. Ab. P./ August 1907, p. 93.

(27) Ibid .— 44 Some further Studies on Nocturnal Paralysis,” December 5th, 1907, p. 751-

(28) Ibid .— “The Mechanism of Amnesia,” 4 J. Ab. P./ April, 1909. ‘ P. I./August,

p. 236.

(29) Ibid .— 44 Certain Pulse Reactions as a Measure of the Emotions,” 4 J. Ab. P./
October, 1909, p. 261.

(30) Courtney. — 44 On the Clinical Differentiation of the various Forms of Ambulatory
Automatism,” 4 J. Ab. P./ August, 1906, p. 123.

(31) Ibid. —“Psychasthenia: its Semeiology and Nosologic Status among Mental
Disorders,” 4 J. A. M. A./ February 29th, 1908, p. 665.

(32) Ibid .— 44 The Genesis and Nature of Hysteria: a Conflict of Theory,” 4 Boston J./
March 12th, 1908, p. 341.

(33) Dana.— 44 The Limitation of Hysteria,” Amer. Neur.Assoc , June, 1906. 4 J. N. M. D./
November, p. 717.

(34) Ibid .— 44 The Limitation of the Term Hysteria, with a Consideration of the Nature
of Hysteria and certain allied Psychoses ” 4 J. Ab. P./ February, 1907, p. 269.

(35) Ibid .— 44 Psychotherapy,” 4 J. N. M. D./ June, 1908, p. 389.

(36) Dkaver.—“G astric Neuroses,” 4 A. J. M. S./ February, 1909, p. 157.

(37) Dercum.— 44 Hysteria, its Nature and its Position in Nosology,” 4 J. A. M. A.,
November 23rd, 1907, p. 1729.

(38) Ibid .—“An Analysis of Psychotherapeutic Methods,” 4 Tlierap. Gaz./ May 15th,
1908, p. 305.

(39) Dewey.— 44 A Case of disordered Personality,” 4 J. Ab. P./ October, 1907, p. 141.

(40) Diller.—“ Hysterical Blindness,” 4 J. A. M. A./ April 24th, 1909, p. 1307.

(41) Diller and Wright. — 44 A Study of Hysterical Insanity with an especial Considera¬
tion of Ganger's Symptom-complex. Report of eight Cases,” Amer. Neur. Assoc., May,

1908. 4 J. N. M. D./ January, 1909, p. 25.

(42) Ibid .— 44 The Differential Diagnosis between Hysterical Insanity and Dementia
prcecox ; with Report of an Illustrative Case of Hysterical Insanity/' 4 A. J. I./ October,

1909, p. 253.

(43) Donley.— 44 Three Cases of Association Neuroses, with Remarks on its Genesis,”
4 Bost. J./ November 3rd, 190-1, p. 484.

( 44) Ibid .—“On Neurasthenia as a Disintegration of Personality,” 4 J. Ab. P./ June,

1906, p. 55.

(45) Ibid .— 44 A further Study of Association Neuroses,” 4 J. Ab. P./June. 1907, p. 45.

(46) Ibid .— 44 Neurasthenia. Its Relation to Personality,” 4 N. Y. M. J./ December 28th,

1907, p. 1197.

Ernest Jones.

143

(47) Ibid .—“The Clinical U9e of Hypnoidization in the Treatment of some Functional
Psychoses/' ‘ J. Ab. P./ August, 1908, p. 148.

(48) Ibid .—“ Obsessions and Associated Conditions in so-called Psychasthenia,”
4 J. Ab. P./ June, 1909, p. 171.

(49) Drummond.—“T he Mental Origin of Neurasthenia/’ 4 B. M. J./ December 28th,

1907, p. 1813.

(50) Edes.—“T he present Relations of Psychotherapy,” ‘J. A. M. A./ January 9th,
1909, p. 92.

(51) Edgeworth.—“O n Hysterical Paroxysmal (Edema,” ‘ Quarterly Journ. of Med.,
January, 1909, p. 135.

(52) Farrar.—“ Psychotherapy and the Church,” 4 J. N. M. D./ January, 1909, p. 11.

(53) Fox.— 44 Report of a Case of Dissociated Personality, characterized by the Presence
of Somnambulistic States and Ambulatory Automatism,” 4 J. Ab. P./ August, 1909, p. 201.

(54) Frost.—“ Hysterical Insanity.—Report of a Case presenting Ganser’s Symptom-
complex,” 4 A. J. I./ January, 1907, p. 301.

(55) Ibid .—“ Neurasthenic and Psychasthenic Psychoses,” 4 A. J. I./ October, 1909, p. 259.

(56) Gayer.— 44 A Case of alternating Personality characterized chiefly by Ambulatory
Automatism and Amnesia, with Results of Hypnotic Experiments,” 4 J. A. M. A./ July 4th,

1908, p. 9.

(57) Gordon.— 44 On Double Ego: with Report of an Unusual Case,” 4 A. J. M. S./
March, 1906, p. 480.

(58) Ibid .— 44 Hysteria : Nature of the Malady,” 4 N. Y. M. J.,' August 10, 1907, p. 250.
(59; Gradle.- 44 The Blindness of Hysteria,” 4 J. A. M. A./ April 24th, 1909, p. 1308.

(60) Harris. — 44 Colored Thinking,” 4 J. Ab. P./ June, 1908, p. 97.

(61) Hart, Bernard.— 44 A Case of Severe Head Injury in a Psychasthenic,” 4 B. M. J./
August 17th, 1907, p. 389.

(62) Ibid .— 44 A Philosophy of Psychiatry,” 4 Journ. of Ment. Sci./ July, 1908, p. 473.

(63) Hbcht.—“H ysteria in Children,” 4 J. A. M. A./ February 23rd, 1907, p. 670.

(64) Ibid .— 44 Morbid Somnolence,” 4 A. J. M. S./ March, 1908, p. 403.

(65) Henke and Eddy.— 44 Mental Diagnosis by the Association Reaction Method,”
"Psychol. Rev./ November, 1909, p. 399.

(66) Hinkle.— 44 Some Results of Psychotherapy,” 4 J. N. M. D./ June, 1908, p. 392,
Disc.

(67) Hoch, August.—“T he Psychogenetic Factors in some Paranoic Conditions, with
Suggestions for Prophylaxis and Treatment,” N. Y. Psychiatrical Soc., March 6th, 1907 ;
4 J. N. M. D./ October, 1907, p. 668, Disc.

(68) Ibid .— 44 The Psychogenic Factors in the Development of Psychoses,” 4 Psychol.
Bull./ June, 1907, p. 161.

(69) Ibid .— 44 A Study of the Mental Make-up in the Functional Psychoses,” N. Y.
Psychiatrical Soc., November 4th, 1908 ; 4 J. N. M. D./ April, 1909, p. 230. Disc.

(70) Holmes.— 44 Hysteria of the Ear,” 4 Laryngoscope/ September, 1907, p. 581.

(71) Hoover.— 44 A New Sign for the Detection of Malingering and Functional Paresis
of the Lower Extremities,” 4 J. A. M. A.,' August 29th, 1908, p. 746.

(72) Hud 80 n-Makuen.—“H ysterical Mutism,” 4 Internat. Clinics/ 1907, vol. i, p. 189.

(73) Hyblop.— 44 Apparent Subconscious Fabrication,” 4 J. Ab. P./ December, 1906, p. 201.

(74) Ja8Trow.— 4 The Subconscious/ 1906.

(75) Jelliffe.— 44 Hysteria and the Re-education Methods of Dubois,” 4 N. Y. M. J./
May 16th, 1908, p. 926.

(76) Ibid .— 44 The Re-education of Dubois,” 4 J. N. M. D./ June, 1908, p. 389.

(77) Jones, Ernest.— 44 True Tactile Aphasia,” 4 Rev. Neurol./ January 15th, 1907, p. 3.

(78) Ibid .— 44 The Clinical Significance of Alloehiria,” 4 Trans. First Internat. Congress
for Psychiatry and Neur./ September 5th, 1907, p. 408 ; 4 L.’ September 21st, p. 830.

(79) Ibid .— 44 The Mechanism of a Severe Briquet Attack contrasted with that of
Psychasthenic Fits,” 4 J. Ab. P./ December, 1907, p. 218.

(80) Jfcid. —“The Precise Diagnostic Value of Alloehiria,” 4 Brain/ vol. xxx, p. 490.

(81) Ibid .—“The Side affected by Hysterical Hemiplegia,” 4 Rev. Neurol./ March 15th,
1908, p. 193.

(82) Ibid .—“ Rationalisation in Everyday Life,” 4 J. Ab. P./ August, 1908, p. 161.

144 Clinical Psychology and Psycho-Pathology.

(83) Ibid .—" The Significance of Phrietopathic Sensation/* ‘ J. N. M. D./ July, 1908,
p. 427.

(84) Ibid. —“ Psycho-analysis in Psychotherapy/* Annual Meeting of Amer. Therap. Soe.,
May 6th, 1909; ‘ J. Ab. P./ June, 1909, p. 140; ‘Montreal Med. Joum./ August, 1909, p. 495.

(85) Ibid. —"Remarks on a Case of Complete Auto-psychic Amnesia,” ‘ J. Ab. P./
August, 1909, p. 218.

(86) Ibid. —" The Pathology of Dyschiria/* ‘ Rev. of Neurol, and Psychiatry/ August,
1909, p. 499, and September, 1909, p. 559.

(87) Ibid. —“ Psycho-analytic Notes on a Case of Hypomania/* * A. J. I./ October, 1909,
p. 203.

(88) Ibid. —"The Psycho-analytic Method of Treatment/* Niagara District Med.
Assoc., November 24th, 1909.

(89) Ibid.— ‘‘The Dyschiric Syndrome/* ‘ J. Ab. P./ December, 1909.

(90) Ibid. —" Freud*s Dream Theory/* Amer. Psychol. Assoc., December 29th, 1909.

(91) Lane.—"T he Mental Element in the Etiology of Neurasthenia,” Boston Soc. of
Neur., January 19th, 1906; * J. N. M. D./ July, 1906, p. 463.

(92) RoquE, La.—" Hysterical Affections of the Abdomen/’ * A. J. M. S./ June, 1907,

p. 912.

(93) Kerb, Le.—"R eport of a Case of Hysterical Aphasia and Paralysis,” ‘Brooklyn
Med. Journ./ 1905, p. 155.

(94) Linenthal and Taylor.—"T he Analytic Method in Psychotherapeutics. Illus¬
trative Cases,” ‘ Bost. J./ November 8th, 1906, p. 541.

(95) Lloyd.—" Notes on a Case of Spontaneous Somnambulism,” ‘ J. Ab. P./ February,
1908, p. 239.

(96) McBride.—" Deafness due to Hysteria and Allied Conditions : Seven Cases,”

‘ Edinburgh Med. Journ./ May, 1906, p. 391.

(97) McDougall.—" State of the Brain during Hypnosis,” ‘ Brain/ 1908, pt. 122, p. 242.

(98) Ibid . —" The Physical Basis of Mental Dissociation.” ‘ B. M. J./ October 24th, 1908,
p. 1315.

(99) Meyer, Adolf.—"T he Relation of Emotional and Intellectual Functions in
Paranoia and in Obessions/* ‘Psychol. Bull./ August, 1906, p. 255.

(100) Ibid. — t( Fundamental Conceptions of Dementia Preecox,” ‘ B. M. J./ September
29th, 1906, p. 757.

. (101) Ibid .—" Fundamental Conceptions of Dementia Price ox,” N. Y. Neur. Soc.,

October 2nd, 1906; ‘ J. N. M. D./ May, 1907, p. 331. Disc.

(102) Ibid. — "The Relation of Psychogenic Disorders to Deterioration,” Boston Soc.
of Psychiatry, November loth, 1906; ‘ J. N. M. D./ June, 1907, p. 401. Disc.

(103) Ibid .—"Misconceptions at the Bottom of ‘ Hopelessness of all Psychology,’**
‘ Psychol. Bull./ June, 1907, p. 170.

(104) Ibid .—"The Role of the Mental Factors in Psychiatry,” ‘A. J. I./ July, 1908,
p. 39. Disc.

(105) Ibid. — " The Problems of Mental Reaction-types, Mental Causes, and Diseases/*
‘ Psychol. Bull./ August, 1908, p. 245.

(106) Mills.—"P sychotherapy: Its Scope and Limitations/’ ‘Monthly Cyclopa?dia
and Med Bull./ July, 1908.

(107) Ibid. —"The Differential Diagnosis of Grave Hysteria and Organic Disease of the
Brain and Spinal Cord, Especially Disease of the Parietal Lobe,” Philad. Neur. Soc.,
Deeeml>er 18th, 1908; * J. N. M. D.,’ July, 1909, p. 407.

(108) Ibid. —"Hysteria, What it is and What it is not,” > A. J. I./ October, 1909,
p. 231.

(109) Mitchell, J. K.—"Report on a Case of Hysterical Mutism/* Amer. Neur.
Assoc., June, 1906; ‘ J. N. M. D./ April, 1907, p. 253.

(110) Ibid. —" Diagnosis and Treatment of Neurasthenia,” ‘ Bull, of the Johns Hopkins
Hospital,’ February, 1908, p. 41.

(111) Mitchell, Weir. —" Motor Ataxy from Emotion,” Philad. Neur. Soc., February
26th, 1906 ; ‘ J. N. M. D.,’ May, 11H>9, p. 257.'

(112 ) Munstekbero.—‘ Psychotherapy,’ 1909.

(113) Oettinoer. —" A Case of Recurrent Autohypnotic Sleep, Hysterical Mutism and
Simulated Deafness ; Symptomatic Recovery with Development of Hypomania.” ‘ J. N. M. D./

March. 1908. p. 129.

Krnest Jones. 145

(114) Onuf.—“S pasm of the Apparatus of Binocular Fixation and Superinduced
Blepharospasm in a Hysterical Patient with a Theory of Their Pathogenesies," ‘ J. Ab. P./
October, 1907, p. 155.

(115) Packard.—“T he Feeling of Unreality/' ‘ J. Ab. P./ June, 1906, p. 09.

(116) Parker. “The Visual Fields in Hysteria, illustrated bv a Study of Fifty
Cases, ‘ J. A. M. A./ July 10th, 1909, p. 91.

(117) Patrick.—“ Ambulatory Automatism/' Amer. Neur. Assoc., May 7th, 1907 ;

4 J >*. M. D./ June, 1907, p. 353.

Pershing.—“T he Cure of Hysterical Paralysis by Ke-education of Kinesthetic
Centres/* * J. A. M. A./ May 11th, 11 07, p. 1509.

(119) Peterson.—“ The Galvanometer as a Measurer of Emotions/' 4 B. M. J./ Septem¬
ber 28th, 1907, p. 804.

_(120) Ibid. —“The Galvanometer in Psychology," N. Y. Neur. Sot?., November 12th,

1907, ; ‘ J. N. M. D./ April, 1908, p. 273; ‘ J. Ab. P./ April, 1908, p. 43.

(121) Ibid. —“The Seat of Consciousness," N. Y. Neur. Sot*., October 6th, 1908;
‘ J- Ab - P-/ December, 1908, p. 307 ; ‘ J. N. M. D./ February, 1909, p. 97.

(122) Ibid. —“Some New Fields and Methods in Psychology," ‘N. Y. M. J./ November

13th, 1909, p. 945. J

(123) Peterson and Scripture—“P sycho-physical Investigations with the Galvano¬
meter," N. Y. Neur. Soc., March 2nd, 1909; ‘ J. N. M. D./ July, 1909, p. 426.

(124) Prince, Morton.—“ Some of the Present Problems of Abnormal Psychology,"
St. Louis Congress, September 24th, 1904; ‘ Psychol. Rev./ March, 1905, p. 118.

(125) Ibid. —“Case of Multiform Tic including Automatic Speech and Purposive
Movements," Boston Soc. of Neur.. March 16th, 1905. ‘ J. N. M. D./ January, 1906, p. 29,

(126) Ibid. —‘The Dissociation of a Personality/ 19o0.

(127) Ibid. —“The Psychology of Sudden Religious Conversion," ‘J. Ab. P./ April,

1906, p. 42. . F

(128) Ibid. —“Hysteria from the Point of View of Dissociated Personality," ‘ J. Ab. P./
October, 1906, p. 170, and ‘ Bost. J./ October 4th and 11th, 1906, pp. 372 and 407.

(129) Ibid. —“Experiment to determine Co-conscious (Subconscious) Ideation," ‘J. Ab.
P./ April, 1908, p. 33 .

(130) Ibid. —“ The Unconscious," ‘J. Ab. P./ October, 1908, p. 261: December, 1908,
p. 335; February, 1909, p. 391 ; April, 1909, p. 36.

(131; Ibid. —“The Psychological Principles and Field of Psychotherapy," ‘ J. Ab. P./
June, 1909, p. 72.

(132) Prince and Coriat.—“C ases illustrating the Educational Treatment of the
Psycho-neuroses," 4 J. Ab. P./ October, 1907, p. 166.

(133) Prince and Peterson.—“E xperiments in Psycho - galvanic Reactions from
Co-conscious (Subconscious) Ideas in a Case of Multiple Personality," ‘J. Ab. P./ June,

1908, p. 114.

(134) Putnam. —“A Consideration of Mental Therapeutics as employed by Special
Students of the Subject," ‘ Bost. J./ 1904, p. 179.

(135) Ibid. —“Recent Experiments in the Study and Treatment of Hysteria at the
Massachusetts General Hospital with Remarks on Freud's Method of Treatment by ‘Psycho¬
analysis/ " ‘ J. Ab. P./ April, 1906, p. 26.

(136) Ibid. —“The Bearing of Philosophy on Psychiatry, with Special Reference to the
Treatment of Psychasthenia," ‘ B. M. J./ October 20th, 1906, p. 1021.

(137) Ibid.—** The Treatment of Psychasthenia from the Standpoint of Social Conscious¬
ness," ‘A. J. M. S./ January, 1908, p. 77.

(138) Ibid. —“The Service to Nervous Invalids of the Physician and the Minister,"
‘ Harvard Theolog. Rev./ April, 1909.

(139) Putnam and Waterman.—“C ertain Aspects of the Differential Diagnosis between
Epilepsy and Hysteria," ‘ Bost J./ May 4th, 1905, p. 509.

(140) Raines.—“R eport of a Case of Psychochromesthesia," ‘J. Ab. P./ October, 1<K)9
p. 249.

(141) Ricksher.—“ Impressibility in Dementia Price ox," ‘A J. I./ October, 1909, p. 219.

(142) Ring. —“The Association Test and Psycho-analysis," ‘Bost. J./ January 7th

1909, p. 16.

(143) Ruggles.— “ Observations on Ganser’s Symptom,” ‘A. J. I./ October, 1905, p. 307.

]()

140

Clinical Pxychology and Psycho-Patholoyy.

(144) Russell, J. W.—“ Hysterical Somnambulism showing Abnormal Acuity of Vision
in the Somnambulic State,” ‘ B. M. J.,’ March 14th, 1908, p. (518.

(145) Savill. — 4 Lectures on Neurasthenia/ 3rd edition, 1908.

(146) Ibid. — 4 Lectures on Hysteria/ 1909.

(147) Ibid. — 44 The Psychology and Psychogenesis of Hysteria, and the Role of the
Sympathetic System,” 4 L./ February 13th, 1909, p. 443.

(148) Schofield. — 4 Functional Nerve Diseases/ 1908. •

(149) Schwab. —“The Use of Social Intercourse as a Therapeutic Agent in the Psycho¬
neuroses, a Contribution to the Art of Psychotherapy,” Amer. Neur. Assoc., Mav. 1907 •
‘ J. N. M. D./ August, p. 497.

(150) Scott. — 44 An Interpretation of the Psycho-ana-ytic Method in Psychotherapy with
a Report of a Case so treated,” 4 J. Ab. P./ February, 1909, p. 371.

(151) Scripture. — 44 Experiments on Subconscious Ideas,” N. Y. Neur. Soc., October
8th, 190/ ; 4 J. N. M. D./ March, 1908, p. 181.

(152) Ibid.— 1 14 Penmanship stuttering,” 4 J. A. M. A.,’ May 8th, 1909, p. 1480.

(153) Sidis, Boris.— “ An Inquiry into the Nature of Hallucinations,” 4 Psychol. Rev./
January, 1904, p. 15; March, p. 104.

(154) Ibid. — 4 Multiple Personality/ 1905.

(155) Ibid. — 44 Are there Hypnotic Hallucinations ?” 4 Psychol. Rev./ July, 1906, p. 239 ;
4 J. Ab. P./ October, 1906, p. 188.

(156) Ibid. — 44 Studies in Psychopathology,” 4 Bost. J.,’ March 14th, 1907, p. 317 ; March
21st, p. 357 ; March 28th, p. 394; April 4th, p. 432; April 11th, p. 472.

(157) Ibid. — 44 The Doctrine of Primary and Secondary Sensory Elements,” ‘Psychol.
Rev./ January, 1908, p. 44, and March, p. 106.

(158) Ibid. — “ An Experimental Study of Sleep,” 4 J. Ab. P./April, 1908 ; 4 P. I ' June

p. 63 ; August, p. 170. ”

(159) Ibid .— 44 The Psychotherapeutic Value of the Hypnoidal State,” 4 J. Ab.P./ June,
1909, p. 151.

(160) Sidis, Boris and Kalmus.— “A Study of Galvanometrie Deflections due to
Psycho-physiological Processes,” ‘Psychol. Rev./ September 1908,p. 391, and January, 1909,

(161) Sidis, Prince and Linenthal.— 44 Contribution to the Pathology of Hysteria
based upon an Experimental Study of a Case of Hemianesthesia, with Clonic Convulsive
Attacks simulating Jacksonian Epilepsy,” 4 Trans. Assoc. Amer. Phys./ 1904, p 446 • 4 Bost
J./ June 23rd, 1904, p. 674.

(162) Spiller.— 44 Psychasthenic Attacks simulating Epilepsy,” 4 J. Ab P 'February

1907, p. 256 ; 4 J. N. M. D/ June, 1907, p. 411, Disc. •

(163) E. W. Taylor.— 44 A Case of Somnolentia,” ‘Bost. J./ 1905, p. 398.

(164) Ibid .— 44 Attitude of the Medical Profession toward the Psychotherapeutic Move¬
ment,” 4 Bost. J./ December 19th, 1907, p. 843 ; 4 J. N. M. I)./ June, 1908, p. 401.

(165) Ibid. — 44 Simple Explanation and Re-Education as a Therapeutic Method”
4 J. Ab. P./ June, 1909, p. 120.

(166) J. J. Thomas.— “Hysteria in Children,” Amer. Neur. Assoc.. Mav 1907-

4 J. N. M. D./ June, 1908, p. 209. * *

(167) Ibid .— 44 Some Aspects of Psychotherapy,” 4 Bost. J./ January 7th, 1909, p. 7.

(168) Town.— “ Association Tests in Practical Work tor the Insane,” 4 The Psychol
Clinic/ February, 1909, p. 276.

i roc. oi tne ooc. tor

Jusy<

(169) Verrall.— 44 On a Series of Automatic Writings. 1
Research/ October, 1906, p. 432.

(170) Waddle.— 44 Miracles of Healing,” 4 Amer. Journ. of Psychol./ April, 1909, p. 219.

(171) Walton.— “The Classification of Psycho-neurotics, and the Obsessional
Element m their Symptoms,” 4 Amer. Neur. Assoc./ May, 1907 ; 4 J. N. M. D./ August, p. 489.

(172) Waterman.—“ The Treatment of Fatigue States,” 4 J. Ab. P./ June, 1909*, p. 128.

(173) White. —“The Theory of the Comjdcx,” 4 Interstate Med. Journ./ April, 1909,
p. 243.

(174i Tom Williams. — “A few Hints from Personal Experience in Psychotherapy "
‘ Monthly Cyclop, and Med. Bull./ July, 1908. * ’

(17o) Ibid. I lie Hole of the Physician in producing or maintaining Maladies pro¬
duced by the Imagination,” ‘Amer. Med./ August, 1908 , p, 367,

Fil’uext Jours.

U7

(170) Ibid. —“Considerations as to the Nature of Hysteria, with their Application to
the Treatment of a Case/' ‘ Intermit. Clinics/ October, 1908, p. 44.

(177) Ibid. —“ The Differential Diagnosis of Functional from Organic Palsies,” ‘ Arch,
of Diagnosis/ October, 1908. _

(178) Ibid. —“The Elements of Diagnosis between Spasmodic Movements of the Face
and Neck,” ‘Virginia Med. Semi-monthly/ October 9th, 1908.

(179) Ibid. —“Recent Advances regarding Hysteria in relation to Traumatic
Neuroses/' ‘ Monthly Cyclopaedia and Med. Hull./ November, 1908.

(180) Ibid. —“The Present Status of Hysteria/’ ‘N. Y. M. J./ January 9th, 1909, p. 53.

(181) Ibid. —“The Differential Diagnosis tatween Neurasthenia and Some Affections of
the Nervous System, for which it is often Mistaken,” ‘ Arch, of Diagnosis/ January, 1909.

(182) Ibid. —“Mental Causes in Bodily Disease: the most frequent Cause of the
Origin of * Nervous Indigestion/ ” ‘ J. Ah. P/, February, 1909, p. 38(5.

(183) Ibid. —“ The Trend of the Clinical Concept of Hysteria/’ * Host. J./ March 25th,
1909. p. 304.

(184) Ibid.— “The Clarification of our Concepts concerning Hysteria/’ ‘Monthly
Cyclopaedia and Med. Bull./ March, 1909 ; ‘ Canadian Journ. of Med. and Surg./ May, 1909,
p. 278.

(185) Ibid. —“The Importance for Research and Treatment of Distinguishing Clinical
Types among Psycho-neurosis,” ‘ J. Ab. P./ April, 1909, p. 32.

(180) Ibid. —“The Psychological Bases of Inebriety,” ‘ N. Y. M. J./ April 24th, 1909,
p. 833.

(187) Ibid. —“The Difference between Suggestion and Persuasion—the Importance of
the Distinction,” ‘ Alienist and Neurologist/ May, 1909, p. 158.

(188) Ibid.—** Psychoprophylaxis in Childhood,” ‘ J. Ab. P./ June, 1909, p. 181.

(189) Ibid. —“ The Traumatic Neurosis and Babinski’s Conception of Hysteria,” ‘ Med.
Rec./ October 2nd, 1909, p. 557.

(190) Witmer. —“Mental Healing and the Emmanuel Movement,” ‘The Psychol.
Clinic/ December, 1908, p. 212; January, 1909, p. 239; February, p. 282.

(191) Woodman. —“General Considerations as to the Nature and Relationships of
Hysteria,” * J. N. M. D./ January, 1908, p. 23 ; Febuary, p. 77 ; March, p. 153.

(192) Yerkes and Barry. —“The Association Reaction Method of Mental Diagnosis,”
‘ Amer. Journ. of Psychol./ January, 1909, p. 22 .

Dementia Praecox.*

By G. H. Harpkk-Smith, M.D., B.C.Cantab., M.B.C.S, L.B.C.P.

CoNTKNTS.

P Vi. K

Introduction II s

Definition and Historical Survey 149

Symptomatology 15<>

The Simple Form 152

The Hebephrenic Form 152

The Katatonie Form 152

The Pamnoidal Form 154

Physical Signs ........ 155

Frequency . 156

Age at Onset and Sex ....... 156

Course and Termination ........ 157

Treatment .......... 15N

Pathology:

Changes in the Brain ........ 159

Chemical Examination of Brain ...... 1(50

Changes in the Blood t . 161

Examination of Cerebro-spinal Fluid and Blood .... 162

Chemistry of Urine ....... 163

Etiology and Pathogenesis ....... 163

Conclusions ........ 167

Description of Cases ........ 1(57

References ........ ISO

Introduction.

Dementia pnecox is a term which has been applied by Professor
Kraepelin, of Munich, to a definite group of mental disorders commencing
usually at or about the period of adolescence and terminating, in the
majority of cases, in dementia.

This observer admits that the variety of clinical forms included under *
this definition is very great, and that the connection between them may
not be readily perceptible, but asserts that there are certain fundamental
symptoms which can be recognised in all cases which justify the state-
* Accepted ns a tlu-sis fur the M.D. degree of Cambridge University.

(t. H. Harper-Smith . 149

ments lie lias made, Many authorities, however, object to the use of the
term on the ground that sufficient evidence has not been produced to
warrant the recognition of dementia pnecox as a definite clinical entity,
and this they state can only add to the confusion which already exists in
the nomenclature of disorders of the insane.

I have had the opportunity of studying in the London County Asylum
at Clavbury a large number of cases similar to those described by Pro¬
fessor Kraepelin. I am convinced of the correctness of Professor
Kraepelin’s observations, and I believe that it is possible to recognise
under this heading certain obscure cases which hitherto have defied a
suitable classification.

I propose in this thesis to record the main features of interest connected
with this form of insanity, and to add a description of some of the more
important cases which have come under my observation.

Definition and Historical Survey.

Definition .—Dementia pnecox is a psychosis essentially characterised
by a special and progressive psychic enfeeblement commencing usually
during adolescence, and culminating, as a rule, in the disappearance of all
manifestations of mental activity, without ever compromising the life of
the patient.

The onset of the affection is usually signalised by the manifestation of
diverse neuropathic disorders, these being in turn followed by the appear¬
ance of psychic derangements of various types, such as excitement,
depression, states of confusion and hallucinations.

The commencement at or about the period of adolescence, and a
termination in a more or less complete dementia, are the most character¬
istic features of the malady.

Historical survey .—The earliest reference to a mental state resembling
dementia pnecox is in a small volume entitled “ Lehrbuch der Storungen
des Seelenlebens,” written by Professor Heinroth, of Leipzig, and pub¬
lished in 1818. It is as follows:—“The whole appearance, the posture,
the attitudes of the patient bear the stamp of this condition. His glance
is lifeless, the face expressionless—except for a dillness which is the result
of inactivity. His posture is one of languor, and his movements are slow
and dilatory. . ” This is his description of one of the various forms
of dementia, and he here anticipates the later conception of dementia
pnecox.

150

Dcmentta Pr&c<><v.

In 1863 Professor Kalilbaum described a form of mental disease
occurring at puberty and rapidly terminating in dementia. This he called
“ Hebephrenia.” In 1874 the same author described the condition known
as “ Katatonia / 9 or the insanity of rigidity.

In 1871 Hecker contributed his work on “Hebephrenia,” the chief
features of which he describes as follows:—“Onset in close succession to
puberty; the appearance alternately of melancholia, maniacal and con¬
fused states, a speedy psychic decline, with its finality in terminal
dementia, which may be anticipated from the first.”

In 1891 Pick, under the heading of dementia pnecox, described cases,
including hebephrenia, characterised by maniacal symptoms followed by
melancholia and rapid deterioration.

The latest and most original work has been furnished bv Professor
Kraepelin, who has connected certain maniacal and depressed states with
stupor and catalepsy, bizarre attitudes with delusions and hallucinations,
in order to form one comprehensive group—dementia pnecox—-whose
termination is a special form of mental reduction, and has extended the
term dementia pnecox to include the Hebephrenia and Katatonia of
Kalilbaum, together with certain forms of paranoia which undergo early
deterioration.

Symptomatology.

The varied character of the symptoms which are met with in this
affection renders their description a matter of considerable difficulty. It
may here be stated that their very complexity has been the subject of the
keenest criticism at the hands of those who are opposed to Kraepelin's
teaching.

The following varieties of dementia pnecox have been described :—

1. The simple dementia, or heboid phrenia of Kalilbaum.

2. Hebephrenia.

3. Katatonia.

4. Paranoidal forms.

To this list may be added a simple form described by other writers.

It must be admitted that these divisions are largely artificial. Pro¬
fessor Kraepelin himself says : “ Xo rigid line can In* drawn between the
divisions, because the cases run into each oilier and overlap continually.
There are whole series of recurring forms, but between them lie such a
variety of cases, that, in spite of all effort, it is impossible to classify each
case without exception, into a given category.” Form a perusal of his

(1. II. Ha i w Sii tit It.

151

lectures, it is (juit-e clear that lie 4 regards these divisions not as separate
entities, hut as varieties of the s^ine condition ; and he has further
emphasised the necessity of classifying the psychoses upon their course,
and termination, and not purely on their symptomatology. He lias tersely
described the diagnostic point or symptom of this disease to he “a peculiar
and fundamental want of any strong feeling of the impression of life with
unimpaired ability to understand and to remember.” In addition to these
types or sub-divisions there are certain symptoms which are common to all
eases. The first change which is usually noticed is a desire for solitude
and loneliness, with some uncertainty and irritability of temper. There is
a lack of interest in work and pleasure; and an emotional deterioration
shown by bluntness of feeling towards incidents which formerly would
have caused excitement, joy or grief. There may be a marked decrease
in affection, and a loss of the sense of decency. This lack of interest and
loss of emotion gradually becomes more marked, and in from two to three
weeks or months there is an apparent- complete indifference to all that is

taking place. But cases in which the mental condition has improved

under treatment have told me nearly all that had happened while they
were in this state, and have* explained their indifference by stating that
they lacked all power of initiating movements, and thus were incapable of
showing that they appreciated what was taking place. One patient
(\V. D.) was admitted in a state of flexibilitas cerea. He never spoke,

never initiated a movement, and remained in any position in which he

was placed. At the end of three months lie suddenly spoke. He
remembered nearly everything that had happened and gave a good
account of all that had taken place since his admission. He knew the
names of doctors, attendants and patients, and told me the nicknames of
certain patients and appreciated the humour of these nicknames. His
explanation was that he was unable to initiate any movement although he
desired to do so.

Another patient (H. M.) was very similar. Neither of these patients
had any feeling of hunger during this state. The latter patient had
certain stereotyped movements. He said afterwards that he had no
desire to do these but was quite unable to control his actions. Neither
of these two cases recovered.

Other patients, after the onset, develop impulsiveness, hallucinations
or delusions, and other .symptoms which will be mentioned under their
a p ]) ro p ri a t e headings.

The patients are well oriented in all respects and show no evidence of

152

Dementia Pnecov.

clouding of consciousness. If closely watched, they may be seen to
observe keenly all that is going on without giving any sign at all that they
do so. One (Mr. C.) who had stereotyped movements, mutism and
negativism, was persuaded after some difficulty to write answers which
showed that there was no dulness of consciousness.

The memory is but little disturbed. The will power is lost and
judgment is, without exception, affected. Although the patients can
remember what they hear and what takes place, their train of thought
suffers, and under strange circumstances they are helpless. There is a
lack of all power of initiation. Patients may develop sudden impulses or
stereotyped movements, but these are quite subconscious, even when
the impulse is to self-destruction. The impulse to this is perfectly aimless.
The normal mental state is never regained.

I. The simple form .—Patients suffering from this form are seldom seen in
asylums. The condition usually commences about the age of 16-18 years,
in a subject who previous to the onset of symptoms was considered a bright
and intelligent child. The onset of this variety is insidious, and it may be
quite impossible fo fix its date, because initial symptoms are not appreciated
at their true value. A lack of interest in surroundings and a desire for
seclusion may be the first change noticed. There is a failing ability to
assimilate new facts, a retarded mental intellect slowly progressing to
dementia without the development of impulses, hallucinations, or delusions.
The patients become semi-automatic, and are frequently conscious of their
state. They may suffer from headache and insomnia, and may be the
victims of vague fears and hypochondriasis.

II. Hebephrenia .—This form of dementia prtecox is usually of more
abrupt onset than the last, although the prodromal period may extend over
several months, during which time the patient suffers from insomnia, head¬
ache, anorexia, and perhaps loss of flesh. The symptoms of the onset of
the attack are generally confusion and depression.

These patients are liable to develop states of excitement or depression
accompanied by systematised delusions, hallucinations and impulses, mystic
ideas and eroticism. Kraepelin and Trommel* have drawn special attention
to the incoherence in speech and writing which is of special importance in
the diagnosis. This is characterised by the persistence of ability for correct
grammatical construction, the richness of unusual and new words, and the
lack of meaning in both written and spoken language. This disordered
language corresponds to the change in their manners and behaviour. The
aspect of these patients, their attitudes, gestures, methods of eating and

(t. If. Harper- S mi th.

153

drinking*, ;iml walking, are l)izarre and artificial. Hallucinations and
delusions may be combined with dulling of the emotions, childish idleness
and senseless laughter, and usually mental enfeeblement is established
within two years. Profound deterioration occurs in about 75 per cent, of
the cases, and only 8 per cent, can be considered to improve.

III. The katatunic forte .—This variety, like the other forms of
dementia prmcox, is usually sub-acute or chronic in its onset, and may be
preceded by similar prodromal symptoms. Occasionally the onset may be
sudden, the exciting cause being some severe emotional shock or fright.
In these cases the patient may enter at once into a profoundly stuporous
condition. Following the more or less vague symptoms of the prodromal
period the typical symptoms of the disease develop, viz. katatonic stupor
and katatonic excitement. Katatonic stupor is characterised by negativism
and automatic obedience or suggestibility. Negativism is characterised by
a resistance to all external intervention, any effort to place the patient’s
limbs in a particular position is strongly resented, and results in a condition
of muscular tensiou. If one is successful in placing the limbs in the desired
position they are immediately returned to their former state. Resistance
may be carried to such an extent that the patients may refuse to eat, to
dress, or to sit down. There may be voluntary retention of urine and
fmces, and an insensibility to all external influence. No attention is paid
to questions. The patient may remain absolutely mute, while sensory
stimuli of considerable strength may be applied without eliciting any
response. This condition of negativism to all outward influence is a
marked symptom. It is often accompanied by the performance of certain
movements illustrative of muscular tension, such as grimacing and frowning
A peculiar feature, known by the Germans as €: Suautzkrampf,” consists in
a stereotyped movement of puckering up the lips and then protruding
them rapidly, which movements may be repeated for hours. Quite the
reverse of this picture is that of automatic obedience or suggestibility,
which is characterised by the adoption of katatonic attitudes, in which the
patients persist in maintaining the most extraordinary positions into which
they may be placed (flexibilitas tvrea).

Automatic suggestibility is further shown in some cases by a mechanical
obedience on the part of the patients to do as they are told. Fcholalia and
echopraxia belong likewise to this group of symptoms.

In katatonic stupor there is lack of co-ordination in all movements, and
muscular reaction is retarded. For example, when asked to shake hands
tlie patients will usually very slowly put out the hand, and when it is

154

Denim 11a Prxcoie.

taken they never grip the proffered hand, and never shake it, and do not
withdraw their own ; at other times they take no notice. Dr. Stoddart
regards as distinctive the ape-like character of the hands, and a peculiar
handshake, the patient holding out the hand stiffly and straight, and
frequently rudely withdrawing it at once. The method of writing is also
peculiar. There is much delay in commencing, and patients have to he
asked to write several times. They hold the pencil in whatever position
it is put in the hand, making no effort to get it into the writing position;
the paper has to be placed underneath the pencil. If paper and
pencil are placed on the table in front of them, they make no
effort to write. They write very slowly, with much hesitation, and with
apparently great effort in forming each letter, and in completing, con¬
necting and touching up what has been written. Repetition of letters,
words and sentences is commonly present. Muscular fatigue soon becomes
apparent. If the katatonia is profound, they cannot be induced to write.
It it is less profound, they can be made to write with great effort; but
they are very slow, and repetition is very marked. In cases with slight
katatonic symptoms the first few answers are written fairly well; but the
writing soon becomes slower, and they commence to repeat words and
letters, and have to be stimulated frequently.

These attacks of katatonic stupor may alternate with phases of kata-
tonic* excitement. Here the condition of passiveness and stupor is replaced
by increased psychomotor activity, and is characterised by the performance
of purpo-eless actions, stereotyped movements and verbigeration. Most
interesting is the continued repetition of the same movements; for example,
patients will persist in walking round in a circle, or will clap their hands
together for an indefinite period, or dance, gesticulate, and make grimaces.
As an interesting example of this purposeless repetition of certain move¬
ments, J can recall to mind the case of a young male suffering from kata¬
tonic excitement, who was in the habit of seeking the corner of the room
and there would proceed to beat the side of his head with his hand for
hours together, varying this performance by spitting into his coat sleeve
at intervals. The constant repetition of this action had completely worn
away the hair from one side of liis head.

The temperature of these cases during the acute stage may be raised
t<> 1 ()()°—102° V.

IV. The jHtnuioidal form .—This form is characterised by the rapid
development of mental deterioration, with complete retention of conscious¬
ness for a considerable time. This is accompanied by delusions and

(!. II. lljtrjwv-Smith.

155

hallucinations and sensory phenomena which are the predominant
symptoms for several years. The liallucinations of sitrlit and hearing and
the fantastic delusions of persecution and of grandeur may equal, even
if they do not surpass, in their extravagance those of general paralysis
of the insane. These are the features which characterise this
form of dementia pnecox. This condition differs from true paranoia in
that it develops rapidly, that the fantastic delusions are not based on fact,
and that prominent hallucinations are present. Paranoia, on the contrary,
develops slowly, hallucinations are few, and the delusions are based on
some actual fact which is misconstrued.

Recoveries in this group do not take place.

Physical Skins.

Most patients suffering from dementia pnecox become emaciated with
the onset of the disease. It is of interest that High ini, conducting meta¬
bolic experiments on these cases, found that in the acute phase of the
disease the results indicated an excessive metabolism and a destruction of
the sulphurized and phosphorized proteids of the organism; in the more
chronic phase, however, he found that this excessive metabolism abated.
Later, under treatment they may regain and even exceed their normal
weight, but they are liable to considerable fluctuations in this respect
during the progress of the disease. Cardiac arhythinia and bradycardia
may be present; the pulse is usually small and feeble, the skin dry, the
extremities eyanosed and cold. Constipation is always present and
troublesome. The urine is scanty, of high specific gravity, and often
contains excess of urates and phosphates. 'Die knee-jerks are usually
increased, and the tendon reflexes may be exaggerated. The cutaneous
reflexes are abolished or feeble in 50 per cent, of the cases, and are always
greatly diminished in the kata tonic group. The pupils in most cases are
widely dilated. They are equal and react to light and accommodation.
In a few cases I have noted slight inequality or irregularity of the pupils.

A fine general tremor is present in several cases. Sorieux has noted
cases with exophthalmos and enlargement of the thyroid gland, but 1
have seen no cases with these symptoms. Before and during the onset
there is a history of insomnia in all eases, and ainomia is very common.

In females menstruation is often irregular, and in some cases there is
amenorrhcea.

In the katatonic cases there is dribbling of saliva from the mouth, but
probably no increase of salivation, as all the secretions are retarded.

Dementia Pnecox.

15(3

Fkequency.

Professor Kraepelin’s observations lead him to believe that 14 to 16
per cent, of the total admissions to asylums are cases of dementia pnecox,
and those of Dr. Paul Serieux at the Maison de Saute do Ville Evrard
are very similar. In this country the percentage is not so high, and this
may be accounted for by the fact that the disease is not generally
recognised by many English alienists. Further statistics must therefore
be awaited before any correct indication of the frequency of dementia
pnecox can be obtained. My own belief, however, is that the figures
given above underrate the frequency of the disease. This is borne out by
a recent publication of Dr. Ryssia Wolfsohn, who in an examination of
2215 insane patients has discovered no less than 647 cases of dementia
pnecox, an average of 30 per cent. (23 per cent, males ; 39 per cent,
females).

Age at Onset.

The average age of onset is between twenty and thirty years of age.
I have seen only a few cases commencing outside these limits. Of 296
cases observed by Professor Kraepelin, 60 per cent, began before the age
of twenty-five. The age of onset further appears to vary with the type
of malady. For example, 72 per cent, of the hebephrenic forms, 68 per
cent, of the katatonic, and 40 per cent, of the paranoidal forms, are
stated to commence before the age of t wen tv-five.

Dr. Serieux, who has studied 50 cases which have come under his own

rrvation, ogives the age of onset as follows :
From 15 to 20 years

9 cases

, 20 „ 25 ...

O „

25 „ M0 ...

12 „

M0 „ M5 ...

" „

, ■•{■» „ M .

M „

Total

50

Dr. Bolton from a study of 100 cases states that the average age of
onset varies from fifteen to thirty years in males, and from sixteen to
thirty years in females.

Sex.

The di sense appears to be equally common to both sexes.

Cr. H. ILirprr-Smith.

] 57

Cor use and Termination.

Cases of dementia pnecox never recover tlieir normal mental state.
Under favourable circumstances, certain patients may be brought back to
a state approaching the normal, owing to their greater recuperative
energy and reparative powers, but they differ entirely from cases of acute
mania and melancholia in that they never regain their former state. A
case of acute mania may recover and in no way differ from the condition
which existed before the attack. This is not so with cases of dementia
pnecox. The acute stage of excitement with delusions and hallucinations
or the state of katatonia, after a few months or even a year passes off
and there remains a state of mental enfeeblement, which may be followed
by another acute attack after a lapse of two or more years. This state of
mental enfeeblement may be slight or more profound. Such patients
may at first sight appear to be normal. They carry out simple tasks
allotted to them, and are capable of giving a fair amount of attention to
the ordinary routine of life, but a close examination shows a loss of
judgment, a retardation of mental activity, a state of childishness, a
marked diminution of affection, absence of desire and curiosity, and
further a satisfaction with their condition. Others have an absolute lack
of interest in everything. They have to be dressed and at times fed, and
yet show that they know where they are, and that they understand and
appreciate all that is taking place. Certain of these cases in which the
dementia is less marked have been discharged to the care of friends, but
they have not recovered.

Cases of dementia pra^cox, especially those which display the katatonic
form, are especially liable to pitlmonary and intestinal tuberculosis.

‘ I have had the opportunity of examining the post-mortem records of
sixteen consecutive cases which died at the London County' Asylum,
Claybury. The table on page 158 shows that in fourteen of these cases
death was due to tuberculosis, and the average age at death was
twenty-five years.

The cases which escape pulmonary tuberculosis live, under asylum
treatment, fairly healthy' lives, suffering at times from oedema and other
signs of cardiac weakness from which they recover as a rule with rest and
appropriate treatment. A large number of incurable cases whose physical
condition is quite satisfactory, can usually' be found in asylums. Figures
have been given with regard to the prospect of mental recovery in the
various forms of this disease. The hebephrenic is regarded as more

158

Dniunitia L'niror.

Initials.

Sex.

Avfe a* Death.

• Cause of Death.

‘

(t. s.

31

24

Tuberculosis. Both Unit's extensively affected. Ulcera¬
tion of small intestine. Liver, spleen and kidney
affected.

C. H.

31

35

Tuberculosis. Both lungs, and large and small intestine
extensively affected. Caries of sacrum — psoas
abscess.

E. E. N.

M

a 5

Tuberculosis. Both lungs extensively affected.

H. F. K.

31

20

Tuberculosis. Both lungs, large and small intestine
extensively affected. Liver and kidneys affected.

H. G. 8.

31

2:1

Tuberculosis. Both lungs, intestines and peritoneum
affected.

C. J. H.

M

23

Lobar pneumonia. No tuberculosis. .

F. B.

31

27

Tuberculosis. Both lungs extensively affected.

C. C.

F

, 27

Cardiac failure. Bronchitis. No tuberculosis.

M. I).

F

i

28

Tuberculosis. Both lungs, intestines and peritoneum
! affected

M. K.

F

17

Tuberculosis. Both lungs and intestines affected.

Tubercular salpingitis.

F L. 31. 0.

i f

27

Tuberculosis. Both lungs, intestines and mesenteric
glands affected.

31. A. H.

, F

27

Tuberculosis. Both lungs and intestines affected.

J. B.

31

24

Tuberculosis. Both lungs—miliary.

A. R.

31

23

Tuberculosis. Both lungs—miliary.

c. w.

M

24

Tuberculosis. Miliary—both lungs—liver—spleen—kid- ,
ney—bronchial glands. ,

F. W. S.

: 3i

1

23

Tul)erculosis. Both lungs extensively affected.

Total cas *s. 10. Average age at death, 25.

Tuberculosis caused 14 deaths, Lobar Pneumonia 1 death, Cardiac Failure 1 death.
per cent, died from Tuberculosis.

serious tliau the katatonic. In the former variety 75 per cent, of the
cases are stated to reach profound mental deterioration, and only 8 per
cent, to recover. With regard to the katatonic state, 80 per cent, of the
cases lapse into profound mental deterioration and only Id per cent,
recover, and even these show some peculiarity. Xo recoveries are stated
to take place in the paranoidal group. Roughly 25 per cent, of all cases
are said to show a greater or less degree of improvement, but I know of
no symptoms from which we can conclude that this improvement is about
to take place. My own opinion is that there is no real recovery from this
affection. The apparent recoveries are probably due to remissions which
sometimes occur and may lead to erroneous conclusions. I have myself
seen cases which have been discharged as recovered, only to return in tho
space of a few months or years with a fresh attack, and to terminate in
dementia.

Th‘KA I’M KM'.

The most, suitable treatment is rest in bed, with isolation from home,
friends and surroundings. To this end a trained nurse is essential. The

G. II. HurjH'r-Smith.

1 59

pulse aiul weakness of the heart sounds point to a condition of profound
mental and physical exhaustion. Cleanliness and a simple nourishing 1
diet, with open-air treatment where possible, are of the greatest service.
After some months, when the bodily condition lias improved, the patient
may be allowed to get up and take gentle exercise in tlie fresh air. A
warm bath should be given daily. I have tried electrical treatment in
several cases but with no appreciable results. I know of no evidence that
serum therapy or organo-therapy has had any beneficial effect.

Treatment- for gastro intestinal intoxication has met with no success,
and the administration of thyroid and ovarian extract has produced no
beneficial results.

Pathoj.ooy.

Cluuujts in the bruin .—Sufficient cases have not been examined to allow
of any definite conclusions being drawn regarding the pathological changes
found in the brain. The macroscopical appearances are usually normal,
Parchoppe alone stating that there is atrophy of the anterior two-thirds
of the hemisphere and consequently a loss of weight of about 140 grm.

Dr. Mott has reported the microscopic changes in a case of dementia
prmcox in the c Archives of Neurology/ vol. iii; he states that there
appeared to be a deficiency of pyramidal cells in all regions. The Betz
cells showed a marked deficiency of chromophilous substance, the nuclei
being swollen, clear and pale, irregular in outline and often eccentric.
Throughout the whole cortex and subjacent white matter there could be
seen young actively dividing neuroglia cells, especially in the deeper
layers. They were not found in the most superficial layers as in general
paralysis and alcoholic dementia. He further states:—“Whether these
changes in the large Betz cells can be associated with the katatonic
condition, and whether this deficiency of stailiable (nucleo-proteid)
substance in the deeper layers can be in any way correlated with Dr.
Koch’s chemical observation, it is impossible to say.”

Klippel and Thermitte have concluded from histological examination
that there is no inflammatory reaction or any evidence of diapedesis in
the coats of the vessels of the brain and spinal cord, the changes being
entirely confined to the neurones of the association centres, and consisting
of atrophy of the large pyramidal cells, with the exception of those in the
motor-zone, and a granulo-pigmentary degeneration of the same cells,
with a diffuse chromatolysis.

De Buck and Deroubaix from an examination of eight cases state that

160

Dementia ]* t'tea>;e.

the principal lesion consists of a pigmentary degeneration together with a
gradual atrophy of the neurones, which results in a complete disappearance
of the nervous elements. The layers of the cortex most affected are those
of the large pyramidal and polymorphic cells, the vessels being only
slightly affected. The authors suggest that these lesions are due to an
autotoxic action on a predisposed soil, and from an anatomical point of
view they conclude that dementia pnecox resembles closely the exogenous
toxic psychoses and especially that form which is produced by alcohol.

Nissl has found profound changes in the cells, which he has described
under the name of destruction dn noyau. A large number of cells, he states,
appear to be destroyed, but there is no atrophy of the grey matter. The
deep strata of cells (neurogliques), small and large, show signs of
degeneration. The grey matter is, moreover, studded with large nuclei of
neuroglia cells.

Gonzales has described the following changes in a case of dementia
pnecox :—Atrophy of the cells of the Kolandic areas, frontal lobes, pons,
bulb and cord, with increase of neuroglia. There was a state of
pigmentation observed in the cells of the motor areas and in the pons and
medulla. In the Rolandic area the pigment was at times sufficient to
occupy the entire cell body, though usually it only involved the periphery.
He claims to be the first to describe this marked pigmentary cellular
change in dementia pnecox. The case was a married woman, aged 26
years. Regarding the other organs of the body Dide has also noted
changes in the liver, and, according to him, dementia pnecox is a subacute
or chronic mental syndrome of toxic infectious origin. In the hebephrenic
and katatonic varieties of dementia pnecox, chronic enteritis is common.
He states that the liver showed fatty degeneration in all cases. He
considers that the decrease in urea observed in katatonia is due to hepatic
insufficiency. He also states that tuberculosis is very common in
hebephrenia and katatonia.

The chemical elimination- of the brain in dementia ]>nvco,c. — The
chemistry of dementia pnecox has been studied by Koch and Mann, and
their results tend to show that in this disease there is a disordered sulphur
metabolism. A comparison of the chemical composition of normal brains
at different ages has been made by these investigators, in which they
indicate that as the adult age is reached, a highly complex (water insoluble)
organic sulphur compound, liquid xuljthnr, is formed at the expense of
water soluble* organic and inorganic sulphur compounds. Comparison
with the normal shows tliat the brain in dementia pnecox is lacking in

G. H. Harper-Smith .

161

lipoid sulphur and the water soluble organic sulphur, while at the same
time there is an increase in the amount of inorganic sulphur. The fact
that Pighini has recently shown that there is an increased excretion of the
water soluble organic sulphur in the urine in this disease, further points to
the probability of a disordered sulphur metabolism, due to a general
inherent bodily deficiency for oxidation processes.

Changes in the blood .—Pighini and Paoli have described special
changes in the red blood corpuscles by the use of a special method
of staining. Other changes described by them are :—

1. A hydrsemic condition of the blood.

2. An occasional leucocytosis with increase in the polymorphonuclear
leucocytes and of the blood platelets.

The authors state that the changes they have described do not indicate
a degenerated condition of the cells but a physiological one, and they
claim that their investigations support the theory of Kraepelin that
dementia prmcox is due to a disturbance of the organic metabolism.

Dide and Chenais have also investigated the blood in this disease.
They say that it is difficult to deduce any definite conclusions, but one
conclusion is sufficiently clear, that in twelve of their cases there was an
increase of the eosinophiles. The authors state that in their cases the
percentage of eosinophiles rose as high as 3 to 4 per cent., and
this they regard as an eosinophilia. It need hardly be mentioned that
their conclusions based upon this percentage of eosinophiles are quite
incorrect and unjustifiable. Such a percentage of eosinophiles in the
blood is quite normal, and there are few competent pathologists who
would take any serious notice of the rise of eosinophiles in the blood until
a percentage of 8 per cent, was reached.

Dr. Lewis Bruce refuses to accept dementia prrncox as a definite
entity and describes both hebephrenia and katatonia and dementia
paranoia separately under the head of insanities of toxic origin. He
describes katatonia as a distinct disease which passes through three
stages, viz.: 1. The stage of onset. 2. The stage of stupor. 3. The
stage of excitement. In typical cases he describes a distinct febrile
attack which ushers in the stage of stupor. The leucocyte count shows a
moderate persistent hyper-leucocytosis with increase in the polymorpho¬
nuclear leucocytes and large mononuclear cells. At the termination of the
acute stage and just prior to the onset of stupor, he states that there is a
sharp rise of leucocytes, the increase being chiefly in the polymorpho¬
nuclear leucocytes. A transient eosinophilia occurs in every case

11

1G2

]bmrntia Prwrox.

according to this writer. I have carefully examined the blood in twenty
cases of dementia pra>cox, but I was unable to confirm these observations.
I made use of the Thoma-Zeiss haemocytometer and of stained blood
films. In no single instance did I find the number of leucocytes to
exceed 8000 per cubic mm., nor did I find in the stained films any
decided evidence of an excessive increase of the eosinophiles. A slight
degree of anaemia was present in the majority of cases.

Examination of the cerebrospinal fluid and blood .—In conjunction with
Dr. Rae Gibson I have investigated the eerebro-spinal fluid withdrawn by
lumbar puncture from cases of dementia praecox, paying special regard to
the following points :—

1. The presence of micro-organisms.

*2. The presence of protein, as evidenced by the Noguchi test.

3. The presence of cells in the deposit of the centrifuged cerebro¬
spinal fluid.

We have examined the eerebro-spinal fluid withdrawn by lumbar
puncture during life from thirty cases of dementia pra3cox, and obtained
a negative result in twenty-three cases after we had improved our
technique. We are therefore forced to the conclusion that the reported
discovery of any organism in the eerebro-spinal fluid in dementia
pnecox should be regarded with great caution, and in the light of
the difficulties we have encountered, we would suggest that any such
organism may be the result of external contamination.

The Noguchi test for proteins yielded a negative result in all fluids
examined that were free from blood, and the examination for cells in the
centrifuged deposit of the fluid was also negative

Using the same technique we also examined the circulating blood for
the presence of micro-organisms. About 5 c.c. of blood was removed
from the patient ; the greater part was placed in flasks containing 100 c.c.
of sterile broth, and the remainder distributed among various media. In
the twenty cases examined we were unable to detect the presence of any
organisms.

Dr. Lewis Bruce has also made an extensive bacteriological examination
of the blood in this disease, and he states that on one occasion he was able
to isolate a streptococcus from the circulating blood; this organism was
agglutinated by the blood-serum of fifteen out of twenty cases of that
disease, /. e. in 7o percent. He considers that the agglutinin frequently
present in the blood of patients suffering from katatonia is a. specific
agglutinin. Serum treatment so far, he says, has produced no result. A

G. II. JFarpn'-Smith.

1(33

goat was immunised to the streptococcus and the serum of this animal
injected. Beyond a fall of temperature in the acute cases, there was
nothing worthy of note. Babbits experimentally infected with tlie
streptococcus intra-venously or by the alimentary tract developed malaise
with irregular temperature, increased skin reflexes, and mental hebetude.
The disease terminated naturally in about six weeks with the establishment
of immunity to the organism.

The the wintry of the urine .—Pighini has obtained the following results
from the examination of the urine of sixteen cases of dementia prieeox. In
all the cases the urea was considerably below normal. The density was
notably increased in thirteen of the cases. The phosphates were normal,
and in fourteen cases the chlorides were in excess. Albuminuria was only
found in one case, and then was intermittent. Urobilin was present in one
ease. Indican and biliary pigments were absent. The later observation of
this author on the increase of neutral sulphur in the urine has already been
mentioned.

A consideration of the statements which have been put forward by the
various authorities mentioned above will, I think, make it evident that the
pathology of dementia praecox is at present very imperfectly understood.
The histological appearances of the cerebral cortex are by no means
distinctive when a comparison is made between them and those found in
general paralysis of the insane, in which disease the histological appear¬
ances are very distinctive and diagnostic. Chemical aualysis of the brain
substance appears to yield more hopeful results, and I am of the opinion
that in this direction there lies a great field for research, both in this
disease and in all other forms of insanity, especially with the advance of
our knowledge of the chemical constituents of the brain.

Etiology and Pathogenesis.

The cause of this disease is as yet but little understood. Two main
theories, however, must be mentioned : (1) That the disease is due to an
inherited instability of the nervous elements; (2) that the disease is of
toxic origin.

Prof. Kraepelin has found a neuro-psychopathic heredity in about 70
per cent, of the cases of dementia pnecox, while Christian estimates that
this can be obtained in 43 per cent, of the cases. I have found it present
in every case where I have been able to obtain an extensive family
history.

164

Dementia Prascox.

Dr. Ballet, of Paris, is of the opinion that constitutional predisposition
is the most important factor in its production. In seventeen cases of this
disease he was able to trace either a hereditary predisposition or some
personal peculiarity in the patients themselves.

Dr. Ryssia Wolfsohn has made special inquiries into the hereditary
transmission of this form of insanity. He selected 550 cases of dementia
pnecox upon which to study the influence of heredity. In 56 patients no
heredity was found, but it was traced in 494 cases (235 males and 259
females), or in 91 per cent, of the male patients and 85 per cent, of the
female patients. His deductions are as follows :

(1) A hereditary taint has been found in 90 per cent, of the cases (male
and female) of dementia praecox.

(2) Of the four factors, insanity in the relatives is the most frequent,
being about 64 per cent., after which come nervous diseases, then alco¬
holism, and lastly, eccentricity of conduct.

(3) In 34 per cent, of all the cases there was a combination of causes,
especially insanity with alcoholism, and insanity with nervous diseases.

(4) When alcoholism, nervous diseases, and abnormal character appear
as hereditary causes no especial direction of the form of dementia can be
made out, while the transmission through insane relatives seems in some
degree to incline to the katatonic and the paranoidal form of the
dementia.

(5) No connection can be traced between the hereditary taint and the
severity of the symptoms of dementia praecox.

The breaking down of the neurones is due to some cause which is best
included under the term stress. This stress may be great or slight
according to the inherent resistance of the brain cells, the more faulty the
organism the less the stability and the less stress required to reach the
breaking point. The advent of puberty in itself constitutes a stress, and
there is superadded at this time the greater strain of education and the
worries of obtaining a livelihood. Undoubtedly the period of adolescence
is one of the most dangerous, when the emotions and physical powers are
undergoing a new and wonderful development, as it is at this period that
the least stable succumb.* Other causes of over-exertion and of physical
and moral exhaustion, such as menstrual disorders and the puerperium,
have an unquestionable influence. Masturbation has been held to be an
important factor in the production of the disease, but it is more probably
a symptom than a cause. I have found a history of alcohol in one case
only, and in no case has there been any history of acquired syphilis.

G. H. Harper-Smith.

165

On the other hand, the exciting cause may be an auto-intoxication,
possibly arising from some disturbance of the sexual glands, or from some
functional insufficiency of the ductless glands, causing a bio-chemical
change which has a toxic effect on the higher nervous mechanism.
Professor Kraepelin has advanced the theory that the disease is due to an
auto-intoxication acting upon a subject with a defective family history
during an acute disease or during the various periods when the mental
and physical powers are subject to the greatest strain.

My own belief is that the disease is due to an original developmental
defect or inherent instability of the higher nervous mechanism, and that
the physical symptoms suggesting auto-intoxication are the result of the
imperfect formation of the central nervous system.

The views held by Dr. Lewis Bruce and others that the disease is of
toxic origin and is due to bacterial invasion have not yet been confirmed,
and I am not prepared to accept them in favour of the former theory. In
the one case in which Lewis Bruce claims to have obtained a culture of a
streptococcus from the blood, it is quite open to doubt whether this may
not have been an accidental contamination of the flask, which is very
difficult to avoid, even with the most rigid precautions, and confirmation
of his results must come from other workers before the organism he
isolated can be looked upon as a causal agent in the disease. Further,
the recovery of an organism from the blood does not necessarily indicate
that that organism is the cause of the disease. Organisms have been
isolated from the circulating blood in other forms of insanity, for example
in general paralysis of the insane, the pyogenic cocci, the bacillus coli
communis and other organisms have been obtained, but these are not
considered to be the causative agents of this disease. It is reasonable
to suppose that during the various phases of any exhausting disease, there
may be a transient invasion of the blood stream by various micro¬
organisms, and it is possible that this may be the case in dementia pnecox,
and that the blood serum of the patient may have the power of
agglutinating the organism which has been recovered from the
circulating blood.

The suggestion that the bacterial origin of dementia prtecox can be
substantiated by the presence of a leucocytosis has some grounds of merit,
but may at the same time be fallacious, for it is to be remembered that
several substances will cause some increase in the number of leucocytes in
the blood, when injected into the blood stream or into the subcutaneous
tissues. Even such fluids as normal saline when poured into the peritoneal

160

Dementia Prseco.w

cavity will induce this to a marked degree. A leucocytosis, then, by itself
is not sufficient evidence of bacterial invasion ; it may be due to the
production of some abnormal body as the result of an altered metabolism,
or to the passage of substances from the alimentary tract into the blood ;
and these may or may not be produced by bacteria.

With regard to the changes produced in a rabbit by the injection of
the streptococcus (for example, that of mental hebetude), surely the rabbit
shows this particular feature as a normal characteristic.

Those who oppose Professor Kraepelin’s nomenclature do so mainly on
the following grounds :

1. That the term dementia pnecox is inadmissible and unsuitable.

2. That only the katatonic form comes under his definition.

3. That dementia pnecox does not exist.

With regard to the first objection, the term dementia is criticised on
the ground that Professor Kraepelin himself admits to a small percentage
of recoveries. Personally I doubt whether any true recovery does take
place in this disease; at least my own limited experience inclines me to
the opposite view. The term pnecox (youthful, early or premature) is
objected to on the ground that cases are reported as commencing between
35 to 40 years, which is past the period of adolescence and past the age at
which the word premature is applicable. Now, dementia may set in at
various age periods, and if this occurs prior to 70 years of age, it may be
regarded as premature so far as the dementia is concerned, and the earlier
the appearance the more hopeless the case, for the earlier onset points to
the earlier dissolution of the cortical neurones. It is also possible that,
the few cases that are only noticed as commencing at the age of 35 to 40
years, may have presented mild and undiscovered symptoms at a much
earlier period of life. Objections of this description are a mere quibble of
words. If there is any justification for Kraepelin's views, then the title
lie lias chosen should be retained until such time as a better one can be
discovered.

There are others who can only comprehend the katatonic form as con¬
forming to Kraepelin’s description of the disease. It is to be remembered
that Kraepelin himself has spent years of labour in evolving his ideas, and
it is hardly probable that others can appreciate his observations to the full
without prolonged and arduous study. To turn for a moment to other
diseases, no one would deny that a person suffering from the cervical form
of locomotor ataxia was not afflicted with that disease because he did not
possess an ataxic gait, and no one would deny that a person was suffering

G . H. Harper - Smith .

167

from Graves’ disease because either the protrusion of the eyes or the
enlargement of the thyroid was not apparent when all other symptoms
pointed to that disease. So, too, I consider that no one is justified in
denying that a particular case is one of dementia pnecox because the
katatonie state is not manifest when all other symptoms are apparent.

Those who deny the existence of dementia pnecox as a definite entity
would appear to forget that Kraepelin has not endeavoured to prove the
existence of a new disease. He has throughout disclaimed any such
intention, and has merely endeavoured to group together under a particular
title certain symptoms and physical signs which appear to be common to
a form of insanity commencing usually during adolescence and terminating
in dementia. If under this particular heading he is able to include a
number of types which previously have been classed under such vague
terms as adolescent insanity, melancholia, stuporose melancholia and such
like, he has earned the gratitude of many who are bewildered with the
existing nomenclature of the disorders of the insane.

Conclusions.

In conclusion, I am of the opinion that (1) there exist certain cases of
insanity with definite mental and physical symptoms to which Professor
Kraepelin has given the name dementia pnecox (for the purpose of
advancing and simplifying scientific research) ; (2) that these cases

commence usually about the period of adolescence, run a fairly regular
course and never regain their proper mental faculties, although the pro¬
gress of the disease can be arrested to a certain extent by early and
careful treatment; (3) that hereditary influence plays a most important
part in rendering the individual predisposed to mental breakdown at those
periods when the stress of physical or mental development is liable to re¬
act upon the higher nervous centres; (4) that a proper appreciation of
Professor Kraepelin’s discussions will do much to promote a better under¬
standing of these conditions and the early and appropriate treatment
which is necessary for the welfare of those who are the victims of this
form of insanity.

Case 1.—G. W—, male. Age on admission, 19 years. Date of admission,
May 21st, 1903. Single. Occupation, clerk in Hoard of Trade. First
attack.

Family history .—Mother died of cancer of uterus. Mother’s great
grandfather died insane.

168

Dementia Pr&co-x.

Family history of father .—Father’s father was alcoholic and had
rheumatism and eczema. Died at the age of 61 years, cause unknown.
Father’s mother was healthy; died at the age of 52 years.

Family .—(1) Father of patient, aged 53 years, healthy. (2) Sister,
died young, pulmonary tuberculosis. (3) Brother, died young, diphtheria.
(4) Brother, alive and healthy, aged 46 years. (5) Sister, alive and
healthy, aged 44 years. (6) Brother, alive and healthy, aged 42 years;
(7) Brother, aged 40 years. Chorea or tic. Twitchings of head since a
child, otherwise healthy.

There were three children by this marriage. (1) Son, died aged
11 years, status epilepticus. Fits started when he was five years of age.
(2) Daughter, aged 25 years, married, no children. (3) Son (patient).

Previous history (from father).—Patient was a full term child. Mother
healthy during pregnancy, difficult labour. As a child was very sharp.
Had measles. Went to private school when five years of age. Was
extremely brilliant and took several prizes for drawing, painting, etc.
Passed Cambridge Local Exams., taking prize for drawing. When
sixteen years of age he was put in an auctioneer’s office; this was not
good enough for him, and he passed the examination as copyist at Trinity
House and the Board of Trade. He always studied a lot, especially
shorthand, but always avoided social life, taking life very seriously.
Patient complained that he could not sleep, and he was heard walking
about his room at night. He became very shy and lost his appetite.
About this time his mother developed cancer. Patient sat and moped a
lot, and took no interest in his work. At his office he would sit and do no
work. He was sent into the country, where he walked all day and took
but little food. For six weeks his condition remained the same. He was
dull, stuporose, and lacked interest in his surroundings, and finally tried to
jump in front of a train at the railway station.

Doctor at workhouse states: He is in a condition of semi-stupor. He
lias changed from a bright intelligent young man to a condition of mental
feebleness. He has a fixed expression of the eyes, spasm of muscles of
face, slowness of pulse, and coldness of extremities. Questions have to be
repeated, then he answers in almost inaudible tones, repeating his answer
several times. Gazes about in an absent-minded and indifferent manner,
unless his attention is aroused.

Physical state on admission. —Ears, lobes attached. Palate, not
examined, refuses to open his mouth. Hands and feet cyanosed. No
emaciation. Fibrillary twitchings of muscles of face and hands. Pulse

G. If. Harper-Smith.

169

80, irregular. Heart sounds, no murmur, second sound feeble. Lungs
healthy. Pupils dilated, react to light and accommodation. Knee-jerks
exaggerated. Often repeated contractions of muscles of forehead, pulling
up his ears. Face mask-like, with occasional symmetrical twitching of
facial muscles.

Mental condition on admission .—Patient lies in bed in supine position,
Mask-like expression, no play of features when he talks. When questions
are repeated he will answer in a mouotonous almost inaudible tone. He
lias to be shouted at before he will answer. His answers are rational, but
he repeats them. He takes no notice of his surroundings. Makes
peculiar grimaces. Does nothing for himself. Defective habits. Saliva
dribbles from mouth. He will stay in any position in which he may be
placed, but there is a passive resistance to being moved. No rigidity
Constant stereotyped movements of the face, and he is constantly rubbing
the thumbs against the first finger of both hands. Occasionally, for about
twenty seconds, he turns pupils up under lids, or rapidly twitches both
upper eyelids ; this is repeated at intervals of a few minutes. At times he
will sit for hours pulling his moustache with his left hand. He was turned
on his side in bed, in which position he lay with his knees drawn up
almost to his chin. In this position he was lifted on to the floor, and
placed on the small of his back; he remained quite rigid for several
minutes. He was then lifted on to his feet by the attendant and dressed.
He passively resists all attempts to dress him. He is fed on sop with
a spoon, and each meal has to be started, for if he is left with food before
him he takes no notice. When pricked with a needle he gives an
occasional grunt, but otherwise takes no notice. He ignores his mother
and father when they visit him.

Progress of case ; June 30th, 1903.—Remains in same state of anergic
stupor, but has developed impulses. On occasions he will suddenly strike
at anyone near him, immediately relapsing to his former state. He has
attempted strangulation with his braces.

September 9th, 1903.—Remains much the same. He has gained in
weight and takes quantities of nourishment. He is now quite rigid if any
attempt is made to move him. Has to be carried about. He has many
stereotyped movements, raises and lowers eyelids, moves ears and scalp
backwards, constantly moving lips and tongue as if trying to remove a
hair from the tongue. If a lighted cigarette or pipe is placed in his mouth
he will smoke, but when they require relighting lie takes no notice but
merely stops smoking and sits with the cigarette or pipe in his mouth.

