Journal Of Mental Science 62.1916 Princeton

The journal of mental science.

London : Longman, Green, Longman & Roberts, 1859-1962.

http://hdl.handle.net/2027/nj p.32101074924489

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PRINCETON UNIVERSITY

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THE JOURNAL

• •»

OF

MENTAL SCIENCE.

EDITORS :

John B. Lord, M.B. Thomas Drapes, M.B.

Assistant Editors:

Henry DeYine, M.D. G. Douglas McRae, M.D.

VOL. LXII.

J. & A. CHURCHILL.

7, GREAT MARLBOROUGH STREET.

MDCCCCXVI.

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PRINCETON UNIVERSITY

" In adopting our title of the Journal of Mental Science, published by authority
of the Medico-Psychological Association, we profess that we cultivate in our pages
mental science of a particular kind, namely, such mental science as appertains
to medical men who are engaged in the treatment of the insane. But it has
been objected that the term mental science is inapplicable, and that the term
mental physiology or mental pathology, or psychology, or psychiatry (a term
much affected by our German brethren), would have been more correct and ap¬
propriate ; and that, moreover, we do not deal in mental science, which is pro¬
perly the sphere of the aspiring metaphysical intellect. If mental science is
strictly synonymous with metaphysics, these objections are certainly valid; for
although we do not eschew metaphysical discussion, the aim of this Journal is
certainly bent upon more attainable objects than the pursuit of those recondite
inquiries which have occupied the most ambitious intellects from the time of
Plato to the present, with so much labour and so little result. But while we
admit that metaphysics may be called one department of mental science, we main¬
tain that mental physiology and mental pathology are also mental science under
a different aspect. While metaphysics may be called speculative mental science,
mental physiology and pathology, with their vast range of inquiry into insanity;
education, crime, and all things which tend to preserve mental health, or to pro¬
duce mental disease, are not less questions of mental science in its practical, that
is in its sociological point of view. If it were not unjust to high mathematics
to compare it in any way with abstruse metaphysics, it would illustrate our
meaning to say that our practical mental science would fairly bear the same rela¬
tion to the mental science of the metaphysicians as applied mathematics bears to
the pure science. In both instances the aim of the pure science is the attainment
of abstract truth; its utility, however, frequently going no further than to serve
as a gymnasium for the intellect. In both instances the mixed science aims at,
and, to a certain extent, attains immediate practical results of the greatest utility
to the welfare of mankind ; we therefore maintain that our Journal is not inaptly
called the Journal of Mental Science, although the science may only attempt to
deal with sociological and medical inquiries, relating either to the preservation of
the health of the mind or to the amelioration or cure of its diseases; and although
not soaring to the height of abstruse metaphysics, we only aim at such meta¬
physical knowledge as may be available to our purposes, as the mechanician uses
the formularies of mathematics. This'is our view of the kind of mental science
which physicians engaged in the grave responsibility of caring for the mental
health of their fellow-men may, in all modesty, pretend to cultivate; and while
we cannot doubt that all additions to our certain knowledge in the speculative
department of the science will be great gain, the necessities of duty and of danger
must ever compel us to pursue that knowledge which is to be obtained in the
practical departments of science with the earnestness of real workmen. The cap¬
tain of a ship would be none the worse for being well acquainted with the higher
branches of astronomical science, but it is the practical part of that science as it
is applicable to navigation which he is compelled to study .”—Sir J. C. Bueknill,
M.D., F.R.S.

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PRINCETON UNIVERSITY

THE

MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

THE COUNCIL AND OFFICERS. 1915-16.

president.— DAVID GEORGE THOMSON, M.D.

PRESIDENT elect.— JOHN KEAY, M.D.
ex-presidbnt.— JAMES CHAMBERS, M.A., M.D.
treasurer.— H. HAYES NEWINGTON, F.R.C.P.

f JOHN R. LORD, M.B.

editors of journal.-; LEWIS C. BRUCE, M.D., F.R.C.P.

I T. DRAPES, M.B.

DIVISIONAL SECRETARY FOR SOUTH-EASTERN DIVISION.

J. NOEL SERGEANT, M.B.

DIVISIONAL SECRETARY FOR SOUTH-WESTERN DIVISION.

JAMES V. BLACIIFORD, M.D.

H. T. S. AVELINE, M.D. (Acting Sec.).

DIVISIONAL SECRETARY FOR NORTHERN AND MIDLAND DIVISION.

T. S. ADAIR, M.D.

DIVISIONAL SECRETARY FOR SCOTTISH DIVISION.

ROBT. B. CAMPBELL, M.D., F.R.C.P.

DIVISIONAL SECRETARY FOR IRISH DIVISION.

RICHARD R. LEEPER, F.R.C.S.

GENERAL SECRETARY.— M. ABDY COLLINS, M.D.

R. H. STEEN, M.D., M.R.C.P. (Acting Hon. Gen. Sec.).

CHAIRMAN OP PARLIAMENTARY COMMITTEE.

H. WOLSELEY-LEWIS, M.D., F.R.C.S.

SECRETARY OF PARLIAMENTARY COMMITTEE.

R. H. COLE, M.D., M.R.C.P.

(both appointed by Parliamentary Committee, but with seats on Council).

SECRETARY OP EDUCATIONAL COMMITTEE.

J. G. PORTER PHILLIPS, M.D., M.R.C.P.

(appointed by Educational Committee, but with seat on Council).
registrar.— ALFRED MILLER, M.B.

MEMBERS OP COUNCIL.

REPRESENTATIVE.

M.J. NOLAN | Ireland.

NOMINATED.

JAMES CHAMBERS
GEOFFREY CLARKE
W. R. DAWSON
H. J. MACKENZIE
G. E. PEACHKLL
G. M. ROBERTSON
J. G. SOUTAR

[The above form the Council.]

neruconn i ai i v js.

E. H. BERESFORD
H. J. NORMAN
T. E. K. STANS FIELD
R. H. STEEN
T. SEYMOUR TUKE
NORMAN LAVERS
G. STEVENS POPE
J. W. GEDDES
J. R. GILMOUR
D. HUNTER
N. T. KERR
JAMES ORlt

Div.

j-S.E.

^ S.W. Drv.
|n. &M.

|Scotland.

Div.

AUDITORS

DAVID BOWER, M.D.

) DA

•} R. PERCY SMITH, M.D., F.R.C.P.

ENGLAND

SCOTLAND -

ESf litninary. —H. J

EXAMINERS.

(E. D. MACNAMARA, M.A., M.D , B.C., F.R.C.P.

]R. II. COLE, M.D., M.RC.P.

T. C McKENZIE, M.I)., Ch.B., F.R.C.P., M.P.C.

JAMES H. MACDONALD, M.IL.Ch.B., F.R.F.P.&S.Glnsg.
J. REDINGTON, F.RC.8., L.R.C.P.I.

J. O’C. DONKLAN, L.K.C.P. & S.I.

Examiners for the Nursing Certificate of the Association :

Final— It. R. LEEPER, F.RC.S.I.; F. R. P. TAYLOR, M.D., B.S.;

R. B CAMPBELL, M.D., F.R.C.P.Ed.

McKENZIE M.B., C.M.; DAVID ORR, M.D., C.M.Edin.