170

Dementia Pried*,v.

He never speaks, but at times he will give three or four loud screams, and
occasionally suddenly strike those near him, immediately lapsing to his
former state.

March 30th, 1904.—He is losing weight, is pale and anaemic, appetite
poor. Never speaks. There is now no rigidity, but the stereotyped move¬
ments persist. Occasionally impulsive. He resists slightly if his limbs
are moved, and when they are released he slowly replaces them.

March 30th, 1905.—For a year has been just the same, but now when
impulsive he is violent and abusive for two to three minutes, then lapses
into former state.

September 20th, 1907.—A little improved. He has had a note book
and pencil given to him, and spends a lot of time drawing in it. He draws
well from life and pictures he sees in the wards. He goes over the lines
in his drawings time after time, and his hands move very slowly. If asked
to write, he sits with pencil in hand and several times appears about to
do so, but I never induced him to write. He now walks about when told
to do so, but negativism is marked towards strangers, although he will do
what the attendants ask him to do. He was taken over to the Laboratory
to-day; he stood up in the room taking no notice of surroundings, with
stereotyped movements of face and hands. He was told to sit down, but
would not and resisted an effort made to force him to be seated. When
told to stand up he would not, and when told to remain seated he
immediately stood up. He displayed in turn automatic obedience and
negativism, but did not speak. I then took his note book and pencil from
him ; he asked for them back. I said, ‘'Why do you want them ? ” He
replied, “ Because father gave them to me/’ I opened the note book and
he requested me not to look at it as it was private. I then placed it cm
the top of the door and told him he could have it; he at once walked
to the door and reached up and took the book. I then gave the pencil to
the attendant and told him to place it on the table in the next room.
When I told the patient he could have it, he promptly walked down the
passage into the room, took the pencil and came back. That night I took
the pencil away from him. He argued with me for some time a‘s to why
he should have it, but would not talk on any other subject. 1 told him his
pencil was in his coat in another room; he at once went and obtained the
pencil and came back. He was at no time threatening or abusive, but
quite polite and rational in his demands for his pencil. His comprehension
appeared clear.

January, 1909.—Patient now shows signs of dementia. He is a case of

G. H. Harper-Santh

171

katatonic dementia pnveox, with no signs of improvement since onset, but
a very gradual progression to dementia.

Case 2. —H. M—, male, single. Age on admission, 24. Admitted 21st
March, 1900. Occupation, paper stainer. First attack.

Family history .—Not obtained.

Precious history .—Passed Standard V. Henglers Garden Board School.
After leaving school he worked in a saw mill, but held several situations
before admission to Asylum. He states that he was discharged from some
for carelessness and from others because trade was bad. He admits
drinking “ four ale ” in excess, and that he used to get drunk. He
attended Great Ormond Street Hospital till 5 years old for rickets.

Doctor at workhouse states that the patient was brought to him in a.
state of excitement, having been found, it was asserted, attempting to hang
himself. He soon lapsed into a state of extreme mental depression and
would not answer questions, or did so in such an undertone as to be almost
inaudible. In this condition he has remained for some days, showing no
disposition to occupy himself in any way.

The lunatic attendant at workhouse states that he has seen the patient
repeatedly performing acts of masturbation.

Physical .state on admission .—Amemic ; extremities cyanosed ; pulse 80,
irregular; small; constipated; palate low and broad; lungs and heart
normal; forehead narrow and frontal bones thickened; tibiie curved from
rickets; generally ill developed; height 4 ft. 10 ins.; weight 7 stone.

Mental state .—He sits about all day and does nothing. He never
initiates any movements, and has to be dressed. Questions have to be
repeated several times before he answers, and then he speaks in a slow
and monotonous undertone. He never speaks unless addressed. He is
dull, apathetic, and unemotional. There is slight mental confusion. His
memory is fair. There is reluctance to taking food.

September 3rd , 1900.—He has become stuporo.se and resistive and has
to be fed by the tube. He resists senselessly all attempts to move him,
and he will remain for hours in any position in which he is placed. He
takes no apparent interest in anything going on around him. He passes
his urine and fajees in bed or in his clothes. Kverything has to be done for
him.

May 20th , 1902.—With the exception of a few weeks at a time, he has
been fed by the tube since September, 1900, and has remained in the same
state. During the last few months he has become fatter, and brighter
mentally. He has lost all resistance, but is still dull and apathetic. He

172

Dementia Prsecox.

now dresses himself, takes his food, is clean, and does a little work on the
farm. At times, however, he stops working and remains in a fixed
attitude till started again. Negativism has gone, but he is quite
unemotional and lacks initiative.

April , 1903.—He has remained in an improved state during the past
year, but has suddenly relapsed into a condition of anergic stupor. He
has to be fed by the tube and is again in a state of flexibilitas cerea and
negativism. He remains sitting or standing in any position he is placed
with all his muscles tense and resistive. He looks vacantly in front of
him. His face is expressionless, and he takes no notice when addressed.
He grimaces, puckers his forehead and moves his ears, and at times rubs
his hands together, or his head with his right hand for hours.

March 30 th, 1903.—During the past year he has remained in the same
condition. Electric baths have been given (ten minutes) three times a
week for two months, but with no mental change. However, he now takes
his food and is becoming fatter.

December, 1907.—He has remained in practically the same state; at
times, however, he has to be fed by the nasal tube. He has been having
cold baths each morning. At the present time he is much brighter, but
sits most of the day in the ward apparently taking little notice of what is
going on around. He is always fidgeting, frowning or rubbing his hands
on face, etc., or together, or rubbing his fingers with his hands or
pulling at his coat with both hands. He gets up when called, dresses
himself, is clean, and has a certain amount of pride in his appearance. He
speaks aloud and asks for what he wants. When addressed he smiles and
answers readily. His face now has a lot of expression, and his memory is
fair. He remembers being fed by the tube, when and who fed him, etc.,
and his negativism, and states he wanted to take his food and wanted to
do what he was told, but could not .start. He says that he always made
an effort but it was no good, and that he understood all that was said and
done around him when he was in a state of flexibilitas cerea. He is cheerful
and does a little automatic work, such as sweeping and scrubbing. When
asked if he would like to go home, he smiles and says “ I wouldn't mind ”;
he gives the same answer when asked if he would like some tobacco, or a
shilling, or to see his mother. He was given three pieces of paper the
same size with A on 1, B on 2, and C on 3. He was told to fold them up
and to give A to me, B to an attendant, and to put C in his pocket.
These directions were given quickly and were not repeated. He carried
them out correctly. He knows the value of coins and can do addition

d. H. Harjw-Smith. 173

and subtraction sums. He writes and spells well both copying and
from dictation.

January , 1909.—The symptoms remaining now are his dulness and
apathy, his lack of initiative and a few stereotyped movements, and he has
remained in this state for the past two years.

He is a case that could go to the care of friends as improved , had he
the friends to take him, but it would be impossible for him to earn his
living.

Case 3.—W. A. D—, male, single. Age on admission 25 years. Ad¬
mitted February 28th, 1908. Occupation, soap maker. First attack.

Family history .—Not obtained.

Previous history. —He was educated at Bromley Road Board School.
He left school at the age of thirteen when he was in the 4th standard
He was quick but lazy. He was employed at the Central London Railway
and at Cook’s Soap Works, and at both places he was a steady worker.

Doctor at workhouse states that he refused to speak and to move
himself. He held himself in a rigid position.

Physical state on admission. —Teeth clean, carious, a few stumps;
tongue red and clean; palate high and narrow; ears deformed, large and
flat; forehead narrow and low. Chest symmetrical, well developed;
muscular; no emaciation ; lungs healthy. Respirations 14, three or four
shallow then one deep inspiration; heart irregular, sounds are normal;
pulse 80, irregular in time and force. Pupils equal, react to light and
accommodation. Heart becomes very irregular if a loud noise is made
near him. Fibrillary twitchings of facial muscles. Constipation.
Adenoids. Cyanosis of feet and hands. Sensation, heat, cold, and pain,
no reaction. Height 5 ft. 11 in.; weight 12 st. 7 lb.

Mental state. —Patient lies in bed on his left side curled up ; he takes
no notice of any remark addressed to him, although spoken loudly and
repeated six times. He takes no apparent notice of anything. When an
attempt is made to raise his head he passively resists. When his limbs
are moved there is rigidity, and he remains in whatever position he is
placed. His eyes are closed, and if any attempt is made to open them lie
tightly shuts the lids. When the upper lid is raised he turns the eyeball
right up out of sight. He was placed in bed on his back and both arms
were lifted straight up from the bed; he remained in this position for
twenty minutes and then put them down on the bed. There is complete
loss of all spontaneous movements. Face is mask-like and expressionless,
except when frowning. Every few minutes there is a contraction of

174

Drnumtia Pr<cco<e.

muscles of forehead, at times accompanied by a slight whining noise.
When food is placed in his mouth he swallows it. When placed on stool
he passes urine and fieces; he is not defective in his habits, but would be
if he were not placed on the stool at intervals. There is mutism.

The patient was laid flat on the bed and his right leg was raised
six inches; it remained in this position for 1 minute 18 seconds. The leg
was at once raised again and lie held it in position- 1 minute 5 seconds,
and on raising again for subsequent periods of 85 seconds, 45 seconds,
25 seconds, 15 seconds, and afterwards for periods, of 5 to 10 seconds,
showing the rapidity with which muscular fatigue comes on.

March 1 at, 1908.—Patient has not spoken since admission and there is
no change in his condition. He has no reaction to heat, cold, or pain ; a
needle can be placed in him anywhere, and even if it is left there lie
takes no notice. Since admission he has laughed on two occasions when
something humorous took place in his presence, although apparently he
was not taking any notice at all.

May 10th, 1908.—This evening when he was being put to bed he
suddenly screamed incoherently and then called the attendant bv name.
I went down and saw him ; he spoke quite rationally, and his memory
was exceedingly good for all past events both before and during his state
of katatonia, of which there were no signs present. He told me the
names of the doctors that had seen him, the names of the other patients
in the ward, and all that had happened around him since admission, and
his comprehension was quite clear. He stated that lie had desired to talk,
but had been unable to do so.

January, 1909.—He remained apparently quite rational for three weeks
during which time he worked well and read a great deal. He then
rapidly developed signs of dementia. He is at present dull, unemotional,
and lacks all interest in his surroundings and all power of initiative.
He dresses himself when told to do so, slowly and mechanically. He does
not move all day, and will sit quietly for hours where he is placed. He
will answer simple questions at times, but usually takes no notice.

He is a case of dementia p nee ox (katatonia) with rapid progression
to dementia.

Cask 4.—E. (I. H —, female, single. Age on admission 19 years.
Admitted 29th May, 190b. Occupation, fancy box maker. First attack.

Family history .— Father’s mother died aged 74 years; always healthy.
Father’s father died aged 45 ; diabetes. Mother’s mother died aged 32;
cause of death, parturition. Mother’s father died aged 09; senile decay.

(i . If. 11a r/>er- S m ith .

175

Mothers sister, aged 40; lupus of face. Mother’s sister, aged 44;
healthy. Mother’s brother, aged 40; died at sea. Mother’s brother,
aged 17; died paralysis, duration 14 days. Father has five brothers, all
healthy.

Family. —(1) Miscarriage; (2) Girl, aged 26 years, healthy; (4) Girl,
aged 24 years, healthy; (4) Boy, aged 20, healthy; (5) Twins; Patient.
Four miscarriages followed birth of patient.

Previous history .—Patient was a full term child, a twin. She was late
in walking—suffered from diarrhoea—scarlet fever, aged nine. At school
from 4i to 13 years of age, left when in the 6th standard, after passing
top examination. She always did well. She started box work and was
a very steady and good worker. Always suffered from a me mi a, and treat¬
ment for years did but little good. Three weeks before admission she
developed the idea that she had done something wrong, that she owed
money and that people were coming after her.

Doctor at workhouse states that patient refused to take food and would
not speak.

Physical .state on admission. —Ears, lobes attached ; palate, broad and
low; teeth poor, several carious; gums inflamed; saliva dribbles from
mouth. Very anannic but well nourished. Constipation. Heart sounds
normal; pulse 60, very small, difficult to feel at wrist, regular. Skin dry
and cold; no secretion of sweat. Urine 1*020, acid, phosphates. Hands
and feet cold and cyanosed; hair dry. Face, fixed expression, mask-like,
absolutely no play of features; eyes, winking very frequent, more so than
normal; pupils dilated, equal, react readily to light and accommodation :
Babinski’s sign normal. Lungs healthy. Chest and limbs well formed.

Mental state .—Patient lies in bed in supine position with head and
shoulders raised from the pillow; she makes no effort of any kind to get
comfortable. Her expression is mask-like, and she remains quite still,
taking apparently no notice of her surroundings. When an attempt is
made to move her limbs there is passive resistance. She will do a few
acts after being told several times. She very slowly put out her tongue
about \ inch. A question “ How old are you ?” was repeated several times;
she answered in an almost inaudible tone, and the same occurred when
asked her name. She writes her name and address, and yes and no in
answer to questions. She holds the pencil just as it is put in her hand,
making no attempt to grip it correctly. She writes very slowly and
deliberately, a good hand with spelling correct. She will not answer any
questions referring to the last three weeks. She was made to sit up in

176

Dr mr hi in Praerox.

bed in order to write, in which position she remained; there is absolutely
no voluntary movement. When her right arm was raised above her head
and released, she held it there ; after three minutes the left arm was raised,
the right arm came down slowly with jerky movements to the bed, and the
left arm was held up. After ten minutes the right arm was raised and the
left arm came down to the bed. There is passive resistance against all
attempts to move her limbs. She is lifted from her bed in the morning
and dressed, and is fed with a spoon, a nurse holding her hand and
conveying the spoon to her mouth. After this has been repeated a few
times she proceeds to feed herself, continuing until the sop is finished.
When placed in a chair she sits there all day, never moving or taking any
apparent notice of what is going on around. She is walked round the
airing court between two nurses. She takes no notice of her mother, and
does not alter in the least during her visits. She at times answers a few
questions, and these answers show no mental confusion or dementia.

October , 1906.—Patient has remained in the same state since admission,
but during the last few w r eeks she has improved. She now converses
and takes a little interest in her surroundings, is clean in her habits and
looks after herself. Her memory is good, but she is still dull.

March , 1907.—Patient’s mother took her out on trial as she had been
in same state as noted above for some months. She relapsed after being
out four weeks, and when brought back was in the same state as when she
was first admitted.

January , 1908.—Patient has remained in same state since last
note.

January , 1909.—The patient is still in Asylum and remains in a state of
stupor. She never speaks and has to be fed with a spoon, and is defective
in her habits.

There is in this case a family history of neuroses, diabetes, tuberculosis,
and paralysis. I am unable to obtain information regarding the nature of
the paralysis. The mother had four miscarriages after patient was born,
showing that at this time procreation in the parent was enfeebled.
The fact that the patient wavs a twin would also account for her having a
defective stability of the neurons. At school she showed signs of good
mental development. After usual onset she developed signs of katatonia.
There has been no improvement in this case. Her progression to
dementia is very slow.

Cask o. —M. F—, female, single. Age on admission twenty years.
Admitted November 14th, 1906. Dressmaker. First attack.

G. H. Harper-Smith.

177

Family history. —Father’s fatlier died at fifty ; tuberculosis. Father’s
brother, Colney Hatch Asylum. Father’s sister died at thirty-four;
tuberculosis. Of this sister a son died at eleven years of age, two
daughters at twelve and two years respectively, and another child
died in infancy, all from tuberculosis. Mother’s mother, Colney
Hatch Asylum. Mother’s cousin, Colney Hatch Asylum. Father has
asthma, drinks heavily, and his wife states that he is mentally defective.
Mother aged forty-nine years, healthy. The mother has three sisters and
one brother all married and healthv. One sister lias a son nyed twelve
years who has tuberculosis.

Family. — 1. Son, died in Colney Hatch Asylum, aged twenty-four,
tuberculosis. 2. Son, alive, aged twenty-six years, healthy, o. Daughter.
Patient. 4. Daughter, aged nineteen years. Has been in Temperance
Hospital for “ mental breakdown ” for six months and has improved a
little. 5. S<»n, alive, aged eighteen years, healthy. 6. Daughter, alive,
aged seventeen years, healthy. 7. Daughter, alive, aged fifteen years,
has tuberculosis. 8. Son, died, aged two years, from tuberculosis. “The
doctor said he was an imbecile.”

Previous history. —Patient was a full term child. She was bright at
school and left at the age of thirteen, when in the top standard. She
then became a dressmaker and was always a hard and steady worker. A
few months before she was taken to the infirmary she became reticent
and solitary in her habits. She spent a lot of time “ brooding,” and one
day she suddenly threatened to “ knife ” the family. Doctor at the
workhouse states :—“ She states she held sexual intercourse in a workroom
filled with people, with a man named Rev. Barber who was dressed
in woman’s clothes. She is absolutely positive that this is so, and has
taken medicine to prevent consequences. The mother states that patient
has become very idle and sleepless of late.”

Physical state on admission. —Nutrition good. Palate, broad and low ;
teeth clean, a few carious. Constipation. Heart regular; pulse GO,
small. Lungs healthy. Skin dry; hands and feet eyanosed. Pupils
dilated and equal, react to light and to accommodation. Knee-jerks
equal and exaggerated. Chest and limbs well developed. Catamenia
irregular for some months; amende.

Mental state. —The onset was acute. The patient was in a state of
excitement after prodromal period for two months, during which she was
sleepless, reserved and brooding. She is now excited and talkative ; her
conversation is incoherent, full of long sentences, and unusual and strange

12

178

Demrntia Vrxcox.

words. She is extremely erotic, and has had many mysterious ideas.
She states that she is under the influence of Mr. Barber, that he has seduced
her, and that she is a very important woman. She must go into the world
and do what he tells her. She decorates her dress in an extraordinary
manner with anything she can obtain ; at the same time, however, she is
untidy and slovenly. She strikes strange and peculiar attitudes, and
walks in a bizarre manner. She appears to do these things without any
consideration of her surroundings, and takes no notice of anyone. At
times she is impulsive, but the impulses are quite senseless. She has to
be dressed, and everything has to be done for her. She has no apparent
pleasure in the visits of her relatives or in receiving presents from
them.

January 2nd, 1907.—She has now become much quieter, but is dull,
reticent, and lacks all interest in her surroundings. She is idle, childish
and at times laughs senselessly. She is still incoherent in her conversa¬
tion, writing, and actions.

January 9th, 1909.—She is now demented, and has lost her impulses.
She dresses herself, is clean in her habits, and eats her food, but beyond
this she dees nothing. She can answer a few simple questions, but
usually, when addressed, she does not answer.

I consider this to be a case of dementia pneeox hebephrenia; after an
acute onset of excitement and hallucinations she remained for two years
in a peculiar condition, best described as a state of incoherence in
words, writing, action, and behaviour. During this time she. has been
slowly progressing to dementia.

Case 6 . —A. D—, single; age on admission, 28 years. Admitted
February 5th, 1907. Male, hawker; first attack.

Family history .— Father died seven years ago of phthisis, was
alcoholic; mother dead some years, cause unknown; father’s uncle,
alcoholic.

Precious history .— From brother, who is a clerk in Civil Service.
Patient went to St. Matthew’s National School when aged four, and
left at the age of fourteen when in the 0th standard (highest standard,
7th). He was dull at school, “ easy-going and easily imposed on.” He
obtained first prize for writing and for drawing. When he left school ho
be came an errand boy, and brother lost sight of him till he came here.

Patient states that he earned his living drawing portraits in public
houses, and drank a lot of beer. At one time he was employed by the
‘Star,’ and sketched for them. The ‘Star’ have sent him presents of

(*. H. Ha rprr-Sinith.

179

drawing mfaterials since lie came here, in appreciation of his services. He
states that he got into had company, that all his money was taken from
him each week, leaving him just enough to live on, and that his friends
thought him an idiot.

Doctor at workhouse states : “ He is acutely melancholic and deluded.
He says he is dead and that his stomach is falling out, that he has ruined
his constitution by leading a wrong life.”

Physical -state on admission .—Head circumference, 22 in.; skull square,
protuberances over frontal and occipital bones; eyes close set; ears, lobes
attached and small ; palate high and very narrow ; teeth irregular and
decayed; pupils equal, react to light and accommodation; knee-jerks
equal, exaggerated.

Mental state. —He lies in bed in a supine position. Has a dull, set,
vacant expression, and takes no notice of what is going on around. When
addressed he does not answer, but stares straight in front of him. He
does nothing for himself, and after he has been dressed he sits where he
is placed with his lips apart and saliva dribbling from his mouth. He lacks
all initiative and is quite unemotional. He eats any food that is given to
him, and is defective in his habits.

February 28th, 1907.—Patient remains in the same state of stupor and
tlexibilitas cerea, with negativism. He has a habit of moving his head
slowly from side to side. He apparently now watches all that goes on
around him, and has a good appreciative perception of rational conditions,
but he is in an absolutely subemotional state. He passes his motions and
urine under him.

March 80th, 1907.—He now does a little for himself, helps when he is
dressed, but still has marked impairment of volition.

September 14th, 1907.—There has been a gradual improvement in this
patient during the last few months, but he remains demented. He dresses
himself, takes his food well, attends to Nature’s calls, and asks for what
lie wants. He does no work in the ward, but picks hair when a bundle is
placed in front of him. He often sketches other patients, and his work
is good. He talks freely, repeats questions put to him, and frequently
repeats portions of his answers or words. His memory is fair.

“ How old are you ? ” “ Twenty-four.”

“ What day were you born ?” “ 12th September, 1888.”

“ How long have you been here ? ” “ Six months.”

“ Yes?” “Yes.”

“ What day is this ' ”

“ About the 10th.”

180

Vewrnfia VrtvcoA'.

“Of wliat? ” “September. Yes, to-day is September, Yes.”

“What year?” “1907.”

“What have you done during your life?” “I have had a funny
career, but I have never had trouble with the police. Of course, I am
a bit silly. I am a sketcher, of course not an expert, but a gifted person.
I came here of my own accord. 1 am sane, but did not want to give the
public trouble.”

“Will you write your name on this paper ?” He sits looking at paper,
with pencil in hand, and flourishes it as if about to start, but does not.
After question was repeated three times he says, “ Shall 1 write my
grandfather’s name ? Shall I write my own name ? 1 was a great

swimmer when a boy—Shall I write my name ? ” He then wrote his
grandfather’s name, slowly and deliberately, at times lifting pencil and
flourishing it a lot over the paper. He then wrote his grandfather’s
address—“ Neal St., Long Acre.” Then he wrote his own name, and then :
“ My grandfather was a good family, Long Acre, yes—Long Acre—of
course. I’m not insane. 1 get my living sketching in public houses.”

He mutters to himself and says lie hears funny voices and that it is an
“illusion.” He has delusions of persecution, stating that people pull his
bed from under him, and pull his clothes off him, but lie adds, “1 don’t
mind—no—no— it does not matter.” There is no forcible complaint
demanding justice as in paranoia. There is a good deal of dementia,
complete dulness of emotions, and loss of association of ideas.

January, 1909.—Patient is still in the Asylum. He daily does a little
work, hair picking, and this he performs in a mechanical manner. He is
dull, apathetic, and lacks initiative.

There is a history of amentia, an ament of high order. There is also
a history of drink and stress at puberty. I look upon him as a case
of dementia pnecox (katatonia) gradually progressing to dementia.

HlBLIOURAPHY.

(1) Hr I’ve, Lewis .— 4 Studies in Clinical Psychiatry.'

(2) Candler, J. P. —* Archives of Neurology and Psychiatry,’ 1909.

(a) De Huck and Dkkocbaix. — 4 Le Nevraxo,’ vol. vii, p. 191.

(4) L)ide and Chknais. — 4 Anna. Med. Psychol.,' 19o2.

(.">) (ioNZA lks. —‘ Kiv. Speriinent. di Freniatria.’ vol. xxx.

0>) Harper-Smith and Rak Gibson. — 4 Archives of Neurology and Psychiatry.’ 11)09.

(7) Johnstone. — 4 Journal of Mental Science.’ llHCi, vol. li, p. 711.

(5) Koch .— 4 Archives of Neurology,’ vol. iii, 11K>7; Zcit. fur Physiologische

Chemie, 1907. Rd. liii, H. 9.

(9) Koch and Mann. — 4 Journal of Physiology.’ vol. xxxvi, 1907 ; 4 Archives of

Neurology and Psychiatry,’ vol. iv, 1909.

G. Jl. Harper-Smith.

181

(10) PuiHiNi.— ‘Riv. Speriment. di Freniatria/ vol. xxiii. 1907.

(11) Kraepelin. —‘ Psyehiatrie/ 1904, vol. ii, pp. 170-288; idem. ‘ Lectures on Clinical
Psychiatry/ translated by Johnstone, 1904.

(12) Meter, Adolf.— 1 Journal of Nervous and Mental Diseases/ p. 831, 1907.

(18) Mott, F. W.—‘Archives of Neurology/ vol. iii, 1907.

(14) Pighini and Paoli. —‘ Riv. Speriment. di Freniatria/ 190o, vol. xxxi, f. 11.

(1 5» Serieux.—‘R ev. de Psychiatrie/ 1902, p. 241.

(10) Wolfsohn, Rybsia.— ‘ Allg. Zeitsch./ Bd. Ixiv, H. 1.

The Pathology of Dementia Praecox, especially in relation to the

Circulatory Changes.*

By (i. H. Kak Gibson, M.D., M.R.C.RK.

Thk physical condition of patients suffering from dementia pnecox is
so characteristic and so different from that in other types of insanity that
it has always been regarded as one of the outstanding features of tin’s
disease.

It is difficult to attract the attention of the patient either by speaking
or by a sudden noise, and when he had been induced to respond to any
advances the mental reaction is very slow. It takes sometimes minutes to
obtain an answer to the simplest question, yet apparently the patient is
making an effort to reply. Movements, when they are performed, are
slow, ill-timed, and frequently misdirected. The patient is apathetic, and
has frequently an appearance of stupor, which at times is accompanied
with a certain facility, so that he is easily made to smile. This
sluggish, torpid state* is not confined to the mental faculties, for we
see present all the features eminently characteristic of low physical
condition. The signs of a low state of vitality are seen not only in the
expressionless face and expressionless hand, but also in the shallow
breathing, the feeble pulse, the cold extremities, and the various gastric
and intestinal derangements which are so constantly noted in these
patients.

It was these physical abnormalities, and more especially the circulatory
defects, which first suggested an examination into the condition of tlie
blood-pressure, f was advised by Dr. Mott to estimate the arterial tension
in these cases, in order to see whether any circulatory defect was present
which might be associated with the mental and physical states above
alluded to.

At Claybury, Colney Hatch, and Morningside Asylums i estimated the
blood-pressures in over a hundred cases of dementia pnecox, and have
* Abstract of a Thesis for the Ilegree of M.I>. at the University of Edinburgh.

(}. H. Rue Gibson.

183

further, l»y way of controls, taken readings in other types of insanity and
in sane people, some of whom were in good health and others suffering
from various bodily diseases.

Fig. 1.—Tracing from a normal male aged between 20 and 80. Systolic pressure 185.
Diastolic pressure 100. Normal systolic pressure. Diastolic pressure rather high.

At Colney Hatch the readings were obtained in the presence of Dr.
Mott and Dr. (xilfillan ; at Clayburv Dr. Harper-Smith very kindly gave me
his assistance; and at Merningside 1 was helped by Dr. Babington and Dr.
Simpson.

184

1

* ^ a * ^. 7 s *.

Fig. 2. - Tracing from the pulse of a patient with dementia pnecox. Katatonia,
female, aged 25 years. Systolic pressure KK. Diastolic pressure 74.
(Gibson's sphygmomanometer.)

»s>c>

Fig. 5. —Same patient. Systolic pressure 1)5. Diastolic pressure 70. Very low
hlood-pressuro. Systolic and diastolic pressures have a very small interval
between them. (Erlanger's sphygmomanometer.)

185

Pulse

Fio. 4.—Tracing 1 from the pulse of a male patient with dementia prascox. Paranoia,
aged 4 a years. Systolic murmur 1)4. Diastolic pressure 82. Low blood-
pressure. Small interval between systolic and diastolic pressures. (< Jibton's
sphygmomanometer.)

w*.

to

I 'J:'

... v ,

■' .

6 ^

~?<^y rfj^ fa-

Fig. 5. —Tracings taken from the same patient on a different day with Erlanger’s
sphygmomanometer. Systolic pressure 10 H. Diastolic pressure 70. ( Erlanyer’s
sphygmoma nometer.)

The Vtttholoijn of Dementia VnvcOiV.

18 (>

For the sake of accuracy, and for a comparison of results, tliree
instruments were employed—Gibson’s and Erlanger’s graphic sphygmo¬
manometers, and the Riva Rocci sphygmomanometer.

In every case readings were taken with the Riva Rocci, and the other
two instruments were used in selected cases by way of illustration.

I have divided the results obtained according to sex, with the following
sub-divisions, as they belong to the three types of the disease—katatonia,
paranoia, and hebephrenia.

The other types of mental disease which I have examined are epilepsy,
general paralysis, and congenital imbecility.

The normal blood-pressure in a healthy adult, between twenty and
thirty years of age, may be considered to be 130 mm. of mercury, as
obtained from readings with the Riva Rocci sphygmomanometer. This
agrees almost exactly with the readings obtained by Gibson’s and
Erlanger’s graphic sphygmomanometer.

Several writers, among whom are Janeway, Hill, Doleschal, and
Jnrotzev, place the normal blood-pressure in the healthy adult between
100 and 130 nun. of mercury, but the'majority estimate it at rather a.
higher level. Some of the writers who are in favour of this higher reading
for the normal arterial pressure are Hayaski, Hensen, Thayer, Retain, von
Basel), Gibson, and Russell. The average for women is slightly lower
than for men, and is probably 12o mm. of mercury.

It will be noticed that in cases of disease of the circulatory system, as
in aortic and mitral disease and in aneurysm, as long as the lesion is com¬
pensated and the general bodily health remains in good condition, the
arterial pressure is well maintained, and may even be higher than normal.
This is very well shown in the tracings taken from people suffering from
cardiac disease. In one case of aortic disease the pressure was as high as
HH) mm. Hg., and in no case was it below 130. In the cases of mitral
disease the lowest reading obtained was 120, which was in a case of
incompetence with poor compensation. In aneurysm the tracings were, if
anything, rather higher than normal.

The tracings of the cases of amemia showed a very different state of
affairs; the arterial tension was low, being especially so in a man with
secondary anaemia.

In the cases of general paralysis the average results in the cases of
seven men whose average age was forte-five, was 13t<; and 120 for ehdit
women with an average age of forty-four. This shows that in general
paralysis there is apparently no marked deviation from the normal, as it

(}. H. llm* Gibson .

187

is practically the height of blood-pressure commonly found in people at
that age.

In epilepsy I was rather handicapped by not being able to obtain many
female cases. The results obtained are rather below normal. Isolated
cases, however, gave readings which show little deviation from that of
health. The men, whose average age was thirty-six, had an average
pressure of 120, and the two women I examined, one a case of epilepsy
with ovarian affection, show an average of 124.

The tracings and readings taken from cases of congenital imbecility
are interesting from the fact that they show low arterial tension. Six
male congenital imbeciles, of an average age of twenty-one, had an average
systolic pressure of 115; and four women, of an average of thirty-four, had
a mean pressure of 109.

In the cases of dementia pnecox two facts are noticeable: In the
first place, the average of the readings is low; and, in the second place,
there is a very frequent occurrence of readings below 100 mm. of mercury.

The katatonic males, of an average age of twenty-eight, had an average
systolic blood-pressure of 113 mm. Four of these cases, however, showed
readings of below 100 mm. Eighteen females with katatonia, of an
average age of twenty-eight, had an average pressure of 111 mm. Six
had pressures of below 100 mm.

Thirteen males, of the hebephrenic type of dementia pnecox*, of an
average age of thirty, had an average pressure of 118 mm.; and fourteen
females, of an average age of twenty-seven, had an average pressure
of 114 mm. In each set of cases there were two with blood pressures of
less than 100 mm.

The average arterial tension was higher among the paranoiac cases
than in the other two types of the disease. This was especially so among
the female patients, of whom I examined thirty cases.

Sixteen male patients with dementia paranoidis, of an average age of
thirty-five, had an average pressure of 113 mm. In two instances the
tension was below 100. The female patients, of an average age of forty,
had a blood pressure of 125 mm. The higher pressure in this group of
cases may be partly accounted for by the fact that the average age
of these patients was higher than that in the other two varieties of
the disease.

188

Tint Pathology of Dementia Drsee.ox

Blond-Pressure in Twelve Cases of Rpilop&y.

Males. B.P.

Aire.

Females. 1 B.P.

Aire.

1. J. C— . . 105

34

1. Mrs. R— . 115

45

2. A. W— 155

HO

2. Mrs. M— . 133

34

3. J. R — . . 105

29

4. R. B— . 110

25

Average B.P. . 124

| 5. W. L— . . 110

43

„ Age . 39*5

0. J. R— . 145

53

7. R. T— . 130

2H

8. T. S— . . 123

3H

9. J. J— . . 105

35

10. <4. D— . . 114

25

Average B.P. . 120

„ A^e

36

Blood-Press are. in Fifteen ('uses of General Paralysis.

Males.

B.P.

Age.

Female*.

B.P.

Age.

1. D. J—

140

35

1. Mrs. F—

_

119

38

2. J. R—

150

58

2. Mrs. C —

115

50

3. R. F— .

ItiS

34

3. Mrs. A —

116

50

4. VV. M- .

127

32

4. Mrs. S—

150

45

5. W. \i— .

123

44)

5. Mrs. A—

145

70

H. J. W— . . 1

123

58

6. Mrs. S —

127

L'S

7. J. 0- . . !

141

64

7. Mrs. L-.

110

22

8. Mrs. B —

128

■ 42

Average B.P.

138

„ Age

45

Average B.P. . 126

,, Age . 445

_ _ _

_ _

JUowl-P rcs.sn re ni

Ten Cam>* of Conynitnl Imbecility.

Males.

B.P.

Age.

Females.

i

B.P.

I_

Age.

1. H. R— .

W5

23

1

1. J. Y— .

100 I

24

2. J. B-

108

20

2. M. 11— . . 1

120

60

3. W. S— .

119

19

3. M. K— .

Hi)

30

4. <t. B —

125

19

4. L. D— .

117

24

5. <4. D - .

114

25

6. <T. T-

1 18

19

Average B.P.

109

„ Age

34*5

Average B.P.

115

0

H

Rae Cl ihfion,

18 «>

luihly owing to its eccentric position. There are
also groups of proliferated neuroglia nuclei.
Magnification Jjlto.

190 The l:\itholoij // of Dementia Prxcox.

Blood-Pressure in Thirty-three Cases of Katatonia.

Males.

H.I*.

Aire.

i

Females.

B.P.

Aue.

1. M. B—

97

21

1. H. E -

89

25

2. S. A—

125

1 32

2. J. C- .

145

39 1

| 3 W. M — .

124

27

3. K. B— .

88

24

| 4. F. E- .

87

19

4. E. L— .

98

27

1 5 W. W— .

Ho

23

5. M. B - .

135

22

0. J. R—

97

31

0. W. K- .

117

29

1 7. G. L- .

103

28

7. H. P— .

125

31

8. T. L—

110

1 21

8. (\ M — .

127

1 28

9. A. H —

128

i 43

9. E. M - .

87

18

10. C. R—

122

27

10. A. P- .

loo

25

11. T. M —

103

j 25

11. F.C— .

107

30

1 12. H. J—

140

37

12. K. C -

H7

33

13. H. H —

140

41

13. M. F—. .

117

29

14. M. H—

110

25

14. l. a— .

120

41

15. T. E—

112

19

15. 8. W— .

97

20

10. E. T— .

120

23

Average B. P.

113

17. L. M- .

120

27

„ Age

28

18. A. 8— .

114

20

i

Average B.P.

111

>’ Age

28

Blood-Pressnre

in Forty

-six Cases of Paranoia.

i

Males.

B.P.

Aire.

Females.

B.P.

Ai*e. |

1. F. L—

100

20

1. A. C— .

145

02 i

2. G. B—

90

33

2. 8. K— .

102

07

3. J. A—

1(H)

29

3. F. M— .

138

30 !

4. T. A—

•JO

27

4. E. B— .

112

38 1

5. G. W— .

100

25

5. M. H— .

150

55

0. G. N— . . 1

1->S

30

0. L. P— .

107

29

7. M. H—

120

34

7. M. A- .

135

40

8. B. 0-

120

31

8. M. 8— .

135

51

9. H. W— .

97

27

9. J. H- .

140

39

10. 8. P—

149

00

10. G. P—

115

29

11. L. P—

111

48

11. A. 1>— .

105

31

12. P. G— . 1

129

37

12. K. S— .

95

32

13. 8. A— . . 1

147

49

13. A. 8- .

115

33

14. X. G— . .i

117 1

41

14. L. E— .

130

40

15. M. X— .

109 |

30

15. M.G— .

130

30

16. J. A—

107

31

10. A. R— .

135

37

17. R.P- .

110

33

Average B.P.

• 113 1

18. K. F— .

239

40

,, Ago

15

19. B. M— .

113

41

20. 8. L— .

135

1 42

21. A. 8—

145

44}

22. B. L—

120

33

23. P. J—

133

28

24. 8. 8— .

130

! 50

25. A. M— .

123

| .27 '

20. M. F— .

109

42

27. H. E— .

137

I 41

2S. J. P— .

141

' 55

29. F. W— .

130

38

30. P. A— .

117

J 23

Average B.P.

125

A ge . 40

G. II. Jiae Gibson.

191

Blood-Pressure in Tirenly-seren Cases of Hebephrenia.

1

Males.

B.P.

Age.

Females.

B.P.

Atfe.

1. H. C— . ’ 1

119

27

1. R.M- .

14H

39

2 G. S —

125

25

2. M. 0- .

139

35

3. W. M- .

133

33

3. K. R— .

145

40

4. J 0—

S'S

30

4. 0. E—

loo

22

5. E. D— .

97

28

5. M.F— .

115

27

«. J. B—

m

49

0. F. A— .

100

25

7. W. C—

130

31

7. E. J— .

100

24

8. W. L— .

no

22

8. H. D— .

114

19

9. F. B —

150

43

9. W. G— .

93

27

10. D. 0 —

100 j

27

10. E. B— .

HS

22

11. H. G— .

102 1

20

11. H. K— .

113

30

12 W P— .

115

24

12. M. K — .

112

31

, 13. C. S—

117

31

13. F. W— .

123

34

14. E. 11— . .1

101

19

Average B.P.

118

„ Age

30

Average B.P.

114

1

Age

27

Table of Blood-Pressures.

I

Dementia prtecox katatonia
„ , hebephrenia

„ „ paranoia

Epilejjsy ....
General paralysis
I Congenital imbecility

Mai.km.

Average B.P.

Average age.

Average B.P.

Average age.

113

28

Ill

28

118

30

114

27

.113

35

125

40

120

36

123

39-5

138

45

126

44 5

115 1

21

109

34'5

Fkmalkm.

From tlie above tables it is evident that in dementia prajcox tliere is,
generally speaking, a low arterial tension, indicating a circulatory failure
which may be associated with many of the physical manifestations
characteristic of the disease, viz. cold extremities, chilblains, blue fingers,
feeble pulse, and a general low bodily condition.

What part, if any, does this circulatory condition play in the production
of the mental symptoms? To answer this question 1 have investigated the
histology of the brains of four cases of dementia prmcox, with the view of
ascertaining if there are changes in the structure of the cortex and sub¬
cortical tissues which could be associated with defective circulation.

While working in the Laboratory at Claybury, four brains were
examined microscopically. Three of these were the brains of patients who
had died in Claybury Asylum, and one was that of a patient who died

102

The Pafholugif of Dementia Fraeeox.

Fig. 8.— Section of top of ascending frontal convolution : dementia prsecox, Cajal stain,
showing twisting of the apical processes of pyramidal cells. Magnification 400.

Fig. 0.—Dementia pnecox, showing twisting of apical processes of pyramidal cells.

Magnification .’UiO.

G. II. Rue Gibson.

193

in Bexley Asylum, for whose history and post-mortem notes I am indebted
to Dr. Stansfield.

Histological Changes in the Brain.

The changes I detected in greater or less degree in each of these four
brains are in the main similar to the appearances described by various
authors. These appearances may be regarded as commonly occurring in
dementia pnncox, yet cannot be considered as pathognomonic of the disease
as they occur in other conditions.

Before, however, we can correlate these histological changes with the
symptoms manifested during life, it is necessary to exclude conditions
which may be coincident or accidental. The most important of these is
post-mortem change. In the brains under discussion, this may, I think,
be eliminated. The three patients who died at Claybury Asylum were
placed in the cold-chamber at the Laboratory immediately after death,
and at the post-mortem examination I placed the brains at once into 5 per
cent, formol. In the case of the patient who died at Bexley Asylum, the
post-mortem w'as performed at a time after death which would exclude
the probability of post-mortem changes; the brain was placed in
5 per cent, formol.

For the microscopical examination, the same procedure was adopted in
each of the four brains under investigation. Sections were cut from
various parts of the frontal, parietal, temporal and occipital lobes, the
optic thalamus, the pons, medulla and cerebellum. Portions of the caudate
and lenticular nuclei were also examined. The right and left hemispheres
were chosen indifferently, and in two of the brains sections were taken
from both hemispheres.

There was no sign of wasting in three of the brains. In the one case
where it occurred, it was confined to the region of the superior and
ascending frontal regions. The cerebral convolutions were well formed
and were conventional in type ; there was no thickening of the membranes
and no sign of granulation in the fourth ventricle.

Sections were cut, of bfx in thickness, from paraffin blocks and stained
with hematoxylin and eosin, hematoxylin and Van Gieson and polychrome
blue, and by Nissl methods; also by the Heidenhain eosin method for
neuroglia. Portions of the tissue were also prepared for staining by the
Cajal neurofibril and the Weigert Pal methods.

13

194

The Pathology of Dementia Prseeox.

Microscopical Changes.

The most marked changes were in the ascending and the superior
frontal convolutions. The rest of the frontal region was affected, but not
to such an extent. The posterior and inferior portions of the brain showed
much less abnormality than the anterior and superior. In the inferior
parietal and temporo-sphenoidal convolutions and in the occipital lobe few
changes were to be found. The alterations affected principally the deeper
layers, and the psychomotor cells of Betz and the large pyramids were
markedly affected, as was also the polymorph layer (figs. 6 and 7). Slight
abnormalities could, however, be detected throughout the entire depth of
the cerebral cortex, but near the periphery they were less marked.

The normal arrangements of the cells into the columns of Meynert was
disturbed, and the general appearance was rather irregular.

In the cells themselves, various alterations in size, shape, and staining
reactions were visible. Some of the cells were swollen, and their sides
were more rounded, so that they appeared more circular than normally.

Some cells were faintly stained, others were small and shrivelled, with
broken and interrupted cytoplasm and without any sign of nuclei. These
different abnormal cells were not found in groups, or confined especially
to any one part, but frequently were seen lying side by side, so that it was
quite common to observe a normal cell lying beside an affected one.

Besides the faintness of staining which many of the cells presented,
there was a homogeneous aspect, so that in sections stained by polychrome
blue the cells presented a uniform dull purple staining.

Changes were also seen in the nucleus which had undergone alteration
and assumed various shapes. In some instances it was slightly distended,
in others it was greatly enlarged, while occasionally it was eccentric and
at times extruded.

Extrusion of the nucleus was not found very frequently, but when it
occurred it w’as accompanied by various manifestations indicative of cell
disintegration and destruction.

Twisting of the apical processes of the cells giving them a cork-screw
shaped appearance was frequently observed; and the dendrons were
deficient in number or apparently broken off or atrophied (figs. 8 and 9).
This cork-screw appearance Dr. Mott ascribes to the atrophy of the
dendrites, which keep the cell in position and make taut the apical
process ; consequently when these atrophy or disappear the apical process

E CELLS FROM CORTEX. DEMENTIA PRitCOX.

Tn .vcr.rome stain Magn i fi Cc\li on nigh 480, i o'.v 160.

G. II. Rae Gibson.

195

is no longer held in a tense straight vertical position towards the surface
and therefore becomes lax and twisted.

Chromolytic changes are usually observed, for instead of the mosaic
pattern presented by the Nissl bodies, a fine dust, scattered irregularly
through the cell, may be seen, or the basophil substance is in clumps, or
seen running in long threads. Accompanying this change and usually
preceding it is a deficiency or absence of chromophilous material in the
dendrons (vide Plate).

There was in addition, generally speaking, a proliferation and hyper¬
plasia of the neuroglia cells, especially in the deeper layers of the cortex.

There was in these sections none of the signs seen in sections from
cases of general paralysis, no sign of perivascular cell infiltration or of
vascular proliferation. In one of the brains, that of a man who had been
completely demented for some years, there was a considerable deposit of
pigment appearing through the brain substance and also in the cells
themselves.

In addition, many of the cells showed signs of vacuolation, many
vacuoles occurring at times in one cell.

It was noticeable, further, that the supporting cell substance was
less dense than usual; there was a general appearance of thinning and
vacuolation.

In one of the brains, in the case of a man who had shown marked
stereotyped movements during life, the Betz cells were the most affected—
an interesting fact, in view of the psychomotor phenomena this patient
exhibited during life.

Changes similar to those which I have found have already been
described by several writers. Dunton noted a slight cell change which
was distributed over the whole surface of the brain, but most marked in
its appearance in the region of the first frontal convolution.

Dr. Stewart, investigating a case in the Claybury Laboratory, found
chromolytic changes with eccentric nuclei, which was most marked in the
larger and middle layer of pyramids, but also present in the smaller layer.

Dr. Mott refers to four cases with marked dementia, where there were
marked evidences of degenerative changes in the pyramidal cells.

Various other investigators, among whom are Alzheimer, De Buck and
Deroubaix, have noted similar changes in the polymorph layer and in the
layer of the larger pyramids.

The abnormality in the Purkinje cells which Lannois and Paviot have
described, I was unable to find.

Thr J\ttholotjif of Jhmentia 1 'r&aw.

190

Dr. Mott, in tlie Croonian Lectures, 1900, has described two sets of
changes which occur in experimental anosmia which had been artificially
induced in animals by Dr. Leonard Hill. Firstly, when two carotid and
two vertebral arteries have been ligatured in dogs which subsequently
recovered completely. Secondly, when a subclavian was tied instead of
one of the vertebrals, so that a sufficient collateral circulation could not
be restored soon enough and the animal died at a period varying from
one quarter to twenty-four hours. In the first set of experiments
the dogs were demented and paretic, remaining for some days in a
state similar to those dogs in which Goltz removed the cerebral hemis¬
pheres. They were restless, irritable, stupid, standing with a fixed gaze
and their legs spread out.

Dr. Mott, on examination of the brains of these dogs, found various
changes in the nerve cells. The cells were swollen up, with bulging sides.
The nuclei were likewise increased in size and were at times eccentric.
Alterations were further noted in the chromophilous material, the Nissl
bodies had disappeared and their place was replaced by a fine dust : in
addition to these changes there were other cells which were irregular in
outline, with broken cell-walls and extruded nuclei. Examination of
the spinal cord ten days after ligature of the arteries showed only a few
degenerated fibres in the crossed pyramidal tracts. Dr. Mott was
therefore of opinion that the universal changes noticed in the cortical
cells were of a functional character. This observation accords with the
fact that the animal recovers all its cerebral functions completely and in
a fortnight after the operation, as far as can be judged, behaves like a
normal dog.

In the case of the second series of experiments, in which ligation of
the arteries supplying the brain was performed in such a manner that a
collateral circulation was not established, quite different appearances were
noticed.

The cortical changes showed a shrivelling rather than a swelling of the
cells, and the cell bodies showed more signs of fragmentation with the
extrusion of the nuclei and twisting or rupture of the terminal processes.
The perivascular spaces were greatly dilated and scattered; through the
protoplasm of the cell was a fine dust of chromophilous particles. The
cells and their processes stained a uniform pink or purple, and there was
none of the differentiation and brilliant colouring met with normally in
sections stained by means of the methylene blue and safranine, or of
polychrome blue.

(r . H . Hits* (ribson .

197

These cell changes have been described by Dr. Mott: “The whole cell
stains uniformly, but not with a brilliant coloration. If a double stain has
been used, for example methyl blue and saffranine, the whole cell may be
stained a uniform dull purple, the processes, as well as the body of the
cell, having a homogeneous instead of a differentiated reaction to the dyes.
One animal, a monkey, which became demented and paretic after ligature
of both carotids and one vertebral, was killed on the fifth day and the
following changes were found. The nerve-cells and their processes were
stained uniformly a diffuse dull purple and were readily discerned on
account of the dilatation of the lymph space in which the neurone
lies; scattered through the protoplasm of the cells was a fine dust of
coloured particles; the special processes of the cells were either destroyed,
or twisted like corkscrews; in many the dendrites had disappeared, but
in some the axis cylinder could be traced with unusual distinctness,
probably due to some swelling. Many of the cells were swollen up and
others were shrunken. Some could be seen with phagocytes sticking to
them and devouring the dead cells.”

As Dr. Mott has shown, “ every neurone has a specific energy of its
own, and its functional capacity and durability depend upon three
factors:—

1. The inherent vital energy to maintain biotonic equilibrium.

2. The condition of the circumambient medium which provides the
necessary chemical substances for functional activity and repair of waste.

3. A capacity of the neurone for storage of energy whereby it is
enabled to meet stress under conditions in which immediate repair of waste
is rendered difficult or impossible.”

From the study of the family histories of cases of dementia prsecox,
and the frequent occurrence of a family hereditary predisposition, it is
evident that in these patients the brain-cells have probably insufficient
vital energy to maintain biotonic equilibrium.

These faulty hereditary tendencies make the nerve-cell more liable to
suffer under adverse circumstances than would be the case in persons who
were without family predisposition to nervous and mental troubles.

Verworn, in his recent work, has determined that the spinal centres,
were capable of discharging without receiving oxygen or nutritive
material. From this it is evident that the spinal motor neurones possessed
a store of latent energy which, under certain circumstances, such as
various stimuli, “ could be converted into potential energy, independently
of the circulating blood.” When there is failure of repair of waste, there

198

The Pathology of Dementia Praeeox .

ensues loss of function which has been termed exhaustion 'paralysis . Dr.
Mott has pointed out that this may be due to “ failure of the oxygen
storage, or in exceptional experimental cases, to failure of organic
material.” The ganglion contains reserve stores of oxygen and of organic
material. The former are more readily exhausted than the latter. When
a nervous centre is exhausted, it is on account of the using-up of the
reserve oxygen substance and the neurone is, as it were, asphyxiated.

When we consider the fact that many of these patients are the heritors
of neuropathic destinies, it is not unlikely that the inherent defect lies not
only in the possession of insufficient vital energy to maintain biotonic
equilibrium, but also in the oxygen storage capacity of the cells. The
result of this is that any conditions limiting or destroying the supply of
oxygen to the nerve-cells will have much more marked results than in
normal tissues.

Several factors may unite together to cause conditions unfavourable
to the stability of the nerve cell. The equilibrium of the cell elements
may be disturbed by various toxins, bacterial or auto or cyto-toxins, and if
this occurs in normal cells, it is much more probable that it will take place
in those which are inherently defective.

Many of these patients are subject to tuberculous disease, and, as
Dr. Mott has pointed out, the tuberculous toxin may be an important
causative or exciting agent in these changes.

The similarity of the changes noted in dementia pra3cox to those found
in the brains of animals as a result of experimental anaemia points,
however, to other factors which may have an important share in bringing
about these changes.

It has already been shown that these patients suffer from a grave
circulatory defect. The feeble pulse, the various digestive disturbances,
and the cold extremities which are so frequently met with in these
patients, bear witness to the fact that the various components regulating
the blood flow are not functioning properly.

The post-mortem manifestations exhibited by these patients confirm
the appearances so frequently noticed in life. Their hearts are frequently
dilated, and the ventricular walls flabby and dilated.

It is, however, not only the vis a tergo or force pump action of the
heart which is affected in these patients. Persons suffering from dementia
prrecox are shallow breathers; during inspiration they exhibit very slight
chest expansion, so that the vis a fronte or sucking mechanism of the
heart is also markedly impaired.

(i. H. line Gibson .

199

These various conditions, coupled with the fact that these patients lead
a sedentary existence, all tend to cause a low state of arterial tension.

Any lowered state in the circulatory tension will be felt in the brain as
much as in the various organs of the body from the anatomical arrange¬
ments which govern the cerebral mechanism. The anatomical arrangement
of the veins of the brain, and more especially of the longitudinal sinus,
with its various tributaries, is such that any change in the general
circulation will show its effect in this region.

Dr. Mott has demonstrated the importance of this arrangement of the
cerebral circulation in the determination of neuronic destruction in general
paralysis.

“The veins of the brain have no muscular fibres in their coats; they
consist of an adventitia, lined by an endothelium, and the large veins
which run into the longitudinal sinus often run for an inch or so in the
substance of the dura mater before opening into the sinus in a direction
opposite to that of the current. The chordae Willisii in the sinus and in these
sinusoidal veins would facilitate stagnation of the blood, and this would
occur much more frequently than it does were it not for the fact that the
great anastomotic vein is connected by a large vein with the lateral
sinus, so that obstruction in the longitudinal sinus finds a relief by this
connection.”

In his paper on the etiology and pathology of general paralysis. Dr. Mott
has shown that the thickening and opacity of the pia arachnoid membranes
correspond with those parts of the brain which are drained by the superior
longitudinal sinus.

The portions of the brain in which the maximum changes were found
in dementia praecox were mainly in the anterior portions of the hemispheres.
The mesial surface of the frontal lobe, the top of the temporo-sphenoidal
and the anterior two-thirds of the upper and outer surfaces of the
hemispheres were most affected, and the appearances were most marked
in the upper part of the ascending frontal and the superior frontal
convolutions.

These are the portions of the brain drained by the superior longitudinal
sinus.

These alterations are not mainly biophysical, as shown by dropsical
aspect of the cells, due to the absorption of cerebro-spinal Huid and the
chromatolysis; biochemical changes have also taken place, as shown by
the shrunken appearance of some of the cells and the change in the
staining reactions.

200

The Pathology of Dementia Prtecox.

It is probable that oxygen is diffused through the whole nerve cell in
a state of chemical combination; therefore it is not difficult to understand
how these biochemical changes are brought about by circulatory factors
interfering with the blood flow through the brain.

It is probable that, in the early stages of dementia prajcox, the change
is purely a physical one, brought about by various factors tending to lower
the general health. In this stage, the nerve cells are deteriorated and in a
state of low vitality. As the disease progresses, there is an accumulation
of the products of destructive metabolism, and with it degeneration of the
cell elements, which goes on to a state of actual destruction.

How far the actions of various toxins aid in the production of these
changes is difficult to say. It is commonly said that various forms of
mental disease are a result of intoxications, but so far we are ignorant
of their cause and of their chemical properties. It is not unlikely, however,
that some form of intoxication is an important factor in the production of
the Changes seen in this disease, in conjunction with the circulatory defect
and the mechanical arrangements of the cerebral blood supply.

In any case, we see the formation of a vicious circle, which any
pathological process tends to accelerate, in which impaired nutrition,
the shallow breathing, and the low state of the arterial tension all
participate.

Treatment.

The treatment which I have adopted at Morningside is directed towards
stimulation of the circulation, so as to cause an increase in the blood-
pressure, not only in the general systemic circulation, but also in the
vessels of the brain.

The patients were induced to take cold baths and were well rubbed
down afterwards, and they were sent out for rather more vigorous walks than
is customary with asylum patients. They were further directed to practise
breathing exercises. Their food was carefully attended to and extra diet,
along with milk, custards, and maltine and cod-liver oil, given with a view
to improving the general health of the patients. The drugs employed
were mainly cardiac tonics and those which seemed to yield the most
satisfactory results were digitalis, strophanthus, nux vomica, caffeine and
adrenaline. Of these, the results apparently obtained with minims of
tincture of digitalis and 10 minims of tincture of nux vomica were the
best. These drugs were administered three times a day for a fortnight as

(l . IL Rue Gibson.

201

a general rule, and then an interval of a week was allowed to elapse. In
the case of the patient M. G., the nurses were emphatically of the opinion
that the patient was better while she was taking the medicine and not so
well during the intervals.

Of the eleven cases in which the treatment was adopted, two have been
discharged, and two are shortly going out: one recovered completely
mentally, but unfortunately developed phthisis and died in the institution;
one recovered from her katatonic condition, but has since turned into a
state of what might be termed criminal lunacy, and five have shown
practically no lasting change, though even in the most unsuccessful cases
certain slight changes, which can, I think, be ascribed to the treatment,
were noticed.

The general health was, in every case, attended to for a period of at
least three weeks before any drugs were administered.

The cases were all of the katatonic variety, with one exception. The
first change noticed in the patients was an increased restlessness, which
showed itself in various ways. One patient, who had been apathetic and
apparently demented for months, suddenly attempted to throw herself out
of the window, and patients who had previously been quiet and well-
behaved, taking no interest in the surroundings, became irritable and
quarrelsome. They all professed dislike to their medicine, and in several
cases it was necessary to administer it forcibly. In one case, C. B., the
treatment was successful in little more than two months, but in the other
cases the average period was from three to six months.

The following is a brief account of the clinical histories of the cases on
which the treatment was tried :

E. L—, aged 20 years, female, single; domestic servant. Admitted to
the Royal Edinburgh Asylum on the 16th October, 1909. Her mother had
been insane and was also at Morningside. There was nothing in the
previous history of the patient of any moment; she had been of average
intelligence at school and showed a certain ability, especially in
arithmetic.

When admitted was mentally enfeebled, with a poor memory and no
proper idea of her surroundings. When I first saw her, at the commence¬
ment of November, she exhibited all the signs of katatonia; she never
spoke; had to be fed; was untidy in her habits and personal appearance,
and sat still listlessly and apathetically. Her arms and legs could be placed
in any position, and when so left, remained for several moments; she also
showed a slight tendency to Schnautzkramf. Her general health was

202

The Pathology of Dementia Prseeox.

fairly good, but her blood-pressure was so low that the pulse was almost
imperceptible at the wrist, and with the graphic sphygmomanometer no
pulsation could be obtained. With the Riva Rocci, the blood-pressure was
estimated at 98. Her hands were very cold and her fingers covered with
chilblains; her ankles and feet were swollen and oedeinatous. She was
treated with digitalis ; with digitalis and nux vomica ; with strophanthus;
hypodermic injections of strychnine, but with very little result. Certainly
she was more restless and spoke occasionally, but except for the fact that
her blood-pressure at times was 108 and once rose to 112, there was very
little change. When she was treated with adrenaline, however, she began
to improve and is at the present moment progressing steadily. She takes
her meals and talks, and except for a slight facility, is almost in a normal
mental .state. The adrenaline has been discontinued, but she still
continues to get small doses of digitalis and will very shortly be
discharged.

M. G—, female, aged 28 years, single; lady’s companion. Admitted
to the Royal Edinburgh Asylum on the 11th October, 1909.

An uncle and a sister were insane. She had always led a reasonable,
quiet, steady life, and had had no illnesses beyond the ordinary complaints
of childhood. She had an attack of influenza two years before admission,
and, six weeks later, was thrown out of a motor car and her chin was
rather badly damaged. Six months before admission, she attempted
suicide by strangulation. When she came to us she was very depressed;
thought that she had been poisoned, and that she was dead; was refusing
her food and under the impression that she had done grievous bodily harm
to her relations. Mentally, except for the fact that her memory was very
bad, there was only slight impairment; she talked readily and coherently,
but had auditory hallucinations, to which she responded. Her physical
health was very poor; she was thin and anmmic, and her heart was
very irregular and her knee jerks greatly exaggerated. When I saw her
first, in the beginning of November, she was very depressed, sitting for
hours without speaking and slightly katatonic. Her heart was irregular
and her pulse very feeble, and her blood-pressure 112 mm. of mercury.
Her general health was carefully attended to, and the anaemia treated by
putting the patient to bed and giving her milk and Blaud’s pills, and at
the end of six weeks her condition had improved so much that it was
deemed expedient to start treatment with cardiac tonics. She expressed
great dislike to the drugs, and on several occasions it was necessary to
administer them by means of the nasal tube. She was under treatment

G. H. Ran Gibson.

203

for altogether seven months, and the most satisfactory results were
obtained with adrenaline, administered by the mouth. This, as with the
other cardiac tonics, was administered over periods of a fortnight, with
weekly intervals. During the intervals of treatment, the patient was
undoubtedly not so bright as while the drug was being administered. She
eventually improved so considerably as to be discharged recovered.

Gr. K—, female, aged 27 years, single; housekeeper. Admitted to the
Royal Edinburgh Asylum on the 23rd August, 1909.

For some months previous to her admission had been dull and listless,
untidy in her appearance and personal habits, neglecting her work, and
sleeping badly. She had gradually sunk into a condition of apathy,
and for some weeks had not spoken or taken any interest in her
surroundings. As she had been refusing food, it was necessary to remove
her to an institution. She had once attempted suicide by precipitation.
There was the history of an older sister who had been insane, suffering
from what appears to have been systematised delusional insanity; the
father also was weak-minded. On admission she was wringing her hands,
spoke seldom, only to complain of the great sins which she had committed,
and showed slight signs of katatonia. Her physical health was weak ; she
was very thin and anaemic, but her heart and lungs were healthy. When
I saw her first, in the beginning of November, she presented all the signs
of katatonia, she had to be tube fed, and she was an excellent example of
Schnautzkramf. Her eyes were tightly shut, and she sat for hours in one
position with her head bowed. From the middle of December, 1909, to
the commencement of April, 1910, she was treated with digitalis and nux
vomica, and during the fortnights while the drugs were administered she
was resistive and impulsive; but, at the end of three and a half months*
treatment, there was very little change in her mental condition. On the
10th April she suddenly showed a marked improvement; sat up straight,
talked sensibly, took her food, and conversed fairly rationally ; said she
was sorry for the trouble she had caused, and inquired after her relations.
Shortly after she developed a cough and a swinging temperature,
and though her mental condition continued to improve, she died on
the 8tli May of acute miliary tuberculosis.

C. A. B—, female, aged 24 years, single, was admitted to the Royal
Edinburgh Asylum, on the 20th October, 1909, with a history that for
some time past she had lost all interest in her work, had been troubled
with sleeplessness, and had had no appetite for her food. She attempted
to commit suicide on at least one occasion by strangulation, and had

204

The Patholotjy of Dementia PrsecotV.

demanded to be given a razor with which to cut her throat. She
was occasionally violent, and for seven weeks prior to her admission had
been regarded and treated as insane.

When admitted to the asylum she was at first very depressed and her
memory was impaired. She suffered from various delusions—amongst
others, that she was guilty of unpardonable sins; that her food was
poisoned, and that everybody was conspiring against her.

Her appearance was decidedly depressed; she sat still, with her head
bowed, saying nothing.

Her heart and lungs were both healthy; but her hands were cold and
covered with chilblains, and her blood-pressure was 106.

When I first saw her, iu the beginning of November, she was very
slightly katatonic. She was refusing her food, and had to be fed on several
occasions. Her appearance was that of complete depression, and she
looked exceedingly unhealthy. Her general health was attended to for
three weeks, after which it was thought that she was ready to be treated
with various cardiac tonics. She at first was very resistive when the
drugs were administered, and complained bitterly about the bad taste.
Altogether she was under treatment for about two months and a half,
during which time she was treated almost entirely with digitalis and
tincture of nux vomica. At the end of this time she had entirely
recovered, and remained so for the next three months when she was
discharged. I have heard from her several times since, and she still
remains in the best of health.

C. P—, female, aged 15 years, admitted to the Royal Edinburgh,
Asylum on the 8tli of January, 1910; a mill-worker. .

About three months previous to admission she had had a great fright,
as when she was alone in the house a drunken man had suddenly entered
the room in which she was asleep. The August before, she had had an
accident and fallen on her head and had been insensible for some three days,
during which she had what was described as a fit. She apparently had
recovered from this completely, and remained perfectly well until four
weeks before she was admitted. She then completely altered in her
conduct; refused to work; her conduct was extraordinary in many ways;
she threatened suicide and almost entirely refused to speak to anybody.
She was sent to the Royal Infirmary, where she became completely
katatonic, and remained there for four weeks.

When she was admitted to the Royal Edinburgh Asylum she was
an extremely marked case of katatonia, taking no interest in her

G. If. Rtu j Gibson .

205

surroundings, answering none of the questions which were put to her,
showing no signs of emotion, and with no expression on her face. As her
physical health appeared excellent she was at once treated with cardiac
tonics—first with digitalis, and later on with strophanthus. On the 23rd
of February she began to speak; but for some time previously her
movements had been much less rigid. By the middle of March she was
speaking with comparative facility, and by the beginning of April she
was able to work in the laundry and was in every way apparently
normal. Since then she has shown no further indications of katatonia,
but her general character has undergone a complete change. She is now
what might be termed a criminal type of lunatic. She is defiant in her
manner; attacks the nurses; fights with the other patients; is perpetually
breaking windows, and refuses to do anything that she is asked. But,
mentally, she appears to be quite active, as she writes long letters to her
relatives and is able to talk intelligently and even cleverly.

B. 1)—, aged 20 years, single. Admitted to the Royal Edinburgh
Asylum on the 16th March, 1909, with the history that six months
previous to admission she became quiet-, silent, unable to sleep, and had
no appetite for her food.

When admitted she was morose, melancholic, dejected; answered
questions very slowly and with apparent difficulty; contented herself
with monosyllabic answers. She was perpetually asking to get home,
and at times crying. She had hallucinations of hearing, and said that
she heard her sisters and relatives talking to her. She was very ansemic,
but otherwise in fair bodily health. Her general appearance was both
dirty and untidy.

She was still in the institution when I saw her in the beginning of
November in the same year, and during her residence had made no
improvement whatsoever. She was occasionally impulsive, smashing glass
and trying to esc ipe, occasionally striking the nurses. After her general
health had been attended to in the manner described above, she was
treated with adrenaline. This was continued for two periods of a fort¬
night, with a week's interval, and, as there was apparently no change, she
was treated with digitalis, at first alone, and then along with nux vomica.
The treatment was continued at intervals for nearly five months, during
which time her blood-pressure rose from 102 to 104. Under treatment she
was at first exceedingly restless, occasionally noisy and excited; but
gradually this passed off and, instead of spending most of the day asleep,
or sitting still in the corner, she requested to be allowed to work. She

20 6

The Pathology of Dementia Praecox .

is still continuing to improve, and will probably be discharged in the
course of a few weeks.

The five cases in which the treatment yielded no lasting results were
those of patients who had all been resident for more than two years in the
institution, and two had been inmates for over five years. In these cases
I consider that the dementia had been so firmly established that actual
degeneration and destruction had taken place in the brain cells, so that no
improvement could be expected. I do not insert their histories, as they
were typical cases of dementia praecox, four exhibiting katatonic symptoms,
while one was a case of the hebephrenic variety.

In conclusion, I should like to express my thanks to the Laboratory
Committee of the London County Council for the assistance accorded to
me and the hospitality enjoyed by me at Claybury.

I take this opportunity of thanking Dr. Mott for his unfailing kindness
and consideration ; his advice was invaluable, and his constant encourage¬
ment most stimulating.

Dr. G. M. Robertson, of Morningside, kindly permitted me to practise
the treatment on various cases under his care, and to him my heartiest
thanks are due.

Conclusions.

1. That the changes in the nervous elements in dementia pnecox are at
first functional, and that in the later stages of the disease actual degenera¬
tion and destruction takes place.

2. During the early stages of the disease, temporary recovery is
possible. Recovery during the later stages of the disease cannot occur.

3. Though recovery does take place during the early stages of the
disease, it is only temporary, as all cases tend to relapse.

4. Bad hereditary tendencies are important predisposing causes to the
onset of dementia praecox.

5. Circulatory disturbances, by impeding the supply of oxygen to brain
tissues predisposed to disease, are important exciting factors in the onset
of dementia praecox.

6. Toxins, whether microbial-toxins, auto-toxins, or cy to-toxins, probably
play a certain part in the causation of this disease.

7. That the mental state is largely dependent on tlie physical and
especially the circulatory condition, and that in early cases any improve¬
ment in the two latter is bound to show its effect in the former.

G. H. Ran Gibson.

207

Bibliography.

Alzheimer.— 44 Krapelin: Psychiatry,” 6. Auflage, Bd: ii, S. 181.

Dolbschal. — 44 Vergleichende Untersuchungen des Gartner’schen Tonometers mit dem
v. Basch'schen Sphygmomanometer,” Inaug. Dissert., 1900.

Du Buck and Deroubaix. — 44 Le Nevraxe,” vol. vii, f. 2, p. 161.

Dunton, W. Kush, Jun.— 4 American Journal of Insanity/ vol. 59, No. 3, 1903.

Hayaski, T.—“Vergleichende Blutdruckmessungen an Gesunden und Kranken mit.
den Apparaten von Gartner, Riva Rocci und Frey,” Inaug. Dissert., Erlangen, December,

1901.

Hill, Leonard. — 44 On Rest, Sleep and Work and the Concomitant Changes in the
Circulation of the Blood,” 4 Lancet/ 1898, vol. i, p. 282.

Jarotzey, A.— 44 Zur Methodik der klinischen Blutdruckmessung,” 4 Centralbl. fiir in.
Med./ 1901, vol. xxii, p. 599.

Lannois and Paviot.— 44 Les lesions histologiques de Tecorce dans les atrophies du
cervelet,” 4 Nouv. Icon, de la SalpStri&re/ August 15th, No. 6, p. 513 ; November and
December, 1902.

Mott, F. W. — 4 Archives of Neurology/ vol. iii, p. 329.

Ibid.— 4 Croonian Lectures/ p. 39.

Ibid. — 4 Croonian Lectures/ p. 46.

Ibid. — 4 Archives of Neurology/ vol. i, p. 186.

Potain, C.— 44 La pression arterielle de Phomme k Tetat normal et pathologique,” Paris,

1902.

Russell, W.— 44 Arterial Hypertonus Sclerosis and Blood Pressure,” p. 53.

Stewart. — 4 Archives of Neurology/ vol. iii, p. 330.

Thayer, W. S. — 44 On the Late Effects of Typhoid Fever on the Heart and Vessels,”
4 Am. Journ. of the Med. Sci./ 1904, vol. cxxvii, p. 391.

v. Basch, S.— 44 Die Herzkrankheiten bei Artsriosclerose,” Berlin, 1901, p. 3.

On the Cortex of the Auditory Centre, the Insula, and Broca’s
Convolution in a Case of Deaf-mutism.

By A. B. Dkoogleever Forthyn.

Demonstrater of Zoology , University of Amersterdam.

The following researches concern the brain of a male deaf-mute, whose
internal ear has been investigated by Mr. Sidney Scott, M.S.* They
were performed in the Pathological Laboratory of the London County
Asylums, and I would here express my indebtedness to the Pathological
Sub-Committee of the London County Council for permission to work in
the laboratory. To the director of the laboratory, Dr. F. W. Mott, F.R.S.,
I owe great thanks for the material and for many valuable suggestions.

Material and Methods.

The material consisted in the brain of a man named S.H—, who suffered
from an ear disease when six months old, and became deaf and dumb in
consequence. Besides that he was an epileptic, and probably a congenital
imbecile. He understood what was said to him by finger demonstration.
He died at the age of thirty-two of acute lobar pneumonia and cardiac
failure in Claybury Asylum. Post-mortem : the weight of the brain
appeared to be 1,470 grammes.

Two normal brains from female adults whose hearing during life was
normal were obtained from Charing Cross Hospital; these served as
controls. I will indicate them with the letters A and B. Brain B was in
every respect a normal one, but brain A was obtained from a chronic
alcoholic, who, however, did not present any psychic manifestations like
Korsakoff's disease.