IRELAND

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PRINCETON UNIVERSITY'

11

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PARLIAMENTARY COMMITTEE.

T. S. ADAIR.

ROBERT ARMSTRONG-JONES.

H. T. S. AVELINE.

FLETCHER BEACH.

E. H. HERESFOR1).

JAMES V. BLACHFORD.

DAVID BOWER.

LEWIS C. BRUCE.

It. B. CAMPBELL.

JAMES CHAMBERS.

R. H. COLE ( Secretary ).

M. A. COLLINS {ex officio).

J. O’C. DONELAN.

THOS. DRAPES.

J. R. GILMOUR.

AV. GRAHAM.

P. T. HUGHES.

D. HUNTER.

THEO. B. IIYSLOP.

N. T. KERR.

R. L. l.ANGDON-DOWN.

R. R. l.EEPER.

J. R. LORD.

P. W. MACDONALD.

T. AV. McDOWALL.

W. F. MENZIES.

CHAS. A. MERCIER.

JOHN MILLS.

W. F. NEL1S.

H. HAYES NEWINGTON.

M. J. NOLAN.

JAMES ORR.

BEDFORD PIERCE.

HENRY RAYNER.

G. M. ROBERTSON.

SIR GEO. II. SAVAGE.

G. E. SHUTTI.EWORTH.

R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE SPENCE.

T. E K. STANSFIELD.

R. II. STEEN.

ROTIISAY C. STEWART.
DAVID G. THOMSON.

T. SEYMOUR TUKE.

ERNEST WHITE.

H. WOLSELEY-LEWIS ( Chair -
mun.)

EDUCATIONAL

T. S. ADAIR.

3. R. ARMSTRONG-JONES.

H. T. S. AVELINE.

FLETCHER BEACH.

J. V. BLACHFORD.

1. J. S. BOLTON.

LEWIS C. BRUCE.

R. B. CAMPBELL.

23. JAMES CHAMBERS.

19. It. H. COLE.

M. A. COLLINS {ex officio).

2. MAURICE CRAIG.

H. DEVINE.

J. FRANCIS DIXON.

11. J. O’C. DONELAN.

THOS. DRAPES {ex officio).

J. R. GILMOUR.

12. W. GRAHAM.

18. B. HART.

It. D. HOTCIIKIS {ex officio).

17. P T. HUGHES.

13. JOHN KFAY.

N. T. KERR.

R. It. LEE PER.

JOHN It. LORD {ex officio.)

14. J. H. M tCDO.N ALD.

P. W. MACDONALD.

4. THOS. W. McDOWALL.

H. J. MACKENZIE {exofficio).

T. C. MACKENZIE {ex officio).

COMMITTEE.

16. W. TUACII MACKENZIE.

22. E. D. MACNAMARA.

S. R. MACPHAIL.

W. F. MENZIES.

C. A. MERCIER.

JAMES MIDDLF.MASS.

ALFRED MILLER {ex officio).

W. F. NELIS.

H. HAYES NEWINGTON.
MICHAEL J. NOLAN {ex officio).
DAVID ORR.

JAMES ORR.

5. L. It. OSWALD.

J G. PORTER PHILLIPS {Sect,.)
BEDFORD PIERCE.

J. REDINGTON {ex officio.)

15. WILLIAM REID (Aberdeen).

6. GEORGE M. ROBERTSON.

R. G. ROWS.

21. AV. SCOWCROFT.

7. R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE SPENCE.

T. E. K. STANSFIELD.

8. ROBERT H. STEEN.

9. W. H. II. STODDARr.

FREDERIC It. P. TAYLOR.
DAVID G THOMSON.

10. T. SEYMOUR TUKE.

20. AV. R. VINCENT.

LIBRARY

FLETCHER BEACH.

HELEN BOYLE.

M. A. COl.LINS {ex officio).

HENRY DEVINE.

BERNARD HART.

COMMITTEE.

THEO. B. HYSLOP.

E. MA POTHER {Secretary).
HENRY RAYNER.

W. II. B. STODDART.

DAVID G. THOMSON {ex officio).

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Ill

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RESEARCH COMMITTEE.

T. STEWART ADAIR.

J. SHAW BOLTON.

J. CHAMBERS.

M. A. COLLIN8 {ex-officio).
H. DEVINE.

T. DRAl’ES.

E. GOODAl.L.

JOHN KEAY.

J. R. LORD.

H. HAYES NEWINGTON.
DAVID ORR.

FORD ROBERTSON.

R. O. ROWS.

R. PERCY SMITH.

1). G. THOMSON ( ex-officio ).
W. J. TULLOCU.

Lectures at:—(l) University of Leeds; (2) Guy’s Hospital; (3) St. Bartholomew’s
Hospital; (4) University of Durham; (o) University of Glasgow; (6) University of
Edinburgh and Medical College fur Women, Edinburgh; (7) St. Thomas’s Hospital;
(8) King’s College; (9) Westminster Hospital; (10) St. George's Hospital; (11)
University of Dublin and National University of Ireland ; (12; Queen's University of
Belfast; (13) Lecturer at School of Medicine, Royal Colleges and Medical College for
Women, Edinburgh; (14) St. Mungo's College, Glasgow ; (15) Aberdeen University;
(16) St. Andrew's University and Dundee University ; (17) Birmingham University;
(18) University College, London ; (19) St. Mary’s Hospital, London; (20) University
of Sheffield; (21) Victoria University, Manchester; (22) Charing Cross Hospital;
(23) Middlesex Hospital. _

LIST OF CHAIRMEN.

1S41. Dr. Blake, Nottingham.

1842. Dr. de Vitrd, Lancaster.

1813. Dr. Conolly, Ilanwell.

1814. Dr. Tlnirnani, York Retreat.

1847. Dr. YViutle, Warncford House, Oxford.

1851. Dr. Conolly, Hnnwell.

1852. Dr. Wintle, Warncford House.

LIST OF PRESIDENTS.

1854. A. J. Sutherland, M.D., St. Luke’s Hospital, London.

1855. J. Thu main, M.l)., Wilts County Asylum.

1856. J. Hitchmnn, M.D., Derby County Asylum.

1857. Forbes Winslow, M.D., Sussex House, Hammersmith.

1858. John Conolly, M.D., County Asylum, Hnnwell.

1859. Sir Charles Hastings, D.C.L.

1860. J. C. Bucknill, M.D., Devon County Asylum.

1861. Joseph I.alor, M.D., Richmond Asylum, Dublin.

1862. John Kirknmn, M.D., Suffolk County Asylum.

1863. David Skae, M.D., Royal Edinburgh Asylum.

1861. Henry Munro, M.D., Brook House, Clapton.

1865. Win. Wood, M.D., Kensington House.

1866. W. A. F. Browne, M.D., Commissioner in Lunacy for Scotland.

1867. C. A. Lockhart Robertson, M.D., Haywards Heath Asylum.

1868. W. H. O. Sankey, M.D., Sandywell Park, Cheltenham.

1869. T. Lnycock, M.l)., Edinburgh.

1S70. Robert Boyd, M.D., County Asylum, Wells.