The three brains were preserved in formalin. In order to cut the
cortex everywhere as vertically as possible, the parts to be studied, Le.,
the gyri of Heschl, the first temporal gyrus, the insula and Broca's
convolution were first drawn, and subsequently divided into pieces, each
* Mr. Scott’s results will be communicated in the ‘Proceedings of the Royal Society of
Medicine.’

A. B. Droofjleerrr Fortuj/n.

209

not more than 2 c.m. in length. These, after dehydrating in alcohol,
were embedded in paraffin at 52° C., and cut by means of the Rocker
microtome into a series of sections of 10/i. In the series the number
of sections was counted, and every hundredth section was taken out,
stained with Nissl-Seifen-Methylenblau from Griibler and studied. If
necessary more sections were treated in the same way. It will be obvious
that by knowing the thickness and number of sections the precise
place of a section should be indicated in a drawing of the brain made
when it was still intact.

The Hkschl-gyrus and the First Temporal-gyrus.

Only the left temporal lobe of the deaf-mute was studied by me, the
right one being used for other purposes.

Fig. 1.—Outlines of four giant cells.
Camera drawings. 110 Mag.

Fig. 2. —Outlines of four large supra-
granular pyramids. Camera drawings.
110 Mag.

The outer appearance was quite normal (PI. I, fig. 1). The two gyri
transversi or Heschl gyri were not separated. This may also occur in
normal cases, and accidentally it was true in the normal brain B (PI. I,
fig. 2).

The structure of the normal cortex in the transverse and first temporal
gyri has been described among others by Campbell (’05), Brodmann
(’09), and Marinesco and Goldstein (’10), who discuss also the preceding
literature.

Campbell (’05) discriminates three temporal types of cortex, two of
which are of more importance to us. The first is confined to the gyri of
Heschl. It is chiefly distinguished by the existence of scattered, large
cells in the supra-granular pyramidal layer (or third layer of Brodmann)
called giant cells by Campbell. These giant cells occasionally lie within
or even below the granular layer. Their form varies, at times being

U

210 Auditon/ Centre, the Insula, and Broca's Convolution .

pyramidal, at other times stellate, their processes are stout (Fig. 1),
and so they differ in shape from the large pyramidal cells in the sanie
layer (Fig. 2).

The second type occupying the first temporal gyrus and the anterior
part of the gyrus transversus, resembles much the first one. Compared
with the type of the Heschl-gyrus there are more large pyramidal cells in
the supra-granular layer, but the number of the giant cells is considerably
reduced.

Brodmann (*09), who gives no particulars about the structures of the
different areas is able to recognize two areas on the Heschl-gyrus
indicated by the numbers 41 and 42. The area of the first temporal gyrus
agreeing sufficiently with that of Campbell is area 22, Besides, Brodmann
notices an area 52 being a transition from the Heschl-gyrus to the
insula.

Marinesco and Goldstein (GO) having examined the cortex of the
temporal lobe in a considerable number of normal cases, agree in several
respects with Campbell. They too see a striking difference between the
cortex of the Heschl-gyrus and area 22 in the number of the so-called
giant cells, this being less in area 22. Marinesco and Goldstein raise
objections against the term “ giant cells,” because the giant cells of the
temporal lobe are not comparable with those of the area giganto-pyramidalis
or motor area. This is quite true; but bearing this in mind, I prefer the
term “ giant cells ” to the not very characteristic term “ large cells,” which
is used by Marinesco and Goldstein. Marinesco and Goldstein have found
it difficult to find a difference between Brodmaids areas 41 and 42.
According to them the giant cells” are more numerous in 42 than in 41.

The description of Marinesco and Goldstein was in nearly every point
applicable to the normal brain B, which I studied. I observed the Heschl-
gyrus to be chiefly occupied by an area characterised by a number of giant
cells often lying in small groups, in the third or supragranular pyramidal
layer (PI. II., fig. 1). As I cannot find any reason to divide this area iuto
two, 41 and 42, I shall indicate it as (41 -|- 42) (PI. I., fig. 2). In this
respect I agree with Campbell, and also with Marinesco and Goldstein ; but
not with Brodmann (’09), who, however, himself calls the areas 41 and 42
very similar to one another in tectonical respects (Brodmann ’07).

The form of the giant cells, which were as Campbell describes, rarely
lying in (PI. II., fig. 2) or even immediately below the granular layer, is
often not quite pyramidal, but stellate or spindle-shaped. By this
character and their larger dimensions they differ from the large pyramids

ARCHIVES OF NEUROLOGY, VOL. V. PLATE I.

Fig. 1.

Fig. 1 . —Left temporal lobe of a male deaf mute. Natural size. The red line indicates
the portion cut and studied. The red dotted lines indicate the limits of the areas of different
structures. 38 = area 38 of Brodmann. (3) — (0) spots where the drawings of Plate 11
were taken.

Fig. 2.

Fig. 2.— Left temporal lobe and insula of a normal woman. Natural size. Signification
of the red lines and figures as in Fig. 1.

ADLARD & SON. IMPR

A. B. Drooghever Fortyyn.

211

of the same layer (Figs. 1 and 2). I will not repeat the very correct
description of the other characters of this area by Marinesco and Goldstein,
as these characters are, moreover, to be seen in Plate II., fig. 1.

The other parts of the temporal lobe which I investigated in the normal
case B, possessed the structure of area 22 (PI. I., fig. 2). Therefore they
deviated, as also Campbell remarks from area (41 -f 42), by a reduced
cumber of giant cells, but an increased number of large pyramids in the
third layer (PI. II., fig. 2).

The cortex of the left temporal lobe of the deaf-mute man presented
marked differences from the above (PI. I., fig. 1). The area (41+42)
w?is divided according to the line AB into an anterior part wholly destitute
of giant cells and a posterior part where the number of giant cells was
more than four times reduced (PI. II., figs. 3 and 4). Besides that, the
large pyramids of the third layer were much smaller than in the normal
case, especially in the anterior part, although there was no sharp limit as
with the giant cells. Plate II., fig. 3, taken from the anterior part of the
area (41 + 42) in the deaf mute, and fig. 4 taken from the posterior part
show the changes of the cortex as compared with the normal type
(PI. II., fig. 1). The other slight differences I saw in this area were
probably not abnormal but due to the normal fluctuating variability. I
measured the depth of many parts of the cortex, but noticed it to be
everywhere so variable that, in my opinion, changes which are not obvious
without measurements can only be proved in a statistical way, {.<?., by
measuring the cortex of several brains of deaf-mutes.

Area 22 could also be divided into an anterior part without a single
giant cell (PI. II, fig. 5), and a posterior part where again a reduction of
about four times occurred. The limit between both parts was the same line
AB as found in area (41 + 42) (PI. I., fig. 1). As in normal cases there
were in the deaf-mute less giant cells in the posterior part of the area 22
than in that of area (41 -f 42). Other changes did not occur, the large
supragranular pyramids were not diminished in size (compare PL II.,
fig. 2, with fig. 5).

A small portion of area 22, occupying the most anterior part of the
Heschl-gyrus showed, however, still other changes (PI. II., fig. 6). Here
the cortex was considerably diminished in depth, this being only about
two-thirds of the normal depth (compare fig. 6 with fig. 2). Most of all the
granular layer was altered. The granules were lacking completely in
some spots (fig. 6 to the right), although in other places their number was.
nearly normal. Consequently the granules did not form a continuous

212 Auditory Centre , the Insula , and Broca's Convolution.

layer. In the third layer were no giant cells and no large pyramidal cells.
For this reason the third layer was very thin, and the same may be said
about the layers V and VI. So, in general, this portion of the cortex was
very poorly developed. The limit between this degenerated region and
the other parts of the area 22 was rather sharp, but it passed very
gradually indeed into the anterior part of area (41 + 42).

As by the observed changes the characteristic features of the different
areas had almost disappeared, I had some doubt about the anterior border
of area 22. But I noticed it where it might be expected according to
Brodmann’s map (Brodmann *09), and I could easily recognise the neigh¬
bouring area by the figure and description given of it by Marinesco and
Goldstein (’10).

I now come to the question whether the observed changes must be
ascribed to deaf-inuteness or not. But before doing so it is necessary to
consider my investigations of the second “ normal ” brain A. This belonged
to a woman who was neither an imbecile nor deaf, but who was an
alcoholic case. I cut portions of the areas (41 + 42), and 22, of both
hemispheres of this brain, and found only very few giant cells, certainly no
more than in the deaf-mute; moreover, the large supra-granular pyramids
were diminished in size. In consequence the cortex resembled very much
that of the deaf-mute. I have not tried in this case to decide the extent
of these changes, because the brain as a whole was not well preserved.
But the preservation certainly could not account for the disappearance of
one particular kind of cell.

After I had observed this alcoholic case I was glad to have an oppor¬
tunity of seeing the structure of a small part of the areas 22, and (41-42)
in both hemispheres of another male deaf-mute. This man, named M. S—,
died at the age of seventy-two in Claybury Asylum, where he had stayed for
only three weeks on account of melancholia. An acute purulent bronchitis,
accompanied by oedema of the glottis and fatty degeneration of the heart,
caused his death. He was quite deaf since he had scarlet fever when five
years old. He could only pronounce a few words, but he was intelligent,
and could read and write the “ deaf-mute characters .” Brain weight,
loOO grammes.

The brain of this man had two Heschl-gyri on both sides. Area
(41-42) had lost nearly all the giant cells and most of the large pyramids
on the interior Heschl-gyrus (the one which is nearest to tlie insula).
But on tlie exterior Heschl-gyrus the large pyramids were normal, whereas
the number of the giant cells had been reduced, although not to such a

ARCHIVES OF NEUROLOGY, VOL. V. PLATE It.

Fia. 2.

Fig. 1.

Fig. 1 . —Norimil cortex of area (41 + 42). Three giant cells.

Fig. 2.—Normal cortex of area 22. Three giant cells and one in layer iv.

Fig. M. — Deaf mute. Cortex of anterior part of area (41 + 42) without giant cells.

ARCHIVES OF NEUROLOGY, VOL. V. PLATE Ii.

Fig. 4. Fig. 5.

Fig. 4. —Deaf-mute. Cortex of posterior part of area (41 + 42) with few giant cells (one of them
in drawing).

Fig. 5. —Deaf-mute. Cortex of anterior part of area 22 without giant cells.

Fig. 6 . —Deaf-mute. Cortex of the most degenerated portion of area 22. No granules to the right.
All the sections were cut 10/4 in thickness, and all the illustrations are camera lucida drawings (70
Mag.), i, the zonal layer, n, the external layer of granules, hi, the layer of supra-granular pyramids,
iv, the internal granular layer, v and vi, the layer of infra-granular pyramids and polymorphous layer.

A. B. Droogleever Fortuyn. 213

degree as on the interior Heschl-gyrus. These features were noticeable in
both sides.

On both sides the studied parts of area 22 showed a reduction of the
number of giant cells, and on the left there seemed to be a reduction in
the number of the large pyramidal cells.

On the other hand, that the giant cells are normally always present in
these regions is proved by the fact that Professor Marinesco was kind
enough to inform me, in reply to my question concerning the existence of
these cells in normal brains, that he had found “the giant cells in more
than forty normal cases, but partly in reduced number in one abnormal
case.” *

Had I not found the absence of these giant cells in the case of a woman
who was not deaf I should, on this evidence, have had no hesitation in
associating the deaf-mutism in the cases I have investigated with the
disappearance of these cells.

Now I conclude that probably, although not necessarily, there is some
causal connection between deaf-mutism and the absence of giant cells. I
scarcely dare to connect the changes in the small degenerated region (vide
fig. 1, pi. I), with deafmutism, although they seem to be more in agree¬
ment with the facts observed in previously recorded cases.

I am only familiar with the accounts of two cases of deaf-mutism in
which changes have been described as occurring in the auditory cortical
centres. The first one is that by Siebenmann and Bing (T)7); the second one
is the dissertation of Brouwer (*09), where also a review of the literature is
given .t

Bing asserts the first temporal gyri, especially the left one, to be
narrow in a pathological degree. The cortex of this gyrus is abnormally
thin on account of the narrowness of the infra-granular layers and of the
layer of the supra-granular “small pyramids” caused by the reduction
of the number of their cells. On the other hand, Bing noticed the layer
of the large supra-granular pyramids to be undoubtedly broader, although
the number of these pyramids was reduced.

Brouwer (*09) describes changes throughout the cortex of the gyri of
Heschl, as the internal layer of granules and the polymorphous layer have
become narrower, while the infra-granular pyramids have totally vanished.

# Afterwards I myself found in a small part of the Heschl-gyri of another man with
normal hearing approximately the same number of giant cells as in my normal brain B.

t Brouwer’s results have been published in the German language in ‘ Die Anatomie der
Taubstummheit, herausgegeben von Prof. Dr. Denker, siebente Lieferung; Quix und
Brouwer, Beitrag zur Anatomie der kongenitalen Taubstummheit.

214 Auditoru Centre , the Insula, and Broca's Convolution .

My results do not agree with those of Bing or of Brouwer,* but I may
remark that the cases of deaf-mutism described by these authors are
different in their origin. Bing, as well as Brouwer, have dealt with
congenital deaf-mutism, while in my case an inflammation of the ear was
the cause of the deaf-muteness.

The assertion of Bing that the number of large supra-granular
pyramids in the first temporal gyrus has been reduced is only true in my
case so far as it concerns the giant cells, about which Bing does not
speak, but which he probably includes in the large pyramids. 1 could
not verify Bing’s other statements.

The reduction of the infra-granular pyramids in the Heschl-gyrus is,
as also Brouwer (’09) remarks, perhaps not connected with deaf-mutism.
Their existence in the normal state has been long a point of controversy
between authors; and Marinesco and Goldstein (’10) say that the number
of the larger cells in this layer is very variable. Therefore I am not in a
position to assert that the diminution in development of the infra-granular
pyramids in my case of deaf-muteness was due to pathological conditions.
The other changes described by Brouwer were not visible in my case*
unless it be in the small degenerated area described above.

In conclusion I cannot prove the association of changes in the Heschl-
gyrus or the first temporal gyrus with deaf-mutism. As to the reduction
of the number of the giant cells the investigation of more cases is desirable.

The Insula and Bkoca’s Convolution.

Since the relation of Broca’s convolution and the island of Reil to
articulate speech is now the subject of controversy it appeared to me worth
while to look for changes in these regions of the deaf-mute’s brain.
Hearing is the primary incitation to articulate speech, and before any
changes could be expected to occur in the cortex connected with the sense
of movements incidental to articulation, changes would probably occur in
the cortex where the primary incitation to those movements occurs. It is
not surprising, therefore, that I did not find any deviation in structure of
Broca’s convolution which could not be accounted for by a normal
variability.

The normal structure of the cortex in the insula is not completely
known. Campbell (’05) describes two different areas, the sulcus centralis

* Nor with the cases quoted by Brouwer, except perhaps, if the changes observed by me
really have nothing to do with deaf-muteness the case of Lancia, who found the architectonic
structure normal everywhere in the temporal lobe and the insula.

A. B. DroogU'rvrr Foriuijn.

215

insula? being “ an approximate, albeit not an absolute, dividing line between
the two areas.” One difference between these areas is that the granular
layer is well developed in the posterior insula, but is hardly recognisable
as a lamina in the anterior insula.

Brodmann (*09) too gives a scheme of the insula in which an agranular
anterior area and a granular posterior area may be seen with the sulcus
centralis insulae nearly as a common border. This border is more exactly
the elongation of the sulcus centralis Rolando, which also divides the regio
centralis in a posterior granular and an anterior agranular part. But in
the text Brodmann mentions the existence of four areas in the insula,
although he gives no particulars about them. In this respect he has
enlarged upon his former view (Brodmann *05) when he pointed out three
areas, one dorsoeaudally, one orally and one ventrally situated. He added
the dorsocaudal area to be characterised by a well developed granular
layer.

Now, in my opinion, a description of the normal structure of the insula,
in order to be exact, should be based upon the average of a number of
examinations of brains. I shall be content therefore in describing the
most obvious facts relating to the structure of this region in a normal brain
and that of the deaf-mute. I may at once say there is no essential
difference in structure in the insula of these two brains.

I was able to recognise in the insula three areas (PI. I., fig. 2). In the
first place an anterior one agreeing in extent with the anterior area of
Campbell and of Brodmann, and having the sulcus centralis as its
approximate hinder border. The term “ agranular,” attached by Brodmann
to this area, is not a very satisfactory term, because in the fourth layer
there were many granules (especially well seen in the deaf-mute’s brain),
but scattered amongst them were numerous pyramids. These deprive that
layer of the typical features of a granular layer, although it remains a
layer with many granules.*

The two other layers were situated in the posterior insula (PI. I., fig. 2).
The most dorsal one is probably the same as Brodmann’s dorsocaudal area.
It is recognisable by a very well developed granular layer and by some

* This has also been stated by Marinesco in a' paper which appeared after this paper
was ready for press. He remarks: “En effet, la distinction de Finsula en line region
anterieure agranulaire et une region posterieure granulaire est facile j\ constater. Cela
ne vent pas dire que, dans la region anterieure la couche granule use soit complete merit
absente, car j’en ai trouve une esquisse . . . de sorte que le passage de la III m * it la

V m «“ ne se fait pas d’une maniere tout k fait insensible.” (“ Recherches sur la cyto-archi-
tectonie de l’ecorce cerebrate, premiere partie,” ‘Revue Generate des Sciences pures et
appliquees,’ 21 mc Annee, 1910.)

216 Auditory Centre , the Insula , aw/ Broca's Convolution .

giant cells (fewer than in area 22) among the supra-granular pyramids.
In the deaf-mute’s brain the number of the giant cells was reduced. There
are in the normal case comparatively fewer giant cells, and large supra-
granular pyramids in the postero-dorsal area of the insula than in the cortex
of the Heschl-gyrus. Therefore and because the infra-granular pyramids
are far better developed than in area (41 + 42), it is not a portion of this
area overlapping the insula, but a separate area.

The cortex of the ventral portion of the posterior insula is distinguished
by its granular layer, as compared with the anterior insula and by the
absence of giant cells as well as by the poorer development of the granular
layer from the postero-dorsal insula. As to the claustrum, it was in the
deaf-mute’s brain as well as in the normal one—a layer of spindle-shaped
cells separated by a layer of fibres from the cortex of the insula.

I could not find enough reasons to discern an area like area 52 of
Brodmann (’09) which he regards as a transitional region from the insula
to the temporal lobe.

Conclusions.

As a summary of my results, I may state the following:

1. In a case of non-congenital deaf-mutism the cortex of the Heschl-
gyrus and the first temporal gyrus (areas [41 •+ 42] and 22) contained in parts
very few giant cells, and in parts none at all. A small portion of area 22
showed moreover important reductions in the granular layer, the layer of
the supra-granular pyramids and the infra-granular layers.

2. The great diminution of giant cells also found in a second case of
deaf-mutism may, perhaps, be due to deaf-mutism, but this is not
necessary, because it existed too in a case free from this defect.

3. The cortex of the centre of Broca was normal.

4. The cortex of the insula, where three areas could be distinguished,
was normal, except that the number of giant cells in the postero-dorsal
area was reduced.

Bibliographie.

(1) Brodmann (1905),—“ Beitriige zur histologischen Lokalisation dor Groszhirnrinde,”
‘ III. Mitteilung/ “ Die Rindenfelder dor niederen Affen,” ‘Journal fur Psychologic uiid
Neurologie/ Bd. iv., 1905.

(2) Idem. (1907).—“ Beitriige zur histologischen Lokalisation der Groszhirnrinde,”
* VI. Mitteilung.' “ Die Cortexgliederung des Mensehen,” ‘ Journal fur Psychologic und
N«*urologie/ Bd. x, 1907.

(3) Idem. (1909).—“ Vergleichende Lokalisationslehre der Groszhirnrinde,” 1909.

(1) Brouwer (1909).—“Over doofstomheid en de acustische banen.” Dissertatie, 1909.

A. H. Droogleerrr Fortni/n.

217

(5) Quix and Brouwer (1910).—“ Beitrag zur Anatomie der kongeni talon Taubstunnn-
heit,” ' Die Anatomie der Taubstummheit/ herausgegeben von Prof. Dr. A. Denker, 7. Liefer-
ung, 1910.

(6) Campbell (1905).—“Histological Studies on the Localisation of Cerebral Function,”
1905.

(7) Marinesco and Goldstein (1910).—“Sur Tarchitectonie de Tccorce temporale,”
* L'Encephale/ 1910.

(8) Siebenmann and Bing (1907'.—“Ober den Labyrinth- und Hirabefund bei einem
an Retinitis pigmentosa erblindeten, angeborenen Taubstummen,” ‘ Zeitschrift fur Ohren-
lieilkunde,’ Bd. liv, 1907.

A Case of Diffuse Cancer, with special reference to the Changes

in the Brain.

By Piktko Rondoxi, M.D.(Flomicy)

AND

Edward S. Calthkoi*, M.B., B.S., M.R.C.S., L.R.C.P.

Through the kindness of Dr. Mott we are enabled to report this case,
which was admitted under his care to Charing Cross Hospital.

Clinical Notks.

B. U—, aged 40 years, housewife. Admitted November 11th, 1908.

The following history was obtained from the patient’s husband, the
manager of a chemist’s shop.

The patient went to bed on Monday night feeling slightly giddy
and unwell, a condition from which she had been suffering for some
time. At 9 a.tn. next morning her husband left her to all appearances
quite normal, to go to work. At 8 p.m. her nephew, went to see her, and
was let in by her as they have no servants ; he found her practically
speechless, only able to say yes and no, and weak in her right leg and
arm, especially the latter. Her husband was sent for, and she was helped
upstairs. A doctor saw her that evening. From the fact that she was
already dressed to go out, which she does every day in order to have
dinner with her husband at his shop, the husband considers the attack
occurred about twelve o’clock. On recounting to patient the story by her
husband she agreed with these facts, and intimated by gesture that the
attack came <m about twelve and lasted about ten minutes, and was
preceded by a giddy faint feeling, but no headache. During the attack
she passed her water under her.

The husband gave the following past personal history: She had a
bad attack of rheumatic fever twenty-three years ago, but a voyage to the
Cape restored her health. Even now she complains of vague feelings of

219

Pirtro Random and Edward S. Calthrop .

pain in her legs, but the husband thinks they are chiefly imaginary. There
has only been this one definite attack of rheumatism. Five months ago she
went to a doctor as she had noticed her abdomen getting progessively
larger. Three months ago she was told that she was pregnant, and
she greatly worried over this. There has been morning sickness for the
last three months. The doctor who saw her after the fit at home stated
that she was not pregnant, and diagnosed an ovarian cyst. Two years
ago patient had diarrhoea and took opium, since then she has had free
access, on account of her husband’s business, to drugs, and has been in
the habit of taking up to six drams of laudanum a day. Patient’s mother
died of stroke at seventy-five. Her husband states that she has passed
very little urine lately, and that walking causes her feet to swell
considerably.

Present condition. —Patient lies in bed, looking anxious, with her legs
drawn up; she points to the umbilical region when asked if she is in pain.
She also complains of headache. Complexion very sallow. Eyes appear
very glossy. Difficulty in respiration, almost a stridor; well nourished.

On admission, temperature 100*2° F., vomited four ounces, pulse 116,
and respirations 22. During Thursday she drank a little milk and
swallowed quite normally, although there was some difficulty in getting
her to take any food. She only passed six ounces of urine, there was
a little incontinence, but the sum total, allowing for this, could not be ten
ounces. During Thursday night she vomited a large amount—twenty-four
ounces of darkish fluid—and the temperature dropped to 96*4° F.; this was
accompanied by a cold clammy condition of the skin. She has a certain
amount of loss of control of the sphincter ani, and there is a tendency to
diarrhoea.

Cardio-vascular system. —Pulse 116, low tension, regular. Arteries
not thickened. The blood pressure was not estimated as the patient’s
condition was too grave.

Cardiac impulse not seen. Slight presystolic thrill can be felt. Apex
beat slightly displaced outwards, but in the fifth interspace. Presystolic
murmur can be heard with accentuation of the first sound; all other
sounds normal, but barely audible.

Respiratory system. —Respirations 22. A rough examination showed
no abnormal phenomena.

Genito-urinary system. —No children according to her statement, but
Dr. Ed en considered this doubtful. No miscarriages. Amenorrhcea for
the past three months. On examination there appears to be a torn

220 A Case of Diffuse Cancer.

perineum, which patient dates back to childhood when she fell on a
spike.

Condition of breasts .—Nipples are not those of a multipara, and the
condition of the breasts leads one to negative pregnancy. Incontinence of
faeces and bladder present. Urine, sp. gr. 1030, acid, no albumen or
or sugar, trace of pus.

Abdomen. —On inspection very protuberant and looks tense. Two or
three patches of pigment present over the lower part. The abdominal
wall moves but little with respiration.

Palpation .—Very tense, no thrill, too tense to make out anything
definite, but there seems to be a tumour rising out of the pelvis.
On percussion, resonant above umbilicus, dull below umbilicus to pubes.
Auscultation: No foetal heart sounds, no uterine souffle. Dr. Routh
inspected her abdomen, and said that the torn perinteum would account
for incontinence of faeces. He considered the case not gynaecological.

Nervous system. — She is a right-handed person. Can say “yes” and “no”
on questioning. She seems to understand quite intelligently, and instantly
demurred when on reading to her the husband’s account erroneous facts
were deliberately introduced. Mind quite clear to all appearances. On
two or three occasions she has managed to say “ will you kindly,” and has
said her name. A handkerchief was held in front of patient, and she
was asked to shake hands as many times as there were syllables in the
name of the object presented to her—this she could not do. There is no
alexia; she cannot write properly voluntarily. Patient was too ill to test
her power of copying and writing from dictation. There seems to be no
apraxia and no astereognosis. On whistling “God Save the King” and
suggesting various tunes she picked the right one out.

Cranial nerves. —First to sixth, normal; seventh, weakness on the right
side; eighth to eleventh, normal ; twelfth, patient’s tongue, which she
pulls out with her fingers, deviates to right side.

The condition of the patient was too desperate to allow of anything but
crude tests.

Sensory plivntnnena .—Common sensibility, tactile and pain senses
normal. \S eakness on whole of the right side, especially right arm,
which she can only occasionally hold up a little. Arm muscle, flaccid.

Reflexes. —Babinski present on right side. On Thursday night the knee
jerks were increased on each side, and could only be obtained occasionally
on the right side. No ankle clonus.

Condition from day to day :

Pietro liomloni and Edward S. Calthrop.

221

Friday (two days after admission).—Patient continually vomits i€ coffee
ground” material. Cyanosis and laborous breathing; incontinence of
feces and urine. Abdomen tender on palpation; pulse 120; respiration
rate increasing from 22 to 44 at 5 p.m. She was allowed two drams
opium; this quietened her, and after the administration of oxygen, she
ceased to vomit and slept.

Saturday .—Fair night, no more vomiting and no incontinence;
breathing more easy. Can speak a few words ; is quiet, intelligent and
conscious. Takes her food fairly well ; pulse better. Given a little
oxygen.

Sunday .—Sick once in the night, slept fairly well; complains of no
pain ; speaks a little; slight stridor. On auscultation moist sounds all
over, especially at bases. Feels comfortable, and takes her food fairly
well. At 6 p.m. suddenly became worse; respirations rapid and laboured,
gurgling during respiration. High tension, rapid pulse. Ether was
administered at 8.30, repeated twice. Venesection brought no relief, and
the patient succumbed.

Autopsy .—A large cyst of the left ovary, containing cheesy material,
probably malignant, was found. Right ovary normal. Six inches above
the anus there is an encircling growth and several secondary growths in
the liver. Kidneys; interstitial changes. Heart; thickening of the mitral
valve ; no stenosis, admitted tips of three fingers ; no vegetations. Aortic
valves healthy. Lungs; congestion of each base, fluid in both pleurae.
Brain ; the external appearances were normal, also the basal vessels.
No decortication on stripping. In the middle third of the first right
temporal convolution, extending deeply into the white matter, was a dark
ill-defined patch about 1 cm. long, the consistence of which was normal.
In the middle of the thalamus was a small cavity of a few millimetres’
size with unstained walls. The surface of the right insula, especially
towards the anterior part, was softer than normal. There was no apparent
haemorrhage.

Histological Examination.

In the rectum a typical medullary cancer was found ; the left ovary
had degenerated into a cancerous mass, colliquative and caseous changes
had taken place. It seemed that the primary tumour originated
in the rectum, for some sections show the proliferation and spread
of the cells from the mucosa into the sub-mucosa. The cells vary
in size; they are generally large protoplasmic and show active pro-

222

A Case of Diffuse Cancer .

liferation. The nests have not the glandular structure, which the more
common adenomatous cancer has; we, therefore, consider it to be a
medullary cancer. In the liver there were some small secondary growths
of a more glandular character; the cells were smaller, and did not
show such active mitotic changes. This less active proliferation and more
glandular structure may be but an expression of a diminution in the
virulence of the growth. We note this, because often the metastasis
shows a more proliferative activity, is more atypical, and shows a more
marked anaplasia than the primary growth (Hansemann) ; but Borst also
points out that sometimes a metastatic growth may assume a certain
similarity to the epithelium of the primary growth, from which it has been
detached. In the lungs no secondary growths were found and no
microscopical examination was made. The kidneys show a slight degree
of sclerosis, but are otherwise healthy.

Brain .—In all the sections of the cortex examined there were some
slight diffuse changes and degeneration of the large pyramidal cells, and
in the frontal region on each side there were a few lymphocytes in the
adventitial sheaths around the vessels. This may have been due to a
zonal disturbance of the circulation, a general cancerous intoxication, or a
secondary infection of the patient during the last few days of her illness
(probably commencing pneumonia).

There were also less diffuse but more striking changes in the vessels
and their immediate surroundings, especially in the left hemisphere.
Many capillaries show a proliferation of the elements of their walls; large
clear cells can be seen containing big nuclei, often vesicular, irregular and
showing some karyokinetic changes. The vessels have a more embryonal
character, and it is difficult to distinguish the differences between the
elements of the intima and the adventitia. These appearances might be
compared with those of the small vessels in syphilitic disease of the brain,
to which Nissl and Alzheimer have called attention (endarteritis of the
small vessels). Fig. 9., PI. IV., in Alzheimer's work on general paralysis
gives a very good idea of the changes found in some of the vessels in this
brain; but in this case proliferation of all the coats of the vessels is
not so diffuse as in that of syphilis, and many other features are lacking.
We found these embryonal vessels in the insula region, Broca's area, and
the first left temporal and frontal regions, the latter less marked (the right
side shows little indication of these changes).

Here and there we find in the above-named regions areas of many
small vessels bound together and cut through like the “ bundles of luinina."

223

Pirtro Random and Edward S. Calthrop .

described by Alzheimer in paralysis and other processes of inflammatory
character in the brain ; this appearance is due to a proliferation of vessels
with formation of true “ packets of vessels.” Around these proliferating
vessels cellular infiltrations are absent or very slight; but infiltrations are
more marked in the same regions around other vessels (generally of a large
calibre), and the infiltrating element consists of lymphocytes, and chiefly
some large cells, the nature of which is not easy to determine. These cells
have a large round nucleus, which may be duplicated,, or may be more
irregular in form. The nuclei show a distinct chromatin network, often
arranged around the periphery containing a clear centre. The body of the
cells stains deeply with thionine and haematoxylin; around the nucleus
there is often a clear zone, and the general form of the cells is round, and
about twelve fi in diameter. These cells are not numerous, and generally
form rows along the vessels, and may be sometimes found also in the pial
meshes. We may assume that, at any rate, some of these cells are
degenerated plasma cells. Dr. Mott suggests that they look like the
morular cells , which he described in the infiltrations of “ sleeping sick¬
ness,” and which Spielmeyer admits to be degenerated forms of plasma
cells. Others of the cells show none of the general features of plasma
cells, and we may consider them to be polyblasts in the general sense of
the word, that is, migratory elements in close relationship to lymphocytes,
expressive of a slight but chronic inflammation of the connective tissue.
Some of these cells may arise from the adventitial elements; but the
typical features of the clasmatocytes and clasmatocyte-like, adventitial
cells of Maximow are not to be found here.

At first glance these cells appeared of an epithelial nature, and
suggested that we might have to do with a metastasis of the brain, for,
as stated above, these large cells surround the adventitial sheath as if
they had been carried thither through the blood or lymphatic paths. A
closer examination showed no nest-formation, but free, lion-epithelial,
separate elements.

Certainly a metastasis in the brain would not have been impossible
from a cancer of the rectum : Bruns lias seen one case ; but we ought to
find as a rule metastases in the lungs (Bruns), which are missing in our
case. In the brain the cancerous elements may infiltrate the adventitial
sheaths (Buchholz), or the pachy- and lepto-meninges (Saxer, Fischer-
Defoy, Dahmen, Scheel, Leegard, Curtius, Tharbitz, Knierim) ; generally
with strong tendency to haemorrhages.

We have found no embolus of cancerous cells in any vessel, and may

224

A Case of Diffuse Cancer .

therefore, from the above reasons, dismiss the idea of the commencement of
a secondary formation in the brain. Sections were stained to show the
glia; but there seems to be no general increase, and only a slight one
around some of the vessels. A recent haemorrhage in the first left
temporal convolution was found, showing in parts red cells degenerating,
with deposits of pigment. The haemorrhage has taken place more into the
white matter than the cortex, and consists of many small patches, the
vessels of which show the above described changes very distinctly. In
the left insula some very small haemorrhages were seen infiltrating the
adventitial spaces. The small cyst was considered to be an old lesion.

We will now endeavour to bring into line the symptomatology and
pathology. Apart from the intermittent diarrhoea, the growth in the
rectum caused no symptoms, a not uncommon feature (Milward), and
the metastasis in the ovary admitted of no certain diagnosis.

A presytolic murmur was heard, but the autopsy revealed no apparent
stenosis, although there was some thickening of the mitral valves; the
patient was too ill for a thorough examination of the heart. We now
dwell upon the condition of the nervous system; the patient, six days
before her death, had an apoplectic fit, without any, or very slight loss of
consciousness, which left her with a typical right-sided hemiplegia,
compromising face and tongue, and with increased knee jerks, and
Babinski’s sign ; besides this, there was motor aphasia; she was verbally
mute, and could only say—and then with difficulty—such words as “ yes,”
“no”; “pretty well”; the “Wortrests” so typical of a motor aphasia.
No sensory disturbance was discovered. The symptoms pointed to a lesion
in the left hemisphere, with loss of function of the left motor area, of some
part of the anterior speech area, and probably part of the anterior part
of the insula foot of Broca’s convolution; it may be a thrombosis of
the first and second branches of the left middle cerebral, or a cancerous
embolism in the same branches, or from the mitral valve. The symptoms
being purely cortical negative a haemorrhage. Probably “silent thought”
was also lost to some extent, as the patient could not recognise the number
of syllables in a word. We may assume that the disturbance causing the
hemiplegia took place in or near the cortex, and a haemorrhage on such a
large scale in the cortex (motor area, Broca’s region) ought to have given a
much more severe fit and complete loss of consciousness. We must look
therefore to some other disturbance of the circulation less violent and less
sudden ; in spite of a careful examination of the branches of the middle
cerebral, no embolus was found, but some small branches appeared

Vidro Rondoni and Edward S. Calthrop. 225

blocked, and the microscope lias revealed coagulated blood within their
lumen.

Was this post-mortem coagulation, or true thrombosis intra-vilam ?
The patient only lived six days, insufficient time for proper organisation to
appear; no changes in the vessel walls suggesting the possibility of
thrombosis were found.

In a case of diffuse cancer a marantic thrombosis is possible without any
striking changes in the walls of the vessels. Had there been complete
ischaemia of the nervous tissue normally nourished by the blocked vessels
for six days, more advanced degeneration would have been found. Now
we find in the brain, chiefly on the left side, some uncommon but interesting
changes, a slight chronic inflammation, as evidenced by the infiltrations
with mono-nuclear elements, partly plasma cells and a proliferation of
small vessels. These changes were certainly prior to the fit, and we
have no grounds for admitting the commencement of syphilis or paralysis;
apart from no history of infection, many other features are missing. The
histological conditions are not very obvious, and only a close examination
caused their discovery. We therefore consider the partial similarity to
syphilis from a histological point of view merely accidental, and consider
that they are due to a general intoxication from the cancer. The marked
tendency of cancer to cause a proliferation of the endothelium of the
invaded lymphatics and blood vessels is said to be due, not to an infection,
but as a reaction to the mechanical and chemical irritation. Such an
irritation might conceivably cause a reaction in more distant tissues and
non-invaded territories, the stimulating toxic substances being carried therd
by the circulation. We know that in cancer of many organs there are
changes in the blood—pernicious anaemia, simple leucocytosis—and in the
nervous system—systemic degeneration, mental disturbances (Meyer,
Elzholz, Klippel, and Cheatle). Why could not wo find some slight
process of vascularity in the brain as in many other intoxications and
infections ?

The changes are most marked in the left hemisphere, and it is not
difficult to admit a toxic cause. It is said that arterio-sclerosis pre¬
dominates in the left hemisphere owing to it having taken over the
more directly executive duties. We can explain the hemiplegia with
aphasia by a circulatory disturbance of, perhaps, a thrombosis without
complete obliteration of the walls, in a hemisphere already slightly
affected possessing abnormal capillaries, and an imperfect lymphatic
circulation due to partly infiltrated adventitial sheaths. It may seem

15

226

A Case of Diffuse Cancer.

strange that the region which shows the most marked macroscopical and
microscopical changes, namely, the first left temporal convolution, has
given no symptoms. The aphasia has been motor, not sensory, but we
know that the posterior speech area (v. Monakow, Mingazzini, Mott)
is much larger than it was until recently assumed, and the small patch in
the middle of this convolution can be but of little importance ; moreover,
the critical state of the woman precluded a more thorough examination,
and had we gone more deeply into the matter some disturbance in the
comprehension of words might quite possibly have been discovered. The
small patch in the right thalamus is very old, and bears no relation to the
symptoms. The death of the patient is more than explained by her various
affections, and is an example of the difficulty of diagnosis in a somewhat
disguised primary cancer, and of correlating the cerebral symptoms with a
pathological lesion.

Resume .—A case of primary cancer in the rectum with secondary
diffusion, which was associated with some unusual changes of a slight
inflammatory and degenerative character in the brain, which the general
intoxication may account for. Six days before death a right hemiplegia
with motor aphasia occurred, which may be explained by circulatory
disturbances (thrombosis of vessels without a complete obliteration). The
case is of importance in showing that changes in the brain which are
considered as specific of particular diseases, e. g. } syphilis and general
paralysis, may occur sometimes, more or less marked, without being
connected with them.

# Editorial Note .—Oppenheim and Cassirer (Die Encephalitis) point out
that in cases of non-specific encephalitis there may occasionally be found
peri-vascular lymphocytosis and plasma cell infiltration.

INFERENCES.

Alzheimer. — ‘ Histologische Studien zur Differential Diagnose der Progressiven
Paralyse/ 1904.

Borst. —‘ Die Lebre von den Geschwulsten/ 1902.

Bruns. —* Die Gesehwnlste des Nervensy stems/ second edition, Berlin, 1908.

Fischer, Defoy und Lubarsch.— “ Treatise on Cancer/' 4 Ergebnisse der Allg. Pathol,
und Path. Anat./ January 10th, 1900.

Milward. —‘ Diseases of the Rectum/ Birmingham, 1900.

Mingazzini.—* Lezioni sull Anatomia Clinica del Sistema nervose/ 1908.

Monakow, von. —‘ Gehirnpathologie/ 1905, second edition.

Mott. —Different works in the * Archives of Neurology.’

ADLARD ANL) SON, IMl'R., LONDON AND DORKING.

Reprinted from The Lancet, July 2 and 9, 1910.

®)\t OTfer-Sjjarpqr futures

ON

THE CEREBRO SPINAL FLUID.

Delivered before the Royal College of Physicians of London on
April 22nd and 29th , 1910 ,

By F. W. MOTT, M.D. Lond., F.R.C.P. Lond.,
F.R.S.,

PATHOLOGIST TO THE LONDON COUNTY ASYLUMS; PHYSICIAN TO
CHARING CROSS HOSPITAL ; AND FULLERLAN PROFESSOR OF
PHYSIOLOGY AT THE ROYAL INSTITUTION.

LECTURE I.

Delivered on April $2nd.

THE PHYSIOLOGY OF THE CEREBRO-SPINAL
FLUID.

Mr. President, —Allow me to thank you and the Fellows
of the College for the great honour you have conferred upon
me in asking me to give these lectures, which have been
delivered in past years by distinguished English physiologists
upon subjects having an important bearing upon medical
science.

In the selection of a subject for these lectures I felt how
desirable it was to follow in the footsteps of my dis¬
tinguished predecessors in choosing a subject upon which I
had spent research and one which at the same time would be
of general interest to our profession. I therefore selected
the subject of the cerebro-spinal fluid, the physiology of
which is barely mentioned in the text-books of physiology,
yet as events have shown during the past ten years the
investigation of the cerebro-spinal fluid has proved of the
greatest value in the differential diagnosis of diseases of the
nervous system. I may mention that in the Revue Neuro-
logiqnc for the last ten years there are abstracts of 187
papers. I shall deal with the subject under two headings:
(1) the physiology, and (2) the pathology of the cerebro¬
spinal fluid.

A consideration of the physiology of the cerebro-spinal
fluid will naturally lead to an inquiry as to its physical and

2

Mott: The Cerebro-Spinal Fluid

chemical properties, its source, its destination, and its func¬
tions. Before, however, proceeding to discuss these subjects
in detail I must devote a little time to a brief historical
introduction.

Historical Remarks.

In 1769 Cotugnuo affirmed the presence in human bodies
of a limpid and transparent fluid, like spring-water, that
bathed the nervous centres. Oontugnuo also found this fluid
in flsh and turtles, but his researches failed in the dog, why
one does not know. A good but short description was made
in 1766 by Haller in his researches upon the physiology of
the human body. But Majendie first made a complete study
of the nature of the pressure, of the movements, and of the
rdle of the cerebro-spinal fluid (1825). He thus describes
the existence of the fluid:—

Bntre la pie-m&re et l’arachnolde se trouve un llquide que je propoee
d’appeler c4r^bro-spinale; il exists chez l'homme et chez to us mammi-
ffcree. II sort ft combler le vide qul exlster&it entre le cerveau et le
crftne osseux; 11 se regenfcre avec rapldlte, peut circuler ft travers les
ventriculee cerebraux et les eapaces sous-arachnoldiens du cerveau et de
la moelle. Au moment de 1‘expiratlon le cerveau se gonfle; le llquide
c^rebro-splnale passe du crftne dans le canal vertebral. Quand on
augmente la pression du llquide, on produit dee phenom&nes de
paralysle et, d’autre part, quand par une ouverture on provoque l'lsau
de ce llquide, le cerveau et la moelle n’£tant plus prot4g6s, 11 survlent
une d4bilit4 et une falblesse g6n£rale de l'anlmal.

In 1858 Olaude Bernard showed a notable quantity of a
substance which reduced Fehling’s solution. He affirmed
that this reducing substance was glucose.

In 1891 Quincke introduced lumbar puncture as a means
of treatment for intracranial pressure; it was tried in
meningitis and general paralysis but with no beneficial
therapeutical results. The simple and safe nature of the
operation, however, led to a number of investigations
relating to the cytology of the fluid in pathological con¬
ditions by French scientists—viz., Widal, Sicard, Ravaut,
Abadie; and the successful results obtained in the diagnosis
of the various forms of meningitis led to its universal
adoption as a valuable means of clinical diagnosis; more¬
over, it was found that anaesthesia of the lower extremities
could be obtained by injection of cocaine, stovaine, &c.,
into the spinal subarachnoid space by lumbar puncture; this
added a new and surgical interest to the cerebro-spinal fluid.

The discovery by Castellani of the Trypanosoma gambiense
in the cerebro-spinal fluid of cases of sleeping sickness led
to lumbar puncture and examination of the cerebro-spinal
fluid for trypanosomes becoming a recognised mode of
diagnosis of sleeping sickness. But perhaps the greatest
interest has been aroused by the application to the cerebro¬
spinal fluid of the Wassermann-Neisser serum reaction for
syphilis by Plant and others, with the most satisfactory

Mott: The Cerebro- Spinal Fluid

8

results from a diagnostic point of view of general paralysis
of the insane and, to a less degree, of tabes dorsalis. With
this brief introduction to my subject I will pass on to discuss
in detail the physiology of the fluid, and I will commence
with

Thb Physical and Chemical Properties.

The cerebro-spinal fluid is a fluid sui generi* % for its
physical and chemical properties are different from those of
any other fluid in the organism; it approaches in its com¬
position most nearly the sweat and the tears. The normal
fluid is clear, like water. The specific gravity is 1*006 to
1*008. The cryoscopic point of the fluid is from -0*51° to
-0*66° 0.—that is to say, the temperature of congelation is
very near that of blood (-0* 56°C.). It is, practically speaking,
devoid of all corpuscular elements and it contains only traces
of protein matter, becoming only very slightly turbid on
heating. It is alkaline in reaction, the alkalinity being only
one-half that of the blood (Oavazzani). Calculated in per¬
centages of sodium hydrate it varies slightly in different
animals, and in man in different pathological conditions,
bm it will be observed from the subjoined figures that the
variation is within very narrow limits. On an average it
corresponds to 0* 1 per cent, sodium hydrate.

Alkalinity of Cerebrospinal Fluid .

Per cent.

Male. Dementia (general paralysis ?)... 01076 calculated as NaOH.

„ „ (general paralysis?)...

0*1066

99

General paralysis.

0*1104

99

91 99 9t ••• ••• ••• •••

0*1168

99

99 19 ft ••• ••• •••

0*1249

99

ft 99 9V .. ••• •••

0*1132

99

„ Delusional insanity .

0*1120

99

(Fluids obtained by lumbar puncture during life, all about noon.)

There is no correspondence between the alkalinity and the
rate of flow of the cerebro-spinal fluid ; but inasmuch as an
acid substance is probably formed as a result of activity of
the nervous centres it is possible that after normal sleep the
alkalinity may be slightly greater than at the end of a day’s
work. Although nature generally provides some automatic
mechanism whereby any excess of products of metabolism
are either removed or neutralised by corresponding activity
of secretory processes, in this case an increased cerebro¬
spinal fluid may be expected to flow if my premisses regard¬
ing its mode of origin and functions are correct.

Various analyses show that the principal constituent is
sodium chloride, but it also contains traces of carbonates,
bicarbonates, phosphates, urea, and dextrose. It is probable
that the phosphates, bicarbonates, and carbonates contain

4

Mott: The Cerehro-Spinal Fluid

relatively more potassium than the salts of the blood, for
Geohegan has shown that the ash of the brain in contra¬
distinction to the ashes of all other tissues contained from 20
to 30 per cent, of potassium against 15 per cent, sodium salts.

I have already mentioned that Claude Bernard proved the
existence of sugar in the fluid, but examination of fluid
obtained from meningoceles led Halliburton to the conclu¬
sion that the reducing substance was not sugar but pyro-
catechin. He has, however, abandoned that idea and, in my
judgment, it would be well if it were no longer mentioned in
text-books, as a very able teacher of physiology expressed
surprise when I said that glucose was always present in the
cerebro-spinal fluid withdrawn during life; this teacher still
thought the reducing substance was pyrocatechin. Since I
hope to demonstrate the fact that glucose in the cerebro¬
spinal fluid is very possibly of great importance in the func¬
tions of the central nervous system, I wish to emphasise the
fact that Professor Halliburton himself has adopted the view
that glucose is the reducing substance and is always present
in the cerebro-spinal fluid in normal conditions.

Cavazzani describes the presence of glucose in all cerebro-spinal
fluids; he asserts that in human cerebro-spinal fluid a dlastatic ferment
is present but in smaller quantity than in the lymph. I may mention
that we have incubated six specimens of sterile cerebro-spinal fluid for
two days without the reducing action being materially affected. Sterile
cerebro-spinal fluid has been kept for weeks at the room temperature
without the reducing action disappearing. Cavazzani drew off 205 c.c.
of cerebro-spinal fluid from a hydrocephalic child; this had a specific
gravity of 1 008, and contained 0*98 urea and 0'188 glucose-reducing sub¬
stance. In another case the specific gravity was 1 006; it contained
0*44 urea and O'185 reducing substance, with 4 479 chloride of sodium
per 1000. Cavazzani was able to confirm in these cases his previous
results that the alkalinity of the fluid is greater in the morning than in
the evening.

Results of examination of the cerebro-spinal fluid in reference
to the quantity of sugar in various conditions. —Mr. Sydney
Mann has made for me quantitative analyses of the sugar
(by the Fehling gravimetric method) in the cerebro-spinal
fluid withdrawn by lumbar puncture during life. The amount
of glucose varies from 1*2 to 2*5 per 1000; it will be
observed that in dementia praecox the quantity is invariably
lower than in any other condition.

Reducing Substance in Cerebro-spinal iluid .

Per cent.

Male. Old hemiplegia syphilitica. 0 212 calculated in terms

of glucose.

,, General paralysis .

... 0-186

,, Neurasthenia .

... 0171

Female. Dementia pra‘Cox .

... 0'147

,, ,, ,, .

... 0*146

tt ,, M

... 0-133

t ,, tf .

... 0-127

,, ,, ,, .

... 0-126

fluids obtained by lumbar puncture during life.)

Mott: The Cerebro-Spinal Fluid

5

That this substance which redaces copper salts is glucose
is proved by the facts that it gives with phenylhydrazin the
crystals of osazone which melt at from 205° to 206° ; it is
dextro-rotatory, and by the yeast fermentation test it yields
carbon dioxide. We shall consider later its origin in the
fluid and its functions.

The gate* of the oerebro-spinal fluid. —As far as I have been
able to ascertain there is no account of observations on the
gases of the cerebro-spinal fluid. I have been long impressed
with the importance of investigating this subject. Dr. John
Haldane advised me to use Krogh’s micro-tonometer for this
purpose; the principle underlying the apparatus, simply
stated, is the relative increase or decrease in size of a bubble
of air after it has been freely exposed to the fluid, the gas
tensions of which in relation to the component gases of the
air we desire to ascertain. We found that the bubble after
exposure to fluid which had been drawn off during life in
such a way that it did not come into contact with the air,
did not diminish in size ; it showed rather a tendency to
increase at atmospheric pressure, demonstrating that gas
had escaped from the fluid to the bubble of air, and this
gas was found to be carbon dioxide.

Before continuing these tension experiments it was deemed
advisable to analyse the gases present in the cerebro-spinal
fluid, and, with the assistance of Mr. Mann, I have been able
to do this by employing a very convenient form of mercury
pump invented by Professor T. G. Brodie and Dr. Winifred
Oullis for determining the percentages of gases in salt
solutions. The preliminary results that we have obtained
are shown in the accompanying table:—

Analytic of Gases of Cerebro-spinal fluid: Preliminary
Results .

1. Gases obtained by boiling in vacuo .

CO,. O,. N,.

Per cent. Per cent. Per cent.

1. Dementia pnecox

. 8*488 ...

0*366 ... 2*25 by volume.

2. General paralysis...

. 11-067 ...

0-237 ... 1*42

3.

11-89 ...

0157 ... 102

4. „ „ ...

918 ...

0316 ... 1-97

5.

1119 ...

0079 ... 0-99

2. Carbon dioxide obtained by boiling in vacuo with dilute acid.

Per cent.

1. Dementia pnecox...

.

. 53*21 by volume.

2. Dementia, general paralysis?...

. 54-90

3. General paralysis...

.

. 56-38

4.

.

. 6113

5. „ ••

.

. 56-19

6. „ •» •»•

. 54-41

7. ,, n •••

.

. 54-8

8. „ •• •••

... ... ...

. 64-41

9. Dementia, general paralysis ?...

. 54-73

10.

„

. 58-36

6

Mott: The Cerebro-Sjrinal Fluid

It will be observed that varying small amounts of oxygen
and nitrogen are obtained, but the amount of carbon dioxide
which can be obtained by boiling the fluid in vacuo , on an
average, is 10 per cent, by volume ; this 10 per cent., I may
remark, is obtained by five or six successive operations of
boiling in vacuo , so that it may be presumed this 10 per cent,
by volume of carbon dioxide is in loose dissociable combina¬
tion. If, however, we take 1 c c. of the fluid and treat with
a weak acid in the same way, we then obtain about 50 per
cent, by volume of carbon dioxide. Comparing these results
with the gases obtainable from lymph or serum we find
that

Cerebro-spinal Lymph and

fluid yield. serum yield.

Per cent. Per cent.

By vacuum and heating . 10 . 46 by volume.

By acid and heating in vacuo ... 50 . 50 ,,

Difference representing CO? in
stable combination . 40 . 4 „

It would therefore appear that the carbon dioxide is in a
more stable combination in the cerebro-spinal fluid than in
the blood. The oxygen and nitrogen in the fluid in all
probability did not come from the atmosphere, for the fluid
was drawn off into tubes filled with mercury.

As I observed previously, the investigation of the gas
tensions of the cerebro-spinal fluid has been deferred, await¬
ing the results of the experiments just quoted, and at present
I am unable to give any figures.

The object of these researches is to see if the cerebro-spinal
fluid can, by virtue of its chemical composition and gas
tensions, function as the lymph of the brain. It must,
however, always be borne in mind that the fluid which we
withdraw by lumbar puncture may be the fluid coming from
the perivascular lymphatics of the brain diluted by the
secretion of the choroid plexus. This fluid does not, however,
correspond to ordinary tissue lymph, even if it were diluted,
for the following reasons.

The composition of the fluid is against it being a tran¬
sudation from the blood or a lymphatic secretion, and the
following facts prove this conclusion : (1) It contains 0 02
per cent, of proteins against 7 per cent, in blood plasma ;
(2) it contains 0*02 per cent, of proteins against 4*5 per
cent, in body lymph ; (3) there is an absence of lipochrome;
(4) there are no leucocytes in the normal fluid ; (5) in
enteric fever there is absence of agglutinins; (6) it has no
haemolytic action on the blood corpuscles of other animals ;
(7) it contains no alexins.

Moreover, Cavazzani studied the effect of injection of
lymphagogues of Heidenhain—e.g., peptone, extract of eel’s
blood, glucose, chloride and iodide of sodium—and although
in some instances the rate of flow was increased, the amount

Mott: The Cerebro-Sjrinal Fluid

7

of ash was not increased. Capelletti has shown that in dogs
ether and pilocarpine increase the rate of outflow, atropine
and hyoscyamin diminish it, and amyl nitrite produces no
effect.

In general with a few exceptions experimental observa¬
tions on men and animals have shown that drugs administered
by the month or subcutaneously do not pass into the cerebro¬
spinal flnid ; this rale also applies for bacterial toxins;
neither Blumenthal nor Jacob could find tetanus toxin in the
cerebro-spinal fluid when injected subcutaneously into goats.
Ransom confirmed this in dogs and rabbits, and only in two
of many cases recorded have the results of examination
shown the tetanus poison in the cerebro-spinal fluid. In has
long been known that in the great majority of cases of
jaundice the brain is not stained with bile, nor is the
cerebro-spinal fluid coloured by the bile. I only remember
seeing it on one or two occasions in a large post-mortem
experience. Later on I shall consider the effects of injection
of toxic and other substances into the subarachnoid space.
The facts I have mentioned all speak against the fluid being
either a transudation or lymph secretion, although it is
generally admitted that the perivascular lymphatics open
into the subarachnoid space. Where does it come from ?

Source of the Cerebro-spinal Fluid.

Willis in 1664 called attention to the glandular nature of
certain reddish granulations (the choroid plexus). The
cerebro-spinal fluid is found in all vertebrates, and Pettit
and Girard in 1902 published a monograph on the secretory
function and morphology of the choroid plexus of the central
nervous system, which embraced the systematic study of the
plexuses in different animals belonging to different classes of
vertebrates. They state that Faivre in 1854 affirmed the
intimate relation of the choroid plexus with the cerebro T
spinal fluid. The works of Luschka, and the more recent
work of Kingsburgh, Findlay, Galeotti, Studnicka, together
with the physiological researches of Cavazzaniand Capelletti,
have progressively tended to support this view of the source
of the cerebro-spinal fluid.

Pettit and Girard have been able to establish a generalised
secretory function of the choroid plexus in the different
classes of vertebrates; moreover, by the administration of
substances endowed with a hyper-secreting action they were
able to cause variations in the activity of these structures
and corresponding histological changes in the cells covering
the plexus.

I have examined the choroid plexus in the human subject ob¬
tained in some instances soon enough after death to stain well
with the vital methylene blue method. I throw on the screen
lantern slides illustrating the structure of the human choroid

8

Mott: The Cerebro-Spinal Fluid

obtained from the lateral ventricles. The first is a drawing
by Dr. Edgar Schuster of a small piece of the choroid stained
by vital methylene blue fixed with molybdate and mounted
in Canada balsam ; the specimen is not a section but a piece
of about the size of the point of a large pin ; it is one of the
granulations just visible to the naked eye, and this again we
see is made up of numbers of microscopic granulations
clothed with spheroidal epithelial cells (Fig. 1). The appear¬
ance is just such as we would expect if the cells secreted the
cerebro-spinal fluid.

In sections under a higher power we are able to make out
more definitely the structure of the plexus. Tufts of vessels
are seen surrounded by a loose connective tissue covered by
a single layer of cubical, spheroidal, or polyhedral cells

Fig. 1.

Small choroidal granulation obtained from a sheep's brain
immediately after death stained by the vital methylene-
blue method of Dogiel. The vacuolated appearance of the
cells on their surface Is well shown. Magnification 80.

lying on a basement membrane (Figs. 2 and 3). Around the
arteries and arterioles and lying in the loose connective
tissue numerous nerve fibres are seen in the form of a plexus,
but I have not been able to follow the terminal fibrils
between the cells. This plexus of nerve fibrils from the
choroid plexus of the sheep is well shown in this drawing by
Dr. Schuster (Fig. 4).

I will now project on the screen a photomicrograph of
the human choroid plexus under a magnification of 650
diameters. In one there are many more vacuoles in the
cells than in the other. In one cell of this specimen you see
a clear vacuole quite near the surface ; in the border of the
adjoining cell you observe a cup-like cavity, just such as
one would expect if fluid had escaped from one of the
vacuoles (Fig. 2). Comparison with the lacrymal gland shows

Mott: The Cerebro-Spinal Fluid

9

Fig. 2.

Photomicrograph of a section of the choroid plexus of the
human subject stained by Giemsa fluid. The cells are all
vacuolated: at (a) the section has divided a cell, showing
a vacuole, quite superficial; above this there is a cup as if
a vacuole in an adjoining cell had discharged the fluid
content. Magnification 650.

Fig. 3.

The same section as Fig. 2; the polyhedral cells, supported
by a delicate connective stroma, are seen to cover vascular
finger-like tufts. Magnification 200.

10

Mott: The Cerebro-Spinal Fluid

that the epithelial cells of the choroid plexus present a very
similar appearance. The histological evidence is all in favour
of the choroid plexus being a gland with an external secre¬
tion, but with an internal destination ; it would thus consti¬
tute a mixed type of gland intermediate between a gland
with a duct and a ductless gland. The mode of formation
of this gland is effected in an inverse manner, epithelial
invagination for the gland with an excretory duct, ependymal
invagination for the choroid plexus. In the former case
the vascularisation is peripheral, in the latter it is central.

If we can accept these observations as conclusive proof that
the choroid plexus is the source of the cerebro-spinal fluid
and that it is continually secreting this fluid, then we can
understand its unique chemical composition and its freedom

Fig. 4.

A section from the same preparation as Fig. 1 showing a
plexus of nerves around an artery; some fibres may be seen
entering into the connective tissue stroma of the gland.
Magnification 50.

under normal conditions from all corpuscular elements.
There is abundant evidence that this fluid is continually
being secreted, for Matthieu has collected a number of cases
in which large quantities of cerebro-spinal fluid have drained
away daily in consequence of injuries of the subarachnoid
space by which a communication was established with the
exterior. Surgeons have often recorded observations on
patients who, after fractures of the base of the skull or
extirpation of sub-basilar polypi, have lost large quantities
of fluid amounting in the 24 hours, in some cases, to between
one and two litres (Billroth, Verneuil, Routier, Tillaux).
Halliburton, Hill, and StClair Thomson have also recorded
observations of a case of dripping of large quantities of
cerebro-spinal fluid from the nose.

An argument in favour of the cerebro-spinal fluid being in

Mott: The Cerehro-Spinal Fluid

11

the main secreted by the choroid plexus in the lateral
ventricles is afforded by the effects of increased intracranial
pressure arising from interference with the escape of the
fluid from its principal source in the lateral ventricles. I do
not intend to discuss fully the subject of hydrocephalus, 1
but certain interesting cases which have occurred in my
practice or have come under my notice at necropsies are
instructive. They are cases of internal hydrocephalus
caused by non-malignant slow-growing tumours of the third
ventricle, and one case of chronic basic meningitis caused
by caries of the petrous bone. All four cases had well-
marked signs of increased intracranial pressure, vomiting,
headache, optic neuritis, tremors, fits, and drowsy stupor,
with progressive mental enfeeblement, so that the diagnosis
of general paresis was made in all cases except one, which
was under my care in Charing Cross Hospital.

The patient was a married man aged 32 years; the first
symptom noticed was that while out walking he was attacked
with drowsiness and headache followed by a fit; after
this he was subject to frequent attacks of a similar
nature from which he recovered. Eventually he died,
and at the necropsy a small tumour was discovered
loosely attached to the choroid, which from time to time
could easily have taken up such a position as to block the
iter, and thus lead to distension of the third and lateral
ventricles of the brain. Seeing that the symptoms came on
with drowsiness and headache—this condition ushering in a
fit—we may conclude that at this time the tumour had
attained such a size that if by chance it fell into such a
position as to block up the iter of the third ventricle the
fluid secreted by the choroid plexus accumulated in the
lateral ventricles, which would, of course, necessitate the
prone position and possible dislodgement of the tumour,
thereby the escape of the fluid into the subarachnoid space,
and sooner or later the return of the patient to his normal
state of consciousness, at least this was so in the earlier
stages of the illness.

Here we have a condition of cortical anaemia produced
followed by the effects like those of an experiment—namely,
drowsiness, loss of consciousness, followed by epileptiform
convulsions, and towards the end a persistent dulness of
comprehension, failing memory, and slowness of ideation,
the result of changes in the cortical cells. Doubtless the
drowsy stupor and lethargy which come and go in syphilitic
basic meningitis are largely due to internal hydrocephalus,
produced by the obstruction to the outflow of cerebro-spinal
fluid secreted in the lateral ventricles by the choroid plexus.
As soon as the pressure rises to a certain degree the obstruc-

1 The subject is very fully treated by Sir T. Barlow and Dr. Lees in
their article, Simple Meningitis in Children, System of Medicine,
Allbutt, vol. vli.

12

Mott: The Cerebro-Spinal Fluid

tion is overcome, and an escape takes plaoe into the sub¬
arachnoid space, whence it can flow from the cranial cavity
in the manner previously indicated.

These symptoms of internal hydrooephalus, moreover,
support the view that the cerebro-spinal fluid is, for the most
part, secreted by the choroid plexus contained in the lateral
ventricles.

In support of the statement that the choroid plexus
secretes the cerebro-spinal fluid, I may mention that at the
last meeting of the Physiological Society Halliburton and
Dixon stated that an intravenous injection of the saline
extract of the choroid plexus produces in dogs a marked
increase in the rate of flow of the fluid from the cannula
placed in the subcerebellar cisteraa. Extract of the brain
produces the same result but not so marked.

Destination op the Fluid.

The fluid secreted in the ventricles escapes from the fourth
ventricle into the subarachnoid space by the foramen of
Majendie and the foramina of Luschka.

The foramen of Majendie.— When the cerebellum is raised posteriorly
bo as to expose the tela choroidea one sees at the level of the point of
the calamus scriptoriua a round or oval opening with irregular borders
as if torn. This orifice connecting the fourth ventricle with the sub¬
arachnoid space was first pointed out by Majendie, and has since been
called after its discoverer. It is situated in the mid line and measures
7-8 mm. in length by 5-6 mm. in breadth.

Foramina of Luschka .—These are a pair of lateral orifices connecting
the fourth ventricle with the subarachnoid space. They occupy the
external extremity of the lateral recess which the cavity of the fourth
ventricle forms and from which emerge the origin of the mixed nerves.
Through the foramina of Luschka the choroid plexus of the fourth
ventricle passes.

The existence of the foramen of Majendie has been doubted by
Cruveilhler, Reichert, and Kdlliker who regarded it as an artifact. The
foramina of Luschka have been described by Marc See and Hess. The
last-named anatomist met with them 51 times out of 54 subjects
examined; they are, therefore, nearly constant.

The fluid having escaped into the subarachnoid space Alls
up all the spaces, cracks, and crevices; at the base of the
brain, therefore, it is more abundant than on the convexity;
it forms what are termed lakes, rivers, and rivulets (cistema
and flumina). The quantity of fluid contained in the sub¬
arachnoid space, ventricles of the brain, and central canal
of the spinal cord is about 100 c.c. to 130 c.c., and there is
every reason to believe that this fluid is continually being
secreted, for experiments on animals and observations on
man show that a large quantity of cerebro-spinal fluid can
be drawn off by lumbar puncture and soon be replaced. But
the fluid cannot be continually secreted and not flow away.
According to one view, it escapes along the lymphatics of all

Mott: The Cerebro-Spinal Fluid

IB

the cranial and spinal nerves, thus reaching the receptaculum
chyli and thoracic duct, passing through the paravertebral
lymphatic glands in its passage, and eventually, therefore,
arriving in the venous circulation.

Fla tan’s experiments by injection in the rabbit (r id the
olfactory nerve in particular) demonstrate that the fluid
follows the course of the perineural sheath; then passes
directly into the lymphatic networks of the nasal mucosa;
thence it arrives at the glands of the neck and the naso¬
pharyngeal cavity; but, according to Flatau, the injection
never runs to the surface of the mucosa, as Retzius asserted.
Some of the cerebro-spinal fluid probably does escape along
these perineural lymphatics, and it is probable that these
are the avenues of infection in the production of tuberculous,
syphilitic, epidemic, and pneumococcic meningitis.

However, the observations of Leonard Hill and Cushing
favour the view that the fluid contained in the cerebral sub¬
arachnoid space and perivascular canalicular systems finds
its exit from the cranium by means of the veins opening into
the longitudinal sinus. Hill found that

Saline Injected at any pressure above the cerebral venous pres¬
sure disappears from the cranio-vertebral cavity; the higher the
pressure, the more rapid its disappearance. As a result of injecting
saline coloured with methylene blue, fluid can be traced passing'
straight into the venous sinuses. In so short a time as 10 to 20 minutes,
the blue colour may bo found secreted in the stomach and in the
bladder. On the other hand, the lymphatics in the neck In so short a
time are not coloured. After an hour’s steady Injection the deep
cervical and lymphatic glands are seen to be only partly tinged with the
blue colour.

Cushing, after producing intracranial pressure by injection
of normal saline solution, states that the fluid does not escape
readily from the subarachnoid cavity; even under pressure
not more than from 60 c.c. to 100 c.c. escape in half an hour
perhaps. He agrees with Adamkiewicz that there exists a
free communication between the subarachnoid space and the
longitudinal sinus. He questions the correctness of Key and
Retzius’s hypothesis that the Pacchionian glands act as a
filter, for, as he remarks, they do not exist in very young
children or in some of the lower animals. The nature of
these openings of the subarachnoid space is not known, but
probably they run obliquely forwards, like the veins, into the
sinus, and have, like them, a valvular action, so that the
fluid can flow into the sinus, but blood cannot flow back.
Mercury injected into the subarachnoid cavity found its way
into the sinuses, jugular veins, and right heart. A non¬
absorbable gas introduced into the subarachnoid space pro¬
duced death by cardiac air-embolism, and, if the jugulars
were exposed, bubbles of it could be seen pouring down
towards the heart. Exposure of the cervical lymphatics and
of the thoracic duct, on the other hand, showed in all
instances a complete freedom from gas.

14

Mott: The Cerebro-Spinal Fluid

Reiner and Schnitzler injected a saline solution of potassium
ferrocyanide into the cranium. This salt very rapidly
appeared in the jugular vein. The venous flow was quickened
by the injection. On the other hand, injection of olive oil
caused compression of the cerebral vessels, and slowed the
venous outflow. This rather supposes another way of escape,
and I venture to suggest the cerebro-spinal fluid may get
into the venous blood by the capillaries.

Before giving my reasons for this hypothesis it will be
necessary to give a description of the lymphatic sheaths of the
vessels of the brain. Testut thus describes the perivascular
lymphatics. Robin in 1858 proved the existence of a
membrane surrounding the vessels of the central nervous
system in the form of a sleeve, leaving an interval between
it and the vessels; it is a membranous tube in which the
hlood-vessel is, as it were, suspended. This is the lymphatic
.sheath.

The wall of this sheath is very delicate and is con¬
tinuous with the tunica adventitia. It is constituted,
at least for the larger vessels, of ^extremely fine and
delicate bundles of connective tissue which are the
branches of flattened plate-like cells of a fusiform or
polyhedral shape. The external surface of the sheath is
formed by the nervous substance. Its internal surface
is towards the vessel from which it is separated by a
space which surrounds immediately the vessel. This space
which separates the vessel from the pial sheath is traversed
by very fine trabeculae which extend from its external to its
internal wall. It is filled by a clear and transparent fluid
which from the point of view of its morphological signifi¬
cance should be considered as lymph. It contains in variable
amount lymph corpuscles, fatty granules, and sometimes
even drops of oil. The lymphatic sheaths are observed in
the venules and the arterioles, but they are always better
developed on the latter than on the former. At the place
where the arteriole divides into capillaries, the lymph space
terminates in a cul-de-sac; it is not only that the sheath
ceases to exist but at this situation it is applied against the
wall of the capillary, leaving no recognisable space between
them.

The lymphatic sheaths open into the subarachnoid space,
which thus become their common rendezvous ; vice versa it
may be asserted that the lymphatic sheaths of the vessels of
the central nervous system are intracerebral and intraspinal
prolongations of the subaraohnoid space. Eberth has pointed
out the existence of a continuous endothelial covering on one
or other of the walls. This endothelial covering also occurs
on the trabeculae which traverse the lymphatic space. His
by successful injection experiments has proved the existence
of two sheaths, the adventitial sheath of Robin, and another
periadventitial which surrounds it like a sleeve. His affirms
that the two sheaths are entirely independent of one another;

Mott: The Cerebro-Spinal Fluid

15

that is to say, there is no intercommunication. On the
central side the periadventitial sheaths are connected with
the pericellular spaces. On the peripheral side they end in a
series of lacunae which occur between the external surface
of the central nervous system and the pia mater which
covers them; according to the region these are termed
epispinal, epicerebral, and epicerebellar spaces of His.
Testut remarks that the periadventitial sheaths are con¬
sidered by some anatomists to be artifacts and have not the
same significance as the pericellular spaces. They are
simply interstices nearly virtual in ordinary conditions, but,
in consequence of injection or of pathological conditions,
capable of enlarging and acquiring a real capacity. As in
the adventitial sheaths, the lymph circulates from within
out and very probably passes by simple filtration into the
subarachnoid space by at present little understood com¬
munications.

A study of the histological conditions met with in the
perivascular sheaths in chronic meningo-encephalitis of
syphilis, general paralysis, and sleeping sickness throws some
light upon the structure of the perivascular lymphatics ; in
the normal state the structures are too delicate to permit of
clear observation, but when owing to chronic irritation the
morphological elements actively proliferate, it may then be
seen that the appearances coincide with those of chronic
inflammation of lymphatic structures elsewhere in the body.
Sleeping sickness offers the best material for the study of
the perivascular sheath ; iu this disease the connective tissue
cells of the pial sheath proliferate and form a dense network,
in the meshes of which are abundant lymphocytes and
plasma cells. I came to the conclusion that the plasma cells
and the lymphocytes were the result of the proliferation of
the endothelial cells. This chronic perivascular lymphatic
cell proliferation is the same as, and continuous with, the
cell proliferation of the lepto-meninges. It is associated
with a proliferation of the special connective tissue elements
of the nervous system—the neuroglia (Fig. 5). The normal
cerebro-spinal fluid contains no cell elements, but in all affec¬
tions causing a chronic meningo-encephalitis the fluid contains
lymphocytes, generally speaking, in proportion to the severity
and widespread extension of the meningo-encephalitis,
whether it be due to syphilis, parasyphilis, sleeping sick¬
ness, or tuberculosis.

I have studied the histology of the perivascular lymphatics
in the brains of animals in which Dr. Leonard Hill had pro¬
duced experimental anaemia by ligature of three or more of
the cerebral arteries—e.g., two carotids and one vertebral in
monkeys, the animals dying or being killed at various
periods of time after the operation. The vessels, especially
the arteries, arterioles, and capillaries, are in consequence of
the ligation of the trunk arteries empty and collapsed, yet
the brains on exposure were not shrunken ; they were quite

16

Mott: The ('erebro-Spinal Fluid

pale and watery, and microscopic examination indicated that
the reason that the brains had not shrunken was the fact
that the cerebro-spinal fluid had filled up the spaces which
would otherwise have existed from the blood-supply having
been cut off. Small portions of the brains were generally
hardened in alcohol, but specimens were prepared from one
monkey’s brain in which experiment two carotids and one
vertebral were ligatured, the animal dying 23 hours after.
The brain of this monkey was removed and placed in Mann’s
picric and perchloride of mercury solution (Figs. 6 and 7).

Most of the experimental anaemic brains of the monkeys

Fig. 5.

Inflamed lymphatic sheath of a small spinal artery in a case
of punctate syphilitic myelitis. The proliferation of the
branched connective tissue cells of the pial sheath is well
seen. Drawing by Dr. Edgar Schuster. Magnification 650.

that died as a result of the ligature of the vessels showed a
perivascular canalicular system continuous on the one hand
with the perineuronal spaces, and, on the other hand, with
the subarachnoid space. The perivascular spaces are clear
and transparent, therefore they cannot contain ordinary
lymph because an amorphous deposit of coagulated albumin
would have been precipitated by the perchloride and picric
fluid. It cannot, however, be an empty space, and seeing
that it is continuous with the subarachnoid space it is
reasonable to presume that it is filled with cerebro-spinal
fluid. It is not an artifact due to the hardening, other¬
wise the delicate strands of connective tissue which you

Fig. 6.

Photomicrograph of the brain of a monkey—experimental
anremia—showing two vessels with the dilated perivascular
lymph sheaths continuous with the subarachnoid space;
both are distended with a clear fluid ; fine trabecula can be
seen stretching across from the wall of the vessel to the
nervous substance, therefore tho dilatation is not due to an
artefact. Magnification 2C0.

Fig. 7

Photomicrograph of the subcortical white matter of the same
specimen as Fig. 5, showing the dilated perivascular lymph
spaces distended with a clear fluid; the contained blood¬
vessels are collapsed and empty. Magnification 200.

18

Motfc: The Cerebrospinal Fluid

see stretching across the space would not be present.
In another section of the same brain this canalicular
system is shown surrounding the smaller vessels and con¬
nected with the perineuronal spaces, and here again it may be
observed that there is no evidence of any protein-containing
lymph (Fig. 8). Occasionally the perineuronal spaces can
be seen in direct communication with the space around a
capillary (Fig. 9). These perineuronal and perivascular
lymphatic spaces and their interconnexions can only be seen in
abnormal conditions. In experimental anaemia a space can

Fig. 8.

Photomicrograph of the cortex cerebri of a monkey. Experi¬
mental ana'inia. The dilated perivascular spaces are seen to
be connected with the dilated perineuronic spaces ; this is
rendered clear by the empty condition of the small blood¬
vessels. Magnification 250.

be seen around the capillaries, and stretching across from
the wall to the surrounding nervous tissue are delicate con¬
nective tissue threads, as this photomicrograph shows. It
would thus seem probable that a canalicular system sur¬
rounding the cells and vessels of the brain exists which is
in direct communication with the subarachnoid space. This
canalicular system contains a fluid of non-protein nature
(probably, therefore, the cerebro-spinal fluid), which may
serve as the ambient fluid of the neurons and play the part
of lymph to the central nervous system.

I will here quote a passage from the article on Meningitis

Mott: The Cerebro-Spinal Fluid

19

by Sir T. Barlow and Dr. Lees. “We may here add that
cerebro-spinal fluid as obtained from any point below the
fourth ventricle cannot be an absolutely pure secretion ; it
must contain waste products resulting from cerebral meta¬
bolism, for into the subarachnoid space surrounding the
brain open the lymphatic sheaths of all the cerebral arteries,
and Dr. Bevan Lewis has shown that the nerve cells of the
brain are placed within pericellular sacs, each of which has
a definite lymphatic connexion with the wall of a small
blood-vessel.”

Fig. 9.

Drawing of a small portion of Fig. 1. The large pyramidal
cells are seen with their perineuronic spaces lillcd with a
non-coagulated fluid. The apical process of one cell is seen
in a canalicula which is directly connected with a space
around a capillary. Magnification 500.

Mechanical Effects of the Cerebro spinal Fluid.

The blood-vessels of the cerebro-spinal axis have com¬
paratively thin walls, and the arteries relatively few
muscular fibres and vaso-motor nerves. The uniform
pressure of the fluid sleeve which surrounds the blood¬
vessels serves to support their column of blood. The whole
central nervous system being contained in a closed space,
the cerebro-spinal fluid fills up all the space which is not
occupied by tissues or blood, serving thereby to equalise the
pressure throughout the whole cranio-spinal cavity ; more¬
over, it acts as a water cushion, especially at the base of the
brain, protecting the vital structures of the medulla from
the shock of commotion and concussion. It serves also as a

20

Mott: The Cerebro-Spinal Fluid

self-adjusting mechanism by maintaining a uniform equalisa¬
tion of the blood-supply to the nerve elements during the
rhythmical variations of respiration and circulation. The
question arises, does it play the part of the lymph ?

Function of the Cerebro-spinal Fluid.

If the cerebro-spinal fluid serves as the lymph of the
brain, it may be asked, How is it that generally, with few
exceptions, experimental observations on men and animals
have shown that drugs and bacterial toxins administered by
the mouth and subcutaneously do not pass into the cerebro*
spinal fluid ? Experiments, however, have shown that very
much smaller quantities cf these same drugs and bacterial
toxins injected into the cerebro-spinal fluid of the sub¬
arachnoid space produced much more marked and a much
more rapid onset of symptoms.

Thus Lewandowsky observed that a few centigrammes of
sodium ferrocyanide injected into the subarachnoid space
rapidly produced toxic symptoms, whereas from 4 to
6 grammes injected into the jugular vein in rabbits of the
same weight produced no specific symptoms. This was not
due to the salt solution employed, for a 10 per cent, saline
solution injected into the subarachnoid space produced only
slight effects.

Behring found that hens injected subcutaneously or intra¬
venously with tetanus toxin suffered no effects, whereas
when it was injected into the cerebro-spinal fluid they died
from typical tetanus.

Jacob after introduction of methylene blue and iodine into
the cerebro-spinal fluid was able to demonstrate their
presence in the brain several days later, although these
substances were now no longer present in the cerebro-spinal
fluid. These researches indicate that substances in the
cerebro-spinal fluid can directly act upon the ganglion cells
of the brain and spinal cord. Lewandowsky affirms that
this takes place by way of the lymph channels.

According to the anatomical proofs of Schwalbe, Key, and
Retzius and the physiological observations and experiments
of Quincke and Jacob, the perivascular lymphatics open freely
into the subarachnoid space. They injected methylene blue
and cinnabar, also ferrocyanide of sodium, converting the
latter into Prussian blue, and showed in a most convincing
manner under the microscope the existence of the substances
injected in the perivascular spaces. Lewandowsky, after
injection of methylene blue, also observed imbibition
phenomena which were likewise observed by Bruno.

This experimental evidence tends to support my contention
that the cerebro-spinal fluid comes into relation with the
nerve-cell elements and therefore may be the ambient fluid.
But if substances are unable to pass from the capillaries into

Mott: The Cerebro-Spinal Fluid

21

the lymph spaces, experiments show that substances are
able to find their way rapidly into the blood when
injected into the subarachnoid space. This may be by the
channels already alluded to. But I have shown that the
perivascular lymphatics open into the subarachnoid space,
and if these perivascular lymphatics contained ordinary
tissue lymph the cerebro-spinal fluid would contain a very
much larger amount of protein and lymph cells than it does;
there must be some medium of exchange between the blood
in the capillaries and the neurons, and, therefore, why not
the cerebro-spinal fluid ?

Suppose, then, it be granted that the cerebro-spinal fluid
may function as the lymph of the brain, and is the ambient
fluid in which exchanges take place between the blood in
the capillaries and the neurons, can we explain why sub¬
stances do not pass out of the capillaries into the fluid ?
Most authorities are agreed that there is no lymphatic
sheath on the capillaries, so that we have only, so far as we
know, the wall of the capillary intervening between the
blood and a fluid which is similar to blood plasma in its
crystalloid diffusible substances although not identical, for
its alkalinity is only half that of the blood and the sugar it
contains is less.

The force which determines a movement or exchange
between solutions in immediate contact separated by a more
or less permeable membrane is termed the osmotic pressure.
By this force substances dissolved are displaced to situa¬
tions where they are less concentrated. Water moves in an
opposite direction. This movement constitutes the pheno¬
mena of diffusion and the osmotic pressure is the motive force
which animates matter and produces diffusion of two liquids
unequally rich in dissolved molecules separated by a mem¬
brane ; the more concentrated liquid attracts a portion of
the water contained in the less concentrated liquid. The
osmotic pressure of a fluid is proportional to its dissolved
molecules—in other words, to its molecular concentration.
In human physiology the blood serum is generally taken as a
standard of osmotic pressure, and the terms isotonic, hyper¬
tonic, and hypotonic solutions are terms used in reference to
normal blood serum.

Is it a reasonable hypothesis that the osmotic pressure as
regards water and carbon dixoide is from the ambient
cerebro-spinal fluid to the blood, and that certain of the
salts and sugar pass from the blood to the fluid through the
wall of the capillary? As we have no precise knowledge
of the composition of the cerebro-spinal fluid as it leaves
the cells of the choroid plexus, we can only say it is
possible that this fluid is not exactly the same in compo¬
sition as that which is contained in the subarachnoid
space. By this I mean to infer that the fluid which is
secreted by the epithelial cells of the choroidal gland
in its passage from the subarachnoid space along the peri-

22

Mott: The Cerebro-Spinal Fluid

vascular lymphatics back to the subarachnoid space may
receive substances—e.g., an addition of sugar and possibly
some salts. Whether this fluid, as it is secreted by the
choroid plexus, is the same as that withdrawn from the sub¬
arachnoid space by lumbar puncture is the crucial point
which requires to be settled before the hypothesis I would
draw can be maintained. The hypothesis is that the fluid as
it circulates in the perivascular and pericellular channels
may give up water and carbon dioxide and take up oxygen
and sugar. Seeing that there is no proof to my mind that
the fluid contains a glycolytic ferment, it may, if this hypo¬
thesis is true, be assumed that the ganglion cells produce
the necessary glycolytic ferment by which the sugar can be
converted into neural energy. The observations and experi¬
ments are, however, all in a preliminary stage and much
work still is necessary before any safe conclusions can be
drawn. The results so far obtained, however, are sufficiently
encouraging to lead to a continuance of the work. In my
next lecture I propose to deal with the subject of the cerebro¬
spinal fluid from the pathological point of view.

Bibliography.— Abadie: Result its de l’Bxamen Cytologique de
quelques LIquides Cophalo-rachidiens, Comptes Kendus de la Societe
de Biologic, 1902, p. 946. Adamkie * icz s Quoted by Harvey Cushing.
Behring: Allgeineine Theraple der Infektlonskrankheiten, 1900.
Bernard: Quoted by Dircksen. Billroth: Quoted by Matthieu.
Blumenth&l: liber Cerebrospinalfliissigkeit, Ergebenisse der Physio-
logischen Biochemie, 1902. Brodie and Cullis: Qas Analysis in
Salt Solutions, Journal of Physiology, vol. xxxvl., p. 406.
Bruno: Deutsche Medicinlsche Wocheuschrift, 1899, No. 23.
Capelletti: Accademia Medico-Chlrurgica dl Ferrara, 1900. Castellan!:
Researches on the Etiology of Sleeping Sickness, Journal of
Tropical Medicine, June, 1903. Cavazzaui: Contributions h la
Physiologic du Liqulde Cerebro-spinale, Archives Italionnes de
Biologle, vol. xxxvii., p. 30; Sul Liquido Cerebro-spinale, La Riforma
Medica, anno viii., 1892, Centralblatt fiir Physiologie, 1900, pp. 437-76.
H. Cushing: Some Experimental and Clinical Observations Con¬
cerning States of Increased Intracranial Pressure, Mutter Lecture,
1901, American Journal of Medical Sciences, Philadelphia, 1902,
p. 375. Cutugnuo: Quoted by Dircksen. Dircksen: Etude but
la Composition Chimique et la Concentration Moleculaire du
Liquide Cephalo-rachldien, Thdse de Paris, 1901. Faivre: Quoted
by Pettit and Girard. Findlay: Quoted by Pettit and Girard.
Flatau. Galeotti: Quoted by Pettit and Girard. Goohegan: Zeit-
achrift fiir Physiologische Chemie, Band i., p. 330. Halliburton
and Dixon: Journal of Physiology, vol. xl.; Proceedings of the
Physiological Society, March 19th, 1910. Halliburton, Hill, and
StClair Thomson: Observations on the Cerebro-spinal Fluid in the
Human Subject, Proceedings of the Royal Society, vol. lxlv., p. 343.
Hill, Leonard: On Cerebral Amemia and the Effects which follow
ligation of Arteries, Philosophical Transactions of the Royal Society,
1900; The Physiology and Pathology of the Cerebral Circulation, London,
Messrs. Churchill, 1896. Jacob: Berliner Klinische Wochenschrift,
1898, No. 21; Deutsche Medicinische Wochenschrift, 1900, Nos. 3 and 4*
Key and Retzius: Studienln der Anatomie des Nervensystems und des
Bindegewebes, Stockholm, 1875. Kiugsburgh; Quoted by Pettit and
Girard. Kblliker: Quoted by Testut. Krogh: Some New Methods for

Mott: The Cerebro-Spinal Fluid

28

the Tonometrlc Determination of Qas Tensions in Fluids, Skandlna-
visehes Archiv fiir Physiologic, Band xx., 1908. Lewandowsky:
Zeltechrlft fiir Kllnlsche Medlcln, vol. xl., p. 480. Luschka: Quoted by
Pettit and Qirard. Majendle: Recherches sur le Liquids Cephalo-
raohldien, 1825. Matthieu: Les Fonctlons Rachldiennes Accldentelles,
Monographles Cliniques, 1902, No. 29. Mott and Barrett: Three
Oases of Tumour of the Third Ventricle, Archives of Neurology, Band l.
Pettit et Qirard : Sur la Morphologic des Plexus Choroides du Systems
Nerveux Central, Comptes Rend us de la Soctete de Biologic, July,
1902. Plaut: Die Wassermann'sche Serodiagnoatlk der Syphilis, Jena.
Quincke: Kongress fiir Innere Medicin, Wiesbaden, 1891; Berliner
Klinische Wochenschrift, 1891, 1895, No. 41; Ober Lumbalpunktion,
Deutsche Klinik, Bfg. liv., lvi. Ransom : Zeitschrift fiir Physiologische
Chemie, 1900, vol. xxxl. Reichert: Quoted from Hill, loc. cit. Reiner
and Schnltzler: Quoted from Hill, loc. cit. Routier: Quoted by
Matthieu. Schwalbe: Quoted by Testut. Studnicka: Quoted by
Pettit and Qirard. Testut: Traite d’Anatomie Humaine, tome if.,
1905. Tillaux: Quoted by Matthieu. Verneuil: Quoted by Matthieu.
Widal, Sicard, et Ravant: Cytologie du Liquids Cephalo-rachidien,
Bulletin de la Society Medicale des HO pita ux de Paris. 1901. Willis:
Cerebri Anatomte Nervorumque, Descriptio et Usus, London, 8vo, 1664.

24

Mott: The Cerehro-Spinal Fluid

LECTURE II.

Delivered on April 39th.

THE PATHOLOGY OK THE CEREBRO-SPINAL
FLUID.

Mr. President and Fellows of the College,—I n my
last lecture I endeavoured to point out to you the physiology
of the oerebro-spinal fluid. I discussed its physical and
chemical properties, its source, its destination, and its func¬
tions. To-day I propose to consider the pathology of the
cerebro-spinal fluid.

I will throw on the screen a lantern slide indicating the
pathological conditions which may occur in the fluid.

Table I .—Cerebrospinal Fluid and Pathological
Conditions.

\

Properties, sub¬
stances, Ac.

Normal.

Pathological.

Appearance.

Clear, like

Serous, turbid, purulent,

water.

fibrinous, yellow, red, brown.

Specific gravity.

1-004-1-007.

Increased.

Reaction.

Alkaline.

Alkaline.

Tension.

60 drops per

Hypertension, Hypotension.

minute.

Oryoscopy.

-0-55°.

Hyper- Hypo-

Permeability of
subarachnoid

Nil.

Variable and unstable.

space.

Presence of

Occasional Instances.

drugs.

Toxicity.

Nil.

It does exist, but rare.

Virulence.

Nil.

Sometimes marked.

Chemical Alterations.

Proteins.

Trace globulin.
No albumin.

Excess globulin, albumin, nucleo-

protein.

Lipoids.

Nil.

Cholesterol. Splitting products of
lecithins and sphingomyelin.

Sugar.

015-0-18%.

Excess in diabetes. Probable
decrease In dementia precox.

Urea.

015%.

Excess in uremia.

Choline.

Nil.

Probable trace in acute nervous

degeneration.

Chlorides.

06-0-7%.

—

Carbonates.

013%.

—

Potassium salts.

003% KC1.

No appreciable alteration.

Mott: The Cerebro-Spinal Fluid

25

Propertibs, Substances, Sec.

First as regards its physical properties. Bven in marked
pathological conditions, such as general paralysis of the
insane, the fluid may appear clear like water, and only on
farther investigation may its pathological changes be dis¬
covered. Occasionally, however, the fluid may be turbid,
purulent, serous, fibrinous ; its colour may be yellow, being
tinged with bile, red from the presence of blood, or
brownish-red from the presence of altered blood. In my
experience, however, which is a large one, I have very
seldom seen the fluid other than like clear water, excepting
always the presence of blood from the puncture of a small
vessel daring the performance of the operation. There is
little to be said about its specific gravity, nor about the
reaction. A rough estimate has been made of the tension by
the number of drops per minute ; 60 drops is considered the
normal average. With hypertension an increased number of
drops will occur.

As regards the rest of the table there is little to be said
except as to the presence of drugs. As a rule drugs do
not pass into the cerebro*spinal fluid, and most observers
have not confirmed Majendie’s original observations relating
to the passage of potassium iodide into the cerebro-spinal
fluid, a fact upon which Majendie laid great stress as show¬
ing the manner in which this drug benefited in such a
marked degree certain diseases of the nervous system.
Recently an important observation has been made by Ager.
He has obtained satisfactory results following the adminis¬
tration of urotropine in meningeal affections; the drug is
said to be excreted in the cerebro-spinal fluid in half hour to
one hour after ingestion, and to exert a marked anti-
baoterial effect. It was first employed in a case of cerebro¬
spinal fistula following trephining for cerebral tumour, in
which the discharge became purulent. After the adminis¬
tration of 30 grains daily for a week the temperature became
normal and recovery ensued. Experiments made on
animals have been confirmatory. It is known that tetanus
toxin does not pass into the cerebro-spinal fluid, but to this
I have already referred in my first lecture. I may, however,
remark that we should not expect the tetanus toxin to
be eliminated by the choroidal gland, but from the capil¬
laries in the nervous substance. Here the affinity of the
toxin for the nervous matter would exert itself immediately.
Upon the escape of the toxin from the blood-stream there
should be in consequence no toxin free to pass into the sub¬
arachnoid space from which the fluid is withdrawn.

26

Mott: The Cerebro-Spinal Fluid

Chemical Alterations.

I will now pass on to certain chemical alterations, dwell¬
ing more especially upon those to which we have given
attention in the laboratory at Claybury.

Proteins. —The amount of protein in normal cerebro-spinal
fluid is especially low (about 0 03 per cent.); serum-
globulin may be present in slight amount, but albumin
is absent. In acute and chronic inflammatory conditions,
in fact in all conditions where there is leuoocytosis, there is
excess of globulin, and albumin and nucleo*proteins are
present. In cases of progressive degeneration, in spite of
the large exoess of fluid, the amount of proteins is found to
be greatly increased. This excess consists of globulins,
nucleo-proteins, and a small amount of albumin, the greater
part being coagulable by heat between 73°-80° C. The excess
of globulin is the most marked, and Noguchi describes
the following method for its detection in a small quantity
of blood-free cerebro-spinal fluid. Boil for a few seconds
two parts of the oerebro-spinal fluid with five parts of a
10 per cent, butyric acid solution (in 0*9 per cent, sodium
chloride solution); then add one part of normal sodium hydrate
solution (4 per cent.) and boil again briefly. Noguchi states
that the fluid of parasyphilitic cases gives a granular or
flocculent precipitate on allowing the tube to stand for a
short time, and that cases of alcoholic psychosis, dementia
prsecox, imbecility, epilepsy, and many other non-specific
diseases do not give any precipitate, but that cases of
tuberculous meningitis, pneumococcic meningitis, and epi¬
demic cerebro-spinal meningitis give an enormous amount of
precipitate. I have applied this test to a considerable
number of fluids, and have obtained a positive reaction in
many non-specific cases, in fact, in all cases of dementia,
whether non-specific or specific, and have found that the
amount of precipitate is proportional to the degree of
degeneration of nervous tissue, being most marked in the
progressive degeneration of general paralysis of the insane.
Another test for the globulin present consists in allowing the
fluid to flow gently on to the surface of a saturated solution
of ammonium sulphate, when a characteristic white ring
appears which intensifies on standing. A rough indication
of the excess of protein can also be obtained by precipitating
the total protein content of the cerebro-spinal fluid with
three times its volume of absolute alcohol after rendering it
faintly acid with acetic acid.

Lipoids —In the normal fluids no lipoids are present, but
in degenerative conditions of the nervous system, whether
primary or secondary, lipoids are present in the form of
cholesterol, or, as it was formerly termed, cholesterin, an

Mott: The Cerebro-Spinal Fluid

27

aloohol of the terpene series containing neither phosphorus
nor nitrogen. This substance, the method for detecting
which I shall point oat presently, we have foand present in
practically all cases of general paralysis and chronic
dementia. Generally speaking, the amount present, as
shown by the intensity of the colour reaction, is proportional
to the amount of wasting. It is of interest to note that
frequently in cases of chronic dementia and chronic wasting
diseases of the brain and spinal cord cholesteatomata of
the meninges are found, and I have even seen little plates
and nodules of a cholesterin-containing substance. The
term cholesteatoma was given to those bodies owing to the
fact that crystals of cholesterol are often found in their
centre. Besides cholesterol there are phosphatides, the result
of cleavage products of the lecithins and sphingomyelin.

The presence of lipoids is of interest and importance
because they are indicative of wasting of the nervous struc¬
ture. Moreover, they are of importance in connexion with
the Wassermann reaction. Pighini asserts that cholesterol
is essential for the Wassermann reaction, but inasmuch as
we have found it in the fluid of diseases which do not give
the Wassermann reaction, I do not agree with this state¬
ment. It seems much more likely that the Wassermann
reaction—a subject to which I shall allude much more fully
later—is connected with a particular form of eu-globulin.

Sugar .—The quantity of sugar varies in amount. Probably
the normal quantity in fluid withdrawn by lumbar puncture
is 0*15 to 0*18 per cent. If we could obtain it from the
subarachnoid space without admixture of the fluid as it is
secreted by the choroid plexus, it would possibly show a
higher percentage, approximating that of the blood. It has
long been known that the sugar is increased in diabetes, and
that it diminishes under the influence of treatment. The
relatively small percentage of sugar in the cerebro-spinal
fluid of cases of dementia prsecox is interesting, and if in
a large number of cases we find this diminished quantity
prevails, the fact might be correlated with the clinical
symptoms of this disease.

Urea.— I have not made any estimations of urea. The
normal quantity is 0 15 per cent., and numerous observers
have shown that there is an excess in uraemia.

Choline .—Professor W. D. Halliburton and I made a
number of observations tending to show that choline
occurs in the blood and cerebro-spinal fluid in conditions
where a large amount of nervous tissue was undergoing
degeneration. The existence of choline was demonstrated
by physiological and micro-chemical tests. I am, how¬
ever, of opinion from further observations that the micro¬
chemical tests employed—i.e., the formation of choline

28

Mott: The Cerebro-Spinal Fluid

pl&tino-chloride crystals—were unreliable, and that the
crystals we obtained were more often potassium and
ammonium salts; moreover, a number of post-mortem
fluids were used for our observations, and in the laboratory
we have found, using the periodide test (investigated by
Rosenheim), that a very small quantity of fluid obtained
from any post-mortem within a comparatively short time
of death gives the test denoting the presence of choline
or some substance from which choline is easily dissociable.
We have been unsuccessful in obtaining the test in fluids
obtained during life, even in the cases of general paralysis. A
large number of papers have appeared on this subject, and
the points under dispute are (1) the reliability of the
tests employed; and (2) whether' the substance present is
really choline or some other similar or even dissimilar pro¬
duct of the cleavage of the complex phosphatide molecules.
The questions are difficult to settle owing to the small
quantity of the substance present in the fluid, but it would
appear that, although choline may be split off from the
phosphatide molecule during the course of active degenera¬
tion of nervous tissues, it cannot exist as such in the alkaline
cerebro-spinal fluid. However, as our knowledge regarding
the exact chemical composition of the complex substances
of nervous structures increases, we may be able to ascertain
the nature of the cleavage products of these substances in
nervous degeneration.

I may remark that the potassium salts which are present
in relatively so large amount in brain tissue, and which the
experiments of Macdonald would suggest as being increased in
the fluid in cases of degenerative destruction of the nervous
system, are not appreciably altered in amount. a This does
not prove, however, that the potassium salts do not pass into
the cerebro-spinal fluid and blood and that they are not
increased, for it is extremely difficult to estimate differences

* Myers has estimated the potassium salts In the cerebro-splnal fluid
In a number or general paralytics and non-paralytics with the following
result. General paralytics (13 cases).--Average 0 038 per cent. KC1.
(Highest, 0 064 per cent.; lowest, 0 027 per cent. KC1.) Son-paralytics
(4 cases).—Average 0 033 per cent. KC1. (Highest, 0 039 per cent.;
lowest 0 027 per cent. KC1.) These results were obtained from 10 cubic
centimetres of cerebro-splnal fluid in each case, and It was deemed
advisable, in repeating the work, to make determinations on appreciable
quantities of fluid from two or three cases Instead of on smaller
quantities from each case. I have therefore examined larger quantities
of cerebro-splnal fluid obtained by adding together the fluids from
several cases of dementia prsecox and general paralysis with the
following results:—

Dementia Prsecox.

1. 27 5 c.c. 0*033 per cent. KC1.

2. 27*6 c.c. 0 038

3. 26*0 c.c. 0*030

Average 0*033

General Paralysis.

1. 40 c.c. 0*038 per cent. KC1.
2* 40 c.c. 0*034

Average 0*036 „ „

All fluids used in this Instance gave a positive Wassermann reaction.

Mott: The Cerebro-Spinal Fluid

29

where such small quantities have to be dealt with. More¬
over, seeing that the quantity of potassium salts is approxi¬
mately the same as the blood, any increase would tend to
diffuse.

There is little more to be said about the chemical altera¬
tions, but I will throw on the screen an outline of a rough
method for the chemical examination of the cerebro-spinal
fluid. Ten cubic centimetres of the centrifuged fluid, after
examination for cells has been made, are taken and rendered
faintly acid with acetic acid. Tlj/ee cubic centimetres of
absolute alcohol are added and the whole gently heated on

Fig. 10.

Photomicrograph of crystals of choline periodido obtained
from a small quantity of the cerebro-spinal fluid of a non¬
paralytic case, taken a few hours after death.

a water bath for 15 minutes. After standing overnight it
is again warmed and filtered. The amount of protein can
be approximated at sight or weighed on a tarred filter-paper
or Gooch crucible, the amount of ash being sub¬
tracted from the total weight of protein. The filtrate is
rapidly evaporated to dryness at a low temperature, the
residue is moistened, and a smear transferred on the end of
a glass rod to a slide, and one drop of a saturated solution
of iodine in 10 per cent, potassium iodide is added. The
mixture is now watched under the microscope, when , if
choline is present, brownish-black rectangular plates of choline
periodido rvill be formed. (Fig. 10.) The moisture is

30

Mott: The Cerebro-Spinal Fluid

removed from the residue by evaporation, and another
extraction with absolute alcohol is made. The filtered
extract is evaporated to dryness and extracted with hot
chloroform. The volume of chloroform is reduced to about
2 cubic centimetres and the presence of cholesterol detected
by Liebermann’s test which is thus carried out (Add to
chloroform solution a few drops of acetic anhydride, then
(add concentrated sulphuric acid drop by drop. After a time
a rose colouration of the acid, and a violet colouration of
the chloroform turning to blue, then green, indicate the
presence of cholesterol.)

The test for sugar can be performed on one or more cubic
centimetres of the original fluid, and Noguchi’s and other
confirmatory tests may be made on any remaining fluid.
Many observations have been made based upon the examina¬
tion of fluids obtained after death; I have found, however,
that within a very short time after death the composition of
the fluid so alters that the results obtained are useless and
misleading.

Experiments show that if micro-organisms enter the sub¬
arachnoid space they rapidly multiply in the cerebro-spinal
fluid and lead to a gtheral colonisation. We may suppose
that the micro-organisms invade the perivascular lymphatics
and set up an inflammatory reaction therein, which if it
does not localise the spread will eventually lead to the
organisms getting into the subarachnoid space and by the
movement of the cerebro-spinal fluid lead to a general infec¬
tion of the membranes.

Pathological Conditions.

Time will not permit me to do more than summarise the
abnormal conditions of the cerebro-spinal fluid as a whole, and
I will throw on the screen a table illustrating the principal
features occurring in pathological conditions. In this table
you will observe that I have made four groups, and I shall
dwell more especially upon those points upon which my
assistants at Olay bury and myself have chiefly worked, there¬
fore about which I have special knowledge. (Table II.)

Sleeping Sickness, Syphilis, and Parasyphilis.

The work in which I have been especially engaged has
been the investigation of the pathological conditions met
with in sleeping sickness, in syphilis, and in parasyphilis,
pathological conditions in which there are many points of
similarity. The meninges and perivascular lymphatics in all
three of these diseases are characterised by a lymphocyte
and plasma cell infiltration, and by a hyperplasia of the
neuroglia cells indicative of a chronic inflammatory pro-

Mott: The Cerebro-Spinal Fluid

81

cess, due in all probability in each case to toxic irritation.
In all three of these diseases the cerebro-spinal fluid contains
a large number of mononuclear cells—leucocytes.

I shall have occasion later to demonstrate other points in
connexion with the cerebro-spinal fluid in these diseases. You
will observe how similar is the appearance of the perivascular
lymphatics of sleeping sickness, general paralysis, and
syphilis. But the diseases in question present many patho-

Table II. — Abnormal Conditions of the Cerebro-spinal If laid.

I. Cytological exami¬
nation.— Normal fluid is
practically free from
cells. In pathological
conditions an estima¬
tion is made of the
type and number of
cells.

II. Bacteriological
examination.

(a) Staining the centri¬
fuged deposit.

(b) Cultural methods.

(c) Inoculation.

III. Protozoal ex¬
amination.

(a) Staining the centri¬
fuged deposit.

(b) Examination of a
hanging drop.

(c) Inoculation.

IV. Biochemical.

1. Polynuclear leucocytosis generally indi¬
cates microbial Invasion of the subarachnoid
space by some organism other than the
tubercle bacillus; but polynuclear cytosls
may accompany lymphocytosis in a certain
proportion of cases of tuberculous meningitis.

2. Mononuclear leucocytosis .—Whereas poly¬
nuclear leucocytosls points to an acute in¬
flammatory affection of the meninges, mono¬
nuclear leucocytosis indicates a chronic condi¬
tion. It occurs almost invariably in syphilis
of the central nervous system, general
paralysis, talies dorsalis, tuberculous mening¬
itis, and sleeping sickness. It has been
found In other conditions—e.g., herpes zoster,
acute poliomyelitis, mumps, lymphatic
leukaemia, chloroma, and some cases of
cerebral tumour. Mononuclears may also
replace the polymorphs in the later stages of
microbial infection.

The most important organisms found are:
pneumococcus, streptococcus, bacillus tuber¬
culosis, dlplococcus Intracellularls causing
meningitis. Various other micro-organisms,
together with pneumococcus, pneumo-bacillus
streptococcus, and staphylococcus may, as a
result of secondary or terminal infection,
invade the subarachnoid space.

The only protozoon met with constantly in
the disease which it causes is the Tryp.
gambiense. Only once has the Treponema
pallidum been found.

The Wassermann reaction of the blood
serum combined with that of the cerebro¬
spinal fluid.

logical differences which would explain the different clinical
phenomena. Let me first refer to sleeping sickness, a
disease caused by the Tryp. gambiense. Whether this
chronic irritation of the lymphatics is due to toxins pro¬
duced by the invasion of the blood and lymphatic system of
the body generally or to the presence of the organism in the
cerebro-spinal fluid, is still a matter open to discussion, but
I think from the examination of the brains of over 30 cases

Mott: The Cerebro-Spinal Fluid

of this disease that there is a parallelism between the
somnolence or drowsy stupor which is the characteristic
feature of this disease and the degree and intensity of this
perivascular lymphatic cell infiltration. I would attribute
this to the interference with the circulation of the ambient
fluid of the neurons, whereby they suffer from an insuffi¬
ciency of oxygen. It cannot be explained by an inter¬
ference with the blood circulation, for the anaemia is not
intense enough ; it cannot be explained either by degenera¬
tive changes in the nerve cells, such as we find in
general paralysis, for in those cases, and I may say they
were few, in which a secondary microbial invasion by
diplococci, streptococci, or staphylococci had not taken
place, the brain presented a normal appearance to the naked
eye. There was no wasting, and microscopical examination
did not reveal sufficient changes in the nerve cells to account
for the symptoms manifested during life. Europeans who
have suffered with sleeping sickness, and a Oongo native
speaking English well who died under my care in Charing
Cross Hospital, could be roused from their drowsy lethargy
to answer questions rationally—a very different condition to
that of general paralysis, where the auto-critical faculty is
almost invariably affected. The drowsy lethargy of this
disease I attribute then to tho failure of the oxygen supply
to the cells of the cortex.

We can readily understand how this could be effected, if
the fluid which circulates in the perivascular lymphatics is
the ambient fluid that takes oxygen from the blood to hand
it over to the nerve cells; this progressive, universal, and
intense inflammatory state of the perivascular lymphatics
would interfere with its flow and lead to deficient oxygen
supply. Moreover, there is a vicious circle established, for
the more these lymphatics become obstructed by the actively
growing young cells the more the oxygen that may be in the
fluid will be snapped up by them and the less will be at the
disposal of the nerve cells. Consequently, the oxygen supply
necessary for functional activity of the nerve cells becomes
progressively less and the drowsy stupor deepens propor¬
tionately.

The experiments of Verworn, upon which I have not now
time to dwell, prove the importance of oxygen storage by
the nerve cells and the necessity of its supply for func¬
tional activity. Moreover, the experiments of Baeyer and
Winterstein point to the fact that narcotics act by an inter¬
ference with the capacity of the cell to take up oxygen,
whereas normal sleep is a habit on the part of the cell of
storing rather than of using oxygen.

In widespread generalised syphilitic meningitis and peri-
vascularitis a drowsy stupor is a frequent symptom, but I
attribute this in a measure to the interference with the
escape of fluid from the ventricles of the brain in some
cases, but in others, more particularly to the widespread

Mott: The Cerebro-Spinal Fluid

88

obliterative endarteritis affecting the small as well as the
large vessels, thns producing a generalised anaemia.

In general paralysis the perivascnlaritis may be very
intense, but never so intense as in sleeping sickness. The
dementia, which is the characteristic of the former disease,
is proportional to the atrophy and wasting of the cortical
substance, a condition which is not met with in either
sleeping sickness or syphilitic brain disease. It is a primary
decay of the neurons with secondary and proportional
vascular changes, whereas in syphilitic brain disease the
wasting and degeneration of the neurons occur in foci as a
result of vascular occlusion from endarteritis or the con¬
sequent thrombosis ; the symptoms are obtrusive and coarse
and occur in sudden spells, whereas in general paralysis,
leaving aside the seizures which may occur, the disease is
insidious, continuous, and progressive.

In all these diseases, as I have said before, there is a mono¬
nuclear leucocytosis of the cerebro-spinal fluid ; therefore,
diagnosis by cytological methods will not suffice. There is
generally also a hypertension of the cerebro-spinal fluid.
Now we can leave out a consideration of sleeping sickness,
for no one would diagnose that without finding the Tryp.
gambiense in the cerebro-spinal fluid, lymphatic glands, or
blood. The important point is the differential diagnosis of
syphilis from parasyphilis of the nervous system. Of the import¬
ance of this one cannot be too emphatic, for whereas syphilis of
the nervous system is curable or, at any rate, benefited by
mercurial treatment and administration of iodides, it is
doubtful whether parasyphilis is ever cured or even benefited
by this treatment, and in some cases it positively does harm.
And this leads me to say that I do not regard the diph¬
theroid organisms described by Ford-Robertson as the
organism of tabes and general paralysis as in any way a
specific organism of this disease. My assistant, Dr.
J. P. Candler, made a special study of this subject, and we
have never been able to find the bacillus in the cerebro¬
spinal fluid, and only on one occasion was it seen in the
blood, although we have examined a very large number of
specimens. I think, therefore, we can leave it out of
account as a means of diagnosis. Now I come to a very
important method of distinguishing syphilitic disease of the
nervous system from parasyphilis—I refer to the Wassermann
reaction.

The Wassermann Reaction.

The Wassermann reaction since its introduction has had
many modifications, but it is a general opinion that,
although the theory upon which Wassermann based his
method is wrong, yet empirically, although the method is
more tedious and more difficult of application, it is
nevertheless more reliable in its results; and Dr.

34

Mott: The Cerebro-Spinal Fluid

Candler and Dr. J. Henderson Smith of the Lister
Institute have relied upon this method entirely for the
results which I shall place before you. The reaction is as
follows. A rabbit is immunised against the blood of the ox
—that is to say, several injections of washed ox corpuscles
are injected into the rabbit. The serum of this animal
has then the power of dissolving the red corpuscles of the
ox. This is owing to the presence of two substances—the
complement, which is thermolabile, and the amboceptor,
which is thermostable. If this serum is heated to 56° C.
for 30 minutes it will no longer dissolve washed ox
corpuscles, but if some normal guinea-pig serum be added
the corpuscles are dissolved. This is due to the fact that
the thermolabile substance—the complement—has been
added, and in conjunction with the thermostable ambo¬
ceptor has caused haemolysis.

The serum or cerebro-spinal fluid to be examined is mixed
in varying dilutions with a watery or alcoholic solution of
the liver of a syphilitic foetus ; a small amount of guinea-
pig serum is then added, and the total volume made up to
2 cubic centimetres with saline solution. A series of tubes
containing these mixed solutions is placed in the incubator
at 37° O. for one hour and the sensitised ox corpuscles are
added. The mixtures are again placed in the incubator
for two hours at 37° 0., then taken out and put on ice
overnight. The next morning the amount of bramolysis
in each tube is observed. A control experiment, using
normal serum or cerebro-spinal fluid, should be made
at the same time. A positive reaction is obtained when
the blood or cerebro-spinal fluid causes fixation of the
complement of the guinea-pig serum and haemolysis is
prevented.

It has been found that extract of guinea-pig heart, of
human heart, soaps, and lecithins may replace the extract
of syphilitic liver in this reaction. Consequently, the idea
of the antigen and antibody theory has been abandoned.
Still, it is everywhere accepted that the reaction is a most
reliable aid to diagnosis.

I have purposely omitted to give the details and pre¬
cautions necessary for the satisfactory carrying out of this
reaction as they are given fully by Henderson Smith and
Candler. They have recently examined the cerebro-spinal
fluid of 127 cases of various forms of insanity. Of this
number, 64 were cases of general paralysis, and in 69, or
92*1 per cent., a positive result was obtained. Of these
59 cases, 21 have since died, and the clinical diagnosis of
general paralysis has been confirmed by the post-mortem
investigations. Fluids from 63 cases not suffering from
general paralysis were also examined, and in no single
instance was a positive reaction obtained. A few of these
cases have since died, but none showed at necropsy any
evidence of general paralysis. 17 out of the 21 cases of

Mott: The Cerebro-Spinal Fluid

85

general paralysis above referred to, which came to the post¬
mortem table, showed before death an excess of lymphocytes
in the cerebro-spinal fluid.

The following table shows the results obtained by
Henderson Smith and Candler in general paralysis and
tabes, as compared with those collected from the literature.

Table III. — Comparison of Remits obtained by Henderson
Smith and Candler with those collected from the Literature.

-

Cerebro-spinal fluid.

Serum.

General paralysis.

In literature .

362 cases, 309 positive;
that is, 87*7 per cent.

285 cases, 247 positive;
that is, 86*6 per cent.

Henderson Smith and
Candler's cases

64 cases, 59 positive;
that Is, 92*1 per cent.

10 cases, 9 positive;
that is, 90 0 per cent.

Tabes dorsalis.

In literature .

112 cases, 57 positive;
that is, 50 8 per cent.

176 cases, 125 positive;
that is, 71*0 per cent.

Plaut, who was the first to adopt the Wassermann test for
the cerebro-spinal fluid, obtained as high a percentage as 90
out of 91 cases, and in every case the serum was positive.
He points to the fact that the Wassermann reaction may
occasionally be obtained before there is any cell increase in
the fluid, although this is the exception according to our
experience, yet in one of the cases the reaction was only
obtained a few days before death. The diagnosis was con¬
firmed post mortem, macroscopically and microscopically;
the cerebro spinal fluid was withdrawn two hours after death
and specimens of lateral ventricle fluid and serum from
this case gave strong positive reactions. In this instance,
then, although the fluid eventually became positive, it was
still negative until a short time before death, when the
disease was far advanced. In one of the cases the
fluid remained negative throughout. It is unusual to
obtain a positive reaction of the cerebro-spinal fluid in
syphilis of the central nervous system, although the fluid
may contain a large number of lymphocytes. There does not,
then, seem to be any correlation between the lymphocytosis
per sc and the presence of the body which gives the reaction.
But although syphilis of the nervous system is not accom¬
panied by the reaction in the cerebro-spinal fluid the serum,
unless the patient is under active treatment, always gives
the reaction. The explanation of this is somewhat difficult.
Concerning the chemistry of the Wassermann reaction I have
found that a fluid giving a positive reaction fails to do so
after the separation of the protein fraction. Sachs concludes
that the substance is a globulin and Noguchi has come to

86

Mott: The Cerehro-Spinal Fluid

the conclusion that the substance in the fluid causing the
reaction is attached to the eu-globulin, from which it cannot
be separated by solvents. In repect to the manner in which
this arises in the cerebro-spinal fluid several suggestions
offer themselves, one being that it is a transudation from
the blood. If it were so we should expect to find it in
cerebral syphilis, but as a rule this is not the case.
Inasmuch as I have shown that the cerebro-spinal fluid is
secreted by the choroid plexus I was naturally led to make
a comparative examination of this structure in general
paralysis and other diseases, but although the choroid
plexus in general paralysis as compared with other diseases
of corresponding age showed more frequently cystic degenera¬
tion and denudation of the choroidal epithelium, still I was
unable to associate so far the two facts. A positive reaction
by the Wassermann method is not necessarily associated
with lymphocytosis, neither is lymphocytosis even with a
positive serum reaction necessarily associated with a positive
reaction of the cerebro-spinal fluid. It may be said that a
positive reaction of the cerebro-spinal fluid strongly points
to a parasyphilitic affection. Time will not permit me to
discuss certain theories which I have put forward in explana¬
tion of parasyphilis and the presence in the cerebro-spinal
fluid of a body upon which the fixation of the complement
depends, but I have dealt with the subject in the Morison
Lectures of 1909. I will be content with giving three striking
examples out of a number of the value of this reaction.

Cases Showing the Application of the Test.

1. My attention was called to a case in one of the London
county asylums of a woman with double optic neuritis,
vomiting, and headache. I had her transferred to my care at
Charing Cross Hospital, and on examination Mr. E. T. Collins
found five dioptres of swelling in each disc. The cerebro¬
spinal fluid contained an abundance of lymphocytes but the
Wassermann reaction was negative. After treatment with
mercurial inunction the swelling of the discs rapidly sub¬
sided, the vomiting and headache ceased, and she was able
to read small print, whereas formerly she could not read large
print. She was subsequently discharged apparently cured.

2. The condition of a patient in one of the London county
asylums improved so much that the medical officers were
doubtful as to whether he was a general paralytic. The
Wassermann test was made on the cerebro-spinal fluid with
a positive result. I expressed the opinion that it was cer¬
tainly a case of general paralysis and maintained that the
test was not likely to be wrong. He still continued to im¬
prove and his discharge was contemplated, but the next time
I visited the asylum my predictiop was confirmed. He had

Mott: The Cerebro-Spinal Fluid

37

bad several seizares and within three months he died, and
the examination of the brain left no doubt as to the correct¬
ness of the diagnosis.

3. A woman, aged 34 years, was admitted to Charing
Cross Hospital under my care, said to be suffering from tabes.
There were no signs of syphilis on the body. Her youngest
child was aged 4 years. Fifteen months previously she had
had a seven months stillborn child. Four months ago she
suffered with numbness in the legs, of which she took little
notice ; then she had double vision and tingling in the feet
and legs. For the past 14 days she had suffered with a
girdle sensation. She now complained of lancinating pains
extending from the back down both legs, unsteadiness in
gait and station, a feeling of the soles as if walking on cork,
and pain and cramp in the muscles of the legs. The
pupils were unequal and reacted sluggishly to light and to
accommodation, the knee-jerks were absent, there were
patches of anaesthesia on the legs, and a belt of
thoracic anaesthesia with girdle sensation. After inquiring
into the history and finding that she had suffered with head¬
ache and squint, that the knee-jerks, which were absent on
admission, had returned a few days later, I concluded that
this woman, with a probable duration of infection of less
than four years, was suffering from pseudo-tabes, the result
of syphilitic meningitis, especially as she told me that she
had suffered with a slight stiffness of the neck. I then
obtained Eernig’s sign. The cerebro-spinal fluid showed
390 lymphocytes per cubic millimetre—an enormous number
for tabes dorsalis; this large number could only be accounted
for by a widespread active gummatous meningitis. She was
placed on mercurial inunction, and within a fortnight the
lymphocytes had fallen to 70 per cubic millimetre and
the fluid gave a negative Wassermann reaction. Unfor¬
tunately, the blood was not tested on this or future
occasions. A fortnight later the cerebro-spinal fluid was
examined and only 20 lymphocytes per cubic millimetre were
found, the patient being almost well. A fortnight later there
were no lymphocytes and the fluid was still negative to the
reaction. The pains, anaesthesia, and unsteadiness had
entirely disappeared and the patient was quite well. Over a
year has elapsed and the patient is still quite well, but there
is no guarantee that she may not have a recrudescence of
symptoms, for my experience has taught me that if once the
contagion invades the subarachnoid space producing a diffuse
meningitis, symptoms of a latent affection becoming once
more active may supervene at any period after.

In conclusion, I wish to acknowledge my indebtedness to
my assistants, Dr. Candler and Mr. Sydney Mann, for the
invaluable help they have afforded me in conducting these
researches and investigations.

88

Mott: The Cerebro-Spinal Fluid

Bibliography. —Ager: Medical Annual, 1908, p. 603. Baeyer: Zur
Kenntnia dee Stoffwechaels in den nervdsen Zentren, Zeitschrift fur
Allgemeine Physiologic, Band i., 1902. Candler: A Bacteriological
Investigation of General Paralysis, Archives of Neurology and
Psychiatry, vol. iv. Candler and Henderson Smith : On the Wassermann
Reaction in General Paralysis of the Insane, Brit. Med. Jour., vol. ii.,
1909. Landon : Lumbar Puncture in Meningitis and Allied Conditions,
The Lancet, vol. 1., 1910, p. 1056. Mott: Morison Lectures, 1909,
Brit. Med. Jour., vol. i., 1909; Archives of Neurology and Psychiatry,
vol. iv.; Sleeping Sickness Commission Reports, vol. vii. Mott and
Halliburton: The Physiological Action of Choline and Neurine,
Transactions of the Royal Society, vol. cxci., p. 211; The Chemistry of
Nerve Degeneration, ibid., vol. cxciv., p. 437. Noguchi: The Relation
of Protein, Lipoids, and Salts to the Wassermann Reaction, Journal
of Experimental Medicine, vol. xi., 1909, p. 84. Pighini: Uber den
Cholesteringehalt der Lumbalfliissigkeit einiger Geisteskrankheiten,
Hoppe-Seyler’s Zeitschrift fiir Physiologische Chemle, Band lxi. v
Heft 6, p. 508; Cholesterine et Reaction de Wassermann, Zentralblatt
fiir Nervenheilkunde und Psychiatric, 20, 1909. Plaut: Die Wasser-
mann’sche Serodiagnostik der Syphilis, Fischer, Jena. Verworn : Die
Vorgiinge in den Blementen des Nervensystems, Zeitschrift fiir Allge¬
meine Physlologle, 1906, p. 11. Winterstein: Zur Kenntnis der Narkose,
Zeitschrift fiir Allgemeine Physiologic, Band 1., 1902; Wkrmeliihmung
und Narkose, ibid.. Band v„ 190

Reprinted from The Lancet, October 8 , 1910 .

C|re Scrim

ON

THE HEREDITARY ASPECTS OF NERVOUS
AND MENTAL DISEASES.

Delivered at the Opening of the Winter Set non at Charing.
Crott Hospital on Oct. 3rd , 1910,

By F. W. MOTT, M.D. Lond., F.R.S.,
F.R.C.P. Lond.,

PHYSICIAN TO THE HOSPITAL; PATHOLOGIST TO THE LONDON COUNTY
ASYLUMS; FULLEBIAN PROFESSOR OF PHYSIOLOGY,

ROYAL INSTITUTION,

Mr. Chairman,— Permit me to thank yon and my
colleagues of Charing Cross Hospital Medical School most
cordially for the great honour conferred upon me by the
request to deliver the Huxley Lecture this year. When L
look back on my distinguished predecessors I feel that, with
this honour, there is a great responsibility, for it is not an
easy task for me to deliver a lecture worthy of the occasion m r
and I felt, therefore, some difficulty in the selection of a
subject. I was, however, guided in my selection of the
hereditary aspect of nervous and mental diseases by the
following facts. Heredity is a subject that the master
mind of Huxley illuminated in several of his essays, and it
is fundamental in the study of the Origin of Species and
Natural Selection, which he did so much to forward. Next,
recent developments in our knowledge of the subject of
heredity owing to the labours of Galton, Pearson, and their
followers in the study of biometrics, and Bateson and his
followers in Mendelism, have aroused the keenest interest in
the subject of human inheritance, not only in the medical
profession, but in the thinking and intellectual portion of
the nation. Another reason was that none of the illustrious
lecturers in the past have dealt with the subject of heredity
in relation to disease. Lastly, it is a subject to which 1
have recently devoted a large amount of attention in the
study of the causation of nervous and mental diseases, and
more especially the relation of heredity to various forms of
insanity. The wealth of material in the London County

-2

Mott: The Hereditary Aspects of

Asylums has permitted a biometric investigation in a novel
manner. The subject is one of national importance and
interest, and it affects many social and legislative questions.
The interest taken by the general public in the question of
heredity is a sign of social progress. People are recognising
the truth of Thomson’s saying, “ The present is the child of
the past; our start in life is no haphazard affair, but is
vigorously determined by our parentage and ancestry; all
kinds of inborn characteristics may be transmitted from
generation to generation.”

Doctrines op Heredity.

Fifty years have elapsed since Huxley wrote an essay on
iihe Origin of Species in the Westminster Review , and the
-doctrine of Natural Selection which he upheld with such re¬
markable force remains unshaken and unshakable, but muta¬
tion or discontinuous variation has replaced in great measure
the continuous accumulation of small differences to which
Darwin attributed so much importance in evolution; and it
is interesting to note that Huxley in this same essay said,
“ Mr. Darwin’s position might, we think, have been even
stronger than it is, if he had not embarrassed himself with
the aphorism, Natwra non facit saltum , which turns up so
often in its pages. We believe that nature does make jumps
now and then, and a recognition of the fact is of no small
importance in disposing of many minor objections to the
doctrine of transmission.” Huxley cites the case of the
Ancon sheep, also an interesting pedigree of polydactylism
narrated by Reaumur. I will show a diagram (Fig. 1) illus¬
trating this condition in three generations. Reaumur
narrates this case only as far as the third generation, and
Huxley remarks: “Certainly it would have been a curious
thing if we could have traced this matter any further; had
the cousins intermarried, a six-fingered variety of the human
race might have been set up.” In the light of the Mendelian
law of gametic segregation even this would not be neces¬
sary, for a variation is “not swamped out.” But sexual
selection would tend against the perpetuation of this varia¬
tion, which does not serve a useful purpose, nor is it an orna¬
ment. Huxley in another essay on Hereditary Transmission
and Variation refers to the different product of crossing
a stallion with a she ass, and a male donkey with a
mare. “ Here you see is a most curious thing ; you take
exactly the same elements, Ass and Horse, but you
combine the sexes in a different manner and the result is
modified accordingly. Here, then, is one and perhaps
a necessary cause of variation.” There is in these instances
a prepotency of the male in certain physical characters ; for
on the one hand when the donkey is the sire a mule is
produced with the head, ears, and voice resembling that

Nerroits and Mental Diseases

8

animal, when on the other hand the horse is the sire a hinny
is the product, with head, ears, legs, and voice like the
horse.

Again quoting Huxley: 41 A certain amount of variation
is the necessary result of sexual propagation itself; for
inasmuch as the thing propagated proceeds from two
organisms of different sexes and temperaments, and as the
offspring has to be either of the one sex or the other, it is
quite clear it cannot be a diagonal of the two or it would be
no sex at all; it cannot be an exact intermediate form
between that of each of its parents; it must deviate either
to one side or the other. You will have noticed how very
often it may happen that the son shall exhibit the maternal
type of character, or the daughter possess the characteristics
of the father’s family.”

Fig. 1.

v»

i $ Q CJ Q

ss i 4 Q

I I 1 : 1
O C O 0 6

4 4 5 J

Polydactylism. The circles with black centre Indicate partial
polydactylism. The black circles are complete polydactylism.
The chart is very suggestive of Mendel ism.

The law of ancestral heredity of Galton supposes that
every ancestor of a particular individual contributed its
quota to the heritable qualities of the individual. The law
also states that the average amount of resemblance between
an individual and any particular ancestor is capable of
definite numerical expression. Thus the mean amount of
correlation between (1) the two parents and the offspring;
(2) the four grandparents and that offspring ; and (3) the
great-grandparents and that offspring, and so on backwards
in the ancestral lineage, is believed to diminish in a
geometrical series one-half, one-quarter, one-eighth, which
is the same for all organisms and their characters. Pearson
represents a more rapidly diminishing series: (1) for the two
parents, 0*6244; for the grandparents, 0*1988; for the
great-grandparents, 0*0630, &c. We thus have a mosaic of
ancestral characters.

4

Mott: The Hereditary Aspects of

It is quite possible that the above represents correctly the
average total contributions of ancestors when applied to the
race as a whole, but it cannot be universally applied to
individuals, for, according to Mendel’s theory of inherit¬
ance, certain ancestors may contribute nothing to the
constitution of certain offspring in respect to certain
characters. Moreover, as Maudsley truly says, it is a
conclusion which, however true on the average of such
simple characters as height, is manifestly not true of
individual cases. Anyone selecting for observation different
characters—e.g., noses or ears—can see plainly the nose may
be like the father's or the mother’s, or perhaps one of the
grandparent’s or further back. This fact was well known to
the ancients, and, according to modem ideas of heredity,
there is not much to be said against the teaching of Lucretius.
“ Sometimes, too, the children may spring up like the grand¬
fathers, and often resemble the forms of their grandfather’s
fathers, because the parents often keep concealed in their bodies
many first beginnings mixed in many ways , which first pro¬
ceeding from the original stocky one father hands down to the
next father and then proceeding from these, Venus produces
forms after a manifold chance and repeats not only the
features but the voice and hair of forefathers, and the female
sex equally springs from the father’s seed and males go forth
equally from the mother’s body, since these distinctions no
more proceed from the fixed seed of one or other parent than
our face and bodies and limbs. Again, we perceive that the
mind is begotten along with the body and grows up together
with it, and grows old along with it." The individuality of
every human being depends upon the mingled natures of two
separate parents, and Goethe poetically refers to his own
hereditary endowments in the following lines:—

“ Vom Vater hab ich die Statur,

Des Lebens emstes Fiihren,

Vom Miitterchen die Frohnatur
Und Lust zu fabulieren.”

According to the Mendelian doctrine of dominant and
recessive, the corresponding character of the second parent
always exists in the offspring side by side with the character
which finds expression, only the former, termed recessive, is
obscured by the latter, the dominant. This is the explana¬
tion of a characteristic feature of a particular grandparent
which was not visible in the parent reappearing in the child
(vide Fig. 1). It also accounts for those heritable diseases
and abnormalities which are transmitted by the females in
ancestry and appear in the males—e.g., haemophilia,
Daltonism, pseudo-hypertrophic paralysis. As it passes
from a father through a daughter to a grandson, and so on,
it must be latent in the germ cells (concealed in the body)
though for some obscure reason it has not found expression.
In fact, non-expression of a disease does not necessarily

Nervous and Mental Diseases 5

imply non-inheritance of a disease, rather a predisposition
to disease. It is well known that a hereditary tendency to
nervous disease may have different expressions in successive
generations—e.g., insanity and epilepsy; the hereditary
transmission of nervous or mental disease is rather of the
nature of a neuropathic tendency, the character of the disease
being largely determined by the exciting cause. I have not
time to discuss further the large question of Mendelism in
relation to human inheritance, so far I have not met with any
cases in entire support thereof, in the study of the hereditary
aspect of nervous and mental disease, but, as pointed out by
Professor Bateson, there are many reasons why it has not been
found applicable. Of its enormous importance to biology
and heredity there can be no question; even Professor
Pearson, its most strenuous opponent, said, “The import¬
ance of Mendel’s work and his followers lies in the observa¬
tion of segregation ”—this great fact holds whether Mendelism
in its simple form remains or not.

Thb Rarer Nervous Diseases and Heredity.

Among the rarer nervous diseases in which it is generally
recognised that heredity plays an important part may be
mentioned myotonia congenita, pseudo-hypertrophic para¬
lysis, progressive muscular dystrophy (especially the
Landouzy-Dejerine facio-scapular type), the neuritic type
of progressive muscular atrophy, hereditary ataxia,
Huntington’s chorea, and family periodic paralysis. In
nearly all the recorded cases of myotonia congenita
(Thomsen’s disease) the disorder has existed in several
relatives of the patient, generally in one of the parents
and in the patient’s brothers, sisters, and children. More
than 20 cases of the kind occurred in the family of Dr.
Thomsen in four generations. It is to him that we owe the
first accurate description. As in Huntington’s chorea (a
remarkable pedigree of which I shall show you), other
neuroses frequently occur in the family tree. Many of
Thomsen’s relatives were affected mentally. Sir William
Gowers in the recent discussion on heredity in relation to
disease at the Royal Society of Medicine referred to the
frequency with which pseudo-hypertrophic paralysis is
hereditary; he likewise pointed out that the disease is
characterised by sex limitation, and cited a very remark¬
able case, in which the disease, although not affecting
the females, passed through to the males in several successive
generations; there were two families and probably both
originated in the same stock. Again, he referred to a
remarkable case of facio-scapulo-humeral atrophy (Landouzy-
Dejerine type) which could be traced for six generations.

Family periodic paralysis is a rare disease with a well-
pi^rked hereditary tendency. It is characterised by periodic

6

Mott: The Hereditary Aspects of

attacks of more or less extensive flaccid motor paralysis with
a loss of electrical excitability in the paralysed muscles and
of the reflexes, but without sensory affection or disturbance of
consciousness. Between the attacks the patient is well. In
a family recorded by E. W. Taylor there were 11 cases in
one generation; in the family of a patient of Goldflam there
were 11 cases on the maternal side, and Holtzapple observed
17 cases in four generations. The disease may be trans¬
mitted indifferently through the father or the mother,
although occasionally there has been limitation of trans¬
mission to the same sex. As in other diseases with a similar.
hereditary character, individual cases may occur in which
there is no family history of the disease. A remarkable case
of neuritic progressive muscular atrophy, showing that it
might be of a hereditary character, was reported by
Herringham; the disease was transmitted by females, but
only males were affected. The disease, however, may be
transmitted by both males and females, and both sexes are
affected.

Friedreich’s disease, although called hereditary ataxia, is
seldom directly hereditary—it is a familial disease. Several
families and several isolated cases have come under my
observation, but in the isolated cases no family history of
the disease in ascendants was found, nor was it in the two
cases affecting a number of members of the family ; in one
of these there was a history of consanguinity, the parents of
this family of hereditary ataxia cases being first cousins. A
remarkable pedigree of hereditary ataxia worked out by
Sanger Brown, however, shows the disease occurring in five
generations of a family. Gordon Holmes states that
Schoenborn found a family incidence in 114 of the 200 cases
he analysed. Yet in a not inconsiderable number of recorded
cases the same disease occurred in the ascendants or in the
collateral lines. It may be transmitted through either
males or females. Occasionally there is nob direct heredity,
but the disease occurs in families in which there seems to be
a proclivity to spinal disease ; for instance, a pedigree which
I obtained at Darenth Asylum showed this relationship;
moreover, occasionally, as this pedigree showed, it may be
associated with idiocy. Nolan and Pritzsche have recorded
cases associated with progressive idiocy.

I will now pass on to the consideration of a disease
which I have met with occasionally in the asylums—viz.,
Huntington’s chorea, in which a direct heredity has been
found practically in all the cases studied. The accompany¬
ing pedigree (Fig. 2) is a striking one kindly famished to
me by Dr. C. H. Bond of Long Grove Asylum, under whose
care is the patient of the fourth generation. Huntington,
who first gave a complete picture of the disease, and
after whom it was named Huntington’s chorea, remarks:

“ If one or both of the parents have shown manifestations of
a serious nature, one or more of the offspring almost invari-

Xerturns and Mental Diseases

7

ably suffer from the disease if they live to adult life, but if
by any chance these children get through life without it, the
thread is broken and the grandchildren or great grand¬
children may rest assured that they are free from the disease.
Unstable and whimsical as the disease may be in other
respects, in this it is firm ; it never skips a generation to
manifest itself in another; as soon as it has yielded its claims
it never regains them.” Huntington also remarks upon the
presence of the nervous temperament in all, or nearly all, of
the families in which there is the taint of this disease, and
says “ that nervous excitement to a marked degree almost
invariably attends upon every disease these persons may

Fig. 2.

Paternal great-grandfather suffered with chorea—also paternal
grand-mother and sister. Two paternal aunts and father
suffered with chorea and died in asylums or infirmary—
brother and sister physically unsound. P. t the patient
chorea and insane, one brother in asylum and one died. It
will be observed that the maternal side is quite free from
any taint.

suffer from, although they may not in health be over
nervous.” Heilbronner states that there is a tendency in
successive generations for the onset of the disease to be
delayed, and Wollenberg has shown as this pedigree very
clearly indicates, that choreic heredity in some cases may be
transformed into other neuroses—i.e., epilepsy, imbecility,
paranoia, grave hysteria, &c. Wollenberg has collected
statistics of 128 cases in 22 families, of which 74 were in
men and 54 in women, thus confirming Huntington’s state¬
ment that it is more common in men than in women. Again,
it Was observed by Huntington that “the tendency to in¬
sanity, and sometimes that form of insanity which leads to
suicide, is marked, and the mental condition usually termi-

8 Mott: The Hereditary Aspects of

nated in dementia.” In several cases a microscopic examina¬
tion revealed a marked neuronic atrophy, with some neuroglia
hyperplasia of both the frontal lobes, including also the
central convolutions. Changes in the Betz cells have been
described which might be correlated with the motor disorder
manifested during life. I have observed changes of an
abiotrophic character in the Betz cells in paramyoclonus
multiplex affecting four members of a family ; an uncle was
an epileptic, but no other ancestral defect was discovered.

These forms of nervous disease are usually due to charac¬
teristic morphological defects, and for the most part are best
explained by germinal defects in the specific vitality of
groups of muscles or systems of neurons whereby they waste
prematurely. Sir William Gowers has introduced the term
of abiotrophy for this condition. From a practical point of
view on account of their rarity abiotrophies are of little
importance as compared with insanity and epilepsy, to which
I shall now direct your attention.

Epilepsy.

With regard to epilepsy I feel convinced from my own
observations and experience that Sir William Gowers is
correct when he asserts that there are few diseases in the
production of which inheritance has a more marked influence
and the traceable influence is always far less than that which
exists. Voisin, Fer&, Nothnagel, Dana, Peterson, and Aldren
Turner express similar opinions.

In the discussion of the subject of heredity and disease
Sir William Gowers said: “In my own enquiries into the
heredity of epilepsy I have limited myself to these two
maladies epilepsy and insanity. Heredity was ascertained
in 39 per cent, of 1193 males and 43 per cent, of 1207
females. When epilepsy itself occurred in a parent it was
the father who was epileptic in 49 per cent, and the mother
in 51 per cent. The cases with insanity in a parent are only
one-third the number compared with parental epilepsy. Of
the cases with parental insanity the father was insane in
37 per cent, and the mother in 63 per cent. One effect of
heredity is to increase the female cases. When it was
absent the excess of males amounted to 4 per cent., but in
cases of heredity the same excess was presented by females.
This is partly due to the fact that inheritance is more
frequently from the mother’s side by 17 per cent., and that
the females are in excess by 18 per cent.” These facts
(obtained by Sir William Gowers) are in many ways in striking
conformity with the results obtained by my investigation of
insane relatives in the London county asylums as regards
certain types of insanity which I shall shortly relate. More¬
over, I have observed that a similar heredity occurs in a
considerable number of cases of insane epileptics, at least

Nervous and Mental Diseases

9

20 per cent. Spratling from his large experience at Craig
Colony gives 16 per cent, of similar heredity.

Hereditary Causation of Insanity.

There are a few alienist physicians who do not have a
strong belief in the hereditary causation of insanity, and my
esteemed colleague, Dr. C. A. Mercier, at the discussion on
heredity said: “ When we are confronted with the percentage
of persons among whose near relatives insanity is known to
exist we cannot fail to be impressed with two remarkable
facts, first how relatively small their percentage is, and
second, that the statistics, even if taken at their face value,
do not purport to be anything but an enumeratio simplex and
cannot be made the basis of any valid conclusion until they
are compared with similar statistics of the percentage of
insane relatives among the sane. ” He also stated that the
published statistics are of no value at all for any practical
or scientific purpose. With this I would entirely agree, but
in taking statistics among the sane population we should find
that insanity and epilepsy would often occur in families where
there are neuroses, eccentricity, and even genius, all of
which were variations from the normal average of the species.
I have endeavoured to ascertain what is the proportion of
insane, feeble-minded, and epileptic members occurring in
the pedigrees of my hospital patients; and I am greatly
indebted to my house physician, Dr. W. R. Thomas, for the
careful and painstaking way in which he has obtained informa¬
tion from the friends. In 32 pedigrees, which would include
about 1000 living representative and 250 dead individuals,
there were eight who had been in asylums and in eight
others fits were chronicled. In no case was either parent of
the patient insane or epileptic. Two of the pedigrees
furnished most of the cases. (Fig. 6.) One was a patient suf¬
fering from neurasthenia in which there were, besides insanity
and epilepsy, migraine, hysteria, deaf-mutism, and imbecility,
and the other a patient with exophthalmic goitre with
several neuropathic members in the stock. I must
confess that had I to prove my case by comparing
the pedigrees thus obtained with some pedigrees ob¬
tained at the London County Asylums and Imbecile
Asylum at Leavesden (20 non-selected pedigrees were kindly
taken for me by Dr. F. A. Elkins and his medical officers),
I should not have a very strong case, for in a very consider¬
able proportion of the cases admitted to these asylums
interrogation of the friends elicits no evidence of insanity on
either side. Yet most alienist physicians would not agree
with Dr. Mercier in casting doubt upon the importance of
heredity in the production of insanity. I would rather say
certain types of insanity. Many of the inmates of asylums
are suffering with congenital or post-natal organic brain

10

Mott: The Hereditary Aspects of

disease; these conditions are certainly not due to inheritance.
General paralysis of the insane, syphilitic brain disease, and
softening from vascnlar disease are acquired conditions and
should not be classed among the inherited insanities, nor
should Korsakoff’s psychosis and chronic alcoholism.

Fig. 3.

This pedigree shows a marriage of iirst cousins. The son pos¬
sessed brilliant talents, likewise a grandson, but of two
other grandsons, one was insane, another a suicide. The
fourth generation are all sound.

The following is the key to this figure and all the remaining

figures:—

•

O

%

/

4

7

®

O

e

Z

s

s

&

5

6

9

1. Insane.

6. Brilliant.

2. Physically unsound.

7. Died young.

3. Suicidal.

8. Drunkard.

4. Healthy.

9. Drunkard and insane.

5. Nervous disease.

In all attempts, however, to ascertain what forms of
insanity are especially due to inheritance there is always the
difficulty of finding out by inquiry of the friends what was
the nature of the insanity, not only because the friends do
not know, but also because different opinions may be held
by the medical men who have had charge of the cases, and
different systems of classification and terminology have been
used. Therefore, any statistical inquiry formed upon

Xerroiis and Mental Diseases

11

pedigrees the data of which are based solely upon informa¬
tion which has been obtained of friends of the patient may
have several radical faults. The lack of statistical evidence
of heredity in relation to feeble-mindedness was noticed by
Sir Francis Gal ton in his comments upon the Report of the
Commission on the Feeble-minded, and yet the opinion of
experts was unanimous in favour of the importance of
heredity as a causal factor.

Two years ago an experienced biometrician and scientist,
Mr. Edgar Schuster, kindly undertook to cooperate with me
in the study of the convolutional pattern of the brains
of relatives dying in the asylums, with a view of
seeing whether, just as there is a similarity of physiognomy
in the members of the same family, there is also
a similarity in the convolutionary pattern. An inquiry
was initiated concerning relatives at the various asylums,
and a request was made that brains of relatives
should be kept for examination after the necropsies had
been made. Isolated instances of two or more members
of the same family were known to exist by me in the various
asylums; but it soon became evident that a properly
coordinated card system would reveal the fact that a very
large number of parents and offspring and brothers and
sisters, besides collateral relatives, were resident in the
London County Asylums, or had been recently. In June the
numbers had risen from a few hundred known instances to
1834 (763 males and 1071 females), and since then, owing
to a newly opened asylum not having then furnished full
reports, and owing to the fact that fresh cases are con¬
tinually turning up at other asylums, the numbers have now
reached 2000. These instances have been afforded by the
records of patients under observation during the last two
years, and include their relatives who have died in, or who
have been discharged from, the London County Asylums
previously. A large number of cases of recurrent insanity
are included in these instances—e.g., one case has a record
of 23 admissions—and during the time taken for the collec¬
tion of the above cases several of them have been discharged
and readmitted ; but at the present time it is computed that
over 60 per cent, of the relative cases are still resident in
the London County Asylums. But this list does not include
patients with relatives in the asylums of the Metropolitan
Asylums Board, nor patients with relatives in other asylums
in Great Britain and Ireland.