1871. Henry Maudsley, M.l)., The Lawn, Hnnwell.

1872. Sir James Coxe, M.l)., Commissioner in Lunacy for Scotland.

1873. Harrington Tnke, M.D., Manor House, Chiswick.

1874. T. L. Rogers, M.l)., County Asylum, Rainhill.

1875. J. F. Duncan, M.D., Dublin.

1876. W. H. Parsey, M.D., Warwick County Asylum.

1377. G. Fielding Blandford, M.D., London.

1878. Sir J. Crichton-Browne, M.D., Lord Chancellor’s Visitor.

1879. J. A. Lush, M.D., Fislierton House, Salisbury.

1880. G. W. Mould, M.R.C.S., Royal Asylum, Cheudle.

1881. D. Hack Tuke, M.D., London.

1882. Sir W. T. Gnirdner, M.D., Glasgow.

1883. W. Orange, M.D., State Criminal Lunatic Asylum, Broadmoor.

1884. Henry Rayner, M.D., County Asylum, Hanwcll.

1885. J. A. Fames, M.D., District Asylum, Cork.

1986. Sir Geo. H. Savage, M.D., Betblem Royal Hospital.

1887. Sir Fred. Needham, M.D., Barn wood House, Gloucester.

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1888. Sir T. S. Clouston, M.I)., Royal Edinburgh Asylum.

1889. H. Hayes Newington, F.R.C.P., Tieehurst, Sussex.

1890. David Yellowlees, M.D., Gartnavel Asylum, Glasgow.

1891. E. B. Whitcombe, M.R.C.S., City Asylum, Birmingham.

1892. Robert Baker, M.D., The Retreat, York.

1893. J. Murray Lindsay, M.D., County Asylum, Derby.

1894. Conolly Norman, F.R.C.P.I., Richmond Asylum, Dublin.

1895. David Nicolson, C.B..M.1)., State Criminal Lunatic Asylum, Broadmoor.

1896. William Julius Mickle, M.D., Grove Hall Asylum, Bow.

1897. Thomas W. McDowall, M.D., Morpeth, Northumberland.

1898. A. R. Urquhart, M.D., James Murray’s Royal Asylum, Perth.

1899. J. B. Spence, M.D., Rurntwood Asylum, nr. Lichfield, Staffordshire.

1900. Fletcher Beach, M.B., 79, Wimpole Street, W.

1901. Oscar T. Woods, M.D., District Asylum, Cork, Ireland.

1902. J. Wigleswortli, M.I)., F.R.C.P., Ratnhill Asylum, near Liverpool.

1903. Ernest W. White, M.B.,M.R.C.P..City of London Asy lum, Dart ford, Kent.

1904. It. Percy Smith, M.I)., F.R.C.P., 36, Queen Anne Street, Cavendish

Square, London, W.

1905. T. Outterson Wood, M.I)., F.Ii.C.P., 40, Margaret Street, Cavendish

Square, London, W.

1906. Robert Armstroug-Jones, M.D.Lond., B.S., F.R.C.P., F.R.C.S.Eng.,

Claybury Asylum, Woodford Bridge, Essex.

1907. P. W. MacDonald, M.I)., County Asylum, Dorchester.

1908. Chns. A.Mercicr, M.D., F.R.C. P., F.R.C.S.,34, Wimpole Street, London, W.

1909. W. Bevan-Lewis, M Sc., L.R.C.P., late Medical Director, West Riding

Asylum, Wakefield ; Elsinore, Dyke Road Avenue, Brighton.

1910. John Macplierson, M.D., F.R.C.P.Edin., Commissioner in Lunacy, 8,

Darnaway Street, Edinburgh.

1911. Win. It. Dawson, B.A., M.D., F.R.C.P.I., D.P.H., Inspector of Lunatic

Asylums, Dublin Castle, Dublin.

1912. J. Greig Soutar, M.B., Barnwood House, Gloucester.

1913. James Chambers, M.D., M.Ch., The Priory, Roehampton, S.W.
1914-1915. David G. Thomson, M.D., C.M.Edin., County Asylum, Thorpe,

Norfolk.

HONORARY MEMBERS.

1896. Allbutt, Sir T. Clifford, K.C.B., M.D., I).Sc., LL.D., F.R.C.P„ F.R.S.,
ltegius Professor of Physic, Univ. Camb., St. Radegund’s, Cambridge.

1881. Benedikt, Prof. M., Franciskaner Platz 5, Vienna.

1907. Bianchi, Prof. Leonnrdo, Mauicomio Provinciate di Napoli. Musce N. 3,
Naples, Italy. (Corr. Mem., 1896.)

1900. Blumcr, G. Alder, M.I)., L.Il.C.P.Edin., Butler Hospital, Providence,
U.S.A. (Ord. Mem., 1890.)

1900. Bresler, Johannes, M.D., Oberurtzt, Luben in Schlesicn, Germnny.
{Corr. Mem. 1896.)

1881. Brosius, Dr.,

1902. Brush, Edward N., M.D., Sheppard and Enoch Pratt Hospital, Towson,
Maryland, U.S.A.

1887. Chapin, John B., M.I)., Canaudaigna, N.Y., U.S.A.

1909. Collins, Sir William J., D.L., M.D., M.S., B.Sc.Lond., F.R.C.S.Eng.,
1, Albert Terrace, Regent’s Park, N.W.

1912. Considine, Thomas Ivory, F.R.C.S.I., L.R.C.P.I., Inspector of Lunatic
Asylums, Ireland, Office of Lunatic Asylums, Dublin Castle, Dublin.

1902. Cottpland, Sidney, M.D., F.R.C.P.Lond., Commissioner of the Board of
Control, 16, Queen Anne Street, Cavendish Square, London, W.

1876. Crichton-Browne, Sir J., M.D.Edin., LL.D., D.Sc., F.R.S., Lord
Chancellor’s Visitor, Royal Courts of Justice, Strand, W.C.,
and 45, Hans Place, S.W. (Phesiuent, 1878.)

1911. Donkin, Sir Horatio Bryan, M.A., M.D.Oxon., F.R.C.P.Lond. (Medical
Adviser to Prison Commissioners and Director of Convict Prisons),
28, Hyde Park Street, W.

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Honorary and Corresponding Members. v

1879. Eclioverria, M. G.. M.D.

1895. Forrier, Sir David, M.A., M.D., LL.D., F.R.C.P., F.R.S., 34, Cavendish
Square, London.

1872. Fraser, John, M.B., C.M., F.R.C.P.E., Formerly Commissioner in
Lunacy, 54, Great King Street, Edinburgh.

1898. Hine, George T., F.R.I.B.A., 35, Parliament Street, London, S.W.

1881. Hughes, C. II., M.I)., St. Louis, Missouri, United States.

1909. Kraepeliu, l)r. Emil, Professor of Psychiatry, The University, Munich.

1887. Lentz, Dr., Asile d’Alienes, Tourimi, Belgique.

1910. Macplierson, John, M.D., F.R.C.P.Edin., Cominissioner in Lunacy, 8,

D.irnawny Street, Edinburgh. (Pkksident, 1910-11.) ( Ordinary
Member from 1886.)

1898. Mngnan, V., M.D., Asile de Ste. Anne, Paris.

1912. Muudsley, Henry, LL.D.Kdin., (Hon.), M.D.Loud., F.R.C.P.Lond.,
Ileatlihourne, Bushey Heath, Herts. (Pkesil'ENT, 1871.) ( Formerly
Editor, Journal of Mental Science.)