Before proceeding to give further details of the inquiry I
wish to express my indebtedness to the clerk of the asylums
and the superintendents and medical officers for the valuable
assistance they have afforded me in obtaining information.

12

Mott: The Hereditary Aspects of

Statistical Data Relating to Inheritance of
Insanity.

The 1834 oases are made up from 854 families as follows :
2 instances of 6 of a family, 3 instances of 5 of a family, 12
instances of 4 of a family, 85 instances of 3 of a family, and
752 instances of 2 of a family. Of the 752 instances of 2
of a family, making in all 1504 cases, it will be observed
that the vast majority are directly, and not collaterally,
related. Another fact stands out prominently in an analysis
of the 752 instances of 2 of a family, and that is the much
greater incidence of transmission from parents to offspring
through the female side as the following figures show :—

Parental Heredity.

Males. Females.

Father and son . 44 instances 88 —

Mother .. 51 ,, 51 51

Father and daughter ... 58 „ 58 58

Mother „ . 104 .. — . 208

297 . 197 . 317

It will be observed that the mother transmits to the offspring
in the proportion of 60*7 per cent., the father 39*3 per cent.
This is not accounted for wholly by the fact that there are
more females in the asylums insane than males, for the ratio
of females to males in the asylums is rather less than 11: 8.
Sir William Gowers in his statistics regarding insanity in the
parents and epilepsy in the offspring observed that in cases
with parental insanity the father was insane in 37 per cent,
and the mother in 63 per cent. This, he says, is partly due
to the fact that inheritance is more frequently from the
mother’s side by 17 per cent., and that the females are in
excess by 18 per cent. It will be observed that these figures
of mine closely correspond with his on the transmission of
insanity from mother and father to offspring.

Co/ratcrnal Heredity in Tu o o f a Family.

Two sisters . 130 instances

Two brothers. 87 ,,

Brother and sister ... 13b ,,

310 396

The above table shows when pairs of offspring of the two
sexes are affected the proportion of males to females is
43*9 per cent, to 56 1 per cent., a difference of 12 2 per
cent. But the percentage in which the mother transmits
insanity to the offspring as compared with the father is
as 60-7 per cent, to 39-3 per cent., a difference of 26'4

Males.

.... 174
.... 136

Females.
... 260

... 136

Xerrons and Mental Diseases

13

per cent., and this increase of’ 14*2 per cent, is mainly
due to the fact that she transmits to the daughter nearly
twice as often as the father does. It may well be asked
whether this may not partly be due to the fact that the
daughter, at the time of life when insanity is manifested, is
more at home than the son, and therefore has more to do
with her insane mother.

Grandparents' Heredity .

Female with insane grandfather . 1 instance.

Male „ „ „ . 1 „

Females with insane grandmother .. 6 instances.

Males ,, „ „ . 5 „

This is undoubtedly very much below the proper ratio ; it is
due to the fact that there is far more difficulty of obtaining
records. The hereditary transmission from females, how¬
ever, markedly preponderates.

Collateral Insanity.

Female with uncle. 12 instances ... Male with uncle ... 11 instances

Female with aunt. 33 ,, ... Male with aunt ... 11 ,,

45 „ 22 „

There is here a more marked preponderance of females
affected than males than in direct heredity, but the numbers
are too few to draw any very decided conclusions, except the
fact that the females with aunt affected are as numerous as
all the rest combined.

The proportion of collateral relatives discovered in the
London County Asylums is comparatively small for several
reasons: the information is not so readily obtainable, and
they are less likely to come into the same asylum, as their
residence is not nearly so likely to be in the same district or
county as that of parent and offspring.

I have analysed the above figures, only taking into account
near blood relations (parents and offspring, brothers, sisters,
or brothers and sisters) where two or more representatives of
the family are now resident in the London County Asylums.
The following figures show that of an average insame popu¬
lation of approximately 20,000, 717 cases are thus related,
representing 342 families. We may ask the question, Should
we find in 20,000 adults, living in the County of London,
which some random non-inheritable cause had collected
together, this proportion of direct relationship ? I think not.

The figures, to my mind, in a broad way, are eloquent
in favour of the importance of heredity as a cause of
insanity, and the numbers being great, the data indis¬
putable facts, independent of the personal equation of the
inquirer, enable satisfactory statistics to be made and

14

Mott: The Hereditary Aspect* of

inferences to be drawn in regard to certain points relating
to the hereditary aspect of mental disease.

Analysis of Instances where Two of a Family (near Blood Relations) are
now Resident in the London County Asylums.

Father and son.

Cases.

... 34

Two sisters.

Cases.
... 144

Father and daughter

... 58

Two brothers .

... 80

Mother and son.

... 44

Brother and sister ...

... 160

Mother and daughter

... 102

making a total of 622 cases, representing 311 families. In addition to
the above there are 95 cases in which three (and in two instances four)
members of the same family are now insane residents in the London
County Asylums—31 families. Thus the grand total is 717 cases,
representing 342 families.

Tendency to Inheritance of Different Types
of Insanity.

When taking part in the discussion at the Royal Society
of Medicine on Heredity and Disease, I expressed the
opinion that, without then being able to give any precise
data, the investigation I was conducting had led me to con¬
clude that we should find among these relatives in the
asylums certain types of insanity exhibit a more marked
tendency to inheritance than others, and I enumerated
recurrent or manic-depressive insanity, delusional insanity
and the insanity of adolescence (dementia praecox), and
imbecility as having this tendency most marked. Moreover..
I observed that cases of general paralysis were relatively
few in number. In the light of modern views as regards
the causation of general paralysis being due to syphilitic
infection, I was not surprised to find my inference was
correct. Again, in the evidence which I gave before the
Royal Commission on the Feeble-minded I pointed out that
during the eight years ending Dec. 31st, 1902, there were
8933 patients discharged from the London County Asylums as
recovered; the percentage of readmissions was 25 a 59, and
one-half of these cases were readmitted within 12 months of
their discharge. The clinical records showed that a con¬
siderable number of these readmissions were cases of
recurrent insanity termed “ recurrent mania ” and “ recurrent
melancholia ”; the more modern term for this periodic
insanity is manic-depressive insanity. But by whatever
term it is called there is one feature—viz., periodicity.
When I inquired into the family histories of these cases
I found insanity in other members of the family in 55 per
cent., even though I did not eliminate those cases which
were not visited by friends, and there was no record regard¬
ing inheritance; moreover, I found particulars of many rela¬
tives of patients being in the asylum at the time or who had
previously been in there or died there. These observations

Nervous and Mental Diseases

15

were made at Colney Hatch Asylum, where the superintendent,
Dr. W. J. Seward, had for a long time been in the habit
of taking the history himself from the friends who visited.
I may add that this asylum has afforded valuable informa¬
tion in this research, partly because it is an old asylum with
records often of three generations, and partly because, con¬
taining, as it does, all the Jews, one has the opportunity of
comparing the incidence of inheritance of this race with the
non-Jewish population. I am indebted to Dr. Seward for the
following statistics relating to the percentage of relatives
among the Jewish and non-Jewish population. The number
of cards belonging to Jews is 80, the number belonging to
non-Jewish inmates is 254. The total number of inmates is
2450, and of these 459 are Jews. So that rather less than
one-fifth of the total population is Jewish. A little more
than one-fourth of the relative cards belong to Jews,
so that the incidence of ascertained relationship among
the Jewish inmates is considerably more than among the
non-Jewish. No doubt the temperament of the Jews renders
them as a race more liable to the neuropathic tendency; but
the greater incidence of ascertained relationship among the
Jews is partly due to the following facts : They are more
often visited by their friends. They have more pride
of family, know more about their family, and, as a
general rule, are more intelligent and anxious to afford
information.

Statistics are often distrusted when an inquirer sets out to
find something. I was therefore fortunate in having the
cooperation of such an unbiassed statistician skilled in
biometrics like Mr. Edgar Schuster. The cards were all
sent to him for an independent and unbiassed investiga¬
tion ; his valuable report is published in the forth¬
coming annual report of the Asylums Committee, but
I will summarise his results in great part in his own
words.

There were 319 pairs of parents and children; of these
the children in 69 cases suffered from periodic insanity.
Of the 69 so afflicted 28, or 40*6 per cent., had
parents similarly affected, while in 59*4 per cent, the
nature of the parent's disease was different. Of the
remaining 250 children only 41, or 16 a 4 per cent, had
parents suffering from periodic insanity. Bratz working at
Wuhlgarten Asylum, Berlin, on similar lines has obtained
similar results, but as yet he has not published any
statistics. He speaks of this similarity of insane inheritance
as a Vererbungskreis.

There was even greater similarity of insane inheritance
between brother and brother, between sister and sister, or
between brother and sister, when suffering from this form of
insanity, than between father and mother and son and
daughter. Thus there were 200 pairs in which the first brother
or sister was periodically insane, and in 92, or 46 per cent., of

16

Mott: The Hereditary Aspects of

these pairs the second member also suffered with manic-
depressive insanity, while in the remaining 108, or 54 per
cent., the two members differed in the nature of their
disease.

Where the first brother and sister suffered from some other
form of insanity, in only 13 8 per cent., as compared with
46 per cent., was the other member afflicted with periodic
insanity, while in 86*2 per cent, were other forms associated
together. This indicates similar cofraternal inheritance more
than three times as freqnent in recurrent insanity as in other
forms. Allowing that the term “recurrent ” may have been
used sometimes for a second attack of mania or melancholia
which was not truly a manic-depressive insanity, still it
would not account for this vast difference when dealing with
such a number of cases.

Delusional insanity .—Although the numbers dealt with
are many fewer, yet Dr. Schuster’s statistics show that the
tendency of this disease to run in families is more strongly
marked than between parents and offspring. The tables he
gives show that delusional insanity occurs with almost four
times as great a frequency (33*3 per cent, instead of 9 per
cent.) than among the insane parents of other insane people,
while among the brothers and sisters the frequency is just six
times as great (43*2 per cent, instead of 7*2 per cent.).
There is a decided tendency for the brothers and sisters of
imbeciles to be also imbecile.

In dementia praecox there is a strong correlation between
members of the same cofraternity. Seeing, however, that
quite 80 per cent, of the cases of this form of insanity
occur before the age of 25, it is not surprising to
find Schuster had no available material for statistics on
parents and offspring. Perhaps the term “insanity of
adolescence” is a better one than “dementia praecox.” The
report also shows a strong correlation between brothers and
sisters when affected with chronic mania or melancholia, but
the numbers are perhaps too small to draw any very definite
conclusions.

With regard to general paralysis he found no indication of
this disease running in families. The brothers and sisters of
general paralytics seem no more likely than anybody else to
be themselves general paralytics, and the same may be said
about their children. Of the very few cases of juvenile
general paralysis recorded, only one is the son of a general
paralytic.

The second problem enunciated was, Is there any
tendency for members of the same family (as in some
hereditary nervous diseases) to become insane at similar
periods of their lives ! Seeing that adolescence is the period
in which stress is likely to affect the individual with an
insane inheritance, it is not surprising that Schuster in his
report states that “a strong tendency exists for brothers and

Xervous and Mental Diseases

17

sisters of the same family to become insane at similar periods
in their lives, and only a slight one between parents and
children.”

Appearance of the Brain.

Since certain forms of insanity exhibit so much greater
tendency to similarity of type in parents and offspring and
brothers and sisters, it may be concluded that these cure the
types in which an inheritance of a tendency to insanity is
three or four times as great as in other forms. Now we may
ask ourselves the question, Is there any correlation between
the macroscopic and microscopic appearances of brains of
persons suffering from manic-depressive insanity, delusional
insanity, epilepsy, and insanity of adolescence where there
is no terminal dementia ? It would be difficult in the vast
majority of cases to discover any abnormal morphological
change, nor would microscopic investigation afford much
(if any) help in the elucidation of these psychoses. Indeed,
I know of only one form of insanity that is really (as I have
already said) an acquired organic disease—namely, general
paralysis—which on macroscopic and microscopic investiga¬
tion of the brain post mortem shows such change in the
organ of mind as to justify a diagnosis of the form of
insanity which had affected the individual during life. I do
not mean to say that these psychoses may not eventuate
in a dementia, and then changes may be found in the
brain.

There is a disease affecting Jewish children which is quite
specific in the changes observed in the brain and nervous
system: I refer to so-called “amaurotic idiocy.” Why it
should affect only Jewish children and occasionally occur in
several members of the same family is not known ; nor
is it explicable unless it be by an abiotrophy due to some
racial hereditary condition. This disease shows a patho¬
logical change quite unlike any other disease of the nervous
system that I have seen; the Nissl substance disappears
from without inwards towards the nucleus, and eventually
the nucleus itself dies and the whole cell undergoes a true
fatty degeneration ; the neurons which were the last
developed are the first to go—thus the pyramidal layer of
the cerebral cortex shows this fatty degeneration much more
markedly than the subcortical neurons.

Some Pedigrees Illustrating Inheritance.

Every insane patient should be considered as a biological
study. To say, merely, that one of bis ancestors was insane
and therefore he has a bad heredity, and to label him thus,
as is the common custom, is absurd. What we wish to know
is what he was born with and what has happened to him

18

Mofcfc : The Hereditary Aspects of

since birth. I have found that a conversation with the
mother will very much help in understanding the causes
which have led up to the mental breakdown, and she is often
able and generally very willing to tell all she knows
about the family. I am speaking only of the poorer
classes.

The causes of insanity are seldom simple ; they are in
varied degrees inborn tendencies combined with some form
of mental or bodily stress. I use the word “stress’* in its
widest sense as implying a strain on the important organs
and functions of the body. But it is not within the province
of this lecture to deal with these causes of insanity, for my
object is to dwell upon the elucidation of what were probably
the inborn tendencies. The construction of a pedigree will

Fig. 4.

Paternal. Maternal.

The patient, P, was a murderer, a brother committed suicide,
and two sisters were insane ; although there was a suicide
on the maternal side the insane tendency came mainly from
the father’s stock.

often answer the question, Did the patient come from a
good stock on both sides, or was there physical or mental
defect or both on maternal or paternal or on both sides?
The fact that a cousin was insane, or even several members
of a large stock, does not show a bad heredity ; often, indeed,
with several insane members there will be found men of
genius and men and women of great civic worth (vide
Fig. 3). A bad stock is where we find degeneracy, insanity,
drunkenness, and criminality in the pedigree (Fig. 4), or a
general low standard, mental and physical, in both stem and
branches of the family tree. The general tendency is for
insanity not to proceed beyond three generations. As
a rule, there is either a regression to the normal or the
stock dies out. Not infrequently the stock dies out by
the inborn tendency to insanity manifesting itself in the

19

Xer coils and Mental Diseases

form of congenital imbecility or insanity of adolescence
—dementia prsecox. (Fig. 5.) Such patients are especially
prone to die from tuberculosis; thus 44 rotten twigs are
continually breaking off the tree of life.” (Figs. 8 and

Fig. 5.

Maternal. Paternal.

Fig. 6.

Maternal. Paternal.

This pedigree is of a hospital patient P. suffering with neuras¬
thenia and mental symptoms. It will be observed that
nervous disease and insanity affect a number of members,
especially on the maternal side.

10.) I will illustrate these facts by some examples of
pedigrees.

Consanguinity does not appear to produce insanity or
nervous disease provided both stocks are free from taint,
but if there is insanity or epilepsy, not necessarily in the

20

Mott: The Hereditary Aspects of

first ascendants, but even in the collaterals, then inter¬
marriage of first cousins from these two stocks with
collateral insanity will tend to insanity, in some cases very
marked, in the offspring of the two sane related parents.
I have observed in many of these pedigrees, but have not as
yet compiled precise data, that manic-depressive insanity in
a stock is frequently associated with suicide in the members
so affected, and even in others not affected. The tendency
to suicide often runs in families, and some remarkable
pedigrees have been published in which members of families
in successive generations have taken their lives in a
particular way, and sometimes even at a particular age ;
there is a suicidal obsession. Morel mentions an instance
where seven brothers destroyed themselves though in good
position and suffering no misfortune. Mudge in the first
number of the Mendel Journal has published a remarkable
pedigree of two families that were united by marriage. In
one the members committed suicide by drowning, the other
by shooting. I would explain this by imitative suggestion
acting on a neuropathic stock. A member of a family of
four generations of suicides, of which two were inmates of
the London County Asylums—namely, Oolney Hatch and
Cane Hill—and the pedigree of which I will now show you,
affords a striking example of suicide and insanity in
successive generations:—

Fig. 7.

Admitted to Cane Hill for
attempted suicide by poison:

Patient IV.

I

An epileptic; attempted | |

suicide in 1874 by cutting Mother III. Father sane
her left arm ; was taken
to Colney Hatch, where
she still ‘remains

Committed suicide
by cutting his left
arm ana dying
from haemorrhage

Four children (three I

males and one female); Mother died
all confined in lunatic insane

asylums

Father I. Mother committal suicide ; cut her
left arm and died from haemorrhage

It will be observed that in three successive generations
suicide was attempted or committed by cutting the left arm.

Another interesting case of a suicidal family in which a
member developed impulsive obsessions of suicide and auto¬
mutilation occurred at Cane Hill Asylum and was published

Nervous and Mental Diseases

21

by Dr. H. Devine, accompanied by interesting observations on
the subject. The development of the obsessions in the
patient dated from the annt’s suicide, which is a proof that
suggestion was the cause, acting in conjunction with insane
inheritance.

Alcoholism.

The vexed question of transmission of acquired characters,
specially in relation to alcoholism, is one of great importance
and interest. That the germ cells are sequestered— 11 in
the body and not of the body,” therefore not partici¬
pating in the biochemical changes which occur therein—
and that in prolonged toxic conditions are uninfluenced
in their nutrition and their specific vital energy, is

Fig. 8.

Paternal. Maternal.

Drink and insanity in three generations ; for description see text.

contrary to reason. It may therefore be asked how
it is, as so often happens, a chronic alcoholic may have
offspring mentally and physically sound? The question is
wrapped up in the causes which lead a man to drink, and my
observations seem to show that a man who can drink con¬
tinually for numbers of years and keep out of a lunatic
asylum, a prison, or a hospital, must have possessed an
inherent stable physical and mental organisation, and he
in a measure transmits this, the virility of the stock re¬
maining potent in spite of the vicious habit, although it is
undeniable that his offspring in all probability would have
been stronger and better had he been a temperate man.
Drunkenness in successive generations would undoubtedly
lower the virility, and mental and physical degeneracy would
result. Dr. Archdall Reid has expounded the tendency of
the uncontrolled alcoholic type to work itself out and the
same is true of other types.

22

Mott: The Hereditary Aspects of

I have often noticed that the children of chronic drunkards,
especially when the father drank and the mother was
temperate, are total abstainers. There can be no question
that chronic alcoholism does figure largely in the pedigrees
of patients admitted to. asylums; but the same occurs—
though I think not with such frequency—in the pedigrees of
hospital patients. The accompanying pedigree (Fig. 8) was
always regarded as a proof that alcoholism may be pro¬
ductive of insanity in several members of a family. The
institution of the card system revealed the fact that there
was collateral insanity (Fig. 8). I discovered that the sister
of the drunken paternal grandmother died in Oolney Hatch
Asylum, where she was resident for 20 years, and her

Fig. 9.

Paternal. Maternal.

Pedigree of a woman with two husbands. By her temperate
first husband a healthy stock ; by her second drunken
husband only one of them sound.

daughter, an imbecile, was at Leavesden. Further unbiased
inquiries on these lines are very necessary. Occasionally I have
met with a pedigree (Fig. 9), such as the one I show you, in
which a woman has had two husbands ; by her first husband
(a temperate man) she had a family of healthy children and
numerous grandchildren ; by her second husband (a chronic
drunkard and one of a family of drunkards of several
generations) she had three children, one with a muscular
dystrophy, another an epileptic imbecile, and another
apparently healthy. A few cases such as this may be a
mere coincidence, but multiplied, seeing that they are
almost of the nature of an experiment, would form a con¬
vincing argument in support of the injurious effects
of alcohol on the germ cells. It has long been the
opinion that chronic drunkenness of the parents leads

Nervous and Mental Diseases

28

to mental degeneracy in the offspring in the form
of feeble-minded ness and epilepsy. With this I should
agree, bat that the desire lor alcohol is transmitted from
parent to offspring, in the form of like begetting like
instead of like begetting a tendency to like, is without
foundation. What may be transmitted is the temperament
that induces alcoholism, a lack of will-power and moral
sense. The transmission of an acquired character, such as
the desire for alcohol, is contrary to the doctrine of heredity.

Pedigrees of Imbeciles, etc.

In a number of pedigrees obtained from an imbecile asylum
(Leavesden), for which I am indebted to Dr. Elkins, the

Fig. 10.

Maternal. Paternal.

This pedigree shows the end of a degenerate stock. A woman
of an insane stock marries twice ; by her first husband there
is one child living; by her second husband, presumably
syphilitic, there are two born dead and two others in the
asylum, one being a juvenile paralytic.

superintendent, I observe (though the numbers are not
sufficient yet to give any precise data) that the families are
prolific, quite as prolific as those of the pedigrees of hospital
cases, but there is relatively a larger number of deaths from
various diseases, especially tuberculosis. Some family
pedigrees show a large number of miscarriages and still¬
births associated with imbecility and epilepsy and occasion¬
ally juvenile general paralysis. The cause of this is
syphilis. (Fig. 10) The mental defect in a large
number of these cases in imbecile asylums is undoubtedly
due to organic brain disease and injuries at birth and
after.

I have still another pedigree to show; it illustrates the
transmission of a similar character and life in two genera¬
tions and possibly three. (Fig. 11.) The grandfather was a

24

Mott: The Hereditary Aspect* of

most distinguished man who lived to a great age, much
respected. He had a daughter concerning whose mother no
particulars were obtained. This daughter was a drunkard
and of a defective moral character. She had a daughter
who behaved in a somewhat similar manner, and is at
present in an asylum; she has married twice. By her
first husband she had two still-born children; by her
second husband no children ; fortunately this stock has died
out.

A study of pedigrees teaches us the truth of the conclusion
which Maudsley emphasises in “ Pathology of Mind”:
14 First, that a person does not inherit insanity, but a tendency
or predisposition; and, secondly, that the tendency is in¬
herited from the stock.”. “Nor need the unsound strain

in the stock show itself in any form of actual insanity; it

Fig. 11.

Two generations of drunken mothers and the stock of a great
man is ended.

may appear in some allied nervous disorder, in hypochon¬
driasis. in suicide, in epilepsy, in dipsomania, in weakness of
mind, in neuralgias, in chorea, in stammering, in spasmodic
asthma, in some periodical nerve storm of abnormal character ;
and conversely these disorders of one generation may in their
turn forebode some form of insanity in the next generation.”
(Fig. 12.)

Eugenics and National Degeneracy.

With the spread of the knowledge of heredity and the
interest shown among the intellectual and thinking classes
by the study of such works as Whetham’s “The Family and
the Nation,” more care will doubtless be taken in marriage
selection; moreover, the cult of eugenics—literally good
breeding—a term employed by Sir Francis Galton to denote
the science and art of the improvement of the human race by

Xervowt and Mental Diseases

25

the double process of multiplying the fit and eliminating the
unfit—is daily gaining ground. Again, the study of heredity
teaches that the measure of the physical, mental, and moral
capacity of the individual for civic worth and usefulness
depends largely upon inborn characters; you do not gather
grapes of thorns or figs of thistles. Bateson has truly said,
education, sanitation, and the rest are but the giving or with¬
holding of opportunity. The diminishing birth-rate of the

Fig. 12.

Paternal. Maternal.

This pedigree of four generations is Interesting on account of
its completeness and by the large number of members of the
stock on the maternal side which are affected with insanity,
nervous diseases, and suicide; but there is not a single
alcoholic on either the paternal or maternal aide. The
paternal stock is not free from taint, but the three cases of
insanity and the suicide of the fourth generation, making up
nearly half the living members, have for their parents a
healthy father and a mother with nervous disease. It shows
how necessary it is to study the maternal and paternal pedi¬
grees in coming to any just conclusion about hereditary

transmission.

professional and middle classes with the high birth-rate and
diminished infant mortality of the lower classes is now
agitating the minds of many, but the fact nevertheless
remains that Nature cares little about individuals or societies ;
it is mindful only of the species, and the instinct to
propagate is so rooted in our animal natures that in the
process of the mental evolution of man it has become the
root and stem of the tree of life upon which have been
grafted the moral virtues and altruistic sentiments which are
most nobly personified in maternity. We can therefore
understand how the Madonna and Child has appealed
symbolically to the simple faith and devotion of countless
[pillions.

26 Hereditary Aspects of Nervous and Mental Diseases

An intellectual development, whether of the individual, or
community, or race, that starves the natural instincts of
love, marriage, parentage, and pride of family,—these, the
noblest of all human aspirations, will pay the penalty, and
one way in which the penalty for the starvation of this
instinct will be paid for by advanced civilisation is the
increase of the neurotic, self-regarding type of temperament,
the forerunner frequently of neuroses and insanity.

We are constantly reminded of the fact that insanity is on
the increase; in the last 15 years the London County Council
has opened four new asylums and an epileptic colony, and
is now building another huge asylum; loud is the cry of
national degeneracy, but when people are feeling most
pessimistic about a natural decay of the race it would
be well, if they would remember this passage from
a lecture by Huxley on “ Harvey and the Discovery
of the Circulation of the Blood”: “I myself am of
opinion that the memory of the great men of a nation is
one of its most precious possessions—not because we have
any right to plume ourselves upon their having existed, as a
matter of national vanity, but because we have a just and
rational ground of expectations that the race which has
brought forth such products as these may, and in good time,
under fortunate circumstances, produce the like again. I am
one of those people who do not believe in the natural decay
of nations, I believe, to speak frankly, that the whole theory
is a speculation invented by cowards to excuse knaves. My
belief is that so far as this old English stock is concerned, it
has as much sap and vitality and power as it had two
centuries ago, and that with due pruning of rotten branches
and due hoeing up of weeds which will grow about the
roots the like products will be yielded again. The weeds
to which I refer are mainly three : the first of them is
dishonesty, the second is sentimentality, and the third is
luxury.”

Reprinted from The Lancet, May 13 , 1911 .

% %tdm

ON

HEREDITY AND INSANITY.

Being the last of a Series of Suo Lectures on Heredity delivered
at the Royal Institution in January and
February , 1911,

By F. W. MOTT, M.D., F.R.C.P. Lond., F.R.S.,

PATHOLOGIST TO THE LOHDOH COUNTY ASYLUMS; PHYSICIAN TO
CHARING CROSS H08PITAL; AND FULL BRIAN PROFESSOR,

ROYAL INSTITUTION.

In this my last lecture on Heredity I propose to deal
with the subject in regard to its social and economical
aspects as affecting civilised humanity. Last week I
gave yon some striking examples of the sadden appear¬
ance, apparently as sports, of congenital defects, abnor¬
malities, and diseases which were transmitted through
several, and in some instances through many, generations.
Why, it may be asked, do these conditions not become
general ? Natural selection and survival of the fittest
together with the constant tendency to regression to the
normal average of the race is the answer. In the long
procession of ages evolution has made man as he is with
five toes and five fingers, and of an average stature varying
from 5 to 6 ft., consequently there is always that tendenoy
operating to maintain the normal average of the race, and the
continuous operation of inheritance in the maintenance of
specific racial stability is one of the biggest factors in
heredity.

Natural Selection and Prevention of Perpetuation
of Poor Types.

We may now ask the question. How has nature prevented
the perpetuation of poor types in man? In fact, in what
way has man had to struggle for existence? All through
history we shall find that as among animals and plants, so
with man, the great struggle has been in the same species—
viz., man with man. So the evolution of mental attributes^.

H Mott: Heredity and Insanity

intelligence, quickness of perception, courage, memory, and
will power, have become gradually as essential in the
struggle for existence and propagation as longevity, resist¬
ance to disease, and physical strength. It is the brainy
rather than the bulky than can now survive and propagate.

The great centres of civilisation and human progress have
in the past especially been built up in those regions of the
earth where Nature has provided a great store of energy
which can readily be utilised and converted into human
onergy—e.g., through ages and ages the Nile provided by
its fertilising agency food for millions upon millions of
human beings. But where with a lavish hand Nature pro-
Tides the means for unlimited individual lives, and therefore
almost unlimited propagation of the speoies, it enforces a
-constant and severe struggle for existence by which if
Nature’s methods are not interfered with only those possessing
such mental and bodily conditions suitable for the struggle
survive. In this way blood-thirstiness, craftiness, ferocity,
and animal passions, combined with bodily strength and
resistance to injury and disease, would in earlier times be
the endowments which would best be adapted for survival.

Nature’s Modes of Selection.

However, men who gathered together in large numbers,
-especially when forming conquering armies, are sooner or
later visited by more terrible (because unseen) foes than
these human enemies. Deadly germs or habits to which
-either the conquering or the conquered have in the long pro¬
gression of generation after generation gradually become
immune, finding a new and suitable soil upon which to
develop, devastate and destroy the bold and bloodthirsty as
well as the oowardly and the superstitious; all alike, from
the highest to the lowest, are swept away by epidemic
diseases. This is well exemplified by Holbein's picture of
the Dance of Death. Wars, famine, plague, spotted typhus,
small-pox, syphilis, tuberculosis, malaria, and other diseases,
as well as narootics, have long been the scourges of densely
populated countries. Many of the diseases are filth-begotten.
Consequently those individual communities and races who
have a better chance of survival in the struggle for existence
are those who are most intelligent and cleanly in their
habits. The recent Russo-Japanese war is the first on record
in which one nation lost more men from injury than disease.
This was due to the extraordinary intelligence and cleanli¬
ness of the Japanese in the conduct of their campaign, which
largely contributed to their success.

During the progress of wars there is little opportunity for
knowledge and learning to be displayed, yet if a nation
possesses ancestral stocks endowed with inborn intellectual
greatness, it is only latent during these periods of

Mott: Heredity and Insanity

8

national stress awaiting its opportnnity of shining forth.
This nation, impoverished by two centuries of bloody wars
at home and abroad, by famine and epidemic disease, threw
off the yoke of tyranny with the Reformation, and following
this appeared in England an unrivalled period of intellectual
development. Spenser, Milton, Shakespeare, Marlowe,
Bacon, Ben Jonson, and a host of other stars of lesser
magnitude blazoned forth to enlighten the world for all time.
The history of the world shows that nations decay and die
more often from prosperity and luxury than from striving
and adversity.

Man’s Control of Nature in Relation to Natural
Selection.

Man by his disoovery of the causes and prevention of
disease, and his power of acquiring, accumulating, and dis¬
tributing energy by harnessing the forces of Nature, has
effected a control over Nature and her methods of natural
selection. Hitherto Nature, unmindful of the individual and
mindful only of the species in its operation of survival of the
fittest, said to the blind, the halt, the lame, the diseased, the
feeble of mind and body, “Thou shalt not live.” In this
respect Nature had no choice; her only prevention of
multiplication of the unfit was to exterminate them. But
civilised man, by his control of Nature’s process of selection,
has interfered with the laws of natural selection and survival
of the fittest, and unless, as Ray Lankester says, man enters
fully into the possession of his kingdom and prevents the
perpetuation and multiplication of poor types, racial
degeneration must follow. The proper attitude to take up
in this question as regards the perpetuation of poor types,
according to a well-known journalist, is that laid down by
Huxley : “ We are sorry for you, we will do our best for you
(in so doing we elevate ourselves, since mercy blesses him
that gives and him that takes), but we deny you the right to
parentage. You may live, but you must not propagate.”

To no class of people does this principle apply with
greater force and urgency than to the mentally defective or
feeble-minded. It is only within the last century that the
feeble-minded have had as much chance of survival for
themselves or prospect of banding down their mental and
physical defects to successive generations. But all these
causes which by Nature’s mode of selection weed out the
poor types have been controlled by man without supplying
any alternative scheme of selection such as he uses with
success in his breeding of domestic animals when he employs
only the best types for propagating. At the present time in
Great Britain restriction of families is occurring in one-half
or two-thirds of the people, including nearly all the best,
while children are being freely bom to the feeble-minded, to

4

Mott: Heredity and Insanity

the pauper, to the thriftless casual labourers, to the criminals
and others generally the denizens of one-roomed tenements of
our great oities. Professor Karl Pearson keeps warning us,
25 per cent, of our population, including the above, Is
producing 50 per cent, of our ohildren, and if this goes on
must lead to national deterioration and degeneracy.

Heredity in Relation to Feeble-mindedness and
Insanity.

Before proceeding to the facts which I myself have
collected regarding the heredity of insanity and feeble¬
mindedness, let me cite two remarkable instances of the evil
inheritance of two separate women.

Professor Poelmann of Bonn has recorded the case of a
woman, who was a confirmed drunkard and who died early in
the nineteenth century, who was the direct ancestor of 834
persons. Of these 700 were known, 157 were illegitimate,
162 were professional paupers, 64 were paupers, 181 were
women on the streets, 7 were condemned to death for
murder, and 76 were convicted of lesser crimes.

Then there is the famous Jake’s family. Ada Juke, known
as the “ mother of criminals,” left 1200 direct descendants
of whom nearly 1000 were criminals, paupers, inebriates,
insane, or on the streets. The cost to the State directly in
consequence of this inheritance was £260,000, while the
indirect loss cannot be estimated. Bat these are only extra¬
ordinary and isolated instances of many.

The reading by the general public of such books as the
Whethams’ “ Family and the Nation,” the growing interest
shown by the public in the work carried out by the Galton-
Pearson school of eugenics, together with the publicity
which controversial questions of heredity and transmission
of acquired diseases have obtained, have done something to
awaken the public conscience and the Government, but
probably nothing has appealed more to the thinking man, and,
we should hope, voter, than the rapid addition to the rates
for the maintenance of lunatic paupers and feeble-minded.

Whetham remarks : “ According to the mid-Victorian con¬
cept a man was either sane or insane—quite mad or com¬
pletely cured. How he became mad, how completely he was
cured were not taken into consideration. [I am afraid the
Lunacy Laws and their application are still of that epoch.]
When he was once discharged from the asylum, like the man
in the old song—

'Whither he went and how he fared
Nobody knew and nobody cared.’

Such a method of treatment has bad its effect in the exten¬
sion of inheritance of mental inferiority. The Commissioners

Mott: Heredity and Insanity

5

estimated that the number of those persons who, while not
certifiably insane, are suffering from mental defect is about
150,000, to which must be added at least another 150,000 in
the asylums as well as those who have been in asylums and
have been discharged.”

Moreover, according to a report of Dr. Branthwaite,
upwards of 62 per cent, of the persons committed to
reformatories under the Inebriates Act are found to be
insane or defective in varying degree; and from a study
of hundreds of portraits of inebriates on the black list I am
convinced that quite that proportion of such chronic alco¬
holics are feeble-minded degenerates frequently of a lower
type than the lunatics certified and sent to asylums.

Alcoholism and Insanity.

The general opinion, indeed, of the experts who gave
evidence before the Royal Commission on the Feeble-minded
was that alcoholism in one or both parents exerts its
influence mainly upon the vitality of the children. It is a
question, howeve**, how far this is due to neglect, and whether
the children of drunken parents, if removed from parental
influence and cared for, would show a defective vitality.

The proposition which is so often made that acohol is
the principal cause of insanity should, in my opinion, be
re-stated as the principal cause of admissions to asylums.
There are many facts which show that the high percentage,
20-30, given by some authorities and the Commissioners in
Lunacy of alcohol as the effective cause of insanity is
erroneous. Alcohol in the majority of cases is only a co¬
efficient, and an inherited potential mental instability in
these cases is the efficient cause. In support of my argument
I would refer to the results of a comparison of 2000 post¬
mortem examinations made at Charing Cross Hospital, among
which there were 110 cases of advanced cirrhosis of the liver,
in the great majority of cases (60 per cent.) with dropsy, and
accompanied by a history of prolonged abuse of alcohol. In
my asylum experience there were relatively very few cases of
cirrhosis of the liver and only one case so far advanced as to
be accompanied by dropsy, and that was in a notorious
police-court character who was convioted nearly 400 times
before she was found incapable of taking care of herself.
If she served no other useful purpose she was a valuable
object-lesson of the inefficiency of the liquor laws. In
addition to this evidence true alcoholic dementia of a per¬
manent nature is comparatively a very infrequent condition
according to my experience. Then I should like to allude
to the fact that Dr. Bevan Lewis, Dr. P. W. Macdonald
and Dr. W. G. Sullivan have each independently shown that
there is more insanity, more pauperism, less crime and less
drink in rural districts than in industrial centres and mari-

6

Mott: Heredity and Insanity

time populations, where there is more drunkenness, more
crime, less pauperism, and less insanity. If we oannot
convict alcoholism of being the effective cause of insanity,
we certainly can of most crimes, especially of violence.
Whereas drink and crime are relatively rare among Qaakers
and Jews, insanity is prevalent; this may be due to inter¬
marriage of unsound stocks. I have shown that at Oolney
Hatch Asylum, where there are close on 600 Jews and 2000
Christian inmates, heredity is a more important factor in the
former than in the latter.

I have repeatedly observed that a quantity of alcohol
which may be consumed daily by a man of inherited sound
mind without apparent harm is sufficient to make a potential
lunatic anti-social or certifiable. It follows, therefore, that
alcohol acts as an eliminator of the unstable, the defective,
and those who lack control of the animal passions. In fact,
Archdall Reid in his interesting work on Heredity argues
with much cogency that alcohol weeds out great numbers of
individuals of a particular type, those most susceptible to its
charm and to its poisonous effects upon the mind, and he
reasons that alcohol, like disease, should be a cause of pro¬
ductive evolution. Every race, he affirms, that has had the
experience of alcohol is temperate in the presence of an
abundant supply in proportion to the length and severity of
its past experience of the poison. This, according to Reid,
is Nature’s successful scheme of Temperance Reform.

Alcohol is the most effective weapon oivilised man has to
wipe out inferior and savage races who have previously had
no experience of it.

There is no proof that the drink habit is transmitted to the
offspring. I have observed that a large number of children
of drunkards are total abstainers. If they take to drink it is
because they inherit that weak will power and lack of moral
sense whereby they, like their parent, are unable to resist the
temptation to drink and acquire a vicious habit which, in
spite of the misery caused to themselves and others, they are
unable to resist and overcome.

Tuberculosis and Insanity.

Another cause which in the past has been a powerful agent
in the elimination of the feeble-minded and the lunatic is
tuberculosis. My observations 1 on the relation of tuber¬
culosis and insanity are based upon the collected reports of
all the London County asylums with a population of nearly
20,000 lunatics extending over a period of five years. There
can be no doubt that tuberculosis is especially prone to affect
the insane, particularly individuals suffering from certain
types of insanity—viz., imbecility, adolescent insanity, and

1 Archives of Neurology, vol. iv.

Mott: Heredity and Insanity

7

the depressed melancholic types. Indeed, the death-rate
from pulmonary tuberculosis for the insane between the ages
of 15 and 35 is about 15 times that of the sane for the same
age-period. It was formerly stated that the lunatics acquire
the disease in the overcrowded, insanitary asylums. This is
not the case; the conditions are much more sanitary than in
their own homes, both as regards air-space, ventilation, and
nutritious food. Moreover, it is rare indeed that a nurse or
attendant of the 1800 employed suffers from consumption,
and there is no proof in the few instances which have
occurred that they have acquired the disease owing to their
occupation. Many patients die in the asylums, having been
resident there from 30 to 50 years, and show no trace of
tuberculosis. This only proves that the soil as well as the
seed is essential for the acquirement of this disease. Tuber¬
culosis in the insane is due in part to an inherent nutritional
deficiency, for tuberculosis ard insanity affect both rich and
poor. In speaking of an inherent nutritional deficiency l
refer to a failure to assimilate food when it can be obtained
in abundance. There is, however, a definite correlation
between pauperism and tuberculosis and pauperism and
insanity. In such case deficient supply of nutritious food is
an important factor.

The great decline in the tuberculosis death-rate in the
population which has taken place during the last 30 years is
undoubtedly due to the improvement of the general social
conditions of the people—i.e, the better housing of the
poor, the improvements of the conditions of light and
ventilation in workshop and factory, combined with cheaper
food and the fall in the drink bill. Though we see this
constant fall has been taking place for many years, do we
see a corresponding fall in the number of lunatics and
feeble-minded? Let me show you a chart (Fig. 1) indi¬
cating what has happened : it is taken from the report of
the Commissioners in Lunacy. If alcohol and tuberculosis
were the main causes of insanity, surely we should have had
a fall, but here we have a constant rise, and this tends to
prove my point—that Nature's mode of selection having
been improved away by man’s intelligence, he must exercise
it still further by denying civic rights of propagation to
certain degenerate types.

Insanity and Society.

What is insanity ? We know so little about the minute '
and subtle physiological actions of the brain as an organ of
the mind that we are unable to interpret the derangements
and departures from the normal underlying the true insanities.
We do know that all the nervous units or neurons are
present at birth with all their inborn potentialities. We also
((now that low-grade imbeciles and idiots, as a rule, are borq

8

Mott: Heredity and Insanity

with an insufficiency in numbers and a deficiency in develop¬
mental powers of the nervous units or neurons connected
with the higher functions of the mind—a condition which
no amount of education or feeding can rectify, because there
was a failure in the germinal determinants of those nervous

Fig. 1.

Showing comparative variations in the proportion of the
insane in England and Wales (and of the pauper and private
classes respectively) to the total population, 1869-1910.

structures in the fertilised egg cell; for, as Thompson says,
there is a general agreement among biologists that inborn
variations which give every organism its individuality are the
expression of changes in the intricate architecture of the
germ plasm. This condition of amentia, or lack of mind,
may present itself in several grades—viz., the microcephalic

Mott: Heredity and Insanity

9

idiot and sometimes the hydrocephalic idiot, in which the
animal instincts are alone retained ; the low-grade imbecile,
who may also be an epileptic or oriminal; the high-grade
imbecile, who may also be an epileptic or crimiual. The
last-named are the most dangerous from a racial point of
view because they are not segregated, and breed criminals,
lunatics, drunkards, and the unemployable I do nor. mean
to affirm that all high-grade imbeciles are of this character.
Many of those who are intellectually deficient are not
morally deficient; but where by birth and nurture they are
irremediably defective morally and intellectually it is useless
trying to make them fit for social privileges. Again, there
are those who are not intellectually deficient but who ara
morally defective, born criminals or perverts.

Genius and Insanity.

An individual is considered insane whose conduct is anti¬
social when, owing to a morbid or deranged state of his
mind, he no longer thinks, feels, or acts in accordance with
the usages and customs of the society to which he belongs.
It is, however, hard to draw a line between eccentricity and
insanity on the one hand, and insanity and crime on the
other. Bach are manifestations of a mental degeneracy, and
may exist separately or combined. Many eccentric de¬
generates are insane, but are tolerated and even, in some
notorious cases, adored by society, because combined with
their madness there is often a streak of genius. Some of the
most brilliant men in arts, science, and literature have
either been insane themselves (e.g.. Schumann, Lamb,
Nietsohe) or have come from parents who wore insane
(Turner, Bacon), or there was a taint in the ancestral stocks.
Men like Napoleon and Julius Caesar were said to be
epileptics; Mohamet and Martin Luther had hallucinations.
Tet these men have been the foremost in making the world’s
history. In our times we have reason to thank a mad king
for the discovery of the musical genius of Wagner, and for
having made Munich the Mecca of musicians. It is true
therefore that “ great genius and madness are often close
akin,” but it is also true, as Maudsley affirms, that
often the genius which is thus closely allied to insanity
is of an inferior order—intense, narrow, hysterical, explosive,
not calm, large, whole, and constructive. Between verit¬
able madmen who exhibit fitful flashes of genius, madness
streaked with genias, and persons with real genius who
display eccentricities of thought, feeling, and conduct that
speak of madness, there are a number and variety of persons
who are clever bub flighty, talented but unstable, intense
but narrow, earnest but fanatical, all sorts of persons who,
plunging into new movements good or bad and pursuing
them with intemperate, perhaps distempered, zeal, lack the

10

Mott: Heredity and Insanity

just balance of the faculties, the calm equilibrium of a
stable mental organisation, the true perception or mean of
nature “ which is the highest sanity.' 1 Mandsley further
asks: “ What comparison is possible between Chateaubriand
and Shakespeare, between Jean Jacques Rousseau and
Goethe ? ”

I will now throw on the screen a slide (Fig. 2) illustrating
a pedigree of insanity and genius, and I may say that the
genius in this case possessed in a high degree the calm
equilibrium of a stable mental organisation.

Fig. 2.

A A
k

• § 6
< 5”3

6 6 6 6

Pedigree showing a marriage of (lrat-couslna. The son
possessed brilliant talents (circle in sixths), likewise a
grandson, but of two other gmndsons one was Insane (black
circles) and another a suicide (circle with cross). The
fourth generation are all sound. Circle with black centre ,

physically unsound. Thi same shaded, dead.

Here is the pedigree (Pig. 3) of a great man who lived to
a great age, who married beneath him, and we see the
elimination of the stock. His daughter was drunken and
immoral; her daughter was drunken, immoral, and insane.
By her first husband she had two children born dead, by her
second no children, so the stock was terminated.

According to a recent writer on the madness of Robert
Schumann it is more correct to regard the creative faculties
of this musical genius and his constitutional mental disease
as concomitant but independent phenomena. His genius
shows itself, not in consequence of the mental malformation,
but in spite of it.

Mile. Robinovitch, in an interesting paper La Gen&se du
Genie, showed that of 74 great geniuses only ten were first¬
born. As a rule, the parents of great men are of ripe age
when they are born ; in fact, conception takes place when
cellular potential is at the maximum.

Mott: Heredity and Insanity

11

Heredity and Suicide.

Voltaire pointed out the hereditary character of suicide,
and I have met with several remarkable instances. More-

Fig. 3.

Two generations of dranken mothers, and the stock of a great
man la ended. Circle with quadrants , alcoholism; half
black circle with quadrants , alcoholism and insanity; circle
with black centre , physically unsound; small shaded circles ,
miscarriage or stillbirth.

FIG. 4.

M

yr^

<5q, % <5

T

S h w? 5 ^

The patient (P) was a murderer (bad been insane), a brother
committed suicide, and two sisters were insane; all were
cases of adolescent insanity. Although there was a suicide
on the maternal side, the insane tendency came mainly from
the father’s stock. Black circtcs % insanity; circle with
deep black rim , nervous disease; circle with black centre ,
physically unsound ; circle with cross , suicide; shaded
circlest died young.

over, I have observed that recurrent insanity in a stock is
frequently associated with suicide in the members so affected
and even in others not affected. I will throw on the screen
a slide (Fig. 4) showing homicide, suicide, and insanity.

12

Mofcfc: Heredity and Insanity

The teudenoy to suicide often runs in families, and some
remarkable pedigrees have been published in which members
of families of successive generations have taken their lives in
a particular way, and sometimes even at a particular age—
there is a suicidal obsession. Morel mentions an instance
where seven brothers destroyed themselves though in good
positions and suffering from no misfortune. Mudge, in the
first number of the Mendel Journal , has published a remark¬
able pedigree of two families that were united by marriage.
In one the members committed suicide by drowning and the
other by shooting. Again, here is a remarkable pedigree of
four generations of suioide and insanity that occurred in the
London Oounty Asylums (Fig. 5).

Fig. 5.

An epileptic. attempted
Mjidui* in 1871 by cutting
her li lt arm : \v:i* taken
to Colnry Hatcfe. where
j*be still remain*

Admitted to Cnne Hilt for
attempted suicide by poison
Patient IV

Mother III Father sane

Committed suteido
by cutting hi** left
arm and dying
from haemorrhage

Four children (three male* i

and one female) all eon- Mothcrdied

fined in lunatic asylums insane **

1 ;

(Father l Mother committed suicide: cut lu*r

left arm and died from haemorrhage

Suicide and insanity in four generations.

Ziegler’s Theory of Germinal Determinants.

In my last lecture I showed you a diagram which may be
used to explain some of the facts of heredity, and especially
in connexion with insanity and nervous diseases like epilepsy.
This diagram, which I will again use (Fig. 6), serves to
explain why in a tainted stock some of the offspring may
escape while others are affected, and why if there is a taint
on both sides the chance of tainted offspring occurring
increases, while if there are intermarriages or consanguineous
union not only will the offspring be more likely to be
affected with the taint, but the depth of the degeneracy and
the earlier age at which it will come on will be increased.
This probably accounts in a measure for the prevalence of
insanity amoDg Jews and even Quakers, who are abstemious,
and, as a rule, live in a clean and healthy manner.

Mott: Heredity and Insanity

13

Consanguinity and Degeneracy.

Perhaps the most striking effects of consanguinity can be
observed in some of the royal families and the Caesars. I
will throw on the screen a chart (Fig. 7) of the CaBsars,

A. tniit

A*1«L

( 12 3 4

•—Q

tuu\.

*471)

AAAA j

Fig. 6.

OnenoiwMt

8

inm«tun
r<2utU U

tilt 13 47 H7| j«(» >44V 34)1

antssfits ♦

Bl fcm«k a*«nt
At«i

4 » - n »%**»

[ 0069 WOOQ
-

4«i»* %»Htf

C. Semi MUltt if A X 8

° * Chnimmu A X >»-

[ —Ait 00gQ ) * (+QAA 00DO )

| *wU«41* |

UM 1IM rAM 14014 »4*» ***■• 4M4 4«*4W >4**4

N ^ M M A #0 OA OA OA #A

06 00 00 T 06 06 0D DD 6Q

Diagram explaining transmission of a defect in different
degrees by the same parents. The black figures Indicate
diseased germinal determinants. It will be observed that
A t the male parent, inherits diseased germinal determinants
from both father and mother; B, the female parent, Inherits
slight germinal defects from the mother. Beneath each is
shown the reduction of the chromosomes (germinal deter¬
minants). In C we have illustrated some of the results of
mating A and B. We can thus understand how some of the
offspring are free from taint while others are markedly
affected. (After E. Nettleahip.)

Fig. 7.

Pedigree of the Caesars. Half black circles, insanity ; circle*
ivith K, epilepsy; small shaded circles, died younp.

14

Mott: Heredity and Insanity

beginning with the great Julius, an epileptic, and ending
with Nero. Again, I will show you a chart of the Spanish
succession (Fig. 8) illustrating an hereditary neurosis follow¬
ing a family for 350 years and, as Ireland says, “ sometimes
passing over a generation and appearing in various forms and
intensities, as epilepsy, hypochondria, melancholia, mania,
and imbecility, till at length it extinguished the direct royal
line of Spain. The baneful tendency in the blood was, as
you see, reinforced by dose intermarriages with families of
the same stock, and it is worthy of notice that the house of

Fig. 8.

Pedigree of Spanish Succession. llaJJ black circles , Insanity;
circles with E, epilepsy.

Austria, with which the Spanish line was so often connected
by marriage, had few members insane, and in the end threw
off the hereditary curse. What vigour was in the first Spanish
kings appeared in their illegitimate descendants, whereas
those bom in wedlock inherited the disease. In spite of the
known ancestral taint a match with Spain was much coveted
by the royal families of Europe: as an example we may recall
the silly eagerness shown by James I. of England to marry
his son Charles with the Infanta Maria. Whoever attends
closely to history must know that there is a great deal in
birth, but not birth fixed by laws and traced by heralds, 4

Mott: Heredity and Insanity

16

man who is well made, strong, mentally gifted, and able to
do much work and stand mooh strain must be well bom, and
a race sodden with epilepsy, insanity, and sorofnla, whatever
its fictitious rank, is necessarily low bora, and in reality is
not worth preserving. ”

Investigation op Relatives in the London County
Asylums.

Two or three years ago I was interested in ascertaining
whether there was any resemblance in the pattern of the
brains of members of the same family and I sought the
existence of relatives in the asylums. A few were known to
me, but it soon became evident that there were among the
20,000 lunatics in the London County Asylums a very large
number of near relatives and people who had been resident
in the asylums or had died or had been discharged. I
instituted a card system by which I was able to ascertain
oertain facts relating to types of insanity with which these
relatives were affected and many other facts which con¬
clusively point to heredity being the most important cause of
insanity. There is nothing new in this—it is a generally
accepted fact, but the importance lies in having ascertained
that oertain forms of insanity are especially liable to be
transmitted either in the same form or more often in some
other to the offspring. While in acquired conditions which
cause madness and lead to people being taken to asylums—
e.g., general paralysis of the insane, brain softening from
arterial disease, general arterio-sclerosis, alcoholic psychosis
with dementia, lead encephalitis, tumours, and senility,
heredity plays comparatively little part.

A short time ago there were over 700 patients so nearly
related as parents and offspring, brothers and sisters, in the
London County Asylums. This of itself is a significant fact,
for it is not probable that a similar number of near relatives
could occur in 20,000 people brought together from the
6,000,000 of the population of London for some random non-
inheritable cause. Moreover, it does not take into account
relatives in other asylums or who have been discharged. The
figures, to my mind, are in a broad way eloquent in favour of
the importance of heredity as a cause of insanity.

Law of Anticipation in the Insane.

In the Huxley lecture which I delivered at Charing Cross
Hospital last October I referred to the fact that in the
pedigrees I had studied there was a general tendency for
insanity not to proceed beyond three generations. As
a general rule, there is a tendency to regression to
the normal or the stock dies out. Not infrequently

16

Mott: Heredity and Insanity

the stock dies out by the inborn tendency manifesting
itself in the form of congenital imbecility or the insanity
of adolescence. Such patients, especially paupers, are
prone to die from tuberculosis: thus rotten twigs are con¬
tinually dropping off the tree of life. Morel in 1869 pointed
out that progressive uninterrupted transmission leads finally
to special degenerative forms to imbecility and idiocy, and
with the diminished capability of propagation of the latter
kind the stock therefore gradually becomes extinct.

Mr. E. Nettleship observed what I had said and sent me an
interesting paper a of his own on heredity. In this he points
out that certain eye diseases and diabetes when transmitted
occur at an earlier age in each successive generation ; this
fact had been observed by others and termed “anticipa¬
tion ”; thus owing to an interference with sexual selection
or the disease killing off the patient before the age of
procreation the tainted stock tends to die out, and therefore
it is not often that diabetes or glaucoma, senile and pre-
senile cataract, for example, are transmitted beyond three
generations. Moreover, he remarks : “ Anticipation or ante¬
dating of onset or of completion in a family disease might,
be taken to show the transmission of an acquired character.
But it may be explained as well or better by assuming that
certain defects, taints, or vices of the system, say of the
blood, are not only hereditary in the true or germinal sense,
but able to produce toxic agents in the embryo that have no
relation to the hereditary vice, but yet may and probably do
act in a similar manner as excitant of the hereditary
disease.”

Since then I have collected 420 pairs of parents and
offspring, and the curves which I shall show on the screen
illustrate the facts which this investigation shows. One
broad fact illustrating this ante-dating or law of anticipation
comes out, and that is that 51 per cent, of the offsprirg have
their first attack of insanity before the age of 26; a con¬
siderable proportion of these are congenital imbeciles. This
does not take into account a number of idiots and congenital
imbeciles who have been sent to the asylums of the Metro¬
politan Asylums Board, of which I have no records.
Another fact that stands out prominently and which was
known since the time of Baillarger is that the mothers
transmit much more frequently than the fathers to the off¬
spring—viz., 243 : 177—and that daughters are affected
more often than sons in the proportion of 263 :167. These
facts are shown in the four curves. (Fig. 9.) The base
line is divided into decades, the vertical line is divided into
multiples of two, and represents numbers of parents and
offspring, whose ages at the time of first attack fall in the
given decades. It will be observed in the first curve that

2 Some Points in Relation to the Heredity of Disease, St. Thomas’s
Jlospital Gazette, March, 1910.

Mofcfe: Heredity and Insanity

17

there are 25 eons under 20; these eases are imbeciles and
cases of adolescent insanity, as against one imbecile father;
there are 20 under 30 against two fathers. Now when we
get to the prime of life for first attack in fathers and sons
the onrves almost interseot at the same numbers, bat
whereas the sons drop rapidly the fathers rise rapidly. In
the curve of the fathers and daughters it is not quite the
same. There is not much difference in the curve of the
fathers, but the daughters are much more numerous, and in
four-fifths the age at the first attack is under 30. The curve
of the mothers and sons shows that two-thirds of the sons
have had their first attack under 30, whereas in the mothers

Fig. 9.

Data upon which the Cubtes are Framed.

The diagrams show the relative number of cases in the combination
of insane parents with insane children whose ages at the time of the
first attack fall in the given age periods. Altogether 420 pairs (1 parent
with 1 offspring) have been investigated.

Mother and daughter. 150 pairs.

Father and daughter . 103 „

Mother and son . 93 „

Father and son . 74 ,,

Total . 420 „

These 420 pairs represent 774 cases and 359 families. In the case of the
brothers and sisters (one brother and one sister) 152 pairs (representing
304 cases and 152 families) have been investigated.

18

Mott: Heredity and Insanity

it is after 50. The next curve (Fig. 10) shows parent and
offspring in one curve without separation of sexes, and
exhibits the ante-dating remarkably well. The next curve
(Fig. 11) shows the comparative ages at which brothers and
sisters are affected.

Fig. 10.

Vide (ext.

Fig. 11.

Vide text.

Mott: Heredity and Insanity

19

I have investigated the age at the time of first attack in
413 instances of offspring whose mother or father has been
a resident in a London County Asylum, and have found that
212 (i.e., 51 per cent.) had their first attack at or before the
age of 25.

Analysis oj Cards (1812111) —Instances of two of a family insane

Pairs.

Cases.

Mother and daughter ...

... ... ... Ill ..

. 999 .

it »» son ... ... ...

• •• Ml ••• 64 M

. 128

Father and daughter ...

Ml ••• ••• 72 M

,, it son... ... ...

Ml Ml ••• 62 M

. 104

Brothers and sisters.

• •• Ml Ml 163 ••

Two sisters.

... ... ... 169 ..

. 318

Two brothers .

••• ••• 106 ..

Husband and wife ... ...

... ... ... 49 ..

Other relationships, collaterals, Ac. ... 138 ..

Total .

. 913 ..

108 Instances of 3 of tt family Insane .

. ... 324

17 „ 4

ft ...

. ... 68

3 ,. 5

••• Ml ••

. ... 15

1 .. 6

„ .

. ... 6

1 „ 7

ff Ml Ml ••

. ... 7

Total .

.

... 2246

Total, 2246 case*, made up from 1043 families.

These facts show that almost invariably in the case of
insane parents and offspring the offspring is affected earlier
than the parent, generally much earlier, on the average
approximately at half the age of the parent. In over
50 percent, of the cases the offspring were either congenital
imbeciles or suffered from adolescent insanity. This law of
anticipation which we see so well exemplified is of extreme
importance, and I am not aware that any collection of data
on a large scale has hitherto been forthcoming to show the
truth of Morel's conclusions, which were based upon a large
general experience combined with a remarkable insight into
the nature and causes of insanity. As Ribot says, Morel's
work is not sufficiently known and studied, and I owe my
knowledge of its value to Dr. Henry Maudsley.

Similar Inheritance.

Another interesting fact in connexion with heredity and
insanity is a tendency of similar inheritance in certain types.
I am indebted to my friend Mr. Edgar Schuster,* who
was kind enough to make a biometric investigation

* The results of this Investigation are described more fully in my
Huxley lecture. The Lancet, Oct. 8th, 1910, p. 1067, and the full details
of the investigation are given in the Annual Report of the Asylums
Committee of the London County Council, 1910,

20

Mott: Heredity and Insanity

of the cards of these insane relatives for researches
on this point. He found that certain types of insanity
which I have always regarded as most hereditary showed
a greater tendency to similar inheritance than others
which I have always regarded as less hereditary or dne to
acquired causes. Not only was similar heredity shown in
parents and offspring, but this was even more marked in
brothers and sisters. The types of insanity which show
similar inheritance in much greater proportions than other
forms are recurrent periodic insanity, consequently persons
who would be discharged as cured would tend to have
offspring similarly affected. This correlation was also shown in
paranoia (delusional insanity) still more markedly. Sohuster
noted the fact that in the case of primary dementia of
adolescence there is a strong correlation between brothers
and sisters or sisters and sisters and brothers and brothers,
but there was no available material for parents and offspring
suffering from this disease. This is not surprising when we
consider the 41 Law of Anticipation.”

The Study op Insanity by Pedigrees.

Every case of insanity should be regarded as a biological
problem and the study resolves itself into the acquirement of
a knowledge of what an individual was bom with—Nature—
and what has happened after birth—Nurture. The former
can only be approximately ascertained by a study of the
ancestral stocks, requiring a careful inquiry and analysis of
the family histories of the members in the direct line and, if
possible, of collaterals. By careful attention and inquiries
many important facts in respect to the transmission of a
neuropathic taint can be obtained ; it must always be
remembered that the neuropathic tendency may be manifested
in different members of the stock in different ways. Some
members may suffer from some form of neurosis—e.g.,
chorea, epilepsy, migraine, neurasthenia, exophthalmic
goitre, or diabetes. (Figs. 12 and 13.) In others it may be
temperamental and manifested by eccentricity, melancholy,
exaltation, feeble will-power, or lack of moral sense, mani¬
fested by evil desires or perversions. Such inherited
tendencies of temperament and character may be more or
less restrained by proper nurture, but given an environment
in which suggestion and imitation can play their part
—e.g., temptation to drink, suggestion and imitation
of evil companions and surroundings, pauperism, and
unemployment—and the result will sooner or later be
anti-social conduct in the form of insanity, crime, or
suicide.

These inborn tendencies in one generation may be trans¬
mitted to the next in a more intensive form, and the product
may be congenital imbecility or feeble-mindedness. I have

Mott: Heredity and Insanity

21

Fig. 12.

This pedigree is of a hospital patient, P, suffering with
neurasthenia and mental symptoms. It will be observed
that nervous disease and insanity affect a number of
members, especially on the maternal side. Full black circles,
insanity; circles with deep black rim, nervous disease;
circles with black centre , physically unsound.

Fig. 13.

This pedigree of four generations is Interesting on account of its
completeness and of the large number of members of the
stock on the maternal side which are affected with insanity,
nervous disease, and suicide. There is not a single alcoholic
on either the matemat or paternal side. The paternal stock
is not free fr.>m taint, but the three cases of insanity and
the suicide of the fourth generation, making up nearly half
the living members, have for parents a healthy father and a
mother with nervous disease. It shows how necessary it is
to study the maternal and paternal pedigrees in coming to
any just conclusion about hereditary transmission. Full
black circles , insanity ; circles with deep black rim , nervous
disease; circles with black centre , physically unsound ;
circle with cross , Buicide; shaded , died in early life. It
was observed that the same members of the Btock on the
paternal side were of a melancholy temperament. The
history was obtained from a very intelligent member of the
family.

22

Mott: Heredity and Insanity

found this result occur from the marriage of two first-cousins
who themselves were not insane, but came from a tainted
stock, or in other instances, and the more numerous, there
has been a union of two individuals neither of whom was
epileptic or insane, but they came of two unsound stocks.
According to the diagram after Ziegler (Fig. 6) we oan under¬
stand why the blending of two unsound stocks should lead
to a greater depth of degeneraoj and an affection of a larger
number of members of the stocks, but we can also see why
there are chances for some members born of the union of
two unsound stocks being more or less free from a hereditary
taint.

Even some of the most ardent followers of Weismann and
the non-transmission of acquired characters admit that
environment may affect the germ plasm, and thus they
would account for variations; consequently it may be
assumed that alteration in the blood and lymph which
nourish the germ cells may have an influence on the chromo¬
somes or germinal determinants causing variations to arise of
a pathological nature.

If two neuropathic stocks intermarry, or there is con¬
sanguinity in a tainted stock, the mental degeneracy is
either present at birth of offspring in the form of idiocy or
imbeoility, often followed by epilepsy in early life, or
insanity or epilepsy may occur in adolescence ; and in the
natural course of events this anticipation leads to the
tainted stock either dying out or of elimination of its worst
members, and those members who are comparatively free by
breeding with a sound stock may in several generations
throw off the hereditary curse. Thus Nature tends to revert
to the normal. The accompanying figure illustrates the
effects of consanguineous marriage of first-cousins not them¬
selves affected but coming of a tainted stock leading to an
intensification of tainted germinal determinants and all three
of the offspring being affected in early life with epilepsy or
imbeoility; either they could not, or did not, have the
opportunity of propagating, and so that tainted stock died
out (Figs. 14 and 15). But, as the pedigree shows, another
member, a sister who between 30 and 40 became insane,
married into a sound stock, and the result was a dilution of the
tainted germinal determinants; in the first generation there
was a suicide; in the second, an epileptic and one climacteric
insanity; several members, grandohildren, were of peculiar
temnerament, but in the third generation there was no trace
of insanity, epilepsy, or peculiarity of temperament, thus
proving the truth of Morels opinion. The insane disposition
may disappear by constantly renewing the blood by marriage
with perfectly healthy families; but it is increased and
developed to the most degenerate forms by further inter¬
marriages. This was strikingly exemplified in the Caesars
and the Spanish Succession ( vide Figs. 7 and 8). Morel also
asserts that it may be increased and developed by drunkep

Mott: Heredity and Insanity

23

Fig. 14.

Pedigree illustrating a marriage of first-cousins, who were
sane, but bad presumably hereditary taint. The effect of
consanguinity is shown by two of the three offspring
becoming affected early in life with epilepsy, and the other
with imbecility, the result being termination of the stock.
The pedigree also shows the effect of marrying into a healthy
stock (Fig. 15), whereby the hereditary tendency in three
generations has disappeared.

Fig. 15.

Pedigree of a large healthy stock, showing fertility and lon¬
gevity, with mental and physical soundness of constitution.
There is one instance of acute Insanity which ocourred as
the result of an emotional shock at the age of 20, but this
Individual became a most prosperous man and lived to the
age of 88. This pedigree also shows the connexion with
Fig. 14.

24

Mott: Heredity and Insanity

fathers, &c. In respect to the last-mentioned influence, I
know of no more likely cause of degenerate offspring than
that produced so often in the panper classes by the marriage
or cohabitation of a drunken father with an imbecile mother.
The offspring derives from the former a weak will power and
lack of moral sense, from the latter a feeble intelligence,
often combined with lack of will power and moral sense.

The Increase of Insanity.

By the law of 11 anticipation ” and by the greater
liability of the feeble-minded and insane to suffer from
the effects of tuberculosis, Nature is continually striving
to prevent the perpetuation of poor types. But if this
fact be admitted, how does it oome about that insanity is
apparently so greatly on the increase ? It will be observed
that I say apparently, for the curve shown on Fig. 1
in my opinion somewhat exaggerates the increase for the
following reasons. The standard of sanity has been raised;
the treatment of the insane is now most humane and quite
different from what it used to be. A large number of
lunatics, idiots, and imbeciles who were formerly at large
are now segregated in asylums. Still, we have to remember
that Nature's mode of killing off poor types has greatly
diminished in activity, and numbers who formerly would
have died are now taken into asylums, treated, and dis¬
charged to propagate their species. 12 per cent, of those
discharged from the London County Asylums some years
ago, it was found, were readmitted within 12 months. I
have known one woman who was discharged and readmitted
23 times ; in the meantime she had a large family. It may be
that we are now reaping the harvest we have allowed to be
sown by interference with Nature’s mode of elimination.
Again, it is probable that as fast as Nature eliminates degene¬
rates new tainted stocks are developed by the effects of
environment Dejerine held that neurasthenia may serve as
the starting-point of all the affections of the nervous system ;
according to him it is the source of the great neuro-
pathological family. If it be admitted that neurasthenia be
the starting-point, and this unstable nervous condition may
be produced by such factors as prolonged alcoholic abuse,
sexual excesses, stress of town life, with its feverish pursuit
of gain and pleasure, competitive examinations, the constantly
increasing departure from simple modes of life and the
extension of more refined physical and mental enjoyments,
bringing with them desires and emotions previously unknown,
the imposition of celibacy on women and the unphysiological
conditions of sexual life, whereby the maternal instinct, from
which spring all the higher altruistic feelings, is starved—
then it may be assumed that neurasthenia may be the
reservoir which continually supplies degeneracy in its many

Mott: Heredity and Insanity 25

forms, and according to this view the cumulative effects of
all these conditions in successive generations by leading to
the development of the unstable neurotic self-regarding
temperament of the neurasthenic forms in a stock the
prelude to neurosis and insanity.

Insanity and Pauperism.

Mr. B. J. Lidbetter, relieving officer for Bethnal Green, has
collected facts relating to patients who have been admitted
to London County Asylums showing the correlation of insanity,
pauperism, and disease. He has constructed a number of
pedigrees, some of which I will now give as they are
instructive (Figs. 16, 17, and 18). This work is still in

Fig. 16.

Pedigree showing transmission of insanity and blindness, and
association with pauperism. Half black circles , insanity;
circle with B, epilepsy; circles with T, tuberculosis; small
shaded circles , died young, Ac.; circles with P and star,
pauper. The numbers denote the age at the time of first
attack of Insanity.

progress, and I am hopeful in obtaining the ooftperation of
other relieving officers when it may be possible to obtain
numbers sufficient for the purpose of framing statistics.
Still, some of these pedigrees confirm the opinions which I
had formed that recurrent types of insanity during lucid
intervals may breed a stock of potential lunatics and paupers.
Again they demonstrate the fact that a high degree of
fertility is frequently associated with tuberculosis and a
relatively high death-rate (vide Figs. 17 and 18). In the
Huxley lecture I alluded to similar facts which had been

26

Mott: Heredity and Insanity

ascertained by a comparative study of the pedigrees of 40
hospital patients and 23 pedigrees kindly taken for me by
Dr. F. A. Elkins, superintendent of Leavesden Asylum for

Fig. 17.

Pedigree showing association of pauperism and insanity, with
marked fertility and infantile mortality. IlaJLf black circles ,
insanity; shaded circles , died young; circle with T,
tuberculosis ; circles with P and star , pauper.

Fig. 18.

Pedigree showing association of tuberculosis, pauperism, and
insanity. Also shows infantile mortality and rapidity of
procreation. HalJ black circle , Insanity; circles, with T,
tuberculosis; small shaded circles , died young; smallest
shaded circles , miscarriages, 4c.; circles with P and star ,
pauper.

Imbeciles. Some interesting pedigrees also have been
obtained showing that individuals are discharged from
asylums, have children bom in the workhouse, and later the
individual is received into the asylum again, and these

Mott: Heredity and Insanity

27

children have to be maintained by the ratepayer. Fig. 19 is
an example of this, as is also the following :—

Male. First Attack at Age 15.

In Mylums:

—

27/1/98

to 13/8/98,

Banstead.

In 1888, Bethlem find Ayrshire.

22/12/99

„ 7/4/00.

• 9

24/12/88 to

4/5/89, Grove Hall.

7/12/01

,, 24/3/02,

99

3/11/90 „

6/2/91, Banstead.

5/10/03

„ 19/9/04,

99

21/11/91 . •

2/4/92, Banning

25/1/06

„ 25/6/06,

99

Heath.

6/11/09

23/5/10.

99

1/9/93 „

18/12/93, Hanwell.

13/2/11

99

First child born 29/4/04; second child, 2/7/06; third child, 24/1/09;
fourth and fifth children (twins), 24/1/10.

The whole of this family have been, on and off, chargeable
upon indoor and outdoor relief since 1906, and all the
children are now chargeable.

Fig. 19.

P * • Pmjpi*

Pedigree showing association of pauperism and insanity, and
the birth of offspring during the lucid interval of a case of
recurrent insanity. Half Hack circles , insanity; circles
with P and star, pauper.

Conclusions.

1. Hereditary predisposition is the most important factor
in the production of insanity, imbecility, and epilepsy.
It is the tendency to nervous and mental disease, generally
speaking, which is inherited. This may be termed the
neuropathic taint.

2. Education, sanitation, and the rest, as Bateson has
stated, are only the giving or withholding of opportunity for
good or ill.

3. Alcohol is a powerful coefficient, but not of itself the
main cause, in the production of insanity, except in the
rather infrequent cates of alcoholic dementia.

28

Mott: Heredity and Insanity

4. Certain types of insanity may be transmitted with
greater frequency than others. This has been termed
similar heredity. The types are : Periodic insanity (also
termed “ manic-depressive delusional insanity, and
epilepsy. The general rule, however, is for a different
type'to appear.

5. Mothers transmit insanity and epilepsy with much
greater frequency than do fathers, and the transmission is
especially to the daughters.

6. Anticipation or antedating is the rule whereby the
offspring suffers at a muoh earlier age than the parent;
more than one-half of the insane offspring of insane parents
are congenital idiots or imbeciles, or have their first attack
in the period of adolescence. This adolescent insanity may
take an incurable form of dementia in a large number of
oases; in others it is usually mania, melancholia, or periodic
insanity, and not infrequently epilepsy with or without
imbecility. Very rarely does the parent become insane
before the offspring. This is a strong argument of hereditary
transmission, possibly hereditary transmission of an acquired
character.

7. Regression to the normal average may be (1) by
marriage into sound stooks, or (2) by anticipation or ante¬
dating leading to congenital or adolescent mental disease
terminating the perpetuation of the unsound elements of the
stock.

8. High-grade imbeciles who are not at present in
any way checked in procreating owing to social con¬
ditions interfering with survival of the fittest, together
with chronic drunkards, neurasthenics, and neuropaths, are
continually reinforcing and providing fresh tainted stocks.

9. Recurrent insanity owing to the fact that patients are
not segregated for any length of time is probably the most
potent cause of insane inheritance. Facts tend to support
the opinion that the recurrent types of insanity during lucid
intervals may breed a stock of potential lunatics and paupers.

10. Nature is always striving to go back to the normal
average and only relatively few of a stock are insane. A
stock with a streak of insanity when combined with genius
is not bad, and the same may be applied to a nation ; but
we only want a streak of genius and insanity, the great body
of the nation should be of good normal average, for I believe
that nation will possess the greatest potential virility in the
struggle for existence that can breed from the greatest
number of men and women with good bodily health who
possess a large measure of the three attributes of civic
worth—viz., courage, honesty, and common sense, com¬
bined with parentage, pride of family, and pride of race.

MO RT H WEST ERN U N fVESOiTY
MEDICAL SCHOOL LIBRARY

[Reprinted from the Proceedings of the Royal Society of Medicine,

November , 1910.]

The Comparative Neuropathology of Trypanosome and Spiro-
chaete Infections, with a Resume of our Knowledge of
Human Trypanosomiasis.

By F. W. Mott, M.D., F.R.S.

The study of the diseases produced by spirochete and trypanosome
infection is primarily biological. The contagium vivum is a living
organism whose activities, like that of all living organisms, are for self-
preservation, and especially the preservation of the species. The chemical
toxins which these organisms produce are to enable them to live and
multiply. It is generally believed that the spirochaetes are organisms
whose characters link them to the protozoa rather than to bacteria.
The Spirochaeta pallida contracts, moves, and modifies its structure in
a manner different from a bacterium. The appearance of resting forms
is totally different and they arise in a different manner to the spores of
bacteria. Again, the clinical aspects of affection from a spirochaete
invasion differ from that of bacterial diseases and conform especially to
certain trypanosome infections. .There is a periodicity of the symptoms
altogether unknown in bacterial diseases, but what has struck me from
my own personal experience and knowledge is the great similarity of
the histological lesions of the nervous tissues of chronic trypanosome
infection—for example, sleeping sickness and the mal de coit of horses—
to syphilitic and parasyphilitic lesions. Again, there is similarity in the
fact that lymphocytes and plasma cells are found in the cerebrospinal
fluid in trypanosome diseases of animals and man—for example, sleeping
sickness. Moreover, Levaditi has shown that in point of view of
sensibility in respect to haemolysing poisons, blood corpuscles, spiro¬
chaetes and protozoa generally constitute a homogeneous group, and the
spirochaetes correspond in this respect more to the protozoa than the

Mott: Resume of Human Trypanosomiasis

2

bacteria. It is probable that the periplasium of these protozoa contains
a complex of lipoid substances similar to red-blood corpuscles and animal
cells generally. This is an important fact, for it possibly affords an
explanation of the action of organic arsenic compounds in the treatment
of these diseases ; for it may be that such drugs asatoxyl, soamin, °606,”
&c., have an elective affinity for the lecithin complex entering into the
formation of the periplasium. By the periplasium I mean the osmotic
membrane which covers the viscid protoplasm constituting the body of
the organism. Moreover, we can understand why, when energetically
pushed, they may injure the nervous system and produce neuritis by
combining with the lecithin of the nervous tissue.

Trypanosomiasis corresponds with syphilis in being a disease charac¬
terized by inoculation, a period of incubation, affection of nearest
lymphatic glands, followed by generalization in, the lymph, then the
blood-streams, and afterwards by successive eruptions, due to escape of
trypanosomes from the blood-stream into the lymph spaces of the
tissues, where they set up a similar tissue reaction. Moreover, in severe
trypanosomiasis, as in severe syphilis, there is always, or nearly always,
a polyadenitis. 1 In the central nervous system in sleeping sickness there
is a chronic lymphangitis affecting the membranes and perivascular
spaces, due, no doubt, to the escape of the trypanosomes from the blood¬
stream into the lymphatics in the same way as they escape into the
vessels of the skin; they set up in the perivascular lymphatics a chronic
inflammatory, endothelial and connective-tissue cell hyperplasia. Both
in syphilis and sleeping sickness the location of the evidence of most
severe irritation is in the region of the base of the brain ; this fact may
be due to a direct extension along the lymphatics of the large vessels
and nerves entering the base of the skull, or to the greater amount of
cerebrospinal fluid in this region and the relatively larger size of the fluid
sheaths of the perforating vessels. There is one striking difference
between the effects on the nervous system of infection of Trypanosoma
gambiense and Spirochwta pallida , and that is that, whereas every case
of this trypanosome infection leads eventually to invasion of the nervous
system, in syphilis not more than 5 per cent, to 10 per cent, even of
untreated cases result in invasion of the nervous system. I believe this

1 While the Trypanosoma gambiense is still conveyed to man by a specific fly, the Glossina
palpalis, it is recognized that the Trypanosoma equiperdum owes its pow»r of transmitting
dourine, or the mat dc coit , from horse to horse to the fact that it has acquired the habit of
perpetuating its species by multiplying in tho mucous fluid found at mucous orifices. Possibly
the Spirociueta pallida has likewise acquired new habits, and, though now transmitted direct
from man to man, was at one time dependent upon a biting insect, just as now is the spiro-
cluete of tick fever.

Pathological Section

3

fact has a biological explanation. Examination of the trypanosomes
with the ultra-microscope shows them to be very active, motile
organisms, giving one the impression that they could readily penetrate
the delicate capillary walls of the nervous system, whereas the spiro-
chsetes show a sluggish, screw-like movement. Moreover, whereas in
every case of sleeping sickness trypanosomes have been found in the
cerebrospinal fluid, spirochaetes have never (with one doubtful exception)
been demonstrated in the cerebrospinal fluid. It is probable that they
only exist in the true lymphatic sheath of Robin contained in the
adventitia ; here they set up chronic irritation causing a localized or
diffuse gummatous condition.

With this brief introduction I propose to pass on to a r6sum6 of our
knowledge of trypanosome infection as it affects the human subject in
the production of sleeping sickness, and I shall conclude by a comparison
of the neurp-pathology of this disease with syphilis and parasyphilis of
the nervous system.

Although sleeping sickness had been described by Winterbottom as
early as 1803, it was not until the beginning of the twentieth century,
when the economic future of the British Protectorate of Uganda was
threatened by a devastating epidemic of the disease, that the Colonial
Office, inspired by Manson, approached the Royal Society with the view
of appointing a commission.

Manson and I had, in 1899, investigated several cases which had
come to England from the Congo, and although I have had under
personal observation only a few cases of the disease, I have been from
this time much interested in studying the histological changes in the
nervous system. As a result of the action of Manson, a committee of
the Royal Society was appointed and Castellani was sent out to Entebbe
to investigate the disease. Castellani discovered the trypanosomes in
the cerebrospinal fluid; but, as he had already reported a micrococcus
(probably the same as the Portuguese Commission had discovered) as
the cause of the disease, he did not attach to the trypanosomes the
importance which they deserved; nevertheless he found them in five
cases, and it is quite possible, had he continued to work at Entebbe, he
would have come to a definite conclusion that the trypanosomes, and not
the micrococci, were the cause of the disease.

Bruce, the discoverer of the tsetse-fly disease, was sent out, accom¬
panied by Nabarro and Greig. They placed upon a sure foundation the
causal factors of sleeping sickness: (1) By confirming and largely
extending the discovery of Castellani of the existence of trypanosomes

4

Mott: licsume of Human Trypanosomiasis

in the cerebrospinal fluid and the blood of persons suffering from sleeping
sickness; (2) by proving the existence of trypanosomes in a biting fly,
the Glossina palpalis; (3) by correlating the geographical distribution
of the disease with the geographical distribution of this biting fly;
(4) by communicating the disease to animals, including monkeys, by
inoculation with the cerebrospinal fluid and blood of patients suffering
with the disease, or by allowing flies to bite patients having the trypano¬
somes in their blood, then allowing the same infected flies to feed on
animals and thereby communicating the disease to the animals.

The investigations carried on by the Sleeping Sickness Commission
of the Royal Society established beyond dispute that a specific organism
(the Trypanosoma gambiense) and a specific fly (the Glossina palpalis),
which acted as a carrier, were the essential causes of the epidemic of
sleeping sickness in Uganda.

The Trypanosoma gambiense.

This was the name given to the organism by Dutton, and the
discovery happened in this way. On May 10, 1901, Forde received
under his care at the hospital, Bathurst, Gambia, a European, aged 42,
the captain of a steamer on the river Gambia. The man suffered with
symptoms which were regarded as malarial. Examination of the blood
did not reveal malarial parasites but worm-like bodies concerning the
nature of which Forde was undecided. A little later the patient was
seen by Dutton in conjunction with Forde, and the former recognized
that these worm-like bodies were trypanosomes. Dutton gave an
excellent description of this organism, which he called Trypanosoma
gambiense . The patient died on January 1, 1903. Dutton and Todd,
in their first report of the trypanosomiasis expedition to Senegambia,
1902, described further cases of human trypanosomiasis. Of 1,000
cases examined in Gambia, six natives and one quadroon showed
trypanosomes in their blood. It subsequently was shown that this
trypanosome found in Gambia was identical with that found in Uganda.
Dutton, Todd, and Christy, in their report upon trypanosomiasis upon
the Congo, state that the organisms in the blood of individuals (whether
showing signs of sleeping sickness or not) are identical, and there is no
reason to suppose that the trypanosome observed on the Congo differs
from the Trypanosoma gambiense. Moreover, the pathogenic action
upon animals is the same. Thomas and Linton have made a com¬
parative study of the human trypanosomes derived from different
sources : (1) Trypanosomes brought from Gambia by Dutton and Todd ;

Pathological Section

5

(2) trypanosomes sent by Bruce and Nabarro from Uganda; (3) trypano¬
somes of Dutton Todd, and Christy from the Congo (from the cerebro¬
spinal fluid of sleeping-sickness patients and from the blood of patients
showing no signs of this disease). Thomas and Linton inoculated the
trypanosomes from these various sources into a large number of animals,
and they found that the pathogenicity was almost the same in all cases.
(Nabarro). Laveran has confirmed these researches by experiments
upon animals with three different strains of the human trypanosome.

Plimmer concluded from certain experiments which he made upon
rats that Trypanosoma gambiense and Trypanosoma ugandense are quite
distinct and separate, but Thomas and Breinl (of the Liverpool Tropical
School) made experiments on a large number of rats using several
strains of human trypanosomes, including the two strains used by
Plimmer, and they obtained results similar to those of Thomas and
Linton and Laveran. Consequently it may be affirmed that the
Trypanosoma gambiense , originally discovered and described by Dutton,
is the specific organism of sleeping sickness, whether it be acquired in
the Congo State, Senegambia, Uganda, or Portuguese West Africa. In
the early stages of infection the lethargy characteristic of the disease
does not occur, and the case recorded by Manson, of a European lady
missionary, at first exhibited only the symptoms of trypanosomiasis and
was described as a typical case of infection by Trypanosoma gambiense ;
subsequently, and for a few months prior to death, she developed the
characteristic lethargy. Low and I examined the tissues of this patient
and found the characteristic lesions which I had previously described.
This case and many others which have died since show that the name
“ negro lethargy ” had to be entirely abandoned, for Europeans, and in
fact any human being, may be infected and die of sleeping sickness; and
there is no racial immunity against sleeping sickness. It may be
mentioned that in the 44 Bulletin of the Sleeping Sickness Bureau ” just
published there is a synopsis of fifty European cases; of these, one lived
three and a quarter years and one case six years.

But the name 44 sleeping sickness ” also should be abandoned for that
of “human trypanosomiasis.” There are at present in England three
cases being treated for infection by Trypanosoma gambiense ; l two of
these I have recently seen, and neither shows any lethargy although
trypanosomes are present in the blood and the patients are subject to
irregular paroxysms of fever. One case, owing to the high fever and
sweating that followed, was thought (as in the original case of Forde) to

1 I am indebted to Dr. Daniels, of the Tropical School, for liis courtesy in allowing me to
see these cases.

6 Mott: Resume of Human Trypanosomiasis

be suffering with malaria, until examination of the blood revealed the
true cause. It would be better therefore to follow the convenient
classification of the French Sleeping Sickness Commission. They dis¬
tinguish cas en bon • etat , persons who have no symptoms whatever of
trypanosome infection ; cas suspect , persons who have symptoms which
lead to further investigation; and cas cliniques , cases which can be
diagnosed from the symptoms alone. A more accurate division, which
they make when it is possible, depends on the result of lumbar
puncture (Bagshawe). If invasion of the subarachnoid space has taken
place, it is regarded as evidence of the patient having passed into the
second or third stage ; if not, he is in the first. But I shall have
occasion to refer to this matter more fully later.

The evidence therefore points to the important fact that the changes
found in the central nervous system—which I shall describe fully later—
are due to the infection of the subarachnoid space by the parasites. It
would be interesting to know if other forms of trypanosomes enter the
subarachnoid space or whether it is only the Trypanosoma gambiense ,
because I have never found any lesions like those of sleeping sickness in
any other form of trypanosomiasis, although sections of the brain may
show swarms of trypanosomes in the blood vessels. I am inclined to
think that it is the invasion of the subarachnoid space by the Trypano¬
soma gambiense which renders it so incurable. Bruce doubts whether
a case is ever cured (but vide p. 17). The various drugs—e.g., atoxyl,
soamin, mercury, trypanroth, and antimony—certainly cause the try¬
panosomes to disappear from the blood, but whether they will attack the
organism when once it has infected the cerebrospinal fluid is the important
question to be ascertained. I should doubt it, for these drugs do not pass
from the blood into the cerebrospinal fluid. Seeing that the organism
can easily penetrate the walls of the delicate capillaries of the central
nervous system, once the subarachnoid space is invaded, there is always a
reservoir for reinfection of the blood and lymph streams. Although the
cerebrospinal fluid is not (owing to the absence of proteid) a suitable
medium for development, yet by the production of inflammation of the
meninges the fluid acquires proteid substances, and the organism obtains
thereby a nutrient medium; moreover, the reaction engendered by their
presence is lymphocytic, and not polymorphonuclear phagocytic.

The question arises whether the reappearance of trypanosomes in
the blood may not be due to latent endocellular forms. It will be
remembered that Schaudinn affirmed that trypanosomes may pass
through states of endoglobular development. Since then there lias been

Pathological Section

7

a good deal of discussion upon the relations which exist between intra¬
cellular parasites and trypanosomes, notably concerning Leishman-
Donovan bodies. Carini, in a recent paper from the laboratory of
Mesnil in the Pasteur Institute, describes and figures trypanosomes
undergoing endoglobular development in the blood of Leptodactylus. In
the examination of the tissues of a large number of cases of sleeping
sickness, dourine, and other trypanosome infections, I have found and
described cells which presented appearances suggesting the possibility
that there were endocellular forms; and Salvin Moore and Breinl
described what seemed to be somewhat similar cell forms as occurring
in the spleen, lungs, and bone marrow of rats inoculated with Trypano¬
soma gambiense; these forms they regarded as a resistant form of the
trypanosome.

I will now pass on to the part played by the fly, the carrier of the
disease.

The Glossina palpalis.

Since the publication of the Keport of the Sleeping Sickness Com¬
mission in 1903, it was known that Glossina palpalis was the
transmitter of the disease, but only recently, owing to the researches of
Kleine, published in March, 1909, have we learnt that the fly after the
ingestion of trypanosomes (Trypanosoma brucei) remains non-infective
for eighteen to twenty days, but after that period it is able to infect
susceptible animals. This important observation regarding the
Trypanosoma brucei was confirmed by Bruce for the Trypanosoma
gambiense , and the researches of Bruce and his colleagues make it highly
probable that some flies may remain infective for the rest of their lives.
Bruce and his colleagues made the following interesting experiment:
They inoculated a monkey subcutaneously with a small droplet of fluid
obtained from the gut of a fly that seventy-five days previously had been
fed on an animal infected with Trypanosoma gambiense. The droplet
of fluid prior to injection was found on examination to be swarming
with trypanosomes. When the blood of the monkey was examined
eight days after, trypanosomes were found, showing that it had been
infected (vide fig. 1).

Kleine has also investigated the existence of Trypanosoma gambiense
in the alimentary canal of flies reared from the pupa which were first
fed on animals infected with that parasite, and subsequently on healthy
animals. Kleine’s figures exhibit a marked difference in form. The
slender, red-coloured flagellates, poor in plasma, with dark nucleus he
considered to be male forms. The plump, blue-stained, possessing one,

8

Mott: j Resume of Human Trypanosomiasis

two, three, or more nuclei, he considers to be female forms. He asserts,
with reason, that a sexual increase may occur even in the resting stage.
Kleine, moreover, found parasites in the salivary glands, but he regards
their presence as accidental, and not as playing an important part in
the transmission of the disease. He found no evidence of hereditary or
germinal transmissions, as Leishman has shown to occur with the
spirillum of tick fever. A most important step forward has been made
by these researches of Kleine, confirmed by Bruce, for we now know
that some kind of development of the trypanosomes takes place in the
fly after ingestion ; but whether a sexual process occurs, as Kleine shows,
or whether there is merely such a multiplication as occurs in cultures
is not at present decided with certainty.

It was previously believed that the fly only retained its infectivity
for forty-eight hours, consequently it was thought that it would be
possible to stamp out the disease in an island by one day clearing out its
infective population, and a few days later re-stocking it with healthy
natives. Bruce remarks that it is known by experiment that the fly
can retain its infectivity up to eighty days ; indeed, it is probable that
after a fly has become infected it will harbour the trypanosomes for the
rest of its life, but what the duration of this is under natural conditions
is unknown. Further experimental investigations by Bruce and his
colleagues are of interest, although they by no means afford a
positive solution of the question. The lake shore was cleared of the
native populations in December, 1907, and had been deserted for nearly
one year when the experiments began. Flies in this district were
caught and allowed to feed upon monkeys, with positive results; it was
therefore concluded that the Glossina palpalis on the uninhabited shores
of Victoria Nyanza can retain its infectivity for a period of at least two
years after the native population had been removed. The practical
importance of this continued infectivity of the flies is undeniably great,
but what the cause is, and how it can be prevented, is another matter.
The experiment does not, in my judgment, prove that the flies live two
vears, or that there is germinal transmission. From a conversation
I have had with several Europeans now in England suffering with
infection of Trypanosoma gambiense —notably Mr. Grimes, an elephant
hunter—it is impossible to control the movements of the native, and
numerous means of re-infection of the flies of the district are possible;
in fact, Bruce himself points out the possibility of the flies having fed
on natives who frequent the lake shore in spite of prohibition; or it
might bo explained by the fact that the natives who were employed in

Pathological Section

9

collecting the flies were the subjects of trypanosomiasis, but Bruce
asserts that it cannot be by infection of the flies by natives, because
precautions were taken in respect to fly-boys and canoe-men employed
by the committee ; or, lastly, it is possible that the mammals and birds
along the lake shore have been infected, and so act as a reservoir of
disease. It will be remembered that Koch thought the crocodile might
be a host for the sleeping-sickness parasite.

Bruce sums up : “ There remain then the two theories—long
duration of life of the fly, and a local reservoir. The former at
present cannot be answered, and there is no experimental proof of the

Fig. l.

(1) Rosette form from the mid-gut ( x 1,000). (2-5) Trifpa?iostrma gambicnse

from the blood of the monkey into which a tiny drop of the contents of the mid¬
gut of fly had been injected ( x 1,000). (6-13) Trypanosomes from the fore-gut of
tiy stained by Giemsa ( x 1,000).—Report 10, Sleeping Sickness Commission.

latter, since the injection of the blood of the lake-shore birds and
mammals into susceptible animals has always up to the present
given negative results.” It appears to me that the main difficulty
in accepting Bruce’s conclusions is the fact that the natives may, and
probably do, frequent the lake shore in spite of the prohibition.

It may certainly now be assumed that there is a period of time in
which the fly does not transmit the disease after biting an infected

10

Mott: Resume of Human Trypanosomiasis

person; and experiments appear to show that there is a period in which
it more certainly transmits the disease, and this is correlative to the
finding of large numbers of trypanosomes in the alimentary tract; and,
as Todd suggests, this is an indirect support of the sexual stage, which
Kleine’s observations so clearly indicate. Kleine found that of 410 flies
which had fed on animals infected with Tmypanosoma gambiense , 22
became infected (5 per cent.). It seems therefore necessary that both
males and females should be ingested in order that the flies may become
infective. Bruce was formerly of the opinion that mechanical trans¬
mission played an important part, but recent experiments published in
the Proceedings of the Royal Society , August, 1910, led him to the
conclusion that mechanical transmission plays a much smaller part (if
any) in the spread of sleeping sickness than has been supposed. The
researches of Bruce and his colleagues show that “ cattle may act as a
reservoir of the virus of sleeping sickness, and that healthy animals may
be infected from them by means of Glossina palpalis. It has also
been proved that cattle in the fly area do naturally harbour Trypanosoma
gambiense. It is therefore possible that the cattle and antelopes living
in the fly area may act as a reservoir, and so keep up the infectivity of
the Glossina palpalis for an indefinite period.” 1 The fact that the
geographical distribution of sleeping sickness corresponds with that of
the geographical distribution of this particular fly a priori is against
another source of transmission, although this does not necessarily follow,
for the two modes may be coincident. Glossina morsitans , the fly that
carries the Trypanosoma brucei , has not as yet been shown to act as a
carrier to the Trypanosoma gambiense.

We may next inquire what other possible means there are of the
transmission of the infective organism. Seeing that a scratch in
making an examination of an infected rat probably led to Lieut.
Tulloch being infected with Trypanosoma gambiense , and his death six
months later, it is conceivable that sporadic cases of infection may
arise from other causes than the bite of the specific fly, and the
members of the Sleeping Sickness Commission in the French Congo
bring forward evidence in favour of the transmission of the disease by
biting insects other than glossina ; they think that mosquitoes and other
biting insects are important auxiliaries conveying infection in each hut
from person to person during the night. They say that in regions
where the natives nurse their sick in their own houses the disease
spreads with much greater rapidity than in those where they drive

1 Proc. Hoi/. Soc.. P»., 1910. lxxxii. p. 484.

Pathological Section

11

them away. They give instances of one member of a family after
another becoming infected, and quote instances in which a native was
saved from infection, in their belief, by the use of a mosquito net. They
found sleeping sickness extremely prevalent in marshy districts where
mansonia abounded, and the Commission attributes to this method of
infection, in some instances, the annihilation of whole villages.

Bagshawe, having thus stated the French Commission’s observations,
remarks that in nearly all cases there was a palpalis area near at hand
or within a few miles. Moreover, why is not sleeping sickness endemic
in the southern negro states of America and the West Indies, and why
have there been no epidemics there ? Certainly in the old slave days
numbers of infected negroes must have been conveyed there. Agairf,
the disease is endemic or epidemic only on the shores of the palpalis-
haunted lakes and rivers. In Uganda, inland from the Victoria Nyanza
and out of the reach of tsetse flies, no instance of infection from a sporadic
case has come to light. I am informed by Dr. Grimes that sleeping
sickness occurs nowhere in Rhodesia except on the borders of Lake
Tanganyiki and the Loupopo River flowing from it. He also informed
me that six cases of human trypanosomiasis existed at Broken Hill,
and one European had died of sleeping sickness. No cases, however,
had occurred in southern or north-western Rhodesia, and in those
regions there is no Glossina palpalis.

Another possible means which had been put forward is coitus. We
know that a trypanosome disease affecting equines (especially in mule-
producing countries) is the mal de coit or dourine. In this disease a
trypanosome has probably acquired the habit of direct transmission from
one individual to another by multiplying in the mucous discharges of the
sexual organs, and thus has arisen a new means of perpetuating the
species. Koch and Kudicke put forward the hypothesis that sexual
coitus explained the occurrence of the disease in women who lived in a
palpalis-free area and who said they had never left it.

Kudicke’s experiments support this hypothesis, likewise those of
Manteuffel. The former introduced into the vagina of an uninfected
monkey, taking care to avoid any injury, the blood of another monkey
infected with Trypanosoma gamhiense , and thereby infected it. The
latter showed that blood containing trypanosomes placed upon a small
patch of unshaven sound skin, allowed to dry and then covered with
collodion, was followed in the greater number of animals by infection.
These observations certainly suggest the possibility of infection bv
coitus. But as regards the explanation of the forty-four female patients

12 Mott: Resume of Human Trypanosomiasis

treated by Kudicke, Hodges offers the following suggestions: “ When
the epidemic first swept through the lake-shore district the men, whose
employment naturally carried them into the greatest danger, usually
suffered first. As the men weakened, their occupations, such as canoeing,
were in part taken up by the women, who then ran greater risks and
more often contracted the disease, while many of their husbands by
this time had either died from it or showed obvious symptoms of its
presence/*

If sporadic infection does occur by one or other of the “ auxiliaries ”
described it must be unusual; for if we are sure of one thing in the aetiology
and geographical distribution of this disease in Uganda, it is coincidence
T&ith the habitat of the Glossina palpalis. All the facts therefore point
to the conclusion that something more than mere mechanical transmis¬
sion of infection is necessary—viz., an intermediate host—and we owe
to Kleine’s investigations the proof of this, which the following experi¬
ence in Uganda practically substantiates. In the progress report of
the sleeping-sickness camps in Uganda, 1909, it is stated that “ hundreds
of sick have for long periods been collected in places in which Glossina
palpalis is absent, and the disease has in no case spread either to the
attendants or in the neighbourhood. This has materially assisted to
impress on the natives—a task at first so difficult—the truth of that
which they have been taught concerning the connexion between the
fly and the spread of the disease.”

I have endeavoured to give a resume of our knowledge of the
aetiology of this remarkable disease—a disease not only of great interest
to the medical profession, but also to the general public.

Clinical Study of Human Trypanosomiasis.

My experience clinically is limited to several negroes, including the
three in which I first described in 1899 the changes in the central
nervous system which accounted for the principal clinical phenomena
observed during life ; also of several Europeans, including the first case,
whose nervous system was examined post mortem. But besides these
cases of negroes which have been brought to England and the Europeans
who have returned from Africa and died in England, I have had for¬
warded to me the material from twenty-two cases that have died in
Uganda, as well as material from monkeys and other animals which
have been inoculated experimentally. An account of the pathological
findings in this material formed the subject ot the seventh report of the
Sleeping Sickness Commission.

Pathological Section

13

Description of the Disease.

The following account of the clinical symptoms is based upon my
own experience, the notes of the cases of which I have examined the
nervous system and which died in Uganda, together with knowledge
acquired by reading the admirable reports of the Portuguese Commission
and French Commission, the account given by Nabarro in his valuable
translation of Laveran, and Mesnil’s work on trypanosomiasis, as well
as a recent important progress report on the Uganda sleeping-sickness
camps by Hodges :—

First Stage : Local Infection followed by Generalized Blood and
Lymph Injection .—A history obtained from Europeans shows that
there is a period of incubation extending from the time of infection by
the bite of the fly to the time that the parasite becomes generalized in
the blood. At the point of inoculation a painful red papule, which may
develop into a furuncle, appears; the nearest glands may become enlarged
and painful. Twelve days may pass before the constitutional symptoms
manifest themselves in the form of fever and sweating. This may be
accompanied by swelling of glands, but not necessarily ; there is always
fever, irregular, intermittent, sometimes high fever and sweating, which
occur at the end of the rise of temperature. The patient usually
thinks he has contracted malaria; quinine, however, affords no relief,
and examination of the blood, instead of showing malarial parasites,
reveals the trypanosomes. This is often associated with nervous excita¬
tion, insomnia, headache as well as prostration, weakness, and emaciation.
The respiration and pulse-rates are accelerated apart from the febrile
attacks. Localized oedemas, especially of the face and ankles, puffiness
of the. eyelids, and evanescent, congested, or erythematous patches on
various parts of the body, make their appearance. These symptoms may
considerably improve and even end by completely disappearing at the
commencement of the second period, which marks the invasion of the
subarachnoid space and the presence of trypanosomes in the cerebro¬
spinal fluid.

In negroes the above-mentioned symptoms are usually unobserved or
even absent; consequently the diagnosis could only formerly be made
by the examination of the blood. The parasites, however, are often
very scanty and difficult to discover in the blood. Having been struck
with the frequency of glandular enlargement, I suggested to Greig and
Gray that they should examine the fresh juice of enlarged glands
obtained by excision or puncture. This method for diagnosis was

14 Mott: Resume of Human Trypanosomiasis

performed by them, and found most useful when the organisms could
not be seen in the blood. Moreover, it shows that possibly the
lymphatic glands may harbour the parasites and lead to reinfection of
the blood-stream and the infection of the subarachnoid space when the
paravertebral glands are infected. Eecent work confirms the observa¬
tions of Dutton and Todd that the larger the glands the more likely are
trypanosomes to be found in them. These observers, in a comprehensive
investigation, have found that cervical gland enlargement without obvious
cause in a native who has been exposed to the risk of infection is almost
certainly due to trypanosomiasis, and should be regarded as such until
the contrary is proved. Nabarro remarks: “The observations of Dutton
and Todd in Gambia, and of Bruce, Nabarro and Greig in Uganda, show
that in negroes this first stage is accompanied as a rule by no obvious
signs of disease except the glandular enlargement above referred to.”
The French Commission, however, found that whereas under treatment
some glands diminished in size, others did not; they concluded that the
enlargement of these, though they often contained trypanosomes, was
due to other causes. There are, moreover, cases in which the swelling
of the glands is never very great. This was notably so in the case of
a Persian who died of sleeping sickness, and whose tissues I examined.
Heckenroth mentions the case of a boy who had slight suborbital
oedema, and in whose blood trypanosomes were found. Not until a
year later did any glands become puncturable. Heckenroth considers
oedema as valuable an early sign as gland enlargement. The French
Commission point out that the catamenia ceases in women and sexual
desire is lost in men.

Second Stage : Sleeping Sickness , Lethargy .—The chief symptoms
are fever and nervous manifestations. There is a pronounced expression
of hebetude, which, once it has been seen, can immediately be recognized.
The patient is indifferent to his surroundings, there is apathy and
tendency to sleep or drowsiness, from which, however, he can be aroused
to answer questions and for a brief period of time take an interest in
what is said; but fatigue readily occurs, and, as a rule, answers are only
obtained in monosyllables. He is paretic and unsteady, shuffling or
oscillating in his gait. There is unsteadiness on standing, which in¬
creases on closing the eyes ; there is nearly always tremor of the tongue
and later of the hands when they are held out, and sometimes even
when this measure is not resorted to ; but there is no intention tremor.
The knee-jerks are increased, and neither ankle clonus nor Babinski’s
sign can as a rule be obtained. The speech is slow, and sooner or later

Pathological Section

15

only monosyllables are uttered ; but there is no slurring or elision of
syllables, as in general paralysis, although there is some intellectual
deficiency, as shown by weakness of memory, will power, and attention.
Questions are comprehended as a rule, and the answers given are
rational. There is no grandiose delirium, and hallucinations are but
seldom noticed. There is no tendency to grandiose delusions, and the
autocritical faculty is not wanting, for they keenly realize their hopeless
condition. There is no optic neuritis or changes in the fundus, and
the Argyll-Robertson pupil is invariably absent. The patient may
remain in this condition, gradually getting more lethargic and feeble for
three to six months, and then the terminal period commences in which
there is profound lethargy, intense tremors and muscular weakness, loss
of control over sphincters, and tendency to bed sores.

The resistance to microbial invasion is so lowered by the trypano¬
somiasis that the patients readily fall victims to pneumococcal and
streptococcal infections resulting in bronchopneumonia and septicaemia;
it is not surprising, therefore, that pneumococcal or streptococcal
meningitis complicates the clinical picture in the terminal stages of the
disease, and hastens its fatal termination. In the majority of the cases
of which I have examined the tissues, I have found diplococcal or
streptococcal infection either of the lymphatic glands or of the central
nervous system, generally both.

In the excellent clinical study published in the French report,
attention is drawn to the fact that “ since our arrival in the Congo the
cerebral form of the disease has attracted our attention, and we have
observed numerous cases of insanity and hallucinations. This acute
form of the disease is known to the natives.” From their observation
on twenty-four whites who were patients at the Pasteur Institute, the
members of the Commission conclude that there is a cerebral and
medullary form. The former they divide into diffuse and circumscribed.
The diffuse is manifested by mental and meningeal symptoms of a sub¬
acute character, accompanied by loss of the intellectual faculties. The
circumscribed form is characterized by localized cortical irritation and
destruction, causing epileptiform convulsions and paralysis. The
medullary forms are manifested by paraplegia, with some sensory
troubles and bladder affection. The cerebral forms are incurable; the
spinal progress slowly and respond to treatment. The French report
also states that the mental complications of trypanosomiasis belong to
the category of organic mental alienation, and are characterized before
all by intellectual decadence. It may happen that the intellectual

]6 Mott: Resume of Human Trypanosomiasis

decadence is preceded by a period of slight exaltation. Mental confusion
is more or less profound, and is characterized by stupor, confusion of
ideas, amnesia, and disorientation, to which may be added visual and
auditory hallucinations and non-systematized delusions. The evolution
of these, symptoms is always rapid, in some weeks the intellectual
decadence becomes very profound, and the stupor appears. These
symptoms remind one rather of Korsakow’s psychosis, and it may be
asked whether the treatment by arsenic may not have had something to
do with them. Slight optic neuritis was mentioned. Possibly owing
to the patients being kept alive longer by the treatment, a deeper
affection of the nervous system may have taken place. Against this,
however, I may state that I found the most profound change throughout
the whole central nervous system in four of the cases that died in
England. The most profound changes were found in an uncomplicated
case that was under Dr. Stephen Mackenzie in. the London Hospital
in 1890; the patient lived six months after admission, and the only
symptoms noted up to a few days of death were progressive lethargy,
paresis, and tremors. Three days before death he could be aroused,
and could answer when spoken to in monosyllables or simple phrases,
such as “Good morning the same occurred in the two other cases
which were under my care in the Charing Cross Hospital.

Again, on looking through the notes of the twenty-one cases of which
post-mortem material was forwarded to me for examination, I can find
no mention of paralysis or epileptiform convulsions; in fact, the main
symptoms recorded pointing to the affection of the central nervous
system were progressive paresis, tremors, and lethargy. Many of them,
although in an advanced stage of the disease when admitted to the
hospital, were able to tell where they came from, and give an account
of their previous life. Most of these cases showed an advanced
meningo-encephalitis.

Hodges, whose experience is based upon 5,081 cases received at the
four sleeping-sickness camps at Uganda, thus comments on the effects
of modern treatment:—

“ Speaking generally of the effects of treatment, it must be said that
atoxyl and its allies—though possessing a marked, if transitory, try¬
panocidal action—have not proved to be suitable for routine adminis¬
tration to all classes of cases, and that no considerable number of cures
can be expected to result from their administration by the methods in
use. But it cannot fail to be noticed , by those who have been familiar
with the natural course of sleeping sickness before the use of modern

Pathological Section

17

remedies , that this course is , if not cut short , any rate considerably

modified by the administration of the organic compounds of arsenic.”

Paralysis, paresis, and epileptiform convulsions, which among un¬
treated cases occurred in a small percentage, are now commonly met
with and are often the precursors of sudden death, which itself was very
exceptional before the use of organic arsenic. Sudden or rapid death,
in fact, generally preceded by cerebral symptoms, would appear now to
be almost the rule among such cases as have received full courses of
organic arsenic, while the prolonged lethargic stage which almost
invariably marked the end of untreated cases is either scarcely notice¬
able or absent. It would seem probable therefore that, owing to the
prolongation of the course of the disease by treatment, the nervous
lesions are afforded time to become more pronounced and eventually to
kill the patient, and that this may happen even though all trypanosomes
may have been eliminated from the system.

If this be so, and these nervous lesions are in no way due to the
treatment itself, it of course follows that, when once the disease has
reached a certain stage, the lesions then existing are likely to be pro¬
gressive, apart from the toxins produced by trypanosomes, and that treat¬
ment by trypanocidal drugs during or after that stage will probably
be useless. When this stage actually occurs is not known, and it is
doubtful whether there would be any clinical symptoms by which it
could be recognized, though it has long been agreed that it is necessary
to begin treatment at as early a stage as possible.

I have recently examined the tissues of the central nervous system
of a case of human trypanosomiasis who was treated so energetically
with atoxyl that, owing to neuritis and mental confusion and dullness,
the administration of the drug could not be continued. It had been
given intermittently for eighteen months, and apparently it effected a
cure, for the man lived for three and a half years after treatment had
been suspended, and trypanosomes, which had, early in the disease, been
found in the glands and blood, could no longer be found. Death from
pneumonia occurred, the man for several years having been in excellent
health. I could find no evidence of the characteristic perivascular infil¬
tration of lymphocytes and plasma cells in the brain. It is probable
that the trypanosomes had never entered the subarachnoid space. A
full account of the case wdll be published shortly in the Proceedings
of the Royal Society. I have seen a well-marked perivascular infil¬
tration of the subcortical tissues in a case that died nine months after
infection.

18

Mott: Resume of Human Trypanosomiasis

Before describing fully the changes in the central nervous system in
sleeping sickness, it will be advisable to consider the changes in the
lymphatic glands. We shall then be in a position to compare the same
with those found in the central nervous system and elsewhere.

The occurrence of irregular remittent pyrexia, in cases of infection
by Trypanosoma gambiense y with erythematous urticarial eruptions,
suggests association with paroxysmal elaboration of a poison or the
multiplication of the parasite. The great frequency with which the
lymphatic glands become enlarged may be associated with the paroxysms
of fever and the presence of the protozoa in the glands. It has been
shown that this enlargement is not due to microbial infection; it must
therefore be due either to trypanosomes or a toxin engendered by them
irritating the gland and causing proliferative hyperplasia of the cell
elements. It is a matter of speculation whether the degenerative
changes occurring in the neoplastic formation produce cytotoxins or
not; probably by analogy they do not.

Histological Changes in the Lymphatic Glands .

A lymphatic gland in the first stage of swelling shows the following
changes : Active proliferation of the lymphocytes in the germ-centres so
that they are very densely packed together. In the lymph-cords and
sinuses a very active cell-proliferation can also be observed. The oval
staining nuclei of the endothelial cells lining the lymph-channels can be
seen greatly increased in numbers and proliferating. Numbers of large
mononuclear cells can be seen; these are round, with a deeply-stained
round nucleus. They differ from the small mononuclears by the more
abundant cytoplasm. Others are plasma cells of Marscholko containing
a nucleus with a wheel-like arrangement of chromatin, and all stages
can be traced up to the formation of a typical plasma cell and its final
granular degeneration. The origin of these different types of plasma
cells has always been a matter of dispute. Moreover, it is a question
whether the nuclei seen in the body of branching retiform cells belong
to endothelial plates, or are nuclei of branched connective-tissue cells.
There is no doubt that these nuclei, when subjected to irritation, are
excited to hyper-nutritive activity and proliferate, and produce mono¬
nuclear cells. There is increased vascularity of the gland, and not
infrequently haemorrhages ; in fact it presents the appearance of chronic
inflammation, and we must suppose that the cell proliferation is a
defensive reaction to a noxious agent. The cell proliferation goes on

Pathological Section

19

•

ft k e d

' «Lt

PLATE I.

Changes in the Lymphatic Glands.

Fig. 1. —Lymphocytes in all stages of transition to plasma cells.

Fig. 2. —Lymphocytes, plasma cells, and endothelial cells in all stages of gran ulo-aqueous
degeneration, (x 375.)

Fig. 3.—Thread-like bodies and granules, deeply stained, seen in section of lymphatic gland,
(x 750.)

Fig. 4.— Trypanosome in smear of fresh lymphatic-gland juice. Several lymphocytes and
micronuclei. (x 750.)

Fig. 5. —Trypanosome in a section of lymphatic gland amidst disintegrated cell products.

Fig. 6. —Section of lymphatic gland from a fatal case of sleeping sickness. The glands in
this case were not much enlarged. There is marked proliferation of the endothelial
nuclei of the lymph channel, (x 375.)

Fig. 7.—Proliferation of the connective-tissue cells of the reticulum of a lymph sinus.
Marked proliferation of the nuclei of the endothelial cells seen. This change closely
accords with the change observed in the perivascular lymph spaces of the central nervous
system. (x 375.)

Fig. 8.—Various granules and products of cell and (trypanosome?) degeneration seen in the
perivascular cell infiltration of the central nervous system. ( x 375.)

The preparations were stained with Leishman or Giemsa stain, and the glands used for

preparation of specimens illustrated by figs. 1 to 5, inclusive, were removed during life in the

first stage of the disease, before the invasion of the central nervous system had occurred.

20

Mott: Resume of Human Trypanosomiasis

until, automatically, an increase in numbers deprives the cells of
sufficient nutrition, or they are destroyed by the virus and granulo-
aqueous degenerative changes occur. These necrobiotic changes may
be observed in the glands which are sterile by cultural tests for micro¬
organisms. In this stage there is only very occasionally evidence to be
found in sections of the existence of trypanosomes- I have rarely in a
very large number of sections seen any evidence of trypanosomes or
their degenerated remains. Occasionally I have found the dead parasite
in the form of attenuated thread-like forms, or macronuclei or micro¬
nuclei. According to Greig they can always be discovered in the fresh
juice of the enlarged glands, but Thomas and Anton Breinl consider that
they are not more numerous in the glands than in the blood.

In the third stage of very chronic cases, a few of which I have
examined (one removed during life and sterile), the products of degene¬
ration had been in great part absorbed, and the gland had become dense
and fibrous. This is the final sclerous change that occurs in other
chronic neoplastic formations, the fibrous conjunctival elements prepon¬
derating over the cellular elements. As a rule, in sleeping-sickness
cases, death occurs before this can take place.

Morbid Changes in Lymphatic Structures.

All the observers from the earliest times have noticed the enlarge¬
ment of the lymphatic glands; and Greig, at my suggestion, punctured
the glands and examined the fresh juice. He is of opinion from his
observations that this is an easier and more reliable mode of determining
the existence of Trypanosoma gambiense than examination of the blood
or cerebrospinal fluid. Dutton and Todd came to the same conclusion
working in the Congo State. Many natives in Uganda and the Congo
State have, however, enlarged glands, and yet are not the subjects of
sleeping sickness. They may be, however, and probably in nearly
all cases are, candidates for the disease.

Do the trypanosomes get into the glands and multiply there, setting
up a chronic inflammatory process which terminates in fibrosis ? The
glands may be inflamed and enlarged and yet be sterile as regards
micro-organisms. It is probable that trypanosomes infect the lymphatic
glands by escaping from the ruptured capillaries, or they may have
become infected by the cerebrospinal fluid when this secretion contains
trypanosomes. Similarly by capillary hsemorrhage the trypanosomes
may infect the cerebrospinal fluid and the lymphatic structures of the

Pathological Section

21

central nervous system. If the trypanosomes can set up chronic inflam¬
matory changes in the lymphatic glands (as there is no doubt they do),
and microscopic examination of sections reveals but occasional and
scanty evidence of their presence, it is quite reasonable to suppose that
they can similarly produce chronic inflammatory changes in the
lymphatic structures of the central nervous system. We do not know
if the trypanosomes produce this chronic irritation by their mere
mechanical presence, which seems unlikely, seeing that vessels may be
crammed with trypanosomes in nagana and surra without causing
lymphangitis. There is, according to Plimmer, Thomas, and Anton
Breinl, however, no experimental evidence that trypanosomes produce a
chemical toxin; although that would seem the most probable cause of
the chronic inflammatory change. The numbers of trypanosomes found
in the cerebrospinal fluid are in no way proportional to the changes
found in the central nervous system. Yet there is considerable evidence
(vide Sleeping Sickness Reports, Royal Society) to show that not until
trypanosomes are found in the cerebrospinal fluid does the chronic
inflammatory change take place. If they existed in abundance instead
of sparsely, we might consider that this fluid afforded a suitable medium
for their propagation, and the absence, normally, of lymphocytes in this
fluid might be counted a cause. On the other hand, the small quantity
of proteids which the cerebrospinal fluid contains would not admit of
suitable nutrition.

The posterior spinal ganglia always show some chronic changes,
proliferation of the endothelium of the lymphatic capsules of the
ganglion cells, together with interstitial lymphocyte accumulation, and
these chronic changes may be due to the absorption of toxins from the
neighbouring infected paravertebral glands.

In practically all cases of sleeping sickness the cervical glands are
enlarged, and the most chronic change is found about the base of the
brain. Hence a possibility that the chronic inflammation of the lym¬
phatics spreads along the nerves, spinal ganglia and roots to the central
nervous system, and especially along the lymphatics of the nerves and
vessels entering the base of the skull. Examination of other tissues—
e.g., the heart, pericardium, liver, alimentary canal, and testicles—shows,
though generally speaking in far less degree, an infiltration and accumu¬
lation of lymphocytes in the lymphatics, suggesting a chronic inflam¬
matory reaction of the lymphatics.

22

Mott: Resume of Human Trypanosomiasis

The Histological Changes in the Central Nervous System.

Observations of Bruce and his colleagues show that it is the
invasion of the subarachnoid space by the organisms which cause this
change, and my observations and experience show that there is a
parallelism between the depth of the lethargy and the diffuseness and
intensity of the lymphatic perivascular infiltration.

In the seventh report of the Sleeping Sickness Commission of the
Royal Society I stated, as the result of an examination of a large
number of sections stained by polychrome and eosin, Mallory and
Heidenhain-eosin methods, that the meningeal-cell infiltration was the
result of an irritative process affecting the pia-arachnoid serous mem¬
brane, which was manifested not only by a proliferation of the neuroglia
cells but also by a proliferation of the endothelial-cell nuclei and an
infiltration of the pia-arachnoid membrane with lymphocytes, which
may become transformed into plasma cells. But sections do not show
the mode of origin of these cells in such a clear and demonstrative
manner as the following methods which I adopted. The pia-arachnoid
membrane was stripped off small portions of brain from a number of
cases of chronic sleeping sickness, including the European case under
Dr. Bradford, which was of unusual value, because there was no terminal
or secondary microbial infection, and because there was no noticeable
enlargement of the lymphatic glands. Small portions of the stripped-off
membrane were divided by tearing rather than cutting, so that the
thin frayed edges could be examined under a high power of the
microscope. They were stained by haemotoxylin and eosin, Leish-
man’s stain, polychrome and eosin, and Eisath’s modified Mallory
stain, and mounted in Canada balsam. Several interesting facts were
observed. The fibres forming the interlacing network were coarser
than natural and much increased. Many of the vessels were gorged
with blood and there were many capillary haemorrhages. A variable
number in different cases of large cells containing blood-corpuscles or
altered blood-corpuscles were seen, similar to those seen in sections
These cells were usually oval, sometimes round, with the oval or round
nucleus pushed up to one end. Sometimes the cytoplasm contained
discrete corpuscles, sometimes this endothelial macrophage had digested
the corpuscles and the cytoplasm had assumed in consequence a uniform
orange stain. Some of these cells containing blood-pigment had under¬
gone nuclear proliferation ; four or five deeply-stained, round nuclei could
be seen in one cell. The adventitial sheath of the arteries can be

Pathological Section

23

distinctly seen, and there is often evidence of endothelial-cell proliferation
shown by an increase in the number of large, pale oval nuclei, many of
which could be seen undergoing mitosis and proliferation; they resembled
the endothelial nuclei seen in the lymph sinus of the lymphatic glands,
but the great mass of cell infiltration is in the meshwork of the pial
trabeculae of the subarachnoid space and its prolongation as a sleeve
around the vessels entering the grey matter.

Fig. 2.

Small portion of pial-arachnoid tissue stained by Eisath’s modified Mallory
method mounted on the flat. ( x 500.)

Preparations stained by logwood and eosin and Van Gieson’s fluid
exhibit two kinds of nuclei—viz., (1) large, pale, oval, less often roundish
nuclei, with a delicate nuclear membrane and very fine intranuclear
network, similar in all respects to the oval nuclei of a lymph sinus;
(2) smaller round or irregularly shaped more deeply-stained nuclei
with a narrow investing cytoplasm, also large cells containing similar
deeply-stained nuclei, and not infrequently some cells, two or more,
even as many as six, round nuclei, which are sometimes unequal in size

24 Mott: Resume of Human Trypanosomiasis

and always uniformly, diffusely, and deep stained throughout. These
cells are endothelial cells undergoing endogenous nuclear proliferation.

The endothelial cells of the lymphatic sheath of Bobin and the
endothelial plates lying upon the trabeculae of the subarachnoid space
and the pial sleeve of the vessels, as the result of the chronic irritation
produced by the presence of the trypanosomes in the cerebrospinal
fluid, undergo a progressive formative hyperplasia similar to that of
the lymphatic glands.

In preparations stained by Eisath’s modified Mallory stain, I have
observed large flat endothelial cells without any processes exhibiting
the following appearances of hyperplasia: (a) With the cytoplasm
stained pink, and with an oval or round nucleus in the centre stained
light yellow; ( b) the same form of cell can be seen undergoing
endogenous nuclear proliferation; (c) the same form of cell dividing or
divided into small mononuclears in which there is^only a relatively small
surrounding pink-stained cytoplasm. Besides, w^e find cells which
morphologically resemble the branched retiform cells of connective
tissue of the lymphatic gland, with a large oval unstained nucleus.
These nuclei appear to undergo division to form hyaline mono¬
nuclear cells which are seen proliferating in the inflamed lymphatic
glands. The increase of the large and small mononuclear lympho¬
cytes in the blood may be due to this cell hyperplasia in lymphatic
structures. The meningeal and perivascular infiltration is due not
only to active endothelial - cell proliferation in situ, but also to
accumulation of the lymphocytes by conjunctival proliferation and con¬
sequent obstruction to the outflow of the lymph along the vessels, also
obstruction to the escape of the cerebrospinal fluid from the cranio¬
spinal cavity. The infiltration is found especially around the vessels
having a lymphatic and pial sheath ; this sheath disappears on the
smallest vessels, therefore we can easily understand why it is that the
smallest vessels and capillaries show little or no investing sheath of
cell infiltration. However, in chronic cases, lymphocytes, and especially
plasma cells, can be seen closely applied to them. Do the branching
processes of the neuroglia cells form a meshwork around the larger
vessels and cause obstruction, or is the meshwork in which the mono¬
nuclear cells lie merely the thickened and proliferated trabeculae of the
connective-tissue cells of the lymphatic and pial sheath ? My answer
is that the infiltration around the large vessels and in the membranes
entirely corresponds in appearance with the infiltration which I have
described in patches around the vessels of the visceral layer of the

Pa tliological Section

‘25

PLATE II.

Changes in the Perivascular Lymphatics of the Central Nervous System, &c.

Fig. 1. —Transverse section of a small vessel of the medulla oblongata, showing perivascular
infiltration with lymphocytes. Many of these have a hyaline appearance. The lumen of
the vessel contains blood corpuscles, large and small mononuclear leucocytes, and a try¬
panosome is seen in the centre. This was the appearance presented by the vessels through¬
out the cortical and subcortical structures. The preparation was obtained from a very
chronic case, (x 375.)

Fig. 2.—Small vessel with plasma cells (p) and morular cells (m). (x 375.)

Fig. 3.— Small vessel dividing into two capillaries, showing nuclear proliferation of the endo¬
thelial cells. In the neighbourhood are plasma cells (p), lymphocytes (/), and glia
cells ({ 7 ). ( x 375.)

Fig. 4.— Three large neuroglia cells (</), their branches ending in a network around and upon
a 6mall vessel. In the meshes are lymphocytes (/) and plasma cells ( p ). ( x 375.)

Fig. 5.—Small vessel with proliferation of endothelial nuclei and two plasma cells (p).

Fig. 6.—A transverse section of a vessel in a very chronic case of sleeping sickness in a
European, showing marked perivascular infiltration with lymphocytes, (x 187‘5.)

26

Mott: licsumc of Human Trypanosomiasis

pericardium in the lymphatic spaces of the heart muscle and the
perivascular lymphatics of the liver and the testis. Moreover, I am
unable to trace the processes of the neuroglia cells any farther than the
outer sheath of the infiltration . Again, no place shows the perivas¬
cular and meningeal infiltration better than the lymphatic and pial
sheaths of the vessels in the soft membranes covering the cerebellum
and their extensions between the folia, yet there are no neuroglia cells
seen in the adjacent cortex of the cerebellum, although the neuroglia
cells are seen in abundance in the white matter. The neuroglia pro¬
liferation is therefore not essential for the production of this characteristic
perivascular cell infiltration. As a rule, the subcortical perivascular
infiltrations are more marked and extensively diffused than the cortical,
and this is especially evident about the base of the brain and around
the perforating arteries; this corresponds in a way with syphilitic brain
disease. Sometimes when there is but little evidence of cortical peri-
vascularitis, there may be found very marked infiltration around the
vessels of the base of the brain and the perforating arteries and their
ramifications.

It is often difficult to distinguish lymphocytes from the proliferating
nuclei of glia cells. We may distinguish three kinds of lymphocytes
in transverse sections of blood-vessels and the surrounding tissues:

(1) Hyaline forms, in which the nucleus is pale, staining poorly,
irregular in outline or lobulated, and with a small amount of cytoplasm.

(2) Small mononuclear cells in which the nucleus is irregular in outline
or round, staining either deeply throughout, or the chromatin is arranged
in the form of a wheel, with a central nucleolus, from which straight
spokes pass out to a nuclear membrane ending in little knobs; there
is hardly any surrounding cytoplasm. (3) Large mononuclears possess¬
ing phagocytic functions, the main difference from the smaller variety
being the much larger amount of surrounding cytoplasm; they form
the so-called plasma cells, and are developed from the proliferating
endothelial plates, the same as the smaller lymphocytes; the latter
can develop into them {vide Plate I, fig. 1). Whether an endothelial
plate will form small or large mononuclear cells apparently depends
largely upon the number of nuclei the original nucleus divides into.

In sections of vessels cut obliquely so that the outermost structure
of the wall is shown—that is, the part in contact with sleeve of cerebro¬
spinal fluid—I have seen endothelial cells lying like scales on the bark
of a fir tree, or a tesselated pavement, and presenting all the appearances
of the typical plasma cells of Marscholko. It appears to me a mere

Pa t hulog ical Sec lion

27

PLATE III.

Neuroglia, Hyperplasia, and Proliferation, &c.

Fig. 1. —Section of subcortical white matter of the brain of a monkey that died after infection
by trypanosomes, caused by the bites of infected flies. There is little or no perivascular
infiltration, but a considerable increase in size and number of the perivascular glia cells.
The animal lived only eight months. ( x 320.)

Fig. 2. —Section of subcortical white matter of a monkey that died eighteen months after
infection, and showed the characteristic perivascular infiltration, with lymphocytes and
plasma cells. The neuroglia proliferation is well shown, and in the meshwork of the
branching fibres, which form a reticulum around a small vessel in longitudinal section,
are numerous lymphocytes. ( x 450.) •

Fig. 3.—Transverse section of a blood vessel, with the pia-arachnoid and lymph-sheath much
increased by proliferating cell elements. The lymphocytes are pale and unstained, and
fill the connective-tissue meshwork. The neuroglia cells are seen externally, sending
their processes inwards to join the connective-tissue reticulum of the pial sheath. ( x 375.)

Fig. 4.—Small vessels of brain of a monkey in which experimental anaemia had been produced
by ligature of all four arteries. This is to show the perivascular space filled with cerebro¬
spinal fluid. The supporting trabeculae are well seen passing across from the nervous
matter to the wall of the vessel. It is easily to be understood that if this sheath is filled
with cells entrapped in a thickened and proliferated network, the circulation of the lymph
and cerebrospinal fluid will be interfered with. ( x 750.)

Fig. 5.—Young neuroglia cells undergoing proliferation, (x 375.)

Fig. 6. —Red cells (SUibchenzellen of Alzheimer), rarely met with, although occasionally
appearances like this arc seen. ( x 450.)

28

Mott: Resume of Human Trypanosomiasis

quibble whether plasma cells are developed from lymphocytes or en¬
dothelial cells, since, in my opinion, there is sufficient evidence to show r
that both plasma cells and lymphocytes in chronic inflammatory
conditions develop from endothelial cells of serous membranes and
perivascular lymph structures, and from endothelial plates of the
connective tissues.

The Neuroglia.

It is often a matter of some difficulty to distinguish young neuroglia
cells from hyaline lymphocytes. By use of the modified Heidenhain and
the polychrome and eosin stains, I was able to see all the changes which
Watson described in juvenile general paralysis, and just as in that disease
neuroglia-cell overgrowth is a leading histological characteristic, so it is
of sleeping sickness and chronic trypanosome infections. The young
neuroglia cells may be recognized by their pale-staining round or oval
nuclei with a delicate intranuclear network containing one or two small
nucleoli and a definite nuclear membrane. The chromatin substance is
stained blue; surrounding the nucleus is a well - defined zone of
protoplasm stained pink, of irregular quadrate or polygonal outline.
These cells can be seen in groups and undergoing active division,
especially in the neighbourhood of the ganglion cells. The various
phases in the development of the neuroglia cells can be seen, viz.:
(1) The nucleus, surrounded with an indefinite amount of cytoplasm,
polygonal or irregularly quadrilateral in shape; (2) the protoplasm
tending to form short spike-like processes, sometimes giving it a star-
like appearance; (?, increase of cytoplasm around the nucleus arid
commencing formation and differentiation of the darkly-stained Weigert
stiff fibrils; (4) further development of the Weigert fibrils and extension
of one on to the w^all of a vessel, there ending in a foot-like expansion;
(5) further increase of development of the Weigert fibrils and differentia¬
tion from the pink-stained protoplasm on which they appear to lie ;
((3) the protoplasm is almost entirely differentiated into fibrils, and the
nucleus is shrunken and stains deeply like the fibrils, so that the whole
glia cell is stained a deep blue-black.

Distribution of the Glia Proliferation.

The distribution varies in different cases; it is almost entirely a
primary interstitial overgrowth and not secondary to neural degenera¬
tion. It exists in a marked degree in cases which during life presented

Pathological Section

29

no very marked symptoms pointing to destruction of nervous elements.
In some very chronic cases in which there have been many epileptiform
seizures, there may have occurred sufficient degeneration in the pyramidal
tracts to give rise to a secondary sclerosis, but this is exceptional.

The glia proliferation, which is not visible to the naked eye in
sections of the spinal cord, becomes very manifest when examined w r ith
a low power, and there is a diffuse glia proliferation, as I first pointed
out in the two cases which I first investigated. This diffuse subpial
glial proliferation affects the periphery of the cord and spreads inwards
along the septa; it is not only met with in the white matter, but is
evident also in the grey matter. The situations in the brain where glia
proliferation is most obvious in general paralysis are the situations in
which it is most obvious in sleeping sickness. Thus it is well advanced
in the most superficial layers of the cortex, where large branching cells
with deeply-stained Weigert fibrils can be seen forming a subpial felt-
work . The large branching cells with Weigert processes extending on
to the small vessel walls cannot be seen so well amidst the columns of
cells as in the subjacent white matter. From the examination of the
brains of two monkeys that died of sleeping sickness after experimental
inoculation, the glia-cell overgrowth and extension of processes on to
the vessels appeared to be more marked than the perivascular mono¬
nuclear infiltration, as if this tissue was the first to respond to the
irritation of the noxious agent (vide Plate III, fig. 1). However, examin¬
ation of a case—Mrs. S.—in whom symptoms only existed for two
months, did not show a glia proliferation in excess of the mononuclear
infiltration; nor could I find any neuroglia proliferation or perivascular
infiltration in a chronic case of infection by Trypanosoma gambiense ,
a native of Uganda, who died of pneumonia and pneumococcic meningitis
after an illness of ten days, but who, prior to this illness, had displayed
no symptoms of nervous affection.

The meningeal and perivascular infiltration with lymphocytes and
plasma cells was regarded by Nissl as pathognomonic of general
paralysis ; but I pointed out that plasma cells as well as lymphocytes
occurred in the perivascular infiltrations of sleeping sickness, and I
figured the same on p. 289, vol. ii, Archives of Neurology , 1903. I
mention this because an Italian observer claims to have first described
plasma cells in sleeping sickness.

30

Mott: Resume of Human Trypanosomiasis

Changes in the Central Canal of the Spinal Cord.

Not only is there evidence of a chronic irritative action of the
cerebrospinal fluid by the cell proliferation in the meningeal and
perivascular lymphatics, but in all chronic cases the central canal of
the spinal cord is filled up owing to a proliferation of the cells of the
ependyma. I found that this had occurred in quite juvenile subjects.
It was so in the little Congo negro boy who died in Charing Cross
Hospital in 1898, and I was of opinion then that this fact afforded
evidence of a very chronic nervous affection caused by some irritating
agent. Such change denotes, then, a chronic process of considerable
duration. Examined under a high power, the nuclei of the cells lining
the spinal canal may often be seen undergoing active proliferation, and
specimens stained with polychrome and Heidendain-eosin method exhibit
large pale nuclei with a thin membrane and chromatin granules stained
blue, surrounded by a pink cytoplasm, often with numerous processes.
In some very chronic cases the glia proliferation had led to the forma¬
tion of abundant Weigert fibrils. In the grey matter around the central
canal numerous glia cells having a similar appearance can be seen.

I deem it of little importance whether the glia proliferation precedes
mononuclear cell infiltration, or whether by its doing so it obstructs the
flow of the lymph and entangles the mononuclear cells ; nor do I regard
it of much importance whether we speak of this formative cell hyper¬
plasia as a chronic inflammatory process or not. The important fact to
recognize is that this meningeal and perivascular infiltration is a hyper¬
plastic reaction of fixed tissue elements to a noxious agent —Trypanosoma
gambiense. So far we are on certain ground. It is, however, a matter
of speculation whether this tissue reaction is due to (a) the relatively
few trypanosomes which can be demonstrated in the fluid; (b) the
elaboration of a toxin by them; (r) a transition to some hitherto
undiscovered modified forms.

Changes in the Small Vessels and Capillaries.

The capillaries in the pia and in the brain tissue show the following
changes, but these are not nearly so marked as in general paralysis
of the insane.

The nuclei of the endothelial cells may undergo proliferation, and in
the neighbourhood of the capillaries and small vessels there are often
numerous lymphocytes, plasma cells, and glia cells sending a process on

Pathological Section

31

to the wall of a vessel; but I fail to find evidence of sprouting new
capillaries as seen in general paralysis, nor can I but very rarely find
any evidence of the Stabchenzellen or rod-cells described by Alzheimer
in general paralysis (vide Plate III, fig. 6).

The marked proliferation of the vascular endothelium with hyaline
degenerative changes of the small vessels so frequently met with in
general paralysis is hardly ever seen in even the most chronic case
of sleeping sickness, nor can I find any evidence of endarteritis so
generally met with in all cases of syphilitic brain disease. There
may be a granulo-aqueous degeneration of the lymphocytes and plasma
cells in the perivascular spaces, but I have never seen caseation
nor have I seen tumour formation. This looks as if the trypanosome
when it was surrounded by cells in the perivascular space did not
undergo division and multiply because it requires a fluid medium, but
was walled in by cells and killed unless it had escaped into the free
cerebrospinal fluid. Whereas the growth starting in the meninges and
spreading inwards along the pial sheaths as well as superficially suggests
that the spirochaete multiplies at the expense of the cells, resulting from
the chronic irritation of the endothelial and connective-tissue cells
spreading thereby and setting up fresh cell hyperplasia with the
formation of lymphocytes and plasma cells ; but inasmuch as the walls of
the arteries participate in this cell hyperplasia, endarteritis occurs, and
this, in conjunction with the rapid neoplastic formation, leads to
necrobiosis of the older central portions of the tumour.

Vascular (usually capillary) haemorrhages are met with in all forms
of trypanosome disease, and probably are the result of obstruction
by the organism. Haemorrhages may occur in syphilis, but these are
due to arterial degeneration, as a rule, with thrombosis or rupture of
the vessel.

Changes in the Neural Elements.

Although the meninges are in many cases obviously thickened and
the convolutions flattened (indications of some intracranial pressure), yet
there is no naked-eye wasting of the brain. The depth of the grey
matter of the cerebral cortex is not appreciably diminished, although
the vessels both in the grey and white matter may appear somewhat
congested.

I have not observed granulation of the ependyma of the ventricles,
so characteristic of the meningo-encephalitis of general paralysis of the
insane. Moreover, the marked wasting of the grey matter of the

32

Mott: Resume of Human Trypanosomiasis

cerebral cortex, so characteristic of the disease, is not met with in
sleeping sickness. The convolutions are broad and of normal size, and
the sulci tend to be obliterated in sleeping sickness, whereas in general
paralysis the convolutions are shrunken from atrophy of the neural
elements, cells and fibres, and the sulci are consequently broad and
deep. In both diseases there is thickening of the leptomeninges and
septal and perivascular changes, but here, it seems to me, the similarity
ends. But this statement becomes more apparent and convincing when
the microscopic changes are described. Moreover, a comparison of the
size of the remaining structures of the central nervous system shows that
in general paralysis there is a primary neuronic atrophy which does not
occur in sleeping sickness. Thus to the naked eye the spinal cord in
the latter disease may appear normal as regards amount of grey and
white matter, whereas in general paralysis the cord is often much
reduced in size and there is very obvious neuronic atrophy.

The naked-eye appearances therefore point especially to a primary
parenchymatous degeneration in general paralysis with chronic inter¬
stitial and meningeal inflammation, whereas in sleeping sickness the
morbid change is primarily interstitial and with some secondary
parenchymatous atrophy (vide figs. 3, 4, 5).

Microscopic Examination of the Nerve Cells and Fibres.

In uncomplicated cases that have died within six months of the
onset of the lethargy untreated by organic arsenical preparations, I have
found a widespread diffuse infiltration of the meningeal and perivascular
lymphatics, especially of the subcortical structures, with comparatively
little distortion of Meynert’s column or atrophy of cells. In a European
who was treated and lived one year, having epileptiform seizures for
weeks prior to death, there was a considerable atrophy and destruction
of cell elements; but the perivascular and glia change, as compared with
general paralysis, was out of all proportion to the neuronic atrophy.

Cells .—The changes in the ganglion cells may be considered as due
(1) to the primary lymphangitis, and (2) to secondary microbial toxaemia.
It is difficult to differentiate the cells which are affected by the one
cause from the other. I consider, however, that the chronic change is
indicated in those cells in which (1) there are appearances of atrophy of
the dendrons, the protoplasmic processes being either attenuated or
broken off; (2) there is a perinuclear chromatolysis, the cytoplasm still
exhibiting some remnants of a pattern of Nissl granules in the circum-

Pathological Section

33

ference of the cell and on the dendrons; (3) the nucleus is large and
clear, and often eccentric. Sometimes a dead ganglion cell may be seen
being devoured by phagocytes. The cells of the spinal cord usually
show much less change than the cells of the medulla oblongata and
the cerebral cortex. The cells of the posterior spinal ganglion usually
show chromatolysis, but not destruction {vide Plate TV). The appearance
of the cells in acutely fatal trypanosome affections—e.g., surra and jinga
in animals—could be accounted for by the anaemia caused by the blood
change and the obstruction of the small vessels by the trypanosomes.
In the brain of a rabbit dying of surra one month after inoculation, the
ganglion cells all showed a shrinking of the cytoplasm, a marked
chromatolysis and disappearance of the Nissl granules and swelling
of the nucleus, and a change not unlike that observed in some forms of
experimental anaemia.

Fibres .—In cases uncomplicated by terminal microbial infection,
there is a certain amount of fibre atrophy proportional to the cell
atrophy described. This atrophy is most obvious in the tangential
layer of the cortex cerebri, where the fibres in places are greatly
diminished, or even absent. There may also be some diminution of the
fibres in the super-radial and inter-radial systems, especially in chronic
cases. There is, however, in the brain as in the spinal cord, no definite
system tract sclerosis, the result of atrophy of a neuronic system.
Generally in the lateral columns corresponding to the pyramidal systems
some degenerated fibres can be seen by the Marchi method, but the
glia proliferation tends to follow the distribution of the septa rather
than to accord with any definite atrophy of a system of nerve fibres.
By the Marchi method, the cerebrum, cerebellum, spinal cord, and spinal
ganglia were examined in a number of cases. In most instances the
results were unsatisfactory, owing to a generally diffuse blackening of
the myelin sheaths and the deposition of black granules. I consider
that this change was probably the result of acute changes in the
myelin, brought about by terminal microbial toxaemia, fever, &c. Some
few of the cases, however, did not show this generalized change in the
myelin, and a certain number of fibres showing Wallerian degeneration
were found. These changes we may regard as definite, and indicative
of neuronic decay.

34

Mott: JRSsumd of Human Trypanosomiasis

Examination op Nervous Tissues op Animals Experimentally
Infected by Trypanosomes.

Experimental .Evidence. —Animals inoculated with Trypanosoma
gambiense usually die before the characteristic lesions of the nervous
system can occur. I have examined the tissues of nine animals
(monkeys) which were inoculated at Entebbe in one way or another
with Trypanosoma gambiense. They were all said to have exhibited
the characteristic lethargy, but it is very difficult to differentiate
(according to my experience) between a monkey that sits moping when
profoundly ill and an animal which exhibits a lethargy on account of
the brain lesion.

The tissues of the brains of all the animals sent to me, with the
exception of two, showed no characteristic change. The vessels of the
brain were empty and there was no meningeal or perivascular infil¬
tration. Several of these animals had survived the infection (as proved
by the existence of trypanosomes in the blood) one year. One was
subsequently infected with diplo-streptococci from a case of sleeping
sickness; yet there was no sign of the meningo-encephalitis met with
in every case of human sleeping sickness. This was the experience,
apparently, of Ayres Kopke.

The tissues of two monkeys inoculated with Trypanosoma gambiense
showed, however, the characteristic lesion of human sleeping sickness.
I have examined portions of the tissues, and find that there is a very
marked neuroglia proliferation of the perivascular lymphatics, endo¬
thelial cell proliferation and lymphocyte accumulation, and a few plasma
cells around the vessels of the brain in all the situations examined. In
fact, the lesion in no respect differs essentially from that of human
sleeping sickness.