1911. Moeli, Prof. Dr. Karl, Director, Herzbergo Asylum, Berlin.

1897. .Morel, M. Jules, M.D., 56, Boulevard Leopold, Ghent, Belgium.

1889. Needham, Sir Frederick, M.D.St. And., M.R.C.P.Edin., M.lt.C.S.Eng.,
Commissioner of the Board of Control, 19, Campden Hill Square,
Kensington, \V. (Pbesident, 1887.)

1909. Obersteiner, Dr. Heinrich, Professor of Neurology, The University, Vienna.

1881. Peeters, M., M.D., Glieel, Belgium.

Ji/00. Ritti, Ant., 68, Boulevard Exelmans, Paris. (Corr. Mem., 1890.)

1887. Schiile, Heinrich, M.D., Illennu, Baden, Germany.

1911. Semelaigue, Rene, M.D.Paris, Secretaire des Seauces de la Societo
Medico-Psychologique de Paris, 16, Avenue de Madrid, Neuilly,
Seine, France. ( Corresponding Member from 1893 )

1831. Tamburini, A., M.D., Reggio-Emilia, Italy.

1901. Toulouse, Dr. Edouard, Dirccteur du Laborntoire de Psychologie experi¬
mental it l’Eeole des Hautes Etudes Paris et Medecin en chef de
l’Asile do Villejuif, Seine, France.

1910. Trevor, Arthur Hill, B.A.Oxon., of the Inner Temple, Barrister at Law„

Commissioner of the Board of Control, 4, Allemarlc Street, London, W.

CORRESPONDING MEMBERS.

1904. Bierao, Cactano, 48, Rua Formosa, Lisbonne, Portugal.

1911. Boedeker, Prof. Dr. Justus Karl Edmund, Privat Dozent aud Director,
Fichheuhof Asylum, Sclilactcnsee, Berlin.

1897. Buschan, Dr. G., Stettin, Germany.

1904. Caroleti, Wilfrid, Manicomia de Sta. Crur, St. Andrco de Palamar,
Barcelona, Spain.

1896. Cowan, F. M., M.I)., 107, Porponchor Straat, The Hngue, Holland.

1902. Estense,Benedetto Giovanni Selvatico, M.D., 116. Piazza Porta Pia, Rome.

1911. Falkenberg, Dr. Wilhelm, Oberurzt, Irrenaustalt, Herzberge, Berlin.

1907. Ferrari, Giulio Cesare, M.D., Director of the Manicomio Provinciale,
Iinola, Bologna, Italy.

1911. Friedlander, Prof. Dr. Adolf Albrecht, Director of the Holie Mark Klinik,
nr. Frankfort.

1901. Koenig, William Julius, Deputy Superintendent, Dalldorf Asylum, Berlin.

1880. Kornfeld, Dr. Hermann, Fr. Sehlesien, Han’ptpostluyerstr., Breslau.

1889. Kowalowsky, Professor Paul, Kharkoff, Russia.

1895. Lindell, Emil Wilhelm, M.D., Sweden.

1901. Manheimer-Gommes, Dr., 32, Rue de 1’Arcade, Paris.

1909. Moreira, Dr. Julien, M.D.Bahia, Professor and Director of the National
Manicomium of Riode Janeiro ( Editor of the Brazilian Archives oj
Psychiatry, etc.).

1886. Pnrant, M. Victor, M.D., Toulouse.

1909. Pilcz, Dr. Alexander (Professor of Psychiatry in the ’University of
Vienna), Superintendent Landessanatorium fur Nerven und Geistes-
kranke Steinhof, Vienna.

1890. Regis, Dr. E., 51, Rue Hugnerie, Bordeaux.

Google

Original from

PRINCETON UNIVERSITY

MEMBERS OF THE ASSOCIATION.

Alphabetical List of Members of the Association on December 31st, 1915, with
the year in which they joined. The Asterisk means Members who joined
between 1841 and 1855.

1900. Abbott, Henry Kingsmill, B.A., M.D.Dub., D.P.H.Irol., Medical Superin¬

tendent, Hants County Asylum, Farcliatn.

1891. Adair, Thomas Stewart, M.D., C.M.Edin., F'.R.M.S., Medical Superin¬
tendent, Stortbes Hall Asylum, Kirkburton, near Huddersfield.
(Mon. Sec. N. and M. Division since 1908.)

1910. Adam, George Henry, M.R.C.S., L.It C.P.Lond., Manager and Medical
Superintendent, West Mailing Place, Kent.

1913. Adams, John Barfield, L.R.C.P.&S.Edin., M.P.C., 119, I’cdland Road,
Bristol.

1868. Adams, Josiali O., M.D.lhirh., F.R.C.S.Eng., J.P., 117, Cazenovc Road,

Stamford Hill, N.

1886. Agar, S. Hollingsworth, jun., B.A.Cantab., M.R.C.S.Eng, L.S.A., Hurst
House, Henley-in-Arden.

1869. Aldridge, Chas., M.D., C.M.Aber., L.R.C.P.Lond., Bellevue House,

Plympton, Devon.

1905. Alexander, Edward Henry, M.B., C.M.Edin., M.R.C.S., L.R.C.P.Lond.,
M.P.C., Physician Superintendent, Ashbourne Hall Asylum, Dunedin,
New' Zealand.

1899. Alexander, Hugh de Maine, M.D., C.M.Edin., Medical Superintendent,
Aberdeen City District Asylum, Kingseat, Ncwmachar, Aberdeen.
1899. Allmann, Dorah Elizabeth, M.B., B.Ch.lt.U. 1., Assistant Medical Officer,
District Asylum, Armagh.

1908. Anderson, Janies Richard Sunnier, M.B., Ch.B.Glas., Senior Assistant

Medical Officer,.Cumberland and Westmorland Asylum, Garlands,
Carlisle.

1898. Anderson, John Sewell, M.R.C.S., L.R.C.P.Lond., Senior Assistant
Medical Officer, Hull City Asylum, Willerby, near Hull.

1912. Annandale, James Scott, M.B., Ch.B.Edin., Second Assistant Physician,
• District Asylum, Murthly, Perth.

1912. Aplliorp, Frederick William, M.R C.S.Eng., L.R.C.P.Edin., M.P.C.,

Senior Medical Officer, St. George’s Retreat, KnvonswOrth, Burgess
Hill.

1901. fArchdale, Mervyu Alex., M.B., B.S.Durh., (Medical Superintendent, East

Riding Asylum, Beverley, Yorks) i Capt. H.A.M.C., T.F., No. 16,
General Hospital, British Expeditionary Force.

1905. Archdall, Mervyu Thomas, L.lt.C.P.&S.Ediu., L.S.A.Lond., Brynn-y-
Nenudd Hall, Llaufairfechan, N. Wales.

1882. Armstrong-Joncs, Robert, M.D.Lond., B.S., F.R.C.P., F.R.C.S.Eng.,
Medical Superintendent, London County Asylum, Clay bury, Wood¬
ford, Essex. (Oen. Secretary from 1897 to 1906.) (President
1906-7.)

1910. tAuden, G. A., M.A., M.D., B.C., D.P.H.Cantab., M.R.C.P.Lond., F.S.A.

(Medical Superintendent, Educational Offices, Edmund Street,
Birmingham) ; on active service.