A correlation of the clinical notes of thirty cases of sleeping sickness
before the treatment by organic arsenical preparations was introduced,
with a microscopic investigation of the changes in the central nervous
system, shows that there is a parallelism between the intensity of the
chief nervous symptoms—viz., drowsy lethargy, mental enfeebleness and
fatigue, paresis and tremors—and the generalized chronic diffuse meningo¬
encephalitis. The general intense perivascular infiltration with lympho¬
cytes and plasma cells must interfere with the circulation of the ambient
fluid of the neurons, whereby they suffer from an insufficiency of oxygen.
The fluid which circulates in the perivascular lymphatics is the ambient
fluid that takes oxygen from the blood to hand it over to the nerve

Pathological Section

35

cells. This progressive, universal, and intensely inflammatory state of
the perivascular lymphatics would interfere with its flow and lead to
deficient oxygen supply. There is an interference with the outflow of the
cerebrospinal fluid, but not sufficient to produce a choked disk, so that,
although this may tend to produce cerebral anaemia, it cannot be so
important a cause of the functional defect of the neurones, and yet it
may take part in the production of the symptoms. The principal cause of

PLATE IV.

Changes in the Cells of the Central Nervous System.

Appearance of various large and small pyramidal cells of the cerebral cortex in advanced
cases of sleeping sickness, showing various degrees of chromatolysis, eccentric position of
the nucleus, breaking off and disappearance of the processes.

The cell (h) is obviously dead and being devoured by phagocytes. Below this are two granule
cells (Komchenzellen). (x 375.)

Fig. S is a section of a posterior spinal ganglion, showing an intense interstitial lymphatic¬
cell infiltration with lymphocytes. ( x 90.)

Fig. G shows a portion of the section of the same more highly magnified. Not only can the
interstitial lymphatic-cell infiltration be observed, but there is a proliferation of the endo¬
thelial ceUs of the capsule. ( x 375.)

Mott: Resume of Human Trypanosomiasis

the lethargy, in my judgment, is the perivascularitis. Moreover, a
vicious circle is established, for the more these lymphatics become
obstructed by the actively growing young cells, the more the oxygen
that may be in the fluid will be snapped up by them and the less will
be at the disposal of the neurones. Consequently, the oxygen supply
necessary for functional activity of the nerve cells becomes progressively
less and the drowsy stupor deepens proportionally. The experiments of
Yerworn prove the importance of oxygen storage by the nerve cells and

Fig. 3.

Photomicrograph of the cortex from a case of uncomplicated very chronic
sleeping sickness. The pyramidal cells are not destroyed ; there is not any
increased vascularity ; there is some perivascular and meningeal infiltration, not
nearly so marked as in the subcortical tissue. The columns of Meynert are not
disorganized; this accords with the fact that the main symptoms were paresis,
tremors, drowsy lethargy, but no epileptiform seizures or mental disturbance
beyond enfceblement. (x 150.)

Pathological Section

37

the necessity of its supply for functional activity. In widespread gene¬
ralized syphilitic meningitis and perivascularitis a drowsy stupor is a
frequent symptom ; in general paralysis the perivascularitis may be very
intense in the cortex, but never so diffuse and intense in all the sub¬
cortical structures as in sleeping sickness. The progressive dementia
which is the characteristic of the former disease is proportional to the
atrophy and wasting of the cortical substance—a condition which is
not usually met with in sleeping sickness. In juvenile general paralysis
the primary parenchymatous change is more manifest because convulsive

a Fig. 4. b

Two sections of the cortex in general paralysis ; thickening and infiltration
of membranes, perivascular infiltration, formation of new vessels and marked
atrophy of cortical substance, especially in 6, the frontal region ; a is the post-
central region. ( x a, 120 ; 6, 75.)

seizures are less frequently met with. I have observed two forms of
change in the cells in general paralysis—viz., an atrophic change and
an acute swelling accompanied by chromatolysis similar to that observed
in experimental anaemia. This change is doubtless due to vascular
stasis and accounts for the fact that after prolonged unilateral convulsive

38

Mott: TUsumi of Human Trypanosomiasis

seizures one hemisphere will be found to weigh very much less than
the other, and microscopic examination will exhibit acute destruction of
nervous elements in the hemisphere opposite to the seizures. If we
regard the parasyphilitic affections, tabes and general paralysis, as being
due to premature decay of neurones, it is not to be expected that drugs
which benefit by killing the organisms will be of any service. Seeing

Fig. 5.

Section of the brain of a case of advanced general paralysis, showing the
absence of cells in the superficial layer of the cortex. Numbers of vessels are
seen to which many glia cells are attached. There is a complete absence of
fibres and destruction of the superficial cortical cells (stained by van Gieson
method), (x 262.)

that the spirochaete has never been demonstrated either in the tissues or
cerebrospinal fluid in these affections, whereas it has in gummatous
meningitis, we can understand why mercury, antimony, and arsenic

Pathological Section

39

compounds will, by killing the organism, cure syphilis of the nervous
system and will not cure general paralysis or tabes. But why do these
drugs have no influence in sleeping sickness ? In syphilis the organism
has not escaped into the free fluid, for it has never been demonstrated
there. To rid the nervous system of the syphilitic organism it is there¬
fore probably not necessary for the drug to get into the cerebrospinal
fluid.

BIBLIOGRAPHY.

Alzheimeb. “ Histologische Studien zur Differenzialdiagnose der Progressiven Paralyse.”
Bagshawe. “ Recent Advances in our knowledge of Sleeping Sickness ” (Trans. Soc. Trop.

Med. and Hygiene), Joum . Trop. Med. and Hyg ., 1909, xii, p. 341.

Idem. Bulletin of Sleeping Sickness Bureau.

Bettencourt, Kopke, Gomez de Rezende, Correia Mendes. * “ La Maladie du Sommeil,”
Lisbon, 1903.

Bose. “ Les Maladies bryocytiques (Maladies A Protozoaires),” Centralbl. f. Bakt., Jena,
Abt. 1, 1906, Orig. xlii, p. 705.

Bradford and Plimmrb. “ Trypanosoma brucei, the Organism found in Nagana, or Tsetse-fly
Disease,” Quart. Joum. Micro. Sci ., 1902, xlv, pp. 449-471.

Bbuce. “Discussion on Human Trypanosomiasis,” Brit. Med. Joum ., 1910, ii, p. 864;

Sleeping Sickness Bureau: Bulletin , 1908, i, No. 6, p. 209.

Bbuce and Commissioners. “ Reports of the Sleeping Sickness Commission ” :—

No. I, 1903 (1) Castellani. “ Presence of Trypanosoma in Sleeping Sickness,” p. 3.

(2) Bbuce and Nabarro. “ Progress Report on Sleeping Sickness in
Uganda,” pp. 11-88.

,, II, 1903 (3) Christy. “ The Distribution of Sleeping Sickness, Filariaperstans, Ac.,

in East Equatorial Africa,” p. 3.

(4) Castellani. “ Adult Forms and Developmental Forms of the Try¬

panosome found in Sleeping Sickness,” p. 11.

(5) Low and Castellani. “ Report on Sleeping Sickness from its Clinical

Aspects,” pp. 14-63.

,, III, 1903 (6) Christy. “ The Epidemiology and Etiology of Sleeping Sickness in

Equatorial East Africa, with clinical observations,” pp. 3-32.

(7) Theobald. “ Report on a Collection of Mosquitoes and other Flies
from Equatorial East Africa,” p. 33.

,, IV 1903 (8) Bruce, Nabarro and Greig. “Further Report on Sleeping Sickness
in Uganda,” pp. 3-87.

,, V, 1905 (9) Austen. “ A Provisional List of Diptera,” p. 8.

(10) Nabarro and Greig. “Further Observations on the Trypanosomiases
(human and animal) in Uganda,” pp. 8-47.

,, VI, 1905 (11) Greig and Gray. “Continuation Report on Sleeping Sickness in
Uganda,” pp. 5-273.

(12) Greig. “ Report on Sleeping Sickness in the Nile Valley,” p. 273.

(13) Austen. “ The Distribution of Tsetse Flies,” p. 278.

(14) Gray and Tulloch. “ The Multiplication of the Trypanosoma gam-

biense in the Alimentary Canal of the Olossina palpalis ,” p. 282.
Bbuce, Hamerton, Bateman, and Mackie. “ Duration of the Infectivity of the Olossina
palpalis after the removal of the Lake-shore population,” Proc. Roy. Soc., B, 1909-10,
lxxxii, p. 56.

“Trypanosome Diseases of Domestic Animals in Uganda,” Joum. Trop. Med. and Hyg.,
1910, xiii, p. 265.

Calkins. “ Pathogenic Protozoa,” Pop. Sci. Monthly, New York, 1906-7, lxix, p. 409.
Castellani. “ Researches on the Etiology of Sleeping Sickness,” Joum. Trop. Med. and
Hyg., 1903, vi, p. 167.

Dutton. Joum. Trop. Med. and Hyg., 1902, v, p. 363.

40

Mott: Resume of Human Trypanosomiasis

Dutton and Todd. “ First Report of the Trypanosomiasis Expedition to Senegambia, 1902 ”
Liverpool, 1903.

Idem, “ Gland Puncture in Trypanosomiasis,” “ Thompson Yates and Johnston Laboratories’
Report,” 1906, Memoir xvi, p. 97.

Fobde. Joum. Trap, Med and Hyg., 1902, v. p. 261.

Harvey. “Report on a Case of Experimental Sleeping Sickness in a Monkey,” Joum. of
Roy. Army Med. Corps, 1906, iv, p. 621.

Hodges. “Progress Report, Uganda Sleeping Sickness Camps,” 1909.

Kleine. Deutsch. med. Wochenschr ., 1909, xxxv, pp. 469, 470, 924, 926, 1257-1260.

Kleine. “ Weitere Untersuchungen uber die Aetiologie der Schlafkrankheit von Stabsarzt.
Leiter der Schlafkrankheitsbekampfung in Deutsch Ostafrika.” Deutsch. med.
Wochenschr ., 1910, xxxvi, p. 1400.

Kopke. “ Investigacoes sobre a Doen$a do Somno,” Arch. de Hyg. e Path. Exocitas, 1905,
i, fasc. 1, pp. 1-66.

Laveban. Compt. Rend. Acad. Sci., 1906, cxlii, p. 1065.

Manson. “ Lectures on Tropical Diseases” (Lane Lectures, 1906). (Constable, London.)

Manson and Mott. “ African Lethargy, or the Sleeping Sickness,” Trans. Path. Soc. Land
1900, li, p. 99.

Marshall. “ Trypanosomiasis or Sleeping Sickness,” Rev. of Neur. and Psychiatry , 1906,
iv, p. 112.

Mabtin, Lebceup, et Rouband. “ Rapport de la Mission d’iltudes de la Maladie du Sommeil
au Congo fran^ais,” 1906-8.

Metchnixoff et Roux. Annales de VInst. Pasteur , 1904, xviii, pp. 1, 667 ; 1905, xix, p. 673;
1906, xx, p. 785.

Mott. The Oliver Sharpey Lectures on “ The Cerebrospinal Fluid,” Lancet , 1910, ii, p. 81.

Idem. “The Changes in the Central Nervous System of Two Cases of Negro Lethargy,”
sequel to Dr. Manson’s Clinical Report, Brit. Med. Joum., 1899, vi, p. 1666.

Idem. “ A Case of Negro Lethargy,’* by Stephen Mackenzie, with a Note on the Histological
Changes of the Nervous System, by F. W. Mott, Trans. Path. Soc. Lond ., 1900, li, p. 118.

Idem. “ Observations on the Brains of Men and Animals infected with various forms of
Trypanosomes,” Proc. Roy. Soc., 1905, lxxvi, B, p. 76.

Idem. “ System of Syphilis,” 1910, iv, pp. 20-36.

Idem . “Histological Observations, Ac.” Report VII of the Sleeping Sickness Commission,
1906, p. 3.

Mott and Low. “ The Examination of the Tissues of a Case of Sleeping Sickness in a
European,” Brit. Med. Joum., 1904, i, p. 1000.

Mot^t and Stewart. “ Some further Observations on the Cell Changes in Dourine and
Sleeping Sickness,” Brit. Med. Joum ., 1907, ii, p. 1327.

Nabarro. Translation of Laveban et Mesnil’s “ Trypanosomes et Trypanosomiases,” 1907.

Novy. Joum. of Infect. Dis., Chicago, 1905, ii, p. 250.

Pumuer. “ Note on the Effect produced on Rats by the Trypanosomata of Sleeping Sick¬
ness,” Proc. Roy. Soc., 1905, lxxiv, p. 388; 1907, B. lxxix, p. 95.

Rogers. “Preliminary Note on the Development of Trypanosoma in Cultures of the
Cunningham-Leishman-Donovan Bodies of Cachexial Fever and Kala-azar,” Lancet,
1904, ii, p. 215.

Salvin Moore and Breinl. Lancet , 1907, i, p. 1219.

Schaudinn. Milnch. med. Wochenschr., 1905, lii, p. 1028.

Sioabd et Moutier. “Recherche bact^riologique et histol. dans un cas de Maladie du
Sommeil chez un blanc,” La Presse mAd., 1905, xiii, p. 422.

“ Sleeping Sickness in Whites,” Sleeping Sickness Bureau, Bulletin No. 20, 1910.

Thomas and Anton Breinl. “Trypanosomes, Trypanosomiasis, and Sleeping Sickness,*’
Report, 1905, vi, part 2 (Thompson Yates and Johnston Laboratories, University of
Liverpool).

Thomas and Linton. Lancet, 1904, ii, pp. 1337-40.

Todd and Christy. Brit. Med. Joum., 1904, i, p. 186.

Warrington. “A Note on the Condition of the Nervous System in a case of African
Lethargy,” Brit. Med. Joum., 1902, ii, p. 929.

Watson. “ The Pathology and Morbid Histology of Juvenile General Paralysis,” Archives of
Neurology , 1903, ii, p. 621.

Winterbottom. “An Account of Native Africans in the Neighbourhood of Sierra Leone
to which is added an account of the prosent state of Medicine among them. 2 vols., 1808.

John Bale, Sons & Danielsson, Ltd., 83-91, Great Titch field Street, London, W.

[.Reprinted from the Proceedings of the Royal Society, B. Yol. 83]

Note upon the Examination , with Negative Results , of the Central
Nervous System in a Case of Cured Human Trypano¬
somiasis.

By Frederick W. Mott, M.D., F.R.S.

(Received October 22,—Read November 3, 1910.)

This is the first case in which “a chance has occurred of examining
a cured case of human trypanosomiasis post mortem” according to the
statement of C. A. Wiggins, the Acting Principal Medical Officer of the
Uganda Protectorate, who has kindly forwarded me the tissues for micro¬
scopic examination.

Summary of the History of the Case .—Narain Singh, a Sikh, belonging to
the 4th K.A.R. (aged 30 at death), was found to be suffering from trypano¬
somiasis in June, 1905, and received treatment with inorganic arsenic. The
previous history as far as ascertainable, compiled from extracts of reports and
history sheets, is published in the full account, but, in brief, it may be
assumed that the drug was given intermittently for 18 months or more,
and pushed till toxic symptoms of neuritis, mental dullness, etc., rendered
further energetic treatment impossible; trypanosomes were then no longer
obtained by puncture of the glands. Unfortunately there is no note of
lumbar puncture having been performed until a few months before death,
therefore we do not know whether invasion of the sub-arachnoid space ever
occurred either before or after the treatment. But it is probable that
trypanosomes were never present in the cerebro-spinal fluid, for if they were,
the symptoms of Sleeping Sickness would, in all probability, have come on,
in spite of treatment by atoxyl. Sir David Bruce, in December, 1908 (that
is three and a half years after the trypanosomiasis had been discovered),
saw this man, and stated that he appeared to be in excellent health. A year
later he was seen by Captains Hamerton and Bateman, who reported no
symptoms of Sleeping Sickness. They made a very careful investigation of
the blood, both by microscopic examination and by experimental injection
into monkeys; the results were negative. In June, 1910, lumbar puncture
was performed, and 17 c.c. of fluid withdrawn; the centrifuged fluid showed
no lymphocytosis or trypanosomes; and injection of the fluid into a monkey
was followed by negative results. The patient was attacked with pneumonia
in August, 1910, and died three days after admission to the hospital. At
the post-mortem examination grey hepatisation of the whole right lung was
discovered. Beyond fibrosis and induration of the cervical and inguinal

236

Dr. F. W. Mott. Examination of Nervous [Oct. 22,

glands there was nothing noteworthy in the appearance of the organs and
tissues. The brain was quite normal in appearance, and there was no excess
of fluid.

It may be mentioned that this man contracted syphilis on July 27, 1906,
and he was treated for some time with mercury, and a note on February 15,
1908, is as follows:—Condition the same as August 6, 1907, but no
trypanosomes found in blood or glands, due to fact of taking mercury for
syphilis.

Histological Examination .—Sections were prepared of portions of the
cerebrum, cerebellum and medulla oblongata, by all the methods which
I have previously adopted for the examination of the tissues of Sleeping
Sickness cases. I found no trace of the characteristic meningeal and
perivascular infiltration, nor of gliosis. Sections of the spleen, liver, and
kidney were also examined with negative results.

I have shown that there is a parallelism between the intensity of the
signs and symptoms of Sleeping Sickness and the diffuseness and intensity
of the lymphatic perivascular infiltration with lymphocytes and plasma cells
which is the main cause of the clinical phenomena.

It may be asserted that this case proves that human trypanosomiasis
is curable, but it does not prove that Sleeping Sickness is curable, for I
contend that the diagnosis of “ Sleeping Sickness ” can only be made when
there is proof that the trypanosomes have invaded the sub-arachnoid space.
The case emphasises the importance of early diagnosis of the infection and
the value of early energetic treatment by organic arsenic preparations. How
far the administration of mercury assisted to complete the cure is uncertain.

UGANDA PROTECTORATE.
Death Report.

Entebbe Station, August 17, 1910.

Name.

Nationality.

Age.

Sex.

Date of
admis¬
sion.

Date

of

death.

Disease
for which
admitted.

Cause of
death.

Plaee of death.

Narain Singh,
No. 4662 I.C.
4th K.A.R.

Sikh

30

Male

3.8.10

6.8.10

Bronchitis

i

Pneumonia

Indian Contingent,
4th XA.B. Hos¬
pital.

Previous history as far as ascertainable, compiled from extracts of reports and history
sheets :—

22.6.05. Trypanosomiasis. Received treatment inorganic arsenic.

4.12.06. Gland puncture. Trypanosomes +.

1910.] System in Cured Human Trypanosomiasis.

237

Four injections 2 c.c. atoxyl 20 per cent. December 6, 7, 16, and 17.

18.12.06. Glands trypanosomes +.

28.12.06. Glands trypanosomes —. Atoxyl 20 per cent., 2 c.c.

29.12.06. Repeated atoxyl 20 per cent., 2 c.c.

30.1.07. Glands trypanosomes —.

8.2.07. Glands trypanosomes -.

Condition. —Arsenical neuritis. Drowsy looking. Rheumatic pains.

6.8.07. Condition far from satisfactory. Irregular fever, rapid pulse. Dull and
stupid. Cervical glands enlarged. Trypanosomes not found in glands since March,
1907. Energetic treatment with arsenic impossible owing to symptoms of poisoning
rapidly appearing.

15.2.08. Condition the same 6.8.07, but no trypanosomes found in blood or glands, due
to the fact of taking mercury for syphilis (contracted 27.7.06).

16.12.08. General Condition. —Strong, well nourished. No tremors. Reflexis normal.

Gland puncture and blood examination trypanosomes -.

Differential count. Lymphocytes 70 per cent.

Some tendency to drowsiness when unoccupied.

Last treatment, two injections kharsin, May, 1908.

18.12.08. Proceeded to Mpumu to do duty with the Royal Society’s Sleeping Sickness
Commission. Report by Sir David Bruce—“ This man appears to be in excellent health.’ 7
Returned to Entebbe.

16.12.09.—Report by Captains Hamer ton and Bateman, R.A.M.C., Sleeping Sickness
Commission, Mpumu—“No symptoms of Sleeping Sickness.”

Blood Examination. —Examined peripheral blood. Negative results 14 occasions.

Examined centrifuged peripheral blood. Results negative.

Examined blood from median basilic vein. Results negative.

Examined blood from median basilic vein centrifuged. Results negative.

16.12.09. 4 c.c. blood from median basilic injected into monkey.

29.12.09. 5 c.c. „ „ „ „

1st monkey examined 15 times. Results negative.

2nd „ „ 12 „ „ ,,

13.6.10. Lumbar puncture 17 c.c. Cerebro-spinal fluid abstracted centrifuged.
Trypanosomes —. No excess white cells. 12 c.c. injected into monkey. Monkey
examined twice weekly over one month. Results negative.

General habits. —Intemperate. Had gonorrhoea and syphilis.

Post-mortem appearances 14 hours after Death.

Body of lean but in no way emaciated man.

Externally. —Cervical glands—small, hard, and shotty. Inguinal glands—small, hard,
and shotty.

Chest. —Parietal and visceral pleura adherent right side, due to recent pleurisy.

Right Lung .—Weight 58 ozs. On section the whole lung was in a state of grey
hepatisation.

Left Lung. —Weight 14 ozs. Pleura and lung substance normal.

Heart. —Weight 12 ozs. Right heart distended with blood clot. All chambers and
valves normal. The glands at the root of lungs and around bronchi and trachea were
-enlarged and soft, and some were purulent.

, Microscopic. —Examination of this pus showed organisms resembling pneumococci.

Liver. —Weight 89 ozs. Enlarged and congested. On section, soft and friable.
Probably some fatty change. No obvious fibrotic changes.

Portion preserved for microscopic examination in England.

238 Nervous System in Cured Human Trypanosomiasis.

Spleen .—Weight 14 ozs. Feels hard to the knife on section. Pale appearance and
excess of fibrous tissue on cutting open.

Portion preserved for microscopic examination in England.

Kidneys. —Right, weight 5 ozs. Left, 6 ozs. Both were swollen, the kidney substance
bulging from the capsule when cut into.

Both capsules were a little adherent.

Cortices undiminished. The whole kidney substance appeared a little paler than
normal.

Portions preserved for microscopic examination in England.

Pancreas and Suprarenale. —Normal.

Stomach .—Slightly dilated. No gastritis. Some post-mortem staining.

Intestines. —Normal. Mesenteric and retroperitoneal glands not enlarged.

Brain .—Calvaria normal. Weight of brain, 52 ozs. No thickening of membranes.
Brain substance normal. Ventricles normal in size and no excess of fluid.

Portions of cerebral cortex and cerebellum preserved for examination in England.

(Signed) H. B. Owbn,

Medical Officer, Civil Hospital, Entebbe.

Habbison and Sons, Printers in Ordinary to His Majesty, St. Martins Lane*

[Reprinted from the Proceedings of the Royal Society of Medicine

March, 1911.]

SEVEN CASES OF AMAUROTIC IDIOCY
(TAY-SACHS DISEASE).

By Hildred B. Carlyle and F. W. Mott, F.R.S.

PART I.—By Dr. Caulyll.

Amaurotic family idiocy is a name which has been given to a rare
disease of the nervous system occurring in Hebrew children. For these
reasons a practical knowledge of the disease, as regards clinical symptoms
and diagnosis, can be possessed only by a few; and, further, the objec¬
tion raised by the Jewish race to autopsies increases the difficulty of
obtaining material for systematic pathological research.

The clinical symptoms of the disease are so characteristic that, if
borne in mind, no difficulty in diagnosis should occur; indeed, the
pathology is so distinct as to indicate a correct diagnosis.

In recent years, as knowledge of the disease has increased, many
accounts of cases, partial or complete, have been published; so that a
correct diagnosis is now arrived at more frequently. As yet, how r ever,
the majority of text-books contain no adequate account of this interesting
disease. It is therefore with no apology that I put on record the notes
of six cases which have come under my personal observation during
twelve months’ residence at the East London Children’s Hospital,
together with those of a case recently under Dr. Mott’s care. That the
details of some of these cases are incomplete will be evident to the
reader, but I trust that the shortcoming may be condoned when it is
remembered that in these alien families the details of the medical history
had frequently to be obtained through an interpreter.

2 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

My six patients are not akin to one another, but an elder brother of
the first child whom I saw suffering from the disease had died three
years before of the same complaint. His case, with another under
Dr. Mott’s care, was published in detail by Dr. Mott in the third volume
of the Archives of Neurology , and I shall draw from the notes of that
case for purposes of comparison with those of his sister (Case I).
Case YII is a patient that recently came under the notice of Dr. Mott
at Charing Cross Hospital, and, with his permission, I have included the
history with my series of cases.

One of my patients (Case IV) came under observation in an inter¬
esting way. The mother of the two children mentioned above, a woman
of unusual intelligence, noticed this child in his mother’s arms in a
tram-car. A rapid inspection convinced her that the child could not
see, and she quickly came to the conclusion that his state was identical
with that of her own children. The child’s mother was so impressed
with the statement that her baby could not see, which fact she had not
discovered for herself, that she readily consented to bring him to the
hospital.

The seven patients are all children of Jewish patients, coming from
liussia or Poland. Some of the children were born abroad, others in
England. Five cases are of girls, two of boys. Another member of
the family of my first patient (Case I) died of the disease; and in
Case III there are reasons to suppose that the only other child of that
family may have died of the same affection. The youngest child in the
family of which the patient (Case II) was a member presents certain
very suspicious symptoms, and will be kept under observation.

All the children have now succumbed and their ages at death were
as follows :—

Case I, 2 years 3 months.
,, I a, 12 months.

,, II, 2 years 4 months.
,, III, 1 year 8 months.

Case IV, 2 years 3 months.

,, V, 1 13 months.

,, VI, 1 18 months.

,, VII, 17 months.

Dr. Mott’s other case, reported in the third volume of the Archives
of Neurology, 2 died at the age of 2 years.

In the light of these figures, and of those of other published cases,
it is justifiable to tell the parents that children with this affection will
not reach the age of 3 years. In none of the families from which these
cases are taken is it recorded that the firstborn children were afflicted
with the disease (except in Case III).

1 These cases have died since this paper was written.

* Arch, of Neurol., 1907, iii, p. 218.

Pathological Section 3

In Case I and in Case 1a the fourth and fifth children of the family
were affected.

In Case II the patient was the fourth child of the family.

In Case III the second child was affected (the first child is now
known to have died from the disease).

In Case IV the patient was the second child of the family.

In Case V the fourth child was affected.

In Case VI the third child was affected.

In Case VII the seventh child was affected.

In every case (except Case III) the patient had healthy brothers
or. sisters.

In the case of Jenny M. (Case I) the mother sought advice as to
whether she would be wise in having any more children or not. She
was told there was no reason to believe that her next child would be
afflicted.

Case I.— Jenny M.

Under the care of the late Mr. Hancock at the East London
Children’s Hospital, 1909.

Family history: Parents alive and well. They are Jews, the father
coming from Russia and the mother from Poland. They reside in
Spitalfields. No consanguinity. When married, father was 18 and
mother 17 years old. The patient is the fifth child of the marriage.
The eldest child died at 8 months, of diarrhoea. The second child is now
8 years old and is well. His eyes have been examined and nothing
abnormal was detected. The third child, a girl, died of pneumonia when
a baby. The fourth child, a boy, afflicted with amaurotic idiocy, died at
Shadwell at the age of 12 months (Case Ia). The fifth child is the
patient. No miscarriages. The parents have decided not to have any
more children.

Mother’s family: The mother’s parents are alive and well. No con¬
sanguinity. She is one of seven children, of whom three are dead, the
cause being unknown. One of her brothers is married, but has no
children; her other brother has had four children, who are all healthy.

Father’s family: There is no information about the father’s grand¬
parents; his parents are alive and well. No consanguinity. He has two
brothers and seven sisters; of the latter, one died at the age of 3 years
from croup, and one after living a few weeks. The remaining five are
between 12 and 22 years of age; they are healthy; none are married.
Of the two brothers, one is married and has two children who are well,
the other is 0 years old.

4 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

History : Full-time child, no instruments; breast-fed up to eleven
months. The mother, a very intelligent woman, brought her to see Mr.
Hancock when she was 4 weeks old because she thought the child was
“ going like Jack.” When the child was 3 months old the mother
brought her again, as she noticed that she was partially blind. (Mr.
Hancock found the typical ophthalmoscopic signs.) She noticed also
that the limbs were stiff because she had difficulty in powdering the
groins. The child cried less than other children and did not take any
notice of things. From birth she never recognized the difference between
the mother who nursed her and other people who lifted her up; nor did
she ever play with toys. The general health for twelve months was
fairly good, but gradually she got thinner and took her food badly. She
always lay quietly where she was put, and the power in her limbs
rapidly decreased.

Fig. 1. Case I.—Jenny M. • Fig. 2.

July 9, 1909.

July 9, 1909. Showing the early
“ main en gride.”

On admission, January 9, 1909, aged 1 year and 4 months (the
following meagre notes are all that are obtainable) : Well nourished and
plump. Takes very little notice of people or surroundings, and appears
only to eat and sleep. Heart and lungs normal. No convulsions. No
strabismus nor nystagmus. Limbs spastic. Weight, 19 lb. 11 oz.

Progress: There are, unfortunately, no notes about her progress; but
I am told that the child became progressively thinner, and that nasal
feeding became necessary about May. In July, her weight was 141b.,
and the photographs taken then show the hyper-pronation of the left

Pathological Section

5

forearm. On the right side, the hand has assumed a position of “main
en griffe ” (figs. 1 and 2).

November 9: Always lies in a semi-comatose condition; eyes con¬
tinually open; pupils dilated, reacting slightly to a strong light. The
eyelids sometimes blink, and the eyes are at times withdrawn from a
bright light. Optic atrophy marked. Usually there is a slight internal
strabismus of recent date. The mouth is kept shut, but can be moved
well. There is a slight sucking reflex. The child seems insensitive
to sound; head retracted; back considerably bent with scoliosis and
kyphosis. Right side : Arm kept slightly from the body and extended
at elbow; forearm fully pronated; wrist acutely flexed, and has sore
places on dorsum. Fingers hyper-extended at metacarpo-phalangeal

Fig. 3. Case I.—Jenny M. Fig. 4.

November 12, 1900 (a few hours before November 12, 1909.

death). Note the difference in the deformity
of the two limbs.

joints, and flexed elsewhere ; thumbs fully adducted and slightly
opposed; slightly flexed at metacarpo-phalangeal joint and extended
at the inter-phalangeal joint. Leg flexed at hip and knee; sores
present over knee; foot and toes plantar flexed to the fullest extent.
Left side: Arm slightly flexed at elbow; forearm hyper-pronated ; leg
straight at hip and knee ; position of foot as on right side. These
contractures are w r ell shown in figs. 3 and 4. Abdomen very lax ; no
enlargement of liver or spleen. The plantar reflex is extensor on each
side, as exemplified by a slight straightening of the great toe. Deep

6 Carlyll & Mott: Seven Cases of T ay Sachs Disease

reflexes not obtained. There is great muscular wasting. The position
of the joints can be altered by force, but they tend to return to the
original position, except in the case of the right knee, the muscles
of which are very weak and lax, so that the joint can be placed in any
normal position. There are numerous pressure sores all over the body.
Urine and faeces are passed in the bed. Nasal feeding has been
employed for five or six months. There have been several slight
attacks of bronchitis. The temperature has been normal throughout,
except for some terminal pyrexia.

November 12, 1909: The child died, aged about 2J years.

Immediately after death had occurred the eyes were removed and
placed in fixing solutions. The brain was removed later and hardened
in Muller’s fluid, and subsequently examined by Dr. Mott. No further
examination was permitted.

Case Ia.—Jack M.

This child was under the care of Dr. Eustace Smith, Dr. Coutts, and
Mr. Hancock at the East London Children’s Hospital, in 1906. Dr. Mott
performed the autopsy, and has published the result of his chemical
and histological examination in the Archives of Neurology, iii, 1907.
With his permission, and as the second case in the family (Case I) has
recently proved fatal, I give his notes here for comparison :—

Family history : See Case I.

History : Quite healthy at birth. Normal confinement. No urine
passed for twenty-four hours. When six months old the child developed
a rash which lasted four or five days. Soon afterwards he developed
pneumonia, being dangerously ill for a week. Since this illness he has
not noticed things, and his mother thinks this may be due to deafness.
His attention cannot be attracted. The eyes wander aimlessly. The
mother thinks he should hold his head up better for his age. He has
had an aural discharge for five months. No squint. Breast-fed always;
no other food; bowels regular. Has never walked nor crawled, but at
6 months old could stand firmly on his legs when allowed to do so.
No definite paralysis. The back muscles appear to be quite strong. At
six months old the child was taken to the Moorfields Eye Hospital.
He was admitted, but having contracted measles, was discharged
shortly afterwards.

On admission, January 13, 1906, aged 8 months : Weight, 20 lb.
10 oz. Very well nourished, rather pale. Head of good shape;
fontanelle widely open; no cranio-tabes; hair normal. Eyes wander

Pathological Section

7

aimlessly. Attention appears to be attracted, however, by the ticking
of a watch, and he looks for it in the right direction. When placed in
a sitting position his head does not fall about. Muscular development
appears to be very good. Skin normal. Sleeps and eats well. A very
amiable child. Gastro-intestinal system: Two lower incisors only;
tends to protrude tongue like a Mongol. Abdomen large; spleen and
liver not felt. Bowels usually regular; stools normal. Thorax : Well
covered, good shape ; nothing abnormal in heart or lungs. Nervous
system: Cranial nerves intact; pupils equal in diameter; normal
reactions direct and consensual; eye movements good .in all directions;
no nystagmus nor strabismus ; no paralysis nor muscular wasting.
Reflexes normal for child’s age. Fundi present characteristics of
the disease.

Discharged January 25, condition “ in statu quo.”

Re-admitted February 7, 1906, suffering from pneumonia, following
what was said to have been measles, but which was probably scarlatina.
Very weak. Still well nourished. Neck muscles now obviously weak,
causing head to fall back; no rigidity; no obvious muscular wasting;
reflexes are still brisk; plantar reflex extensor; eyes are unchanged;
well-marked signs of broncho-pneumonia.

February 18 : Has been in a critical condition, but signs in lungs
are now clearing up. Reflexes brisk. Head muscles weaker, but can
move head a little from side to side.

February 24 : Still some bronchitis. Right arm now appears to be
rigid. Desquamating freely.

February 26 to March 10 : Temperature is very irregular, reaching
103° F. at times. Losing weight (14 lb. 14 oz., March 8). Well-marked
oedema of hands and feet; semi-conscious. Rigidity of limbs variable.
Resents ophthalmoscopic examination.

March 31 : Weakness increasing. Temperature subnormal. Profuse
hsematuria. No casts in urine.

April 10 : Marked anaemia ; skin very dry. Much oedema; abdomen
very sunken; skin loose and inelastic ; has fits of crying and irritability.
Does not know anyone ; no hsematuria; rarely moves limbs, and then
only the upper; no vomiting. Eyes nearly always open ; they wander
aimlessly. Limbs alternately rigid and flaccid. Lower limbs powerless;
knee-jerks brisk; Babinski’s sign variable.

April 12: Child died suddenly, aged 12 months.

8 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

Case II.— Milly T.

Under the care of Dr. Eustace Smith in the East London Children’s
Hospital in 1909. Died at St. George’s Infirmary, E., 1910. No
autopsy.

Family history: The parents are Russian Jews, and have been in
England seven years. They are both strong and well. They have had
five children, three older and one younger than the patient. The older
children are boys, aged 12,10, and 5 years respectively (1910). The
youngest of the family is a girl aged 8 weeks. I have recently seen this
child, and she presents a suspicious similarity to early sufferers from
amaurotic idiocy. I was not given permission to examine her eyes.
There is no consanguinity between the parents. When they married
the mother was aged 20 and the father 24. They do not know of any
similar cases of illness in their respective families.

The patient was born at full term without the assistance of instru¬
ments, and was brought up on the breast and the bottle.

History : The child was quite well until a year old, when she seemed
not to see, and w r as taken to a hospital. She seemed to notice only bright
lights, and could not support her head. At 3 months old she had
fallen on her head. Is usually constipated, and has been wasting latterly.
Has had no infectious fevers.

Admitted July 8, 1909, aged 16 months. Well developed and well
nourished. Skin pale. Weight, 16 lb. General muscular rigidity,
especially in arms and legs, which are slightly extended. This stiffness
is easily overcome. No head retraction or spinal rigidity. Child lies in
a restless condition. Eyes rather fixed, and kept open. Sight seems im¬
paired, but she is not blind, for she turns eyes towards objects presented.
(There is no note of an ophthalmoscopic examination.) Cranium well
shaped ; anterior fontanelle almost closed ; no cranio-tabes. Nostrils tri¬
angular shaped. Mouth kept open ; tongue protruded and often sucked.
Abdomen protuberant and rather flaccid. Liver and spleen not palpable.
Knee-jerks decidedly exaggerated. No ankle-clonus. Plantar reflex
extensor. Lungs and heart normal. Child swallows badly.

Discharged July 14, 1909. Whilst under observation, the tempera¬
ture ranged continuously from 100° to 102" F. Lumbar puncture re¬
vealed a sterile fluid containing a few lymphocytes.

Admitted to infirmary, October 25, 1909, aged 19 months. Weight,
18 lb. 10 oz. The pupils were small and reacted. There was apparently
no sight. The face twitched symmetrically. Kernig’s sign was marked.
There was much salivation.

Pathological Section

9

November 13 : Weight, 18 lb. By the kindness of Dr. Bowl an I was
allowed to watch the child’s progress.

December 8 : Weight, 17 lb. The child lay where placed, but started
at sudden noises. Pale and flabby, features becoming pinched. Much
crying. Swallowed fairly well, and did not require nasal feeds. Head
fell back when child lifted. Limbs slightly rigid. Knee-jerks brisk.
Plantar reflex extensor. Thumbs markedly adducted. Examination of
the fundi revealed the characteristic appearances. Lumbar puncture
gave a small quantity of fluid under very low pressure. Shortly after
this child became worse, limbs being much contracted. Nasal feeds
became necessary for a time.

December 26 : Weight, 16 lb. 8 oz.

January 3, 1910 : Weight, 16 lb.

January 12 (see fig. 5) : Swallowing well. Pupils react to light.
Limbs not markedly contracted, but both hands clenched over adducted
thumbs. Plantar reflex indefinite but not extensor. A quantity of fluid
was obtained by lumbar puncture.

Fig. 5.

January, 1910. Case II.—Millv T.

The child stayed in much the same condition for several months,
becoming more wasted and rigid.

The- cerebrospinal fluid (first sample) was alkaline and contained
some sugar. Noguchi’s test showed an absence qf globulin. There were
neither cells nor organisms present. Second sample : Protein content
normal. Choline test negative. No lipoids beyond a trace of cholesterol
present.

July 18, 1910 : Death occurred from pneumonia, following an attack
of measles, at the age of 2 years 4 months. No autopsy was allowed,
in spite of the most urgent appeals for permission.

10 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

Case III.— Fanny M.

Under the care of Mr. Hancock at the East London Children’s
Hospital for a short time. Transferred, on account of an epidemic of
measles, to the Evelina Hospital in 1909, where she was under the care
of Dr. Briscoe. (Owing to Mr. Hancock’s death, the child’s condition
while at Shadwell is not known.)

Family history (1910) : The mother was married once previously in
Poland when she was 16 years old. Of this marriage she had one
miscarriage. She was aged 24 when she married, in 1904, her present
husband. He was 30 years old. No consanguinity. They are Polish
Jews, and have lived in England for five years. The mother’s parents
died when she was a baby. She has one brother, aged 35, who has six
healthy children. The father has one sister and several brothers, who
have healthy children. The parents have never seen any children with
amaurotic idiocy in Poland. They have had two children in all; the
first, a boy (J. M.), was born in Poland, and died in 1907 at the German
Hospital, aged 21 years. The case-notes are not obtainable. He was
weakly from birth, and said to be rickety. Breast-fed for twelve
months. Never used his legs. Became very thin before death. I
have seen two photographs of this child, taken at 3 and 12
months respectively. The first photograph shows a fat, intelligent-
looking baby with widely open eyes. In the second he is also fat, but
presents a rather idiotic look. The limbs appear normal. The mother
cannot say anything definite as to his powers of vision, but I think it
probable that this child was an amaurotic idiot. The mother agrees
that this is probable. (A recent examination of the sections which were
prepared when this boy died, leave no doubt that he died of this
affection.)

History: Born in England at full term; large child at birth; no
instruments. Breast-fed to 8 months. Well up to 6 months, when
she became weaker and could not hold up her head. When about
8 months old it was noticed that she did not observe things like other
children. Sudden noises would start “ convulsions.”

General condition : The child was sent to the Evelina Hospital on
October 7, 1909. She was then 18 months old. Mr. Hancock w ? as
anxious to know how she progressed, and I was very kindly allowed to
examine her there on November 23, 1909, when her condition was as
follows : The face presented a look of dementia, and the child lay
where placed. There were no voluntary movements, even when lumbar

Pathological Section

11

puncture was performed; nor did the child cry. No obvious muscular
wasting and no contractures were observed. The arms and legs were
extended and slightly rigid, but flexion could be performed. Thumbs
markedly adducted. Some foot-drop, but this was not well marked.
Extensor plantar reflex well marked on each side. Knee-jerks obtained,
but not exaggerated. Eyelids sometimes open ; no movements of eyes ;
complete blindness; well-marked optic atrophy. At the macula was a
circular area rather larger than the disk, of the colour of dirty cotton¬
wool, with an ill-defined edge. In the centre of this area was a well-
marked liver-coloured spot. The child on admission had taken food
fairly well, but for some weeks past had been fed by a nasal tube.
Lumbar puncture was readily performed. There was no vertebral

Fig. 6.

Case III.—Fanny M.

rigidity. Two large test-tubes were rapidly filled with clear fluid.
Shortly afterwards the child developed chicken-pox, and on December
20, 1909, she died, aged 1 year and 8 months. I was told that no
improvement had followed the lumbar puncture (fig. 6). The specimen
of cerebrospinal fluid was free of blood, and was not abnormal in cell-
content. Reaction alkaline. Noguchi’s test showed that it contained
no globulin. With Fehling’s solution a rapid reduction took place, as is
usual with normal cerebrospinal fluids. There was but a small amount
of protein. Choline and cholesterol were absent.

Post mortem (December 22, 1909) : Well-nourished child. Fontan-
elle closed. Brain very hard; weight, 38 oz. Ventricles not distended,
but a quantity of fluid escaped on opening the skull cavity. Some pus
was found in the right pleural cavity.

12 Carlyll & Mott: Seven Cases of Tay-Saclis Disease

Through the kindness of Dr. Briscoe, I was enabled to be present
at the autopsy, and to obtain portions of the nervous system and other
tissues for pathological research. This was carried out under Dr. Mott’s
direction, and a portion of the histological and chemical investigations
are based upon researches made upon this material (vide Part II).

Case IV.— Abraham C.

Under the care of Dr. Eustace Smith in the East London Children’s
Hospital, Shadwell, 1908 and 1909. Death occurred in the St. George’s
Infirmary, E., 1909. No autopsy.

Family history, 1910 : Two other children, one aged 6, healthy and
at school; the other died of “ cough ” at 2 weeks old. No miscarriages.
The parents come from Russia and have been ten years in England.
When they married the mother was aged 20 and the father 22. The
mother’s parents are alive and well. She has three brothers, aged 12,
10, and 6 respectively, and four sisters. Of these two are married and
two are still young. Of the former one has two girls and one boy; the
other has one girl. The father’s parents are alive ; he has brothers and
sisters, but nothing is known of them.

History: Full-term child ; breast-fed ; no instruments. At 3 months
old suffered from cramps and constipation; occasional fits. Irritable
for two months and suffered from screaming attacks. For two months
previous to admission mother had doubted whether he could see properly.
A diagnosis of rickets was made at several hospitals.

Admitted to the East London Hospital, October 30, 1908, for
bronchitis. Aged 1 year. Weight, 22 lb.; very rickety and unable to
stand. Well covered with flesh. Irritable and cries a great deal.
Occasional nystagmus; unable to fix objects with eyes. Characteristic
appearances seen in fundi. Limbs flaccid. Both knee-jerks brisk.
Sometimes a slight ankle clonus occurs. Plantar reflex extensor.
Fontanelle normal for age. Liver and spleen not palpable. Four
central incisors, two upper and two lower appearing.

Discharged November 9, 1908.

Re-admitted January 30, 1909, for bronchitis following a recent
attack of measles. Weight, 15 lb. Child apparently quite uncon¬
scious. The only movement is a slight slow rolling of the head from
side to side. Slight general rigidity. Eyes half-closed, exhibiting slow
lateral conjugate movements; pupils small, equal, and circular; no
nystagmus ; optic atrophy. Abdomen flaccid and retracted. No oedema.

Pathological Section

13

February 3 : Lumbar puncture was followed by a slight improve¬
ment. The fluid was sterile and showed a few small lymphocytes, but
not in pathological numbers.

February 9 : Sometimes swallows naturally but generally requires
nasal feeds.

February 19: Gaining weight; total weight now 18 lb. Nasal
feeds not required.

Discharged March 8. Some improvement.

Re-admitted October 1, 1909, for the third time. Weight, 20 lb.
Has taken food well since last admission. Very constipated. Feet and
abdomen said to have recently swelled. Fairly well nourished. Lies
on side with head retracted. Eyes open and staring. When disturbed
eyes move ceaselessly from one side to the other side with rapid, jerky

Fig. 7.

October, 1909. Note the claw hand. Case IV.—Abraham C.

movements. Pupils do not react to light. Legs extended at knee and
ankle, but slightly flexed at hip-joints. Plantar reflex flexor; the
stimulus usually gives rise to slight clonic spasm of arms and legs, as
does any movement of the legs. Knee-jerks increased. No genuine
patella or ankle clonus. Arms slightly flexed at elbows ; wrists flexed ;
claw hands. Joints are resistant to passive movement, but on con¬
tinuing it they become relaxed, and complete flexion and extension can
be obtained. The usual position of the joints is, however, quickly
resumed (fig. 7).

Discharged October 17, 1909.

Admitted November 2, 1909, to the St. George’s Infirmary. By
the courtesy of Dr. Bowlan I was permitted to examine the child on

14 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

December 8. Shortly after admission he had convulsions associated
with oedema of the legs. He swallowed well and cried but rarely. It
was thought that at times he recognized his mother. The head and
arms could be moved by the child. The legs were kept extended and
rigid. Plantar reflex flexor. Kemig’s sign not marked. Well-marked
“ claw ” position of right hand only. Thumbs on each side much
adducted and opposed. Eyes showed bilateral movements. Lumbar
puncture was performed, but the fluid was not found to be under any
pressure. It contained some blood, was alkaline, and contained sugar.
Choline and cells absent.

Death, Christmas, 1909. Age about 2J years.

Case V.— Harry K.

Under the care of Dr. Coutts at the East London Children’s
Hospital, 1910.

Family history: The parents are Russian Jews and are alive and
well. They were not related before marriage. They came to England
in 1903. There are three other children, a boy and two girls, aged 8,
5 and 2£ years respectively ; all alive and well. No miscarriages. The
father is one of seven children ; his parents are alive. The mother is
one of four children; her parents are dead. I can find no evidence
pointing to other cases of the disease in this family.

History: The child was born at full term and without difficulty.
He was brought to Hospital because his back was weak, and because
his mother thought he was “ not like other children.”

On admission, July 12, 1910, aged 9 months: Weight, 17 lb.
Well nourished ; pale; does not look intelligent. Fontanelle not closed.
Plenty of hair. Circumference of head 18J in. Has difficulty in sitting
up. Is at times sensitive to sudden noises. Takes food well. Nothing
abnormal in chest. Abdomen full and lax ; nothing abnormal felt. No
teeth. Long eyelashes. Cranial nerves intact. Eyes of oval shape,
usually open and staring; no lateral movements; no strabismus. The
fundi present a typical picture. The pale area at the macula is about
one and a half times the size of the disk. Optic disks show early atrophy
(Mr. F. Juler). The arteries are small. The pupils react strongly to
light. The child sees objects and follows them with his eyes, but has
no sense of their position when trying to grasp them. There is no head
retraction, but the neck muscles are very weak. The legs are extended
and are spastic, but not markedly so. Knee-jerks very brisk. Kernig’s

Pathological Section

15

sign indefinite. The feet go into clonus on stimulating the soles, but
the legs are only sluggishly moved. The arms move freely at will, the
elbows are rigid and flexed. A Pirquet’s reaction was positive.

July 20: A test-tubeful of fluid, flowing under considerable
pressure, was removed by lumbar puncture. A specimen of blood was
removed from the brachial vein.

July 25 : There was no pyrexia after the lumbar puncture, but the
rigidity was for a time less marked. The operation wound on the arm
healed by first intention. The cerebrospinal fluid showed an absence
of choline and cells. There was no excess of protein. The amount of

Fig. 8.

July 19, 1910. Case V.—Harry K.

carbonates and carbon dioxide in solution was not altered. Cholesterol
was absent. There was no excess of lipoids or fats.

August 2(5 : Weight, 16 lb. Temperature normal. The child lies
precisely where it is put, however uncomfortable the position. He is
almost ridiculously good for his age, rarely crying, and then only on the
greatest provocation. Pie usually looks about him with widely open,
staring eyes, which produce an absurdly vacant expression. He grunts
with pleasure when he is spoken to, and frequently bursts into laughter.
It is evident that he does not recognize his mother. Perception of light
and of bright objects is fairly keen. No squint nor nystagmus; pupils

16 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

react strongly to light. Mouth almost always open; tongue is protruded
sometimes. On being sat up, the weakness of the back muscles is
evident; but if the head is pushed backwards, as it is very readily, the
child can bring it forward to a flexed position. The arms are flexed at
the elbows, and are constantly moving. The forearms are strongly
pronated. The thumbs are adducted and opposed, and the fingers are
kept flexed. Legs somewhat spastic ; knees kept extended ; thighs are
adducted and forcible abduction causes pain and reveals the muscular
rigidity. The plantar reflex is flexor ; knee-jerks easily obtained, but
not very exaggerated. The legs are not moved away from painful

Fio. 9.

July 28, 1910. Case V.— Harry K.

stimuli; they fall helplessly on being lifted. The child takes food well,
but will not be bothered with a bottle. The bowels are regular;
stools and urine normal. (See figs. 8, 9, and 10).

October 1 : Weight, 14 lb. T2 oz. Hands pronated and thumbs
tucked in. Fingers move readily at will. Knees extended ; no equinus;
plantar reflex flexor ; jerks readily obtained. There is some difficulty in
swallowing at times, but nasal feeds are only occasionally needed. The
child has no teeth. The general weakness has increased. On placing
salt upon the tongue the child docs not cry, but makes a slight grimace.

Pathological Section

17

At times there are outbursts of vacant laughter. Pin-pricks do not
readily cause crying. The pupils react slightly to light.

The child was removed by the parents from the hospital on
October 31, 1910. Weight, 14 lb. The child died suddenly on
November 4, 1910, possibly from some accident while being fed. No
autopsy was permitted.

Pig. 10.

August 24, 1910. Note the results of weakness of the neck muscles.
Case V.—Harry K.

Case VI.— Sarah G.

In the Queen’s Hospital for Children, 1910, under the care of Dr.
Bellingham Smith, to whose courtesy in allowing me to admit the child
for a time in the East London Children’s Hospital, and to photograph
her, I am much indebted. (This child was shown at the Royal Society
of Medicine by Dr. Bellingham Smith in May, 1910.)

Family history : Patient is the third child of Polish Hebrews. The
parents are alive and well. They were married in 1902, and have lived

18 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

in England for five years. No miscarriages. According to the history,
the two elder children, a boy and girl, aged 7 and 4£ years respectively,
are both healthy, and this is corroborated by a photograph of them which
I was shown. The father is one of seven children, two of whom died in
early childhood. One of his brothers is consumptive. He has a step¬
brother and four step-sisters. The mother is one of eight, of whom one
died at the age of 3 years. Two of her brothers have two children
each, but she is unable to say anything as to the state of their health.

History : The child was brought to hospital for blindness and inability
to sit up. She could not hold up her head. She has always been breast¬
fed. The symptoms had only been noticed for a month prior to admission,
namely, when the child was 10 months old.

Fig. 11.

July, 1910. Case VI.—Sarah G.

On admission, April 27, 1910, aged 11 months : The child is ex¬
ceedingly fat and well nourished; very apathetic; unable to sit up
without assistance, but on doing so, is unable to support her head unaided.
No movements of head or body are attempted, and those of the limbs are
limited in character. The limbs are rigid to a variable degree, spasticity
being more marked in the legs than in the arms. Plantar reflex flexor.
The tongue is protruded. The appearance of the eyes is typical on
ophthalmoscopic examination. Optic atrophy is fairly advanced, and the
pale area at the macula is rather larger than the disk. There is no
nystagmus, but the eyes exhibit aimless random movements. There
is distinct appreciation of a strong light, but no notice is taken
of surrounding objects. The Wassermann reaction and the Pirquet
cutaneous reaction were negative.

Pathological Section

19

July 18, 1910 (.see figs. 11 and 12) : Age, 14 months old; weight,
171b.; very plump; has two lower incisors; limbs very spastic; legs
and arms being about equal in this respect; unable to sit up; plantar
reflex definitely flexor ; pupils do not reafct to light. After a lumbar
puncture, at which some cerebrospinal fluid under pressure was removed,
there was a pyrexia. The rigidity did not in any w T ay decrease. Per¬
ception of light is slight. The pale area at the macula is smaller, and
the liver-coloured spot larger than in Case Y.

The child died in the autumn of 1910.

Fig. 12.

Case VI.—Sarah G.

Case VII.—P. P.

Female, aged 1\ years. Admitted to Charing Cross Hospital under
the care of Dr. Hunter for broncho-pneumonia and rickets, May 25,
1910. It was thought the child did not see properly, and amaurotic
idiocy was suspected. Mr. Treacher Collins made an examination of
the eyes, with the following result: “ Around each macula there is a
circular area of white opacity on the retina. The macula itself appears
as a dark red spot. The margins of the optic disks are well defined,
but they are pale, especially on outer side. The case is one of so-called
amblyopic idiocy met with in Jewish children ” (E. T. C.)

The case was then transferred to the care of Dr. Mott. The mother,
a Polish Jewess, who could speak only broken English, gave the
following history : The child has been ailing for about four months with

20 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

frequent colds and a cough. A week ago the cough became worse.
During the last two days the child has been drowsy and partly uncon¬
scious at intervals; she has also had twitchings in the arms, and at
times gives sudden jumps. There has been no diarrhoea or vomiting,
and food has been taken well.

Family history: The following history and pedigree were kindly
obtained by Dr. Rees Thomas. Patient is the youngest child of a
family of seven. There is no family history of asthma, consumption,
epilepsy, insanity, or rheumatism. No case of blindness occurred in
any of the children that died young, but the first two children (girls)
both died at the age of 1 year from pneumonia, and it is possible that
they werd afflicted with amaurotic idiocy which, as in this case, was not
detected. The third child, a boy, died at the age of 2 years from
measles. The other three children, one boy aged 6, and two girls aged
4 and 2£ years respectively, are alive and healthy.

On admission: The child lay in a semi-comatose state, slightly
cyanosed, and took no interest while it was being examined; it neither
cried nor struggled. Conjunctival reflex was very dull. Its hands and
feet were cold. Respirations 70, pulse 170, temperature 103*4 F.
Breath-sounds very harsh, and in patches bronchial in type. Moist
r&les, bronchi and crepitations could be heard. Abdomen lax. Head
not retracted.

The physical condition of the patient improved under treatment.
Its appetite never seemed to be satisfied ; it was always crying, but
upon giving it milk the crying would cease. It certainly heard loud
noises, but exhibited no signs of disgust when medicine was given.
Death occurred on July 17,1910, and the autopsy was made by Dr. Mott.

Post-mortem notes : Physiognomy indicates no degeneration, like
that of an idiot or imbecile. Palate shows no abnormality, broad and
flat. Two central incisors, upper and lower, cut. Lower incisors notched,
but certainly not indicative of congenital syphilis. No bruises or rashes.
A little lividity of dependent parts. On opening chest and abdomen
there were no adhesions or fluid. No fluid in pericardium. Slight
beading of ribs. No indication of rickets in legs. Fontanelles still open.
Tongue, fauces, tonsils, and larynx normal. Muscles good colour.
Lungs: Some congestion of both bases. Heart apparently normal.
Liver pale and mottled, suggestive of fatty change. Spleen normal.
Adrenals small and pale. Kidneys rather paler than normal. Mesenteric
glands : A few slightly enlarged ; large gland near caecum. Brain weighs
970 grin.: right hemisphere, 435 grin.; left hemisphere, 435 grm. ;

Pathological Section

21

pons, &c., 100 grin. No excess of fluid. No flattening of convolutions;
decidedly firmer to touch than normal, has a leathery feel. Meninges
not thickened ; convolutional pattern complex. Sylvian fissure hori¬
zontal. Portions of the organs and the brain were removed for micro¬
scopical and chemical examination (vide pp. 188).

Historical Summary.

It was in 1881 that Waren Tay, of the London Hospital, discovered
this disease, and his description of the ophthalmoscopic appearances,
which has now become historic, may be read in vols. i and iv of the
Transactions of the Ophthalmological Society}

Under the heading, “ Symmetrical changes in the region of the yellow
spot in each eye of an infant,” he says that in a child aged 12 months
he found “ the optic disks apparently quite healthy; but in the region of
the yellow spot in each eye there was a ‘conspicuous, tolerably defined,
large white patch, more or less circular in outline, and showing in its
centre a brownish-red, fairly circular spot, contrasting strongly with the
white patch surrounding it. This central spot did not look at all like a
haemorrhage, nor as if due to pigmentation, but appeared to be a gap in
the white patch through which one saw healthy structure. In fact, the
appearances may most suitably be compared with those we are familiar
with in cases of embolism of the central artery of the retina.” In a note
made five months later he adds that “ the disks are undoubtedly becom¬
ing atrophic.”

The disease was named “ amaurotic family idiocy ” by Sachs in 1887
[11]. Twenty-eight of his cases occurred in fifteen families, and ex¬
tensive degeneration of the cortical pyramidal cells was described. A
few years after Sachs’ publication, Hirsch found the same changes, not
only in the cortical grey matter, but also in the grey matter of the entire
central nervous system, including the spinal ganglia; and these observa¬
tions were confirmed by Sachs in 1903 [12].

Further corroboration was brought by Schaffer in a recent study of
eight cases [14]. The name Tay-Sachs disease, by which it is some¬
times known, was proposed by Higier, and in 1908 Apert collected 106
cases, of which seventy-three occurred in twenty-five families [2]. The
observation that the disease is confined to Hebrews was made by Carter
[3]. There is abundant evidence to prove that the retinal changes are
not present at birth.

1 Tra7is. Ophthalm. SocU.K. , 1881, i, p. 55 ; 1884, iv, p. 158.

22 Carlyll &' Mott: Seven Cases of Tay-Sachs Disease

In a case reported by Koller [7], a child aged 2 months showed signs
of muscular weakness; but no unusual appearance was seen except an
indistinct brownish patch at the foveal spot in one eye.

In 1894, Kingdon published a case of a child aged 9 months, who
showed the typical ophthalmoscopic appearances [5]. He had examined
this child when it was 3 months old, and when muscular weakness
was commencing. The fundus was then normal. At a second examina¬
tion, when the child was 5 months old, there was a suspicious haze at
each macula.

Children affected with this disease as a rule succumb at about 2 years
old, but cases have been recorded of children who lived for some years
longer. Sachs is surely unduly careful when he says that the disease is
“ generally fatal” [13]. One of his cases was 5J years old, and Koller
[7] has recorded a case of a patient who had optic neuritis at the first
examination at 2 years of age, and who when nearly 4 years old could
crawl about and mutter a few words. In the region of the macula there
was “ a slight veil-like, milky-bluish haze, gradually fading into the
colour of the surrounding retina. In the centre of the opacity at the
site of the fovea centralis was a cherry-red patch, not very dark, a little
smaller than the disk, and with ill-defined outline.”

It is well recognized that syphilis is not a factor in the disease; and
hitherto no genuine case of amaurotic idiocy hajs been recorded in any
but Jewish children. It has been asserted that the disease is restricted
to Polish Jews, but this is not so ; German and Polish Jews are likewise
affected.

Sachs [13], in his recent paper on the disease, gives it as his opinion
that the tendency to the disease is born unquestionably with the child,
and that it is not acquired, nor due to a toxic cause. Afflicted children
are “ possessed of a nervous system so inadequate to the demands
imposed upon it that its cells, after having performed their function
for a few weeks or months, undergo complete disintegration.”

More than one observer has recorded cases which in some degree
resemble amaurotic idiocy, but which lack certain characteristic features.
The family element may be absent ; but it must be remembered that in
but few such cases can we be sure that no more children would be born
to the parents.

It has been stated above that the true disease is found only among
Hebrews. Wandless [19] has recently reported, as atypical examples
of amaurotic idiocy, three cases in a family known to be five-sixths Irish.
One of the children was 14 years old when he died, and a second was

Pathological Section

23

8 years old at the time of observation. The choroid and retina were
atrophic, the latter showing pigmentation ; the usual changes in the
macula were not present. The autopsy showed complete optic atrophy.
The retinal layers were hopelessly degenerated and no ganglion cells
could be found. The ganglion cells throughout the whole nervous
system were markedly degenerated, and degeneration was observed in
the thymus, adrenal bodies and pituitary gland.

Parhon and Goldstein [9] record the first case observed in
Roumania. The child was a Jew and was 14 months old.

Spielmeyer [17] describes a special form of the disease in which
mental weakness, blindness, and a family character of the illness were
present, but the former did not show itself till 6 years of age, and death
did not occur until puberty.

Spiller [18] also refers to a patient whose illness was allied to
amaurotic idiocy, and who lived until 8 years old.

Gordon [4] reports two cases of Russian Hebrew children, a brother
and sister, in whom mental deficiency was noted in infancy, and blind¬
ness very early in life. Optic atrophy was present, and an irregular
patch of absorption of choroidal pigment was observed in each eye, but
there was no cherry-red spot at the fovea. He urges the opinion that
anomalies in the structure and function qf the ductless glands may be
the real cause of the disease.

Kingdon and Russell [6], in 1897, published a paper dealing with
‘‘infantile cerebral degeneration with symmetrical changes at the
macula.” Five children in a family of seven were affected. In one
of these cases an autopsy was made, when degeneration of the cortical
pyramidal cells was found, with sclerosis of the pyramidal tracts; and a
large amount of free fatty material was distributed throughout the
sections. There was no evidence that these changes had occurred in
other than normally developed tissues. The authors state that “so far
as has been discovered the lesion is purely cortical, and it is just
possible that the retinal changes are due primarily to a degeneration of
the ganglion cells similar to that met with in the pyramidal cells of the
cortex, and that the limited ophthalmoscopic appearance is partly due
to a much greater abundance of those cells in the macula region.”

Schuster [16], in a comprehensive survey of the subject, mentions
five types of the disease, but he points out that, although their general
similarity is remarkable, it is doubtful whether they can all be correctly
included. Some stress is laid upon the fact that the disease is indepen¬
dent of any lesion of the blood-vessels. In the case which he reports
the child died at the age of 15 months. The rods and cones w r ere

1 24 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

normal in places, but swollen for the most part. In the foveal region
the outer nuclear layer showed the following change—namely, the cells
were placed in a convex layer as though increased in the direction of
the vitreous, whilst the scleral side showed concave formation. The
inner nuclear layer was much altered, many cells having perished.
The outer molecular and Henle’s layer were very much pronounced and
less firm than usual. Schuster thinks that from the various changes
seen oedema of the macula region was present. He says that no
absolutely normal ganglion cells were present in the retina, and he
summarizes the changes of individual cells as follows: Increase in
volume; nucleus eccentric, dark and surrounded by dense protoplasm ;
knot-points of mesh work which fills cells thicker than normal; Nissl
granules not preserved ; gradual vacuolation. In some cells the diseased
dendrites were clearly seen.

A few years ago Schaffer, of Budapest [15], contributed an interesting
and well-illustrated article on this disease. He characterizes the minute
pathology of amaurotic idiocy as a cell swelling. The details are best
seen at the ampulla-shaped swellings on the dendrites; the individual
fibrils are made to stand out, and their wave-like form is remarkable.
Schaffer insists that it is the interfibrillary material which is first
attacked, and that the cell degeneration follows. This view is supported
by observers who consider that it is the interfibrillary substance or
hyaloplasm of the cell and dendrites which carry the nervous impulse.
Glia proliferation was well demonstrated. Bielschowsky’s method
showed that the optic nerve was normal, the inference being that the
loss of vision was caused by a central cortical lesion.

From an examination of cells stained by Nisei's method, Schaffer
concludes that the cell body is filled with two forms of network—namely,
the nervous framework or inner neuro-reticulum, and a non-nervous
spongioplasm (Cajal). The latter is more clear in pathological cells
because in these the Nissl bodies have disappeared.

It was further observed that the structure of the cell nuclei was
peculiar; the nucleus was seen to consist of threads, which possibly
corresponded to chromatin, and which formed a network, which occurred
in part only of the nucleus. This is not seen in normal nuclei, and
Schaffer thinks it possible that disease of the cell causes a temporary
greater activity of the nucleus. All parts of the cortex showed a
remarkable lack of fibres. Schaffer concludes by expressing the opinion
that children with amaurotic idiocy possess an abnormally exhaustible
nerve-cell protoplasm, which, becoming paralyzed with the strain of the
earliest functions, soon degenerates.

Pathological Section

25

The characteristics of Mott’s two autopsies [8] were: Absence of
healthy cells in brain and cord; absence of Nissl granules in most of
the Betz cells; glia proliferation; sclerosis of pyramidal tracts. No
fibrils were seen coursing through the cells, as described by Gordon
Holmes. In the case of the second patient (Case Ia), Mott found acute
inflammation of the liver and pancreas, which suggested a toxic cause
for the illness. In the brain there was almost complete disappearance
of tangential fibres, with marked diminution of the super-radial and
inter-radial fibres. The radial fibres were abundant (Weigert-haemo-
toxylin). The anterior and posterior cord roots showed fairly normal
bundles of myelinated fibres, indicating that, although profound changes
had occurred in the cytoplasm of the ganglion cells, the axons were still
capable of function. This fact is important, taken in conjunction with
the statement that it is the interfibrillary substance of the cell, and not
its fibrillary conducting material, which suffers the primary, and so far
invariable, change in the disease.

Mott, in 1907, thought it probable that every nerve-cell in the body
was affected by the morbid process, and he concluded that “ this extra¬
ordinary regressive metamorphosis is brought about by a conspiracy of
morbid factors—namely, an inherent racial lack of specific neuronic
energy and some general alteration in the chemical composition of the
blood, either by the existence in it of a neurotoxin, or by the failure of
some chemical substance to form in sufficient quantity, for the building
up of the nucleo-proteid substance of the nervous system.”

The most important observations which have been made on the
disease in England in recent years have been embodied in papers by
Mott in the Archives of Neurology, 1907 (vide supra), and by Poynton,
Parsons and Gordon Holmes in Brain, 1906 [10]. The following con¬
clusions were arrived at by the latter authors as the result of an elaborate
microscopical examination of the nervous system:—

(1) That there is strong evidence that amaurotic family idiocy is
a primary disease of the nervous elements, and that the neuroglia
proliferation is secondary to this degeneration.

(2) That inasmuch as the nerve-cells are relatively more affected
than the fibres, and as in certain tracts there may be no visible change
in the fibres, the affection may be considered a primary cell disease.

(3) That the primary change is disease of the interfibrillary proto¬
plasm, because this is very much more severely affected than are the
neurofibrils. They also conclude that: (a) The disease is not due to
arrested development, because there is no reason why, if this were the
case, such an arrest should cause a progressive and invariably fatal

26 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

disease ; and because, if it were so, the symptoms would probably be
evident from birth. There is also little anatomical evidence of mal-
development. “ The most easily obtained evidence of the completed
development of the central nervous system—namely, myelination of the
fibres—proves that the final development of the different parts of the
brain is completed at different periods^in a fairly long space of time, and
is not ended until a few months after birth. But the examination of
these brains does not indicate greater abnormalities in the regions which
develop late than in those where development is completed early in
intra-uterine life—e.g., the visual cortex, which is myelinated very early,
is quite as severely affected as the prefrontal region in which the
myelinated fibres appear late. If, however, the disease dates from the
earlier months of extra-uterine life, the development of fibres which
myelinate late may be checked, owing to deficiency of trophic influence
from the diseased cells.” ( b ) The disease is not due to bacterial toxins,
but to (c) some inherent biochemical property of the protoplasm of the
cells, as the result of which it undergoes certain changes which result
in its degeneration.”

The authors further state that, on pathological grounds, the disease
is one “ sui generis,” and must be separated from the class of diplegias.
In this disease the nerve-cells are reduced in number, and those which
remain are shrunken and atrophic. The myelinated fibres are those
most greatly affected, and, unlike amaurotic family idiocy, the disease
is often associated with gross defects or macroscopical changes in the
brain.

REFERENCES.

[1] Allbutt and Rolleston. “ System of Medicine,” 1910, viii, pp. 468-73.

[2] Apert. La Semaine Med. , Par., 1908, xxviii, p. 25.

[3] Carter. Arch, of Ophthal., New York, 1894, xxiii, p. 126.

[4] Gordon. New York Med. Journ ., 1907, lxxxv, p. 1077.

[5] Kingdon. Trans. Ophthal. Soc ., 18S4, xiv.

[6] Kingdon and Russell. Trans. Med.-Chir. Soc., lxxx.

[7] Roller. Med. Rcc., New York, 1896, 1, p. 266.

[8] Mott. Arch, of Neurol., 1907, iii, p. 218.

[9] Parhon and Goldstein. Itev. Neurol ., 1909, xvii, p. 895.

[10] Poynton, Parsons, and Holmes. Brain , 1906, xxix, p. 180.

[11] Sachs. Journ. of Nerv. and Ment. Dis., New York, 1887, xiv, p. 541.

[12] Ibid. Loc. cit., 1903, xxx, p. 1.

[13] Ibid. Osier and McCrae, “ System of Medicine,” 1910, vii, p. 868.

[14] Schaffer. Zeitschr. f. d. Erforsch. u. Bchandl. d. jugendl. Schtcachsinns , Jena, 1909,

ii, p. 19.

[15] Ibid. Journ. f. Psychol, u. Neurol., 1905 ; also Neurol. Centralbl., Leipz., 1905, xxiv,

pp. 386, 437.

[16] Schuster. Archiv. f. Augenheilk., Wiesb., 1909, lxiv, p. 1.

[17] SriELMEYER. Neurol. Centralbl., 1906, xxv, p. 51.

[18] Stiller. Amer. Journ. of Med. Sci., Philad., 1905, N.S., cxxix, p. 40.

[19] Wandless. New York Med. Journ., 1909, lxxxiv, p. 953.

Pathological Section

27

PART II.—By Dr. Mott.

Histological and Chemical Examination of the
Nervous Structure.

Preface.

The histological and chemical investigations contained in this
communication were carried out in the Pathological Laboratory of the
London County Asylums, Claybury. A portion of the microscopic
investigation was made by Dr. Carlyll under my direction, and I wish
here to acknowledge my indebtedness to Dr. Fortuyn for his investi¬
gation of the cell lamination in the visual and auditory areas 4 to Dr.
Edgar Schuster for three very admirable drawings, and to my assistant,
Mr. Sydney Mann, for his chemical investigation, the results of which
form an appendix.—F. W. Mott.

Introduction .

I described two cases of this disease very fully in vol. iii, Archives of
Neurology. I mentioned there my reasons for terming the disease
amaurotic dementia rather than amaurotic idiocy. I pointed out that
the brains were of normal size or even larger than normal average;
moreover, the convolutional pattern was in no respect like that of an
idiot’s or imbecile’s brain; in these two cases the Sylvian fissure did not
slope obliquely upwards and backwards as in the simian brain, and the
superficial surface of grey matter, owing to the complexity of the
convolutions, was by no means deficient in extent; neither did the
microscopic examination of the cortex cerebri indicate a deficiency in
numbers of the cortical cells. Moreover, I showed that the same
characteristic change which is known to affect the cerebro-spinal ganglion
cells also affected the sympathetic.