Aveline, Henry T. S„ M.D.Durh., M.R.C.S., L.R.C.P.Lond., M.P.C.,
Medical Superintendent, County Asylum, Cotford, near Taunton,
Somerset. (Mon. Sec. for S.1F. Division, 1905-11.)

Babiugton, Alice E. May, M.B., Ch.B.Edin., West Riding Asylum,
Wakefield.

Bailey, William Henry, M.D.Lond.. M.R.C.S.Eng., L.S.A., D.P.H.Loud.,
Featherstone Hall, Southall, Midd.

Baily, Percy J.. M.B., C.M.Edin., Medical Superintendent, London County
Asylum, Hanwell, W.

1909. fB.iin, John, M.A., M.B., B.Ch.Glasg. (Assistant Medical Officer, Mental

Hospital, llowditch, Derby); Lieut. ll.A.M.C.

1913. fBainbridge, Charles Frederick, M.B., Ch.B.Edin., Surg. R.N.R.,

Assistant Medical Officer, Devon County Asylum, Exminster.

1891.

1911.

1903.

1891.

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Digitized by

Members of the Association. vii

1906. Buird, Harvey, M.D., Ch.B.Edin., Periteau, Winchelsen, Sussex.

1878. Baker, II. Morton, M.B., C.M.Edin., 7, Belsixo Square, London, N.W.
1888. Baker, John, M.D., C.M.Aberd., Medical Superintendent, State Asylum,

Broadmoor, Berks.

1901. fBarham, Guy Foster, M.A., M.D., B.C.Cantab., M.U.C.S., L.R.C.P.Loud.,
Senior Assistant Medical Officer, Loudon County Asylum, Long-
Grove, Epsom, and Visiting Surgeon, County of Loudon War Hospital,
Epsom.

1913. fBsrkloy, James Morgan, M.B., Cli.B.Edin. (Senior Medical Officer,
Brueebridge Asylum, Lincolnshire) ; Lieut. R.A.M.C.

1910. Bartlett, George Norton, M.B., B.S.Lond., M.lt.C.S., L.R C.P.Lond.,
Medical Superintendent, City Asylum, Exeter.

1901. fBaskin, J. Longhead, M.D.Brux., L.R.C.P.&S.Edin., L.It.F.P.&S.Glas.,

(Llangarran, Salisbury) ; Capt. R.A.M.C.

1902. Baugh, Leonard I). II., M.B., Cli.B.Edin., The Pleasnuuee, York.

1874. Beach, Fletcher, M.B., F.It.C.P.Lond. .formerly Medical .Superintendent,

Darenth Asylum, Dartjord ; Stre'n, Downs Uoad, Coulsdou,
Surrey. (Secretary Parliamentary Committee, 1896-1906. General
Secretary. 1889-i896. l’uKSlDENr, 1900.)

1892. Beadles,Cecil F., M.lt.C.S., L.Il.C.P.Lond., The Clergy House, Englcfield
Green, Surrey.

1902. Beide-Browue, Thomas Richard, M.R.C.S.Eng., L.R.C.P.Lond., c/o
P.M.O. Southern Province, Nigeria, West Africa.

1913. Bedford, Percy William Page, M.B., Cli.B.Edin., County Asylum, Lan-

caster.

1909. Beeley, Arthur, M.Sc.Leeds, M.D., B.S.Lond., M.lt.C.S., L.R.C.P.Loud.,
D. P.H.Camb. (Assistant Medical Officer, E. Sussex Educational
Committee), Windybank, Kingston Road, Lewes.

1914. fBennett, James Woddersp<>on, M.lt.C.S., L.R.C.P.Loud. (Marsden, llkley,

Y'orks) ; Lieut. R.A.M.C., 10th Butt., Duke of Wellington W.R.lt..
1912. Benson, Henry Porter D’Arcy, M.D., C.M.Edin., M.R.C.P., F.R.C.S.

Edin., Medical Superintendent, Farnham House, Fiuelas, Dublin.
1914. Benson, John Rohiusou, F.R.C.S.Eug., L.R.C.P Loud., Resident Physi¬
cian and Proprietor, Fiddington House, Market L ivington, Wilts.

1899. Beresford, Edwyu II., M.R.C.S., L.R.C.P.Loud., Medical Superintendent,

Tooting Bee Asylum, Tooting, S.W.

1912. Berncastle, Herbert M., M It.C.S.Eng., L.R.C. P.Lond., Assistant Medical,

Officer, Croydon Mental Hospital, Warlinglmm, Surrey.

1879. Bevau-Lewis, William, M.Sc.Leeds, M.R.C.S., L.R.C.P.Loud., Elsinore,

Dyke Ron 1 Avenue, Brighton. (President, 1909-10.)

1891. fBlacliford, James Vincent, M.l)., B.S.Durh., M.lt.C.S., L.R.C.P.Loud.,

M.P.C. (City Asylum, Fishponds, Bristol); Lt.-Col. R.A.M.C.,
Beaufort War Hospital, Bristol.

1913. Black, Robert Sinclair, M.A.Edin., M.l)., C.M.Aberd., D.P.II , M.P.C.,

Medical Supt., Pietermaritzburg Mental Hospital, Natal, South
Africa.

1898. Blair, David, M.A., M.D., C.M.Gln^g., County Asylum, Lancaster.

1897. Blandford, Joseph John Guthrie, B.A., D.P.II.Camb., M.lt.C.S., L.R.C.P.

Loud., Medical Superintendent, County Asylum, Rainhill, Liverpool.
1908. fBlandy, Gurth Swinncrtou, M.D., Cli.B.Edin. (Assistant Medical Officer,
Middlesex County Asylum, Napsbury, Herts) ; Lieut. R.A.M.C.
1904. Bodvel-Roberts, Hugh Frank, M.A.Cantab., M.lt.C.S., L.R.C.P.Loud.,
L.S.A., Middlesex Countv Asylum, Napsbury, near St. Albans, Herts.

1900. Bolton, Joseph Shaw, M.D., B.S., D.Sc., F.R.C.P.Lond., Medical Super¬

intendent, West Riding Asylum, Wakefield.

1892. Bond, Charles Hubert, D.Sc., M.D., C.M.Edin., M.R.C.P.Lond., M.P.C.,

Commissioner of the Board of Control, 66, Victoria Street, S.W.
(Hon. General Secretary, 1906-12.)

1877, Bower, David, M.l)., C.M.Aber., Springfield House, Bedford. (Chairman
Parliamentary Committee, 1907-1910.)

1877. Bowes, John Ireland, M.R.C.S.Eng., L.S.A. (address uucoiumunicated).
1900. Bowles, Alfred, M.lt.C.S., L.lt.C.P.Lond., 10, South Cliff, Eastbourne.

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viii Members of the Association.

1896. Boycott, Arthur N., M.D.Loud., M.R.C.S., L.R.C.P.Lond., Medical
Superintendent, Herts County Asylum, Hill End, St. Albans, Herts.
{lion. Sec. for S.-E. Division, 1900-05.)

1898. Boyle, A. Helen A., M.D.Brux., L.lLC.P.&S.Edin., 9, The Drive, Hove,
Brighton.

1883. Boys, A. H., L.R.C.P.Ediu., M.R.C.S.Eng., L.S.A.Lond., The White
House, St. Albans.

1891. Braine-Hartuell, George M. P., M.R.C.S., L.R.C.P.Lond., Medical
Superintendent, County and City Asylum, Powiek, Worcester.

1911. Brander, John, M.B., C.B.Edin., Assistant Medical Officer, London

County Asylum, Bexley, Kent.

1905. fBrown, Harry Egerton, M.D., Ch.B.Glasg., M.P.C. (Menial Hospital,
Fort Beaufort, Cape Province, S. Africa) Major, S. A. Medical
Corps.

1908. fBrown, Robert Cunyngham, M.D., B.S.Durh. (General Board of Lunacy,
25, Palmerston Place, Edinburgh); Major, R.A.M.C., Administrator,
Spriugburu and Woodside Central Hospital, Glasgow.

1908. Brown, It. Dods, M.D., Ch.B., F.R.C.P., l)ipl. Psych., D.P.H.Edin.,
Physician Superintendent, James Murray’s Royal Asylum, Perth.
1903. Brown, Ralph, M.B., B.S.Loud., M.R.C.S., L.R.C.P.Lond., Bethlem
Royal Hospital, S.E.

1912. fBrown, William, M.D., C.M.Glas., M.P.C., District Medical Officer,

Adviser in Lunacy to Bristol Magistrates (1, Manor Road, Fish¬
ponds, Bristol) ; Capt. R.A.M.C.,1'., 2nd Southern General Hospital,
Southmead, Bristol.

1893. f Bruce, Lewis C., M.D., K.R.C.P.Edin., M.P.C. (Medical Superintendent,
District Asylum, Druid Park, Murthly, N.B.) ; Scottish Horse
Brigade, Mediterranean Expeditionary Force. {Co-Editor of
Journal since 1911; Hon. Sec. for Scottish Division, 1901-1907.)

1913. fBrunton, George Llewellyn, M.B., Ch.B.Edin. (North Riding Asylum,
Clifton, York); temp.Lt., R. A.M.C., 2nd Cavalry Field Ambulance,
British Expeditionary Force, France.

Buchanan, William Murdoch, M.B., Ch.B.Gins., Kirklands Asylum
Bothwell, Lanarkshire.

Bullen, Frederick St. John, M.R.C.S.Eng., L.S.A.Lond., 3, Richmond
Park Road, Clifton, Bristol.

Bullmore, Charles Cecil, J.P., L.R.C.P.&S.Edin., L.R.F.P.AS.Glas.,
Medical Superintendent, Flower House, Catford.

Burke, Joseph D. G., M.B., Cli.B.R.U.I., Assistant Medical Superinten¬
dent, City Asylum, Digby, nr. Exeter.

Buss, Howard Decinms, B.A., B.Sc.France, M.D.Brux.ACupe, M.R.C.S.,
L.R.C.P., L.M.S.S.A.Lond., Assistant Medical Officer, Fort
Beaufort Asylum, Cape Colony.

1910. fCuhir, John P., M.B., B.Ch.R.U.I., 198, Camberwell New Road, Camber¬
well, S.E.; Lieut. R.A.M.C.

1891. Caldecott, Charles, M.B., B.S.Loud., M.R.C.S., L.R.C.P.Lond., Medical
Superintendent, Earlswood Asylum, Redhill, Surrey.

1889. Callcott, James T., M.D., B.S.Durh., M.R.C.S.Eng., Medical Superin¬
tendent, Borough Asylum, Newcastlc-on-Tyne.

1913. fCameron, John Allan Munro, M.B., Ch.B.Gins. (Pathologist, Scalebor

Park Asylum, Burley-in-Wharfednle, Yorks); R.A.M.C., British
Expeditionary Force.

1894. Campbell, Alfred Walter, M.D., C.M.Edin., M.P.C., Macquarie Chambers,
183, Macquarie Street, Sydney, New South Wales.

1909. fCampbell, Donald Graham, M.B., C.M.Edin., “ Auchmillam,” 12, Iteid-
haven Street, Elgin ; on active service.

1914. fCnmpbell, Finlay Stewart, M.D., C.M.Glas. (District Medical Officer,

Glasgow Parish, 19, Wcstercrnigs, Dennistoun, Glasgow) ; “ Lin-
dorcs,” Fort Matilda, Greenock; Lieut. R.A.M.C.

1912.

1892.

1908.

1912.

1911.

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Digitized by

Members of the AssoeiatioJi. ix

1880. Campbell, Patrick E.. M.B., C.M.Edin., Medical Superintendent, Metro¬
politan Asylum, Caterliam, Surrey.

1897. Campbell, Robert Brown, M.D., C.M., F.R.C.P.E., Medical Superin¬
tendent, Stirling District Asylum, Larbert. ( Secretary for Scottish
Division from 1910.)

1914. Carlsson, Carl Better, M B., Cli.B.Edin. (address uncommunicated).

1905. Carre, Henry, L.R.C.P.&S.Irel., Woodilee Asylum, Lenzie, Glasgow.

1891. Carswell, John, L.R.C.P.Edin., L.R.F.P.&S.Glasg., 43, Moray Place,

Edinburgh.

1874. Cassidy, I). M., M.D., C.M.McGill Coll., Montreal, D.Sc. (Public
Health) F.It.C.S.Edin., Medical Superintendent, County Asylum,
Lancaster.

1888. Chambers, James, M.A., M.D.R.U.I., M.P.C., The Priory, Roehnmpton.

( Co-Editor of Journal 1905-1914, Assistant Editor 1900-05.)
(PHE8IDENT, 1913-14.)

1911. ^Chambers, Walter Duncauon, M.A., M.D., Cli.B.Edin., M.P.C. (Crichton
Royal Institution, Dumfries, N.B.) ; Capt. R.A.M.C., Inuiskillings.
1865. Chapman, Thomas Algernon, M.D.Glas., L.R.C.S.Edin., F.Z.S., Betula,
Reigate.

1915. Clieyne, Alfred William Harper, M.B., Ch.B.Aber., Assistant Medical

Officer, Royal Asylum, Aberdeen.

1907. Chislett, Charles G. A., M.B., Ch.B.Glasg., Medical Superintendent,
Stoneyetts, Chryston, Lanark.

1880. Christie, J. W. Stirling, L.R.C.P.&S.Edin., Medical Superintendent,
County Asylum, Statrord.

1878. Clapham, Win. Crochley S., M.D., F.R.C.P.Ed., M.R.C.S.Eng., F.S.S., The
Five Gables, May field, Sussex. (Hon. Sec. N. and M. Division,
1897-1901.)

1907. fClarke, Geoffrey, M.D.Lond. (Senior Assistant Medical Officer, London
County Asylum, Bunstend, Sutton, Surrey); Lieut. R.A.M.C.,
No. 24 General Hospital, British Expeditionary Force.

1910. fClarke, James Kilian P., M.B., B.Ch.R.U.I., D.P.H., High Street,
Oakham; R.A.M.C.

1907. Clarkson, Robert Durwnrd, B.Sc., M.D., C.M.Edin., F.R.C.P.Edin.

(Medical Officer, Scottish National Institute for the Education of
Imbecile Children), The Park, Larbert, Stirling.