I have since had the opportunity of examining four such brains of
children dying of this disease, three of which were from Cases I, IH
and VII. In all these cases the brains were of normal average
weight, and the convolutional pattern complex, and in no way denoting
either imbecility or idiocy. Again, I have had the opportunity of
examining the central nervous system in all these cases, and I do not
find a deficiency of numbers of the cortical cells. Moreover, the
sympathetic ganglion cells I found showing the same change, only not

28 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

so advanced as the cerebrospinal ganglion cells. It may, therefore, be
concluded that the disease is an affection of the whole of the neurones
of the body. It cannot be present long before birth or the convolutional
pattern would not develop to its perfect form. We have to ask ourselves,
therefore, what is the cause of this extraordinary disease, in which the
microscopic morphological changes in the nervous system, and the
clinical phenomena are so characteristic as to be unmistakeable for any
other disease ? Is it an acquired disease ? If so, what conditions of life
should limit this disease to the Jewish race. So far, I have been unable
to associate it with any condition of food or environment; it appears to
occur in both breast-fed and artificially-fed children, and I am inclined
to agree with Sachs that there is little evidence to show that conditions
of food or environment can account for the disease. Since it affects
only the offspring of Jewish parents, and frequently several of the
offspring of the same parents suffer with this disease and die of it, it
follows that racial and family heredity do play a part, and probably
are solely responsible for its occurrence.

Morphological and Chemical Investigations in Relation to

the Pathogenesis.

The evidence I have adduced shows that all the nervous units are
present at birth, but from some cause or other their specific vital energy
is so deficient that they are unable to maintain physiological equilibrium;
they are unable to store any reserve of the Nissl substance which many
authorities regard as the material basis of nervous energy ; in conse¬
quence of this, and probably also from the swelling of the cell, the
conductile mechanism itself (neurofibrils) undergoes destruction, with
morphological and bio-chemical changes in the neurones. As the
neurones degenerate and die the neuroglial cells proportionally proliferate
and increase in size, thus altering the consistency and feel of the brain
itself, which has a tough, leathery character. Do the neurones die
because of an inborn deficiency of specific vital energy, or do they die
because the ambient medium contains some toxic substance or lysin
which destroys them, or is it because the ambient medium is lacking in
some substance necessary for the development and maturation of the
neurones ? If it were a toxin or lysin we should rather expect it would
act equally on all the cells of the body, and certainly all the nerve-cells,
which is not the case. It might be a deficiency in the blood of some
substance, for we know that cretinism is due to an absence of the

Pathological Section

29

thyroid gland; but cretinism is a condition of obvious defective brain
development—in fact, we have an idiot’s brain. The thyroid is not
affected in Tay-Sachs disease, nor can I find any gland which is affected;
and I have examined all the tissues of the body in several cases. We
now come to the only other cause—viz., an inborn lack of specific vital
energy of the nerve-cells, due to a racial inherited failure of the
germinal determinants of the nervous system.

The neurones are perpetual elements, they are all present at birth
with all their innate potentialities to respond to stimuli from without;
this leads to their acquiring connexions and associations with one
another; in no part of the body, excepting the reproductive organs in
adolescence, do such important synthetic chemical changes take place as
in the central nervous system of the human being in infancy. The Nissl
substance has to be accumulated in the nerve-cells, especially in those of
later phylogenetic and ontogenetic development; the myelin has to be
deposited around the axial fibres of the neurones, particularly in the
brain cortex, where there is scarcely any present at birth. How is this
accomplished? Although stimulus from without by all the sensory
avenues plays some part in accelerating this synthetic process, neverthe¬
less every neurone has a specific autonomic inherited energy apart from
stimulus. The experiments of Boss Harrison demonstrate the truth
of this fact. The principles of heredity tell us that this autonomic
specific energy resides in the nucleus, which is the soul of the neurone ;
and the experiments of Loeb upon parthenogenesis in Sea Urchin eggs
show that the nucleus possesses an auto-katalytic ferment, which in the
process of segmentation of the egg-cell in reproduction is capable of
decomposing the lipoids of the cytoplasm and recomposing from the
products a more highly phosphorized substance, nuclein.

The experiments of Yerworn and others tend to show that the Nissl
substance is a store of reserve neural energy, and it is contained in the
mesh work of the conductile neurofibrillary substance ; the observations
of Macallum showed that it is a nucleo-protein containing phosphorus,
and it is not unreasonable to suppose that the nucleus of the neurone
produces a ferment substance which, passing into the cytoplasm,
elaborates the Nissl substance out of a phosphorized lipoid obtained
from the ambient medium; this basophil chromophilous material con¬
tained in the interfibrillary mesh work forming a pattern according t>
the arrangements of the fibrils. Verworn and his pupils’ experiments
indicate that this substance unites with oxygen and forms a store of
neural energy. Marinesco terms it kinetoplasm.

30 Carlyll & Mott: Seven Gases of Tay-Sachs.Disease

Now, if we study the microscopic morphological characters of this
disease we shall note a very remarkable and characteristic disappearance
of the Nissl granules, so far as I am aware, not observable in any
experimental conditions, such as ligature of blood-vessels, hyperpyrexia,
or toxic conditions in mammals. Nor have I seen such change in any
human pathological condition. Generally, when the cell is swollen the
nucleus becomes eccentric and the Nissl granules are only found at the
periphery of the cell; the chromatolysis is perinuclear, just the converse
of what is found in this disease. In alcoholic and lead neuritis the
anterior horn cells and the Betz cells of the cortex show perinuclear
chromatolysis, which is doubtless due to reaction of injury to the axon
combined with toxic conditions of the blood.

In Tay-Sachs disease, as is well known, the Nissl substance dis¬
appears from without inwards towards the nucleus, and as the Nissl
substance vanishes so the cell swells up as if a process of hydrolysis had
taken place. In the later stages no Nissl substance can be seen upon
the dendrons, which are also swollen irregularly ; no Nissl substance
can be seen in the greater part of the cell body, which has undergone
a bladder-like distension and often curiously and characteristically dis¬
torted into an hour-glass shape. The swelling and distortion of the
cell is generally proportional to the disappearance of the Nissl substance,
and finally there is only a halo of deeply stained basophil substance
around the nucleus, which may now be displaced from the centre
of the cell; in the case of the pyramidal cells of the cortex it
nearly always takes up a position at the base of the apical dendron
(vide fig. 13 (1)). If the sections are stained with toluidin blue or poly¬
chrome blue it will be found that the bladder-like swollen cells show
a fine intracellular network which stains at the nodal points (figs. 13
(4) (5)) ; the network stains owing to a film of incrustation of basophil
chromophilous substance. Later, when the change is more intense,
the network is incomplete and unstainable areas are seen. I have, so
far, only dealt with the cells stained by basic aniline dyes, but we shall
not have a true picture of this disease unless many methods of staining
are adopted—methods which are applicable to the demonstration of
particular structures.

I shall now advance proofs that the process of decay and death of the
neurones is characterized by a fatty degenerative change with destruc¬
tion of the intracellular neurofibrils ; there are also changes occurring
in the staining reaction of the nucleus, and eventually the nucleus
itself is destroyed, although that is a comparatively infrequent event.

Pathological Section

31

Cellular Changes.

The nuclear membrane is sometimes stained with basophil dyes
deeply; also the nucleolar and intranuclear. network. Generally in cells
which show a marked degree of swelling, the nucleo-plasm also stains with
the basic dye. In the normal cell the nucleo-plasm is unstained by basic
dyes. This microchemical basophil reaction suggests a change in the
normal biochemical function of the nucleus. Are these cell changes due to
a failure in the ambient medium of the necessary materials which may
be required by the nuclear ferment to form the nucleo-protein Nissl
substance, or is it some progressive failure of the nucleus in its reaction
on the cytoplasm, causing the cell to swell up and eventually break
up and destroy the intracellular network? The dendrons also show
characteristic swellings (vide fig. 13 (8) (9), and fig. 15). Although
all the nerve-cells of the central nervous system show the fatty change
in some degree, including the ganglion cells of the retina, which, as
we know, are developed by a bud from the forebrain, yet the neurones
are not equally affected in the whole nervous system, nor even in sec¬
tions of the same part; therefore, specific cell energy does play a part,
whichever view is taken, regarding the pathogenesis. The chemical
analysis of the brain as compared with a normal child’s brain of the
same age shows a deficiency in organic phosphorus and sulphur, and an
increase of water-soluble extractives, containing phosphorus and sul¬
phur. Consequently we cannot suppose that there is an increase of
lipoids in the cells, due to accumulation; but it rather shows that the
nucleus provides a splitting ferment, whereby the cell-plasm is decom¬
posed and broken up, but the nuclear activity does not complete the
vital process by a synthetic action; thus there may be a chemical
decomposition on the way to a fatty acid, e.g., choline, glycerophosphoric
acid and stearic acid, and no recomposition. A fatty acid or soap, or
some lipoid, which takes the Scharlach stain in various degrees of
intensity, may account for this reaction. The cells are also stained by
the Marchi-Pal and Heidenhain methods in varying degrees of intensity ;
in all cases taking the form of very minute particles, which is additional
evidence of its fatty degeneration. In the cortex of the cerebrum and in
the cerebellum, where the degeneration is most intense, an immense
number of granule cells (Kornchenzellen) are seen ; these contain larger
ruby red granules, and are seen scattered throughout the whole of the
cortical grey matter of both the cerebrum and the cerebellum. At first I

32 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

thought these were ganglion cells, but when Scharlach-stained specimens
are counter-stained with methyl violet, with methyl blue, or logwood, it is
then seen that these cells have a nucleus in the middle, and that several
together lie on a ganglion cell, and almost, or completely, obscure it;
sometimes two of these granule cells, joined together, occupy the position
of a degenerated ganglion cell, and take on the characteristic hour-glass
appearance. It may generally be said that the nerve-cells very seldom
indeed show any coarse granules. It looks as if the neuroglia cells
possessed a phagocytic function, as was first pointed out by Bevan
Lewis, and I have seen in both silver preparations and preparations
stained by other methods (photomicrograph 5) appearances suggesting
phagocytic activity of the neuroglia cells.

Two of the three brains examined showed numbers of granule cells
in the white matter as well as the grey, this showing that these cannot
therefore be ganglion cells which have undergone this degeneration.
Numbers of cells filled with deep red stained fat granules are also to
be seen in the perivascular lymph sheaths, as if the endothelial cells
or cells of the adventitia had taken up the fatty matter. Curiously
enough, not much change was found in the cerebrospinal fluid with¬
drawn during life by lumbar puncture.

All the facts show that in this disease there is a fatty degeneration
of the cytoplasm of the neurones, which I find Alzheimer describes in a
recent publication. The satellite cells found in the perineuronal spaces,
or neuroglia cells, show a fatty change, which is probably of the nature
of an infiltration ; that is to say, these cells have devoured the fat pro¬
duced by the degeneration of the neurones ; the fatty contents of these
cells indicate a further process of change, judging from the deeper
coloration by the Scharlach dye, and the larger size of the globules
(vide Plate I). The appearance of the nerve-cells of the cortex makes
it possible that the late stages of hydrolysis convert the cytoplasm into
a thick emulsion, giving the cell that peculiar appearance which is not
unlike that of the cortical cells of the suprarenal body, which we know
contains a phosphorized fatty substance that stains deeply with Schar¬
lach R. Moreover, I have noticed that when there is a considerable
amount of glia fibrillation of the superficial layers of the cortex, and
the microscopic examination of sections of the cortex shows a marked
condition of fatty change in the cells (vide photomicrograph 8), that
the brain substance is semifluid, like cream, so that the tough, leathery,
fibrillated superficial layer of the cortex can be peeled off from the
subjacent semifluid, creamy grey matter.

Pathological Section

33

Detailed Description op Figures and Photomicrographs.

I will now describe, with the aid of the accompanying figures and
photomicrographs, the cell changes which occur when sections have
been stained by particular methods.

Fig. 13, a number of cells showing morphological changes.

(1) A large pyramidal cell of the cortex from a Scharlach-stained
section counterstained with haematoxylin ; the whole cytoplasm is stained
an orange-pink; it presents a fine granular appearance. The cell is
swollen, the nucleus is pushed up towards the base of the apical
dendron, and from the base of the cell there is an oval, bladder-like
swelling. (Magnification 500.)

(2) A similar pyramidal cell stained with Weigert-Pal; the cyto¬
plasm is filled with minute blue-stained globules. The cortex stained
by Marchi method would show similar globules stained blackish-grey.
Again, Heidenhain’s haematoxylin stains these fine globules blue. These
fine granules thus stained may be protoplasmic particles covered with a
film of fat or soap; they are the same as the fine granules seen in (1).
(Magnification 500.)

(3) A cell stained by Scharlach R or Sudan III, showing much
larger granules stained deep red. Most of these, and they are very
abundant in the cortex, are Alzheimer’s Kornchenzellen, and are either
neuroglia cells or satellite cells filled with fatty droplets. It is very
difficult to say whether any of the ganglion cells ever present such
an appearance. (Magnification 500.)

(4) A large cortical pyramidal cell stained with toluidin blue as
recommended by Schaffer, to demonstrate the intracellular network; it
also shows the swelling and characteristic almost hour-glass distortion;
the Nissl substance has almost entirely disappeared; there is still a
little incrustation of the nodal points of the intracellular network around
the nucleus. (Magnification 500.)

(5) A large spinal anterior horn cell; the same description applies
as above in 4. (Magnification 500.)

(6, 7, 8, 9) Various pyramidal cells of the cortex stained by Cajal’s
neurofibril method. Sections were also stained by Bielschowsky’s
method, but the results as regards the points to be described are the same.

(6) shows the basal neurofibril process split, the fibrils passing down
each side of a pale substance which appears to consist of globules or
round particles; the nucleus is connected with fibres coming in from
the apical dendron. In (7) an appearance which is very rarely seen is

Pathological Section

35

shown ; here the nucleus is apparently held in position by intact neuro¬
fibrils passing across the cell from one lateral dendron to the other.

(8) shows an appearance not infrequently seen of the fibrils of the
apical dendron passing along the periphery of the cell to other processes.

(9) shows a large ovoid swelling on one of the processes of a ganglion
cell as if the hydrolytic process had commenced in the process instead
of the body of the cell. (Magnification 400.)

Photomicrograph 1.—A nearly normal cortical pyramidal cell show¬
ing abundant neurofibrils in the processes; this was the only one seen
in a section showing hundreds of cells in a state of degenerative decay.
(Magnification 1,080.)

Photomicrograph 1.

Photomicrograph 2.—A pyramidal cell in which the only fibrils are
seen at the periphery and in the two processes. The fibrils seem to be
continuous between the apical dendrons and the axon. The whole central
portion of the cytoplasm has a coagulated structureless appearance.
(Magnification 1,180.)

36 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

Photomicrograph 3.—A cell of Purkinje stained by the neurofibril
method. The fibrils can be seen passing from the apical dendron to the
nucleus and around the periphery of the cell continuous with the fibrils
of what appears to be the axon, arising from the lower portion of the
distorted, flask-shaped cell. It will be observed that all around the
nucleus there is a complete absence of fibrils. I attribute this to the
disappearance of the basket-like terminal arborization of the stellate
cells, which a subsequent illustration will show are degenerated earlier
than the Purkinje cells. (Magnification 1,260.)

Photomicrograph 2.

Photomicrograph 4.—Cortex stained by neurofibril method. Numbers
of bladder-like cells are seen with a fine granular central portion and
externally surrounded by dark-stained fibrils ; g shows a ganglion cell
which apparently is intact as regards its neurofibrils except that one
process appears to be surrounding a degenerated cell. It will be
observed that this nerve-cell differs markedly from the black-stained*

Pathological Section

37

38 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

neuroglia cells n, of which there are great numbers undergoing prolifera¬
tion. (Magnification 360.)

Photomicrograph 5.—A large neuroglia cell, showing two nuclei and
large stout processes, apparently stuck on to and grasping w T ith its
processes a large degenerated ganglion cell, but some of the fibrils which
seem to come from the glia cell can, by close observation, be seen

n

n

Photomicrograph G. Photomicrograph 7.

to be the undestroyed peripheral neurofibrils of the ganglion cell.
(Magnification 810.)

Photomicrograph 6.—Cortex stained by Weigert (neuroglia method),
subsequently by iron haematoxylin (Hcidenhain’s method). The swollen,
distorted, bladder-shaped pyramidal cells are stained purple owing to

lobules
ted up
top ca:
Bnzellei

40 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

be seen sticking on the degenerated ganglion cells. No axis cylinder
processes can be seen. (Magnification 380.)

Photomicrograph 7.—A Weigert-Pal-stained section of the subcortical
white matter of the ascending frontal convolution; it will be observed
that there are no coarse fibres characteristic of this cortical area present.
This indicates that the large coarse fibres which form the pyramidal
system are absent; this fact may be correlated with an absence of
fibres in the crossed and direct pyramidal tracts of the spinal cord. All
the fibres appear to be attenuated and most of them show degenerative
varicosities. These fibres are all radial fibres and it will be observed
that there is a complete absence of inter-radial association fibres.
(Magnification 330.)

Photomicrograph 10 .

Photomicrograph 8.—Section of the cortex stained by Scharlach R.
The deeply stained cells are Kornchenzellen, the fainter stained cells
with fine granules are the ganglion cells (vide also Plate I). (Magnifi¬
cation 180.)

Photomicrograph 9.—Section of the cerebellum stained by Ranke’s
Victoria blue method. Enormous increase of Bergmann’s neuroglia
fibrils is seen and a dense felting of the surface. (Magnification 450.)

Photomicrograph 10.—Section of the sympathetic (inferior cervical)
ganglion showing peripheral chromatolysis of many of the cells ; the
change in the sympathetic ganglion is not so advanced in this case as
in others that I have examined.

Fig. 14.—Section of cortex stained by Weigert-Pal method showing
the terminal arborization of degenerated fibrils around cells, the bodies

Pathological Section

42 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

of which show minute globules stained by the dye in the same manner
as the degenerated nerve fibrils. (Magnification 800.)

Fig. 15.—Frozen section of cerebellum, after hardening in formalin
a few days, stained with Scharlach. A number of deeply stained smaller
cells are seen amidst the granules which are unstained, many of them
doubtless are Kornchenzellen; some are apparently degenerated stellate
cells—viz., the cells, the axon of which form a basket-work around the
Purkinje cells; the degeneration of these cells would account for the
absence of fibrils seen in the greater part of the body of the Purkinje
cells (photomicrograph 3). The Purkinje cells are visible because stained
a pinkish orange, and the dendrons are swollen and similarly stained
owing to fine granules of fatty substances. (Magnification 200.)

Fig. 16.—Another portion of the same section as fig. 15, but showing
more distinctly the fine particles of fatty substance in fragments of the
swollen dendrons near the surface.

As a control sections of brain of a normal child of the same age were
prepared and stained by Scharlach R and Sudan III; the cells are not
visible, but the white matter is stained more intensely a deep orange red.

Examination of the Retina.

Portions of the retina were removed from one eye, Case VII (vide
p. 165), and preserved for a few days in 10 per cent, formol solution.
They were then floated into distilled water, and transferred to an alcoholic
solution of Scharlach R, or Sudan III, in which they were left for some
hours. They were again carefully floated into weak alcohol to wash
away the excess of stain, caught on a cover-glass with the ganglionic
layer upwards, and mounted in Farrant’s solution.

Fig. 17.—Drawing by Schuster. (Magnification 240.)

The ganglion cells in the retina can be distinctly seen, owing to their
deeper staining. They appear to be much more numerous in some
places than others. They vary considerably in size, as the drawing
(fig. 17) shows. As this method shows the whole cell it must be
either assumed that as in the spinal ganglion there are cells of varying
size in the retina or that the cells differ in size owing to the pathological
change. Against this is the fact they are all uniformly stained a deep
orange colour, in many places on an unstained background. Moreover,
under an apochromatic 2 mm. 140, 4 comp, ocular, the pathological
change appears to be the same. I am therefore led to believe that the
difference in size is due to different-sized ganglion cells in the retina,
a fact which sections would not show.

Pathological Section

43

Fig. 17. Fig. 18.

Fig. 18.—Stratum opticum. Ganglionic layer, inner molecular and
inner layer of granules. (Magnification 450. Schuster.)

The other eye, after hardening in 10 per cent, formol, was embedded
in celloidin, and sections through the whole eye were cut and stained
by polychrome blue, Nissl, Giemsa, and Van Gieson methods. The only
definite observable changes were in the ganglion layer. The cells
appear abnormal in shape, the processes are either indistinctly seen or
obscure. The cells lie in confused clumps, in places appearing as if
joined together. The nuclei and nucleoli are well stained, but the cyto¬
plasm is poorly stained, and appears to consist of a fine intracellular net¬
work faintly incrusted with basophil substance. No Nissl granules are
seen. Here and there ganglion cells can be seen with a swollen process.

The observations of Dr. Fortuyn show that the whole cortex is
similarly affected.

Description of the Coloured Plates.

The coloured Plates I and II are reproductions of drawings by Miss
Kelley to show the appearances presented by Scharlach-stained speci¬
mens. It will be observed that the ganglion cells, wherever they are
taken from, are stained a reddish-orange or orange colour. The granule
cells are stained a deeper ruby-red. I may add that I have employed
some of the methods of staining recommended by Lorrain Smith, 1 but
I have not found that they yielded such good differentiating results as
the Scharlach and Sudan III, or the fuchsin method of Alzheimer.

1 Since this paper was completed I have received an important communication explaining the
action of these various dyes on fats and lipoids : J. Lorrain Smith and W. Mair, “ Fats and
Lipoids in relation to Methods of Staining,” Skand. Arch.f. Physiol Leipz., 1911, xxv, p. 247.

44 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

Explanation of Plate I.

Fig. 1 shows a cortical pyramidal cell swollen up, and filled with
large red-stained fat globules of uneven size, and some coalescing. At the
upper part of the cell is a pale unstained portion, which is apparently
the nucleus. I found only very rarely ganglion cells showing this
appearance. The vast majority of cells with red-stained large globules
were the so-called granule cells (Kornchenzellen).

Fig. 2.—This is a distorted pyramidal cell, in which there are
scattered small red globules. These, again, are rarely met with, and,
as I have previously explained, many cells look like ganglion cells when
only stained with the Scharlach, but which when counterstained by
logwood or methyl violet prove to be one or several granule cells lying
on the decayed ganglion cell, and I would not deny the possibility of this
being the case in respect to both this (fig. 2) and that of fig. 1.

Fig. 3.—This is a ganglion cell in an advanced stage of fatty
degeneration. The whole cytoplasm is permeated with fine globules
of fat. (Magnification 600.)

\

Fig. 4.—A group of small cells of anterior cornu of spinal cord,
stained by Scharlach. The cells are stained a pinkish-orange colour.
One or two show a very fine granulation appearance. (Magnification
GOO.)

CAUIjYLL (t MOTT: Seven Cases of Toy-Sachs Disease. Plate 1.

o

( A IUj ) LTj d‘ 3/()7 7'; Seven of Too Sii<:h^ I'iiousv. [’laic II.

Pathological Section

45

Explanation of Plate II.

Fig 1.—Section of cerebellum stained by Scharlach R. The cells of
Purkinje are seen stained a light orange-red ; also a number of much
smaller cells are similarly stained. But besides these paler-stained
cells, which are degenerated ganglion cells (stellate cells, second type
of Golgi), there are scattered about a number of deep ruby-red cells
arranged in groups and sometimes in rows. These are granulation
cells—amoeboid neuroglia cells filled with fat globules. This particular
preparation from Case YII does not show any of these granule cells in
the white matter; but in the other two cases which I have examined,
numbers of these deeply stained granulation cells (Komchenzellen) exist
in the white matter; especially are they found in numbers in the
perivascular sheaths. The small granules (nerve-cells) which form such
a prominent histological feature of the cerebellum did not take the
Scharlach stain. (Magnification 50.)

Fig. 2.—A Purkinje cell in an early stage of degeneration. It
is covered all over with very fine pinkish-orange granules. In the
immediate neighbourhood are four cells containing coarse red globules.
I believe they are ganglion cells, but they may be granulation cells
(Komchenzellen) in an early stage of fatty change.

Fig. 3.—A Purkinje cell-showing a rather more advanced stage of
fatty change; it is more deeply stained red. (Magnification 600.)

46 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

It will be observed that the ganglion cells vary in depth of coloration
by the Scharlach dye, and the deeper the colour the more obvious do the
particles of fatty substance become. There is also a parallelism between
the distortion in shape of the ganglion cell and the evidences of the
fatty change. The fact that all the ganglion cells, with the exception
of the granules, are degenerated in the cerebellum may account for the
apparent absence of the basket of fibrils around the base of the cells of
Purkinje; this absence of fibrils is shown in photomicrograph 3. If
sections are placed first in alcohol, then in ether for a short time, the
cells no longer stain, all the fat having been dissolved out.

Dr. Carlyll, in his historical summary, has given a r£sum6 of
previous observations on the morphology of this disease, but it is
necessary for me to refer to some important observations by Alzheimer
concerning the fatty change in ganglion cells in this disease, and in the
amaurotic idiocy described by Spielmeyer and Yogt. These observations
I had no knowledge of when I wrote this paper, but I have since found
a description very similar to the above in Alzheimer’s 1 valuable work,
which he kindly sent me. He also gives a number of valuable
methods of staining which I shall adopt in the study of a case that has
recently died, under the care of Dr. Hume, of Newcastle, who has for¬
warded me the brain and the eye for examination. This will form
the subject of a joint paper on the histology by the most recent
methods.

Conclusions.

(1) Reasons are given why the term “ idiocy ” should be abandoned ;
it will be better to adopt the name “ Tay-Sachs disease ” until the patho¬
genesis is known.

(2) Reasons are stated why it is probably a failure in the germinal
determinants of the nervous system peculiar to the Jewish race.

(3) The morphological and chemical investigations in relation to the
pathogenesis are discussed, al6o the hypothesis is put forward that it
may be due to a failure in the nuclear material of the neurones to
build up the nucleo-protein Nissl substance out of lipoid substances
contained in the cytoplasm, which first have to be decomposed by a
nuclear ferment. The autokatalytic ferment action of the nuclear

1 “ Beitriige zur Kenntnis der pathologischen Neuroglia und ihrer Beziehungen zu den
Abbauvorgiingen im Nervengewebe.” Nissl und Alzheimer, “ Histologische und Histopatho-
logische Arbeiten iiber die Grosshirnrindo,” Jena, 1910, iii, pp. 401-554.

Pathological Section

47

material of the fertilized ovum described by Loeb is considered as
affording a somewhat analogous chemical process.

(4) Evidence to show that there is a progressive failure of Nissl
substance proceeding from without inwards towards the nucleus and
a corresponding accumulation of a fatty substance of the nature of a
lipoid, which, accompanied by a process of hydrolysis, would cause a
swelling of the cell and destruction of the intracellular neurofibrillary
network.

(5) The chemical analysis does not throw much light upon the
question; the diminution of the lipoid forms of phosphorus and sulphur
is probably due to the diminution of myelin, owing to failure of develop¬
ment of the myelinated fibres. The corresponding increase of extractive
forms of phosphorus and sulphur may be possibly due to a breaking down
of the more complex to simpler forms of lipoids.

(6) The morphological changes are quite characteristic of the disease.
All the ganglion cells stain with Scharlach in varying degrees of intensity,
more or less intense in proportion to the degree of swelling and obvious
morphological change ; they also stain with Mar chi, Weigert-Pal,
Heidenhain—in fact, all the methods which stain the myelin sheath
or fat. They do not, however, stain satisfactorily by Marchi, like de¬
generated myelin does when the process of decomposition has been
complete to choline, glycerophosphoric and oleic acid. Consequently
it is more correct to say that the cytoplasm may be on the way to this
complete decomposition.

(7) Whereas the ganglion cells very rarely show coarse ruby-red
globules of stained fatty substances, there are, especially in advanced
cases, immense numbers of cells containing these coarse globules, and
forming what Alzheimer terms Komchenzellen; they are neuroglia cells
which have taken up the fat from the dead and decayed ganglion cells,
to which they may be seen sticking sometimes in little, closely aggre¬
gated groups indicative of active proliferation. It is probable that they
have the power of decomposing this lipoid of the dead ganglion cells
and possibly of recomposing nuclear substance necessary for their
proliferation out of it.

(8) Other methods of staining—e.g., toluidin blue, Cajal silver, or
Bielschowsky—show that the intracellular fibrils are ruptured and
destroyed by the swelling leaving only the peripheral neurofibrils, which
can be followed from the dendrons in their course around the swollen
cell to other dendrons or to the axon. In the cortex, the fibrils of the
apical dendrons are seen proceeding to the nucleus, which is usually

48 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

forced up into the apex of the pyramid. It is possible that the cyto¬
plasm is of the nature of a thick emulsion, each particle consisting of
a plasm covered with a film of fat or soap.

(9) The cells of the retina, when this structure is stained with
Scharlach, show a similar change to the nerve-cells of the central nervous
system ; the cells are of varied size, apparently.

(10) In two of the three brains examined there was an accumulation
of granulation cells (Kornchenzellen) along the course of the blood¬
vessels, also endothelial and connective tissue cells of the perivascular
sheath could often be seen filled with the dark, red-stained fat globules.

(11) Any of the methods employed for demonstrating neuroglia
shows an enormous overgrowth of fibrils, especially in the superficial
layers, where it forms a dense feltwork both in the cerebrum and the
cerebellum. This overgrowth is proportional to the duration of the
disease. Throughout the grey and white matter the proliferated
neuroglia cells of large size, with coarse and branching fibres, are seen
in great abundance embracing and sticking to the ganglion cells, out of
which they appear to be absorbing the phosphorized substances necessary
for nuclear proliferation.

Pathological Section

49

APPENDIX.

The Chemical Examination of the Brain in Two Cases of
Amaurotic Idiocy, and Comparison with the Normal Brain.

By Sydney A. Mann.

In a previous investigation 1 of the brain in two cases of this disease
it was shown that in the more advanced case there was a decrease
of nucleo-protein which might be associated with the disappearance of
the Nissl substance in the neurones, and an increase of simple protein
corresponding to an increase of glia fibrils ; also in both cases the lipoid
sulphur and phosphorus showed a diminution, but the smallness of the
size of the samples of brain matter used in that investigation made it
necessary that further analyses should be made on larger samples before
any conclusions could be based on the latter results.

Since that time the methods for the chemical investigation of the
brain have been revised and elaborated a and the following research
has been made on larger samples, using the methods in their amended
form. The methods employed, with full analytical technique, have been
already described 3 but it appears necessary to give a resume of the
scheme of analysis. By means of solvents the chemical constituents of
the brain tissue are separated into four general groups: (1) lipoids,

(2) extractives, (3) inorganic constituents, (4) proteins. The following
scheme explains this separation:—

Moist tissue.

Extract with ulcohol and ether.

!

Extracts.

Evaporate to dryness, emulsify with water,
precipitate with CHC1, in 0’5 per cent. HC1 solution.

Residue.

Dry, weigh, extract
with hot water.

I

(1) Lipoids.
Phosphatids.
Cerebri ns.
Cholesterol.
Lipoid sulphur
compound

I

Filtrate.

Water-soluble extrac¬
tives.

Extractive phosphorus.
Extractive sulphur.

Filtrate.

Water-soluble extrac¬
tives.

Extractive phosphorus.
Extractive sulphur.

Proteins.

Protein phosphorus.
Protein sulphur.

1 Archives of Neurology, 1907, iii, p. 21H.
- Archives of Neurology, 1903, iv, p. 174.

50 Carlyll & Mott: Seven Gases af Tay-Sachs Disease

The variations of the elements phosphorus and sulphur in these
groups were investigated for the following reasons. Phosphorus is the
radical which seems to play the r61e in the building up of the most
complex constituents of the cell, the nucleins and phosphatids, and the
variation in its distribution between these and the water-soluble forms
should therefore give an indication of the amount of formation or
destruction of these important cell constituents. Sulphur occurs in the
body in varied stages of. oxidation, and the variations in the different
stages probably offer a means of estimating the extent to which
oxidizing reactions are taking place in the tissues. Sulphur occurs as
—SH or cystin sulphur in proteins, as sulphonate or taurin like sulphur,
as ethereal sulphates and inorganic sulphates ; it enters the organism
mainly as unoxidized or cystin sulphur and leaves in an oxidized form
us inorganic sulphates.

The following forms of phosphorus and sulphur have been estimated
in this investigation.

(1) Lipoid Phosphorus. —Phosphorus attached to the phosphatid
molecules (lecithins, kephalins, sphingomyelin).

(2) Extractive Phosphorus. —Water-soluble inorganic and organic
phosphorus compounds ; previous experiments have tended to show that
the water-soluble phosphorus compounds extracted from the protein
fraction are mainly inorganic, but it is difficult to say how far the
organic forms may not have been split up in the process of estimation.

(3) Protein Phosphorus. —Phosphorus in combination with proteins,
nucleo-proteid.

(1) Lipoid Sulphur. —Sulphur in combination with lipoids; cannot
be removed by cold dilute hydrochloric acid, but splits off as sulphates
on prolonged boiling with dilute hydrochloric acid.

(2) Neutral Sulphur. —Does not split off as sulphuric acid on pro¬
longed boiling with dilute hydrochloric acid. Does not form lead
sulphide on treatment with alkali and lead acetate. Is not precipitated
by phosphotungstic acid except to a very slight extent (about 5 percent),
lleacts with a naphthyl isocyanate like an amino acid, and represents
therefore an intermediary state in the oxidation of cystin to sulphuric
acid or ethereal sulphates, probably of the nature of taurin.

(3) Inorganic Sulphur. —Precipitated directly by barium chloride in
acid solution. In this investigation the inorganic and neutral sulphur
have been classed together as extractive sulphur, previous work having
shown that the amounts of inorganic sulphur are so small that their
investigation is a difficult matter.

Pathological Section

51

(4) Protein Sulphur .—Sulphur in combination with proteins.

One hundred gramme samples of the minced whdle brain from two
•cases of amaurotic idiocy, with a similar sample of the normal brain of
a child of about the same age, have been investigated according to the
above scheme, with the following results. Table I shows an approxima¬
tion of the main groups of constituents of the brain tissue in percentage
•of total solids :—

Table I.

Simple protein .

Age IS months
Normal brain

35*0

Age 20 months
Amaurotic idiocy
Case III

29*6

Age 17 months
Amaurotic idiocy

Case IV

30-8

Nucleo-protein .

10*3

13-7

100

Phosphatids .

280

21*9

19-8

Cerebrins .

13*9

15-9

12-2

Cholesterol.

11-0

11-8

89

Extractives .. . .. »

Ash ... ... ... ... j

Total phosphorus ...

Not estimated.

1-503 ... 1 357

1-318

Total sulphur .

0-49

0 396

0-47

Moisture ...

81-52

83*44

79-31

The analysis made on

100 grm.

samples of the

uniformly minced

brain confirm the results previously obtained from the analysis of
smaller samples of the grey and white matter separately, that there is
-a decrease of the phosphatids in the brain of these cases, with a
•diminution of the total phosphorus and sulphur. The figures for the
normal brain are in agreement with former analyses made on brain
from children of about the same age with the exception that the nucleo-
protein approximation is somewhat low.

The results of one of the cases previously reported showed a diminu¬
tion of nucleo-protein with a corresponding increase of simple protein
in the grey matter; this change is not apparent in the above cases in
which uniform mixtures of the grey and white matter were analysed.
This does not, however, negative the former result as the amount of
phosphorus in the protein fraction is very small, and when the white
matter (which has not been found deficient in nucleo-protein) is included,
the departure from the normal is greatly increased, and unless it is
very marked may be beyond the limits of chemical analysis. As further
cases are obtainable this point will be further investigated on large
samples of the grey matter separately.

Except in the case of phosphatids, the slight variations in the other
constituents—cerebrins, cholesterol, &c.—may be explained as the result

52 Carlyll & Mott: Seven Cases of Tay-Sachs Disease

of nutritive changes. The above figures, however, are approximations
of the general groups of constituents, and a more accurate idea of the
chemical abnormalities met with in the pathological brains is shown
by the following Table II giving the percentage distribution of the
elements phosphorus and sulphur. Tables II and III show the dis¬
tribution of phosphorus and sulphur in percentage of total phosphorus
and sulphur.

Table II.

Protein phosphorus...
Lipoid ,,
Extractive ,,

Normal

3*9

722

23*7

Case III
5*7
62*5
31*7

Case IV
4*3
58*4
37*2

Table III.

Protein sulphur
Lipoid ,,
Extractive ,,

Normal

59*2

1W4

21*4

Case III
61*2
14*8
24*0

Case IV
59*4
12*5
28*1

The above table shows that there is a marked relative diminution of
the lipoid forms of phosphorus and sulphur with a corresponding increase
of the extractive forms , the protein and sulphur and phosphorus showing
no marked change.

John Balk. Sh»ns & iMNiiaXStsoN, ltd., bii-'Jl, Great Tilchlielci Street, London, W

[Imprinted from the Proceedings of the Royal Society, B. Vol. 84]

Motor Localisation in the Brain of the Gibbon , correlated with a
Histological Examination*

By F. W. Mott, Edgar Schuster, and C. S. Sherrington.

(Communicated by Prof. C. S. Sherrington, F.R.S. Received March 28,—

Read May 4, 1911.)

Motor localisation in the Gibbon has not been hitherto determined
experimentally, probably owing to the difficulty of obtaining a suitable
animal. It appeared to be desirable, therefore, to see whether the habits
and mode of life of this animal could be correlated with an increased
development of the motor cortex. One of us (F. W. M.) had some years ago,
by a comparative study of the convolutional pattern of the brains of Lemurs
and Apes, made the following deduction :f “ The remarkable use this animal
makes of its arms and hands can be correlated with a remarkable expansion
of the cortex in the precentral region, as shown by the development of
a broad gyrus extending from the middle of the precentral region to form the
second frontal convolution. Now if we turn to the Ape’s brain (Macacus),
and see what the effect of this development would be, we observe that it
would push forwards and downwards that portion of the cortex which on
stimulation gives rise to movement of the head and eyes, particularly that
which gives rise to eye movements, etc.” Figures were shown to indicate
that the sulcus arcuatus would be pushed down to join the sulcus rectus.
The following experiments by stimulation, correlated with a complete
histological examination of the cortex in front of the central sulcus, have
confirmed this deduction.

The animal used for the experiments was a male and black in colour; it
was remarkably agile ; when standing or running on the ground it main¬
tained almost an erect posture, using its long arms to balance itself very
much as a man would walk on a tight rope with a balancing-pole. It was
kept for some days before the experiment in the animal room of the
Physiological Laboratory, Liverpool, and it was frequently heard to utter
vocal sounds of very varying pitch and quality. Thus it could imitate the
shrill high-pitched whistles of the guinea-pig and the relatively low-pitched
bark of the dog. A short account of the larynx of this animal will be made
the subject of a future publication.

* A portion of the expense of this research has been defrayed by a Government Grant
from the Royal Society.

t “On the Physiological Significance of the Convolutional Pattern in the Primates,”
‘Brit, Med. Journ./ 1906.

68

Messrs. Mott, Schuster, and Sherrington. [Mar. 28,

Details of the Experiments.

The animal was anaesthetised with chloroform and ether, and a light
degree of anaesthesia maintained after the brain had been exposed.

The accompanying protocol describes the results obtained, and fig. 1 L and
R indicate the points of stimulation.

Protocol of Experiments.

Left Hemisphere .

Unipolar stimulation : diffuse electrode on R. foot; small electrode (ball-pointed, ball
about 0*5 mm. diameter) ; stimulus in Kronecker units (K.U.) :—

500 K.U.—

1. Movements of nostril.

2. Retraction of lip, opening of jaw.

3. Turning of head to opposite side.

4. Extension of elbow.

5. Ditto and movement of thumb.

600 K.TJ. (large electrode with ring loop for application, 4 mm. in diameter)—

6: Flexion of elbow, some retraction of shoulder.

7. Closure of eyelids.

8. Inward rotation of wrist, reaching forward movement from shoulder.

8 (again). Drawing-back movement.

6 (again). Flexion of elbow, drawing-to of shoulder.

8 (again). Drop (flexion) of wrist.

9. Extension of shoulder.

10. Extension of shoulder, accompanied by abduction of wrist, extension of fingers,

with a little abduction of thumb (also relaxation of biceps).

11. Elevation of shoulder.

12. Slight flexion of knee.

Bipolar stimulation (stimulus value in centimetres):—

9 cm.—

13. Wrinkling of forehead.

14. Closure of lower and upper eyelids.

15. Forehead and nostril.

Unipolar stimulation: diffuse electrode on L. foot; loop electrode as before :—

600 K.U.—

16. Flexion of hip.

17. Flexion of knee and extension of toes and hallux (succeeded by flexion).

17 (again). Flexion of knee, extension of ankle and toes, going back into flexion.

17 (again). Flexion of hip and knee, extension of foot and toes.

18. Slight flexion of toes (without hallux), extension of ankle with some opening
(i.e. separation) of toes.

Bipolar stimulation as before :—

18. (again). Slight contraction of toes.

Unipolar stimulation with fine ball-pointed electrode : —

17 (again). Extension of hip and knee, abduction of leg.

17 (again). Abduction.

19. Extension of foot (very slight).

(J9

1911.] Motor Localisation in the Brain of the Gibbon.

20. Distinct flexion of hip and knee, flexion of toes.

20 (again). Flexion of knee, flexion of hip.

21. Mouth.

22. Retraction of tongue.

22 (repeated). Same results. (£ cm. of cortex for tongue.)

1000 K.U.—

23. Eyeballs turned inwards and downwards.

24. Upward movement of eyeball.

23 (again). Eyeballs turned downwards and slightly inwards.

23 (repeated). Same results.

1250 K.U.—

Eyes. No result.

Bipolar stimulation :—

9 cm. No result.

8 cm. Mouth moves.

Unipolar stimulation as before :—

1250 K.U.—

22a. Movement of tongue (protrusion of opposite side).

226 (at lowest point). Movement of tip of tongue.

25. Here a very slight movement of tongue tip was obtained from just behind inferior

extremity of central fissure, tip of tongue deviated to opposite side (but see
below).

Unipolar stimulation : small electrode :—

800 K.U.—

22a. In front of fissure, deviations of tongue as before,

25. And various other points behind fissure, nothing.

1250 K.U.—

22a-6. Well-marked protrusion and deviation to opposite side.

22a-6 (again). Protrusion, obtained repeatedly.

22o-6 (again). Retraction.

25. Nothing.

25 (again). Nothing (repeated).

(Results obtained above from 25 with large electrode attributed to diffusion.)
Right Hemisphere .

Unipolar stimulation : coarser electrode :—

800 K.U.—

1. Extension of wrist, opening of fingers.

2. Extension of elbow and wrist, flexion of fingers.

3. Flexion of fingers, chiefly index, abduction of thumb.

4. Movements of wrist, tendency to pronation.

5. Extension of fingers, hallux, wrist ; some abduction and tendency to pronatiou.

6. Eye-movements, outward and upward.

900 K.U.—

7. Extension of wrist.

1000 K.U.—

3 (again). Flexion of fingers and wrist (clenching of hand).

(Interval of 20 minutes ; stimulation then resumed .)

70

Messrs. Mott, Schuster, and Sherrington. [Mar. 28,

As before, but with fine electrode :—

900 K.U. —

8. Primary eversion of foot, followed by inversion ; movements of hip and knee.

8 (again). Slight eversion, then inversion.

9. Slight flexion of hip and knee, movements of tnink (pelvis raised).

8 (again). Movements of trunk, flexion of hip and knee, dorsal flexion of foot.

8 (again). Extension of foot.

9 (again). Marked extension of foot and extension of knee.

Left Hemisphere.

1000 K.U.—

19a. Dorsal flexion of (right) foot, flexion of (right) hip and knee (walking move¬
ments).

196. As before ; more definite. *

Calcarine Region. (Both Hemispheres.)

Bipolar stimulation; distance between points widened to 6 mm. :—

8 cm.—

1. Left hemisphere, just above polar end of calcarine; slight movement of eyeball
upwards and to left.

2 (repeated). Movement of eyeball upwards and a little inwards.

3. Eight hemisphere, corresponding point to 1 ; movement of eyeball over to left in

wavering manner.

6 cm.—

4. Eight hemisphere, mesial surface of pole ; movement of eyeball over to left, and

somewhat downwards, dilation.

5. Eight hemisphere, outer surface (polar region) ; same result.

6. Left hemisphere, similar point to 5 ; eyes move to right.

7. Left hemisphere, at anterior extremity of external calcarine ; same result.

Larynx.

Left Hemisphere.—Bipolar stimulation : wide electrodes :—

6 cm.—

26. Adduction of chords.

26 (repeated). Same results.

26 (again). Adduction of both chords, but chiefly same side.

Bipolar stimulation (C. S. S. stimulating) :—

5 cm.—

26. Slight adduction.

26a. Same as 26.

The stimulation of the calcarine region of the occipital lobe was not
performed until the motor area had been mapped out, consequently the
cortex may not have been in such a favourable condition for excitation.
Unipolar excitation gave no definite results; the stimulation so given may
not have been dilfuse enough. Dipolar excitation invariably produced
deviation of the eyes away from the hemisphere stimulated when one pole
was placed above and the other below the calcarine fissure; the regions
stimulated extended from the mesial surface of the pole of the occipital

1911.] Motor Localisation in the Brain of the Gibbon .

71

lobe along the external surface to the anterior extremity. The electrodes
placed elsewhere on the occipital lobe gave no movements. It may there¬
fore be inferred that owing to the infolding of the cortex to form the fissure
stimulation of this region by bipolar excitation extended to a sufficient
number of motor neurones, or that it is in this region indicated in fig. 1 R by
area 28 that the optic radiations terminate in greater numbers than elsewhere
in the occipital lobe.

Again, it is probable that unilateral stimulation was inefficient in the
production of adduction of the vocal chord, because this experiment was the
last performed. Definite movements were obtained for a short time, however,
by bipolar stimulation of the region 26 indicated; later on, however, the
same strength of stimulus failed to give any response, -and the animal was
killed.

It is of interest to note that unipolar stimulation gave no result when
applied to the ascending parietal convolution; this fact, as we shall see,
accords completely with the histological observations.

Histological Observations.

At the close of the experiments, after the animal had been killed, the
brain was hardened in situ by an injection of formalin solution through the
carotid artery. It was thought that in this way the structure of the cells
would be best preserved. Subsequent examination showed that this
anticipation was not realised, for the preservation was not sufficiently
good to make a complete survey of the cell lamination of the whole brain
profitable. It was, however, quite adequate for the purpose of determining
the extent of the principal areas in the lateral and mesial surfaces of the
frontal lobe. For this purpose the brain was divided into blocks, arranged in
such a way as to avoid, as far as possible, the necessity of cutting any part of
the cortex obliquely or tangentially, and the planes pf section were plotted
carefully on outline drawings of the surface of the hemispheres. After the
blocks had also been drawn, they were embedded in paraffin in the usual way,
and cut into sections parallel to their faces. The sections were stained with
polychrome methylene blue.

Both hemispheres were examined, but the results have been mapped only
on the drawings of the right hemisphere (figs. 2 and 3). Since the types of
cortex here dealt with have been often and fully described and figured, and
since their structure in this case presents apparently no unusual features,
special descriptions or drawings have not been given.

Figs. 2 and 3 show the distribution of two quite distinct types of
cortex in the lateral surface of the Gibbon’s brain. That portion which is

?2 Messrs. Mott, Schuster, and Sherrington. [Mar. 28,

marked in the diagram with a number of large and small dots is covered by
a type of cortex characterised by the absence of a distinct layer of “ granules ”
or “stellate cells/ 1 and thus corresponding to Campbell's* precentral and

Fig. 1.

L, Lateral Surface of Right Hemisphere ; R, Mesial Surface of Right Hemisphere.

intermediate precentral types, or to Brodmann'sf types 4 and 6. The size of
the dots shows roughly the relative size of the largest cells in the ganglionic
layer or inner layer of large pyramids. The largest of these dots indicate
the presence of cells which may safely be called giant pyramids or Betz

* Campbell, ‘Histological Studies on the Localisation of Cerebral Function, 5 Cambridge,
1905.

t Brodmann, “Boitriigc zur histologischen Localisation dor Grossliirnrinde,” III,
‘Journal fiir Psychologic und Neurologic/ 1905, bd. 4, heft 5—G.

73

1911.] Motor Localisation in the Brain of the Gibbon .

cells; their position thus marks the extent of Campbells precentral or motor
area, or of Brodmann’s type 4. The extent of the intermediate precentral
cortex of the former, or type 6 of the latter, is shown by the smaller dots.
The Betz cells are most numerous, largest, and cover a wider zone on the
mesial surface of the hemisphere above the sulcus cinguli and on the lateral

prs. y Sulcus precentralis superior. rect. f Sulcus rectus, fo Sulcus fronto-orbitalis.

c., Sulcus centralis.

The black dots in the above figures indicate the area covered by the precentral (motor)
and intermediate precentral types of cortex ; the circles the granular frontal type of cortex.

surface in the neighbourhood of the supero-mesial border (fig. 3). On the
lateral surface, below the level of the sulcus precentralis superior (prs.), they
are confined to the anterior wall of the sulcus centralis and to a narrow strip
of the ascending frontal convolution lying immediately in front of that fissure.

74

Motor Localisation in the Brain of the Gibbon .

It will be seen on comparing these figures with Campbell's diagrams of
the brains of the Orang and Chimpanzee, that the distribution of the Betz
cells is very similar in all three cases. The Gibbon presents perhaps a
slightly closer resemblance to the Orang in this respect than to the
Chimpanzee.

It is the distribution of the intermediate precentral area which forms the
most characteristic feature of the Gibbon's brain. The great forward
extension of this area distinguishes it in a very striking way from the
Orang and Chimpanzee, on the one hand, and Cercopithecus and the Baboon
on the other. This extension is most marked in the region whicli may
be described as the middle frontal convolution, namely, that portion of the
lateral surface which lies between the sulcus precentralis superior (jrrx.)
above, and the sulcus rectus (red.) below. The area occupied by the
granular frontal cortex (Campbell’s frontal cortex and Brodmann's type 9)
becomes in this way very much restricted, and above the sulcus rectus it
occupies only the very small space in the neighbourhood of the frontal
pole indicated in fig. 3 by small circles. Below that fissure the layer of
granules or stellate cells is well developed in nearly the whole region
lying in front of the fronto-orbital sulcus (fo.).

Probably as a result of the great development of the intermediate
precentral area the sulcus arcuatus, the upper limit of which in Cercopithecus
and the Baboon arches round the posterior end of the sulcus rectus, and
lies just within or actually forms a boundary to this area, has been pushed
downwards to such an extent that it has become continuous with that
fissure. This condition can be recognised most clearly in the left hemisphere,
where the sulcus rectus has posteriorly a well developed downwardly directed
limb, which is clearly the homologue of the lower portion of the sulcus
arcuatus; in the right hemisphere it is very difficult to recognise the latter
at all.

Another point worthy of attention is that in the cortex of the posterior
part of the middle frontal gyrus the large cells of the ganglionic layer, or
inner layer of large pyramids, are somewhat larger than in the region lying
above the anterior end of the sulcus precentralis superior, or below the
sulcus rectus, but are not nearly so large as those which have previously
been referred to as unquestionable giant pyramids.

Hakujson and So*ns, Printers in Ordinary to His Majesty, St. Martin’s Pane.

[Reprinted from the Proceedings of the Royal Society of Medicine,

February, 1911.]

The Incidence of Gall-stones and of Primary Carcinoma of the
Gall-bladder and Biliary Passages in the Insane.

By J. P. Candler. 1

The following paper is based upon the investigation of 2,228 autopsies
conducted at the London County Asylum, Clay bury, during the past ten
years. The main points to which attention has been directed have been
the investigation of the incidence of gall-stones, and the prevalence of
primary carcinoma of the gall-bladder and biliary passages in the series
of cases examined. The investigation was commenced at the suggestion
of Dr. Mott who, while aware of the frequency with which gall-stones
are found on the post-mortem table at Claybury, could not recall to
mind meeting with a case of primary carcinoma of the gall-bladder. By
reason, therefore, of the importance which is assigned to gall-stones in
the causation of primary carcinoma of this organ, he considered that an
investigation on these lines might yield some points of interest.

The Incidence of Gall-stones .—The total number of autopsies inves¬
tigated was 2,228 ; of these 1,169 were females, and 1,059 males. Gall¬
stones were found in 315, a percentage for both sexes of 1413. Of the
1,169 females there were 210 cases with gall-stones (17 85 per cent.),
and of the 1,059 males, 105 cases (9'91 per cent.).

1 From the Pathological Laboratory of the London County Asylums.

2 Candler: Gall-stones and Carcinoma in the Insane

Reference to Hospital Statistics. —Dr. Hale White estimates from
post-mortem records on Europeans of all ages, and of both sexes that
gall-stones are present in from 5 to 10 per cent. Rolleston estimates the
percentage incidence in post-mortem examinations to be between 6 and
10. Schroeder has found in Strasburg a percentage incidence of 12
for both sexes. In his cases the proportion of female cases was 20 per
cent., against 4'4 per cent, of males, an incidence for females in con¬
siderable excess of that obtained at Clay bury.

Dr. Ticehurst 1 gives the following table on the incidence of gall¬
stones taken from the papers of Naunyn and Kelynack :—

Table I.

Percentage incidence

Observer

Place of observation

of gall-stones

Poulson

.. r

Copenhagen ...

3*8

Peters

Kiel .

5*0

Munk \

Rother l

Munich (10 years)

6*2

Hiller J

Brock bank ...

Manchester (487 cases)

6-5

Fielder

Dresden

7*0

Schloth

Erlanger (24 years)

7*2

Voelcker

286 cases

9*4

Roth

Basle

100

Frank

...

Vienna

100

Schroeder ...

...

Strasburg (7 years)

120

Ticehurst, in his investigation based upon the post-mortem records
of Guy’s Hospital for twenty-five years (1876-1900), found 333 cases of
gall-stones in 11,031 autopsies, a percentage of 2*08, or excluding patients
dying under 20 years of age, 6*3 per cent. %

From the figures above given it w T ould appear that the incidence of
gall-stones among the insane was greater than that found in ordinary
hospital practice, to which fact attention has already been drawn by
Dr. Beadles, who at Colney Hatch Asylum found gall-stones present in
27 per cent, of the female cases, and in 5 per cent, of the males.
Beadles quotes Warnock’s figures of 50 per cent, in females, and 11
per cent, in males dying in Peckham House Asylum (Private), to show
that this excess is by no means confined to pauper lunatics.

The figures from Claybury appear to bear out this contention, but
not so markedly as those of Beadles and Warnock; nevertheless, it is
probable, from the evidence obtainable, that the percentage incidence of
gall-stones is slightly higher among the insane than among the general

1 “ On the Mortality from Gall-stones.” Thesis for M.B. Degree, Cantab. 1903.

Pathological Section

3

population. The greater incidence at Colney Hatch may be due to the
fact that it is the second oldest London County Asylum, and probably
the average age of the inmates is higher than that of Claybury, which is
comparatively a new asylum. ^Reference to Table II, compiled from the
Claybury statistics, shows that, with the exception of the age-period
40—50 years, there is a gradual increase in the percentage incidence of
gall-stones as age advances^ and this percentage agrees fairly accurately
with that given by Schroeder.

Table II.

Age-periods

Total number
of autopsies

Number of case*
with gall-stoues

Percentage

Schroeder's

percentage

0 to 20

16

0

0

2-4

20 „ 30

155

6

3*87

3*2

30 „ 40

375

31

8-26

11*5

40 „ 50

424

27

6-36

11*1

50 „ GO

412

54

13*1

9*9

60 „ 70

440

85

19*31

... —

70 „ 80

337

90

26*70

—

80

69

22

31*83

—

60 and over

846

197

23*28

25-2

The figures which I have recorded give the incidence of the gall¬
stones as regard hospital patients and the insane. It is of importance
to compare the statistics afforded by these two classes, and to ascertain
how far the figures can be used as an indication of the incidence of these
affections among a general population.

The preceding tables show that the incidence of gall-stones among
hospital patients varies considerably in the hands of different observers.
No satisfactory conclusions can be given to account for these variations
from a mere perusal of the figures, unless it be known that the statistics
have been compiled under precisely similar conditions, especially as
regards the number of cases dying at the various age-periods, the per¬
centage incidence of gall-stones at these age-periods, and the number of
cases dying before the age of 20. This last factor is of the utmost
importance, for since gall-stones are exceedingly rare in cases dying
before the age of 20, the inclusion of a large number of such cases before
age 20 will materially affect the tables. This is well shown by the
figures of Ticehurst—the percentage incidence of gall-stones on 11,031
autopsies was only 2 08; of these no less than 3,156 were under 20 years
of age, and only one case with gall-stones was found amongst this
number. The elimination of all cases dying before 20 increased the
percentage incidence to 6*3.

4 Candler: Gall-stones and Carcinoma in the Insane

The percentage incidence of gall-stones at Claybury Asylum was
14’13 on 2,228 autopsies. The number of cases dying under 20 years
of age was only 16, and in none of these cases were gall-stones found.

There is a considerable difference between the incidence of gall¬
stones among the insane (as shown by the Claybury statistics and
elsewhere) and that among hospital cases. Even after the elimina¬
tion of all cases dying before 20 years of. age, there is still a great
difference between the Claybury figures and those from Guy’s Hos¬
pital. The following table shows the total number of gall-stones
found at the different age-periods at the two institutions:—

Table III.

Number of gall-stone*

Age-period

Guy's Hospital

Claybury Asylum

10 to 20

1

0

21 „ 30

11

6

31 „ 40

36

31

41 „ 50

85

27

51 „ 60

91

54

61 and over

107

197

Th 8 table showB that out of an approximately equal number of
cases with gall-stones, the Claybury figures provide a smaller number
at age-periods 40—50 and 50—60, and a considerably greater number
at 60 years and over, than at Guy’s. I have been unable to obtain the
number of cases dying at the different age-periods at Guy’s for com¬
parison with the Claybury figures, and, in the absence of these, I hesi¬
tate to form any definite conclusions. As, however, the incidence of
gall-stones increases with advancing age, the inference is that a rela¬
tively greater number of deaths occurred at Guy’s Hospital between
the ages 40—60 and less from 60 onwards than occurred at Claybury
Asylum.

Mayo Robson has suggested that the incidence of gall-stones among
hospital patients is less than that in a general population because hos¬
pitals are patronized by the labouring classes, in whom the incidence of
gall-stones is less. This may be so, but I am inclined to think that
there is another explanation which may account for any lessened inci¬
dence of gall-stones in the hospital statistics, namely, that a relatively
small number of the aged poor seek hospital assistance, but die from old
age in their own beds or in the infirmaries, and thus fail to provide the
hospitals with the necessary material for complete statistics.

Statistics obtained from asylums (at any rate as far as the relative

Pathological Section

5

incidence of gall-stones is concerned) would be more comparable with
those obtained from a general population from which all cases dying
before the age of 20 have been eliminated, by virtue of the fact that the
population of asylums is not constantly changing as is that of hospitals.
The patients are admitted solely for their mental condition, irrespective
of any bodily, ailments, and many of them on admission are in good
health and ultimately die of senile decay after many years of residence
in the asylum. They therefore provide a greater number of people in
the later years of life than do hospitals. In the Claybury statistics, out
of 2,228 autopsies, 1,258, or 56 per cent., had survived the age of 60;
406, or 18 per cent., survived the age of 70; and 69, or 3 per cent.,
survived the age of 80.

The death-rate in asylums differs from that in a general population
in that there is a greater mortality in the mid-period of life from
phthisis, general paralysis of the insane, pneumonia, and dysentery.
The average duration of life, therefore, among the insane is probably
shorter than among the general population who have survived the age
of 20: and this should tend to diminish the relative incidence of gall¬
stones among the insane. But, in spite of this, the percentage incidence
in the insane is estimated to be higher than in a general population.
Various explanations have been put forward to account for this increased
incidence in the insane, such as the greater prevalence of gastric dis¬
orders, of constipation, of melancholia and lethargic states, and of the
breaking down of nervous tissue with a greater deposition of cholesterol
in the bodily tissues. Thudichum, commenting upon the paper of
Beadles, regarded the high percentage of persons dying in asylums
with gall-stones as being evidence of some causal relationship to
cerebral decay and insanity. No doubt this great authority on the
chemistry of the brain considered the brain decay and resulting choles¬
terol production accountable for the higher incidence of gall-stones among
the insane than among the general population.

The Incidence of Primary Carcinoma of the Gall-bladder and Biliary
Passages as ascertained at Guy's Hospital. —Ticehurst found in 11,031
autopsies, with 333 cases of gall-stones, that there were 45 cases of
primary carcinoma of the gall-bladder (13’5 per cent.), and 15 cases of
primary carcinoma of the bile-ducts (4*5 per cent.), or, combining the
two, a total of 60 cases of primary carcinoma of the gall-bladder and
biliary passages (18 per cent.).

The Incidence of Primary Carcinoma of the Gall-bladder and Biliary
Passages in the Insane. —Of the 2,228 cases examined at Claybury 315

6 Candler: Gall-stones and Carcinoma in the Insane

were found to have gall-stones. In this series there were only two
definite cases of primary carcinoma of the gall-bladder (one male and
one female), gall-stones being found in the gall-bladder in each case. In
other words, the incidence of primary carcinoma of the gall-bladder was
1 in 1,000 of the insane dying at Clay bury during ten years; or, looked
at from the percentage incidence of gall-stones, two cases of primary
carcinoma of the gall-bladder out of 315 cases of gall-stones (0*65 per¬
cent.). Both these cases were proved by microscopic examination. In
addition to these two cases there was one case which occurred at the
commencement of the series which was noted as (?) primary carcinoma
of the gall-bladder, or primary malignant disease of the breast with
secondary involvement of the liver and gall-bladder. The right breast
had been previously amputated, and there was a malignant mass in the
site of the scar. The liver was studded with malignant nodules. The
gall-bladder was involved in a mass of cancer and contained one large
stone the size of a pigeon’s egg. The case was not microscoped.
Even if this be conceded as a case of primary malignant disease of
the gall-bladder, which is very doubtful, the percentage incidence is
only 0*95. ,

Of primary carcinoma of the liver and biliary ducts apart from the
gall-bladder there were only three very doubtful cases occurring very
early in the series. In Case I, the growth in the liver was probably
secondary to malignant disease of the ovary. In Case II it was prob¬
ably secondary to carcinoma originating in the pylorus ; and in Case III
it was noted as probably secondary to primary malignant disease of the
mediastinum. The gall-bladder was quite free from growth in each case,
and there were no stones found either in the ducts or gall-bladder, nor
any evidence of partial or complete destruction of the ducts by cicatricial
contraction, consequent upon the previous passage of gall-stones along
the ducts. These cases were not microscoped. Even if they be included
as possible instances of primary carcinoma of the bile-ducts consequent
upon irritation of stones which had ultimately been passed into the
intestine, the percentage incidence in relation to gall-stones is only 0*95.

It will thus be seen (vide Table IV) that the percentage incidence of
primary carcinoma of the gall-bladder and biliary passages in the insane,
as afforded by the Claybury figures, is markedly less than the hospital
percentage incidence. As the incidence of these diseases among a general
population is based upon hospital statistics, such a wide variation between
the Guy’s Hospital figures and those of Claybury requires some com¬
ment, especially as gall-stones are considered to play so important a part

Pathological Section 7

in the production of primary carcinoma of the gall-bladder and biliary
passages.

Opinions as to the Role played by Gall-stones in the Causation of
Primary Malignant Disease of the Gall-bladder .—The opinion of those
who have studied this subject is almost entirely in agreement—namely,
that gall-stones are a cause of primary malignant disease of the gall¬
bladder and ducts, especially of the former.

Dr. Hale White, quoting from Ticehurst’s figures, states that the
latter found among the 11,031 autopsies at Guy’s Hospital (in which
there were 333 cases of gall-stones) 45 examples of primary carcinoma

Table IV. —Showing a Comparison of the Incidence of Gall-stones and Primary
Carcinoma of the Gall-bladder and Biliary Passages in Cases dying at
Claybury Asylum and Guy’s Hospital.

« -

a rt

I:

1

lii,:

! f

& 5 j

2 i

« ? i

ft

1 t O

t ! a| ■ Pf i

O O | | ! 3 ||

o © 1 S o ® w. . ZZ

©

Ui

et

a

©

o

I;!*!

i

l S§1

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s

c

©

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«*- c -x 1

° «C ,
IIS 1

*& Ijjgo
3 ~ §

•pi

1 in

Guy’s

Hospital

11,031 333 2 08 7,875 G*3 45

13-5

15 I 4*5

GO 18 0

Claybury 1 2,228 I 315 14*13 i 2,212 j 14*24 2 j 0*65 0 I 0 2 | 0*65

Asylum I 1 I | 1 ? 0*95? 3? 0*95? 4?; 1*9?

of the gall-bladder, and in 43 of these, or 95 per cent., gall-stones were
present; and there were 15 cases of primary carcinoma of the bile-ducts,
and gall-stones were present in 11, or 75 per cent. Hale White
concludes that about 20 per cent, of those who have gall-stones sub¬
sequently suffer from malignant disease of the biliary passages. He
further emphasizes that this is not as widely understood as it should
be, the chief reason being that most cases of malignant disease of the
biliary passages are called malignant disease of the liver, and hence the
causative importance of the gall-stones is missed.

Moynihan states that one of the most serious sequelae of chole¬
lithiasis is malignant disease of the gall-bladder or ducts, and that the
close connexion between gall-stones and malignant disease has never
lacked recognition.

8

Candler: Gall-stones and Carcinoma in the Insane

Mayo Robson, on the other hand, states that cancer of the gall¬
bladder is by no means frequent, and as a primary affection is somewhat
rare. It is usually due to the irritation of gall-stones or to extension
from adjoining organs.

Rolleston writes that special interest is attached to the association
of gall-stones and carcinoma of the gall-bladder—Musser, 69 per cent.;
Courvoisier, 91 per cent.; Siegert, 95 per cent.; Futterer, 70 per cent.;
Winton, 81 per cent.; Zenker, 85 per cent. Conversely, it appears that
primary carcinoma of the gall-bladder occurs in from 14 to 4 per cent,
of all cases of cholelithiasis.

Schroeder estimated that 14 per cent, of persons with cholelithiasis
eventually became the subjects of carcinoma of the gall-bladder.

In 149 cases of gall-stones, abstracted from the records of Guy’s
Hospital by Keay, there were 17 cases of carcinoma of the gall-bladder
or cystic duct, equivalent to 11 '4 per cent.

Riedel estimates the percentage of primary carcinoma in chole¬
lithiasis to be from 7 to 8 per cent.

Among 242 cases of gall-stones at St. George’s Hospital there were
10 cases of primary carcinoma of the gall-bladder, or 4'1 per cent.

Rolleston sums up by saying that “gall-stones are present in the
great majority of cases of primary malignant disease of the gall-bladder,
while carcinoma develops in 14 to 4 per cent, of cases of cholelithiasis.”

The evidence, therefore, shows that gall-stones are present in
practically 80 to 90 per cent, of all cases dying from primary carcinoma
of the gall-bladder, while it has been remarked by Ticehurst and others
that gall-stones are rarely found when the biliary passages are affected
by growth secondary to that elsewhere. So far as the Claybury
statistics show they confirm Ticehurst’s statement. Both cases of
primary carcinoma of the gall-bladder contained calculi, while cases in
which the liver was affected with growth secondary to malignant disease
commencing in some other organ showed little or no excess in the
incidence of gall-stones.

The point, however, to which I desire to draw attention, is as to
whether the association between gall-stones and primary malignant
disease of the gall-bladder is so frequent as to justify the opinion that
because calculi are found in 90 per cent, of cases of primary carcinoma
of the gall-bladder they are to be looked upon as so potent a factor
in the causation of this disease. On the one hand we have statements
to show that no less than 20 to 18 per cent. (Hale White and Ticehurst)
and 14 to 4 per cent. (Rolleston) of cases of cholelithiasis succumb to

Pathological Section

9

malignant disease of the gall-bladder and ducts. On the other hand,
Mayo Bobson states that cancer of the gall-bladder is by no means
frequent, and as a primary affection is somewhat rare. These two
statements are diametrically, opposed. The estimates of Hale White,
Ticehurst, and Eolleston are based on hospital statistics. They cannot,
in my opinion, be taken to represent the incidence among the general
population. They are based on selected cases among the general
population, who, on account of symptoms arising from the onset of
carcinoma, seek hospital advice. The inclusion of these cases will at
once increase the incidence of carcinoma of the gall-bladder in relation
to gall-stones and upset the balance of comparison with that of a general
population. The incidence of carcinoma in a general hospital could not
be taken as indicative of the prevalence of this disease in a general
population, nor could the incidence of lung affections among the insane
be used to indicate the frequency of these conditions among the sane.

If we take Hale White’s estimate (viz., that about 20 per cent,
of cases of gall-stones ultimately develop primary carcinoma of the gall¬
bladder and biliary passages) and apply it to the Claybury statistics,
then out of the 315 cases there should have been as many as 60 cases of
primary malignant disease of these regions, or assuming that 10 per
cent, of a general population surviving the age of 20 suffer from gall¬
stones, then two out of every 100 persons should develop primary carci¬
noma—a supposition which I think is not justified. It may be
suggested that the smaller incidence of primary carcinoma among the
insane is due to the fact that their average age at death is lower than
the average age at death of a general population surviving the age of 20.
If all the cases of gall-stones dying before the age of 60 be eliminated
from the Claybury statistics, there still remain 197 cases of gall-stones
occurring from the age of 60 upwards. If Hale White’s estimate be
applied to these cases only, there should have been close on 40 cases of
primary carcinoma of the gall-bladder in the Claybury statistics.

It is not my intention to discuss the various theories as to how gall¬
stones act in producing carcinoma of the gall-bladder, or as to whether
gall-stones precede or are formed after the commencement of malignant
disease of that organ ; there is probably truth in both suppositions. If,
as Mignot believes from experimental researches, a stratified well-formed
biliary calculus can be formed in six months, it seems quite possible that
a calculus could be formed as the result of changes set up in the mucous
membrane by the onset of carcinoma before operation on, or death of,
the patient.

10 Candler: Gall-stones and Carcinoma in the Insane

From the evidence obtained from the post-mortem statistics at
Claybury Asylum I am, however, inclined to the opinion that the
incidence of primary carcinoma of the gall-bladder and biliary passages
in its relation to gall-stones among the general population is by no
means so great as hospital statistics would lead us to believe, and that
consequently there is not sufficient justification for assigning to gall¬
stones so important a r61e in the production of primary malignant disease
of the gall-bladder and ducts.

BIBLIOGRAPHY.

Beadles. Trans . Path. Soc. Lond ., xlvii, p. 82,

Hale White. Brit. Med. Journ ., 1908, ii, p. 1729, and “ Tumours of the Liver,*’ Allbutt
and Rolleston’s “ System of Medicine,” 1908, iv, part i, pp. 204-222.

Mayo Robson. “ Diseases of the Gall-bladder and Bile-ducts,’* Allbutt and Rolleston’s
“ System of Medicine,’* 1908, iv, part i, pp. 223-242.

Moynihan. “Gall stones and their Surgical Treatment,” 2nd ed., 1905.

Rolleston, H. D. “Diseases of the Liver, Gall-bladder, and Bile-ducts,” and Med
Chron. % Manchester, 1895-96, N.S. iv, p. 241.

Schboeder. Quoted by Mayo Robson and Ticehurst.

Ticehcrst, N. F. Thesis for M.B. Degree, Cantab., 1903.

Warnock. Med. Times and Hosp . Gazette , 1894, xxii, p. 667.

A complete bibliography is given by these writers.

John Bale, lions & Danielsson, Ltd,, MJ-Vl, Great Titehtield Street, London. \V.