1892. Cole, Robert Henry, M.D.Lond , M.It.C.P.Lond., 25, Upper Berkeley

Street, W. ( Secretary/ of Parliamentary Committee since 1912.)
1900. Cole, Sydney John, M.A., M.D., B.Ch.Oxon., Medical Superintendent,
Wilts County Asylum, Devizes.

1906. Collier, Walter Edgar, M.R.C.S., L.R.C.P.Loiul., Assistant Medical

Officer, Kent County Asylum, Maidstone.

1903. f Collins, Michael Abdy, M.D, B.S.Lond., M.R.C.S., L.R.C.P.Lond.

(Medical Superintendent, Ewell Colony, Epsom, Surrey) (Hon.
General Secretary since 1912.); Capt. R.A.M.C., British Expedi¬
tionary Force.

1910. Conlon, Thomas Peter, L.R.C.P.&S.Irel., Resident Medical Superin¬
tendent, District Asylum, Monaghan.

1914. fConolly, Victor Lindley, M.B., B.Ch.Belfast (Assistant Medical Officer,
Colney Hatch Asylum, N.) ; Lieut. JR. A.M.C.

1878. Cooke, Edward Marriott, M.D.Lond., M.R.C.S.Eng., Commissioner in
Lunacy, 69, Onslow Square, S.W.

1910. Coombes, Percival Charles, M.R.C.S., L.R.C.P.Lond., Medical Superin¬
tendent, Surrey Countv Asylum, Nctherne.

1905. Cooper, K. 1)., L.R.C.P.&S.Edin., L.R.F.P.&S.Glas., c/o Leopold & Co.,
Apollo, Bunder, Bombay.

1903. Cormac, Harry Dove, M.B., B.S.Madras, Medical Superintendent,
Cheshire County Asylum, Macclesfield.

1891. Corner, Harry, M.D.Lond.,M.It.C.S., L.R.C.P.Lond., M.P.C., 37, Harley
Street, W.

1905. Cotter, James, L.R.C.P.&S.E., L.R.F.P.&S.Glas., Down District Asylum,
Downpatrick,

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PRINCETON UNIVERSITY

X

Members of the Association.

1897. Cotton, William, M.A., M.D.Edin., D.P.H.Cantab., M.P.C.,231, Gloucester
ltoail, Hishopstou, liristol.

1910. Coupland, William Henry, L.R.C.S.&P.Edin., Senior Assistant Medical

Officer, 1, Sen View, South Road, Lam-aster.

1913. Court, E. Percy, M.R.C.S., L.R.C.P.Lcnd., Sevcrnlls Asylum, Colchester.
1893. Coweu, Thomas Philip, M.l)., B.S. M.R.C.S., L.R.C.1*.Loud., Medical

Superintendent, County Asylum, Rainhill, Lancashire.

1911. Cox, Donald Maxwell, M.R.C.S., L.R.C.P.Loud., The Hall, Headcorn,

Kent.

1881. Cox, L. F., M.R.C.S.Eng., Plus Caermeddyg, Llanbedr, R.S.O., Merioneth.

1893. Craig, Maurice, M.A., M.D., H.C.Cantab., F.R.C.P.Loud., M.P.C., 87,

Harley Street, W. (//on. Secretary of Educational Committee,
1905-8; Chairman of Educational Committee since 1912.)

1897. Cribb, Harry Gifford, M.R.C.S., L.R.C.P.Loud., Medical Superintendent,
Whiter ton Asylum, Ferryhill, Durham.

1911. Criehlow, Charles Adolphus, M.R, Ch.H.Glus. Roxburgh District
Asylum, Melrose.

1914. Crookslmnk, Francis Graham, M.D., M.R.C.P.Loud. (travelling), c/o 25,

Duke Street, Piccadilly, VV.

1904. Cross, Harold Robert, L.S.A.Lond., F.R.G.S., Stortbes Hall Asylum,

Kirkburtnn, near Huddersfield.

1915. Crosthwaite, Frederick Douglas, M.B., Ch.B.Edin., D.P.H.Cantab.,

Assistant Physician, Pretoria Mental Hospital, South Africa.

1914. Cruickshank, J., M.D., Ch.B.GIas., Pathologist, Crichton Roval Hospital,
Dumfries.

1907. Daniel, Alfred Wilson, B.A., M.D., B.C.Cantab., M.R.C.S., L.R.C.P.Loud.,

Senior Assistant Medical Officer, London County Asylum, Han well, VV.
189C. Davidson, Andrew, M.l)., C.M.Aber., M.P.C., Wyoming, Macquarie
Street, S \ dney, N.S.W.

1911. Davie, James, M.B., Ch.B.Edin., 84, Braid Road, Edinburgh.

1914. Davies, Laura Katherine, M.B., Ch.B.Edin., Pathologist and Assistant

Medical Officer, Edinburgh City Asylum, Bangonr, Dechmont,
Linlithgowshire.

1891. fDavis, Arthur N., L.R.C.P.AS.Edin. (Medical Superintendent, County

Asylum, Exmiuster, Devon); Lieut. It.A.M.C., T F.

1894. fDawson, William R.,B.A..M.D.,B.Ch.Dubl., F.R.C.P.I.,D.P.H.,Inspector

of Lunatics in Ireland, Claremont, Burlington Road, Dublin. (Hon.
Sec. to Irish Division, 1902-11 ; Pkesident, 1911-12.) Major
R.A.M.C.

1901. De Steiger, Ad&le, M.l).Lend., Countv Asylum, Brentwood, Essex.

1905. Devine, Henry, M.D., B.S., M.R.C.P.Loud., M.R.C.S.Eng., M.P.C.,

Medical Superintendent, The Asylum, Milton, Portsmouth.

1901. Devon, James, L.R.C.P. & S.Edin., 1, North Park Terrace, Hillhead,
Glasgow.

1903. Dickson, Thomns Graeme, L.R.C.P. & S.Edin., Medical Superintendent,
Wye House Asylum, Buxton, Derbyshire.

1915. Dillon, Frederick, M.B., Ch.B.Edin., Clinical Assistant, West End

Hospital for Nervous Diseases, Assistant Medical Officer, Northum¬
berland House, Green Lanes, Finsbury Park, N.

1909. Dillon, Kathleen, L.R.C.P.&S.I., Assistant Medical Officer, District
Asylum, Mullingar.

1905. fDixon, J. Francis, M.A., M.D., B.Ch.Dubl., M.P.C. (Medical Super¬
intendent, Borough Mental Hospital, Humberstone, Leicester);
Lieut. It.A.M.C., British Expeditionary Force.

1879. Dodds, William J., M.l)., C.M , D.Sc.Ediu., Glencoila, Bcllahouston,
Glasgow.

1908. Donald, Robert, M.l)., Ch.B.GIas., 3, Gilmour Street, Paisley.

1889. Donaldson, William Ireland, B.A., M.D., B.Ch.Dubl., Medical Super¬
intendent, County of London Manor Asylum, Epsom, Surrey.

1892. Donelun, John O’Conor, L.R.C.P.&S.I., M.P.C., St. Dymphna’s, North

Circular Road, Dublin,

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Members of the Association. xi

1890. Douglas, William, M.D.R.U.I., M.R.C.S.Eng., F.R.O.S., lirandfold,

Goudhurst, Kent.

1905. Dove, Augustus Charles, M.D., B.S.Durh., M.R.C.S.Eng., “ Brightside,”
Crouch End Hill, N.

1897. Dove, Emily Louisa, M. 15.Loud., 11, Jenuer House, Hunter Street,
Brunswick Square, W.C.

1903. Dow, William Alex., M.D., B.S.Durh., M.R.C.S., L.R.C.P.Lond., D.P.H.,
II.M. Prison, Lewes.

1910. Downey, Michael Henry, M.B., Ch.B.Mclb., L.R.C.P. A S.Ediii.,

L.R.F.P.AS. Glasg., Assistant Medical Ollicer, Piirkside Asylum,
Adelaide, South Australia.

1881. Drapes, Thomas, M.B.Dubl., L.R.C.S.I., Medical Superintendent, District
Asylum, Enniscorthy, Ireland. (Pbesidhnt-klkct, 1910-11; Co-
Editor of Journal since 1912.)

1907. Dryden, A. Mitchell, M.B., Ch.B.Edin., Burailly House, Lockerbie Road,
Dumfries.

1902. Dudgeon, Herbert Wm., M.D., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,

Medical Superintendent, Khanka Government Asylum, Egypt.
1899. Dudley, Francis, L.R.C.P.AS.I., Senior Assistunt Medical Officer,
County Asylum, Bodmin, Cornwall.

1915. Duff, Thomas, L.R.C.P., L.lt.C.S.Edin., L.R.F.P.AS.Glusg., Collington
Rise, Bcxhill-on-Sea.

1903. Duuston, John Thomas, M.D., B.S.Lond., Medical Superintendent, West

Koppies Asylum, Pretoria, South Africn.

1911. Dykes, Percy Armstrong, M.R.C.S., L.R.C.P.Lond., Senior Assistaut

Medical Officer, Fulbourne Asy lum, Cambridge.

1899. Eades, Albert I., L.R.C.P. A S.I., Medical Superintendent, North Riding
Asylum, Chfton, Yorks.

19015. fEager, Richard, M.D., Ch.B.Aber., M.P.C. (Assistant Medical Officer,
Devon County Asylum, Exminster); Major R.A.M.C.,T.F., 2/1
Wessex Field Ambulance, 55th Division, British Expeditionary Force.
1873. Eager, Wilson, M.R.C.S., L.R.C.P., L.S.A.Lond., St. Aubyn’s,' Wood-
bridge, Suffolk.

1881. Earle, Leslie M., M.D., C.M.Edin., 108, Gloucester Terrace, Hy de Park
W.

1891. Earls, James Henry, M.I)., M.Ch.R.U.I., D.P.H., L.S.A.Lond., M.P.C.,

Barrister-at-Luw, Fenstanton, Christchurch Road, Sticathnm Hill,
S.W.

1903. East, Guy Rowland, M.D., B.S.Durh., D.P.H., Northumberland County
Asylum, Morpeth.

1907. East, Wm. Norwood, M.I).Loud., M.R.C.S., L.R.C.P.Lond., M.P.C., H.M.

Prison, Manchester; also 171, Chcetliain Hill Road, Manchester.
1895. Easterbrook, CharlesC., M.A..M.D., F.R.C.P.Ed., M.P.C., J.P., Physician
Superintendent, Crichton Itovnl Institution, Dumfries.

1914. fEder. M.D., BSc.Loml., M.R.C.S., L.R.C.P.Lond. (Medical Officer,
Deptford School Clinic), 7, Welbeck Street, W.; Lieut. R.A.M.C.
1895. Edgerley, Samuel, M.A., M.D., C.M.Edin., M.P.C., Medical Superinten¬
dent, West Riding Asylum, Mcuston, nr. Leeds.

1897. Edwards, Francis Henry, M.D.Brux., M.R.C.P.Lond., M.R.C.S.Eng.,
Medical Superintendent, Camberwell House, S.E.

1901. Elgee, Samuel Charles, L.K.C.P.AS.l., The Epileptic Colony, Ewell,
Surrey.

1889. Elkins, Frnnk Ashby, M.I)., C.M.Edin., M.P.C., Medical Superintendent,

Metropolitan Asylum, Leavesdcn, Herts.

1912. Ellerton, John Frederick lleisc, M.D.Brux., M.R.C.S.Eng., L.R.C.P.

Edin., Rotlierwood, Leamington Spa.

1890. Ellis, William Gilmore, M.D.Brux., M.R.C.S.Eng., L.S.A.Lond., J.P.,

Principal Civil Medical Officer, Singapore, Straits Settlements.

1908. Ellison, Arthur, M.R.C.S., L.R.C.P.Eug., Deputy Medical Officer, H.M.

Prison, Leeds, 120, Domestic Street, Holbeck, Leeds.

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xii Members of the Association.

1S99. Ellison, F. C., B.A., M.D., B.Ch.Dub., Resident Medical Superintendent,
District Asylum, Castlebar.

1911. Emslie, Isabella Galloway, M.D., Ch.B.Ediu., West House, Royal Asylum,
Morningside, Edinburgh.

1911. Euglisb, Ada, M.B., B.Ch.ll.U.I., Assistant Medical Officer, District
Asylum, Ballinasloe.

1901. Erskine, Win. J. A., M.D., C.M.Edin., Senior Assistant Medical Officer,
City Asylum, Nottingham.

1895. Eurich, Frederick Wilhelm, M.D., C.M.Edin., 8, Mornington Villus,
Maninghnm Lane, Bradford.

1894. Eustace, Henry Marcus, B.A., M.D., B.Ch.Dubl., M.P.C., Medical
Superintendent, Hampstead and Highfield Private Asylum,
Glasneviu, Dublin.

1909. Eustace, William Ncilson, L.R.C.S.&P.Irel., Lisronngh, Glasneviu, co.
Dublin.

1909. Evans, George, M.B.Lond., Senior Assistant Medical Officer, Severalls
Asvlum, Colchester.

1891. Ewan, John Alfred, M.A. St. And., M.D., C.M.Edin., M.P.C., Greyuess,
Sleaford, Lines.

1884. Ewart, C. T., M.D., C.M.Aberd., Senior Assistant Medical Officer,
Claybury Asylum, Woodford Bridge, Essex.

1914. Ewing, Cecil Wilmot, L.R.C.P.I.& L.R.C.S.I., Second Assistant Medical
Officer, Chutliam Asylum, near Canterbury.

1907. Exlcy, John, L.R.C.P.I., M.U.C.S.Eug., Medical Officer, H.M. Prison;
Grove House, New Wortley, Leeds.

1894. Farqnliarson, William F., M.D., C.M.Edin., M.P.C., Medical Superin¬
tendent, Counties Asylum, Garlands, Carlisle.

1907. fFarries, John Stothnrt, L.R.C.P.AS.Edin., L.R.F.P.&S.Glas., Ii.If.B.,

communications to Yrthington, Carlisle.

1903. f Fennell, Charles Henry, M.A.. M.D.Oxon, M.R.C.P.Lond., Reform Club,
Pall Mall, S.W.; Lieut. E.A.M.C.

1908. Fenton, Henry Felin, M.B., Ch.B.Ediu., Assistant Medical Officer,

County and City Asylum, Powick, Worcester.

1907. Ferguson, J. J. Harrower, M.B., Ch.B.Ediu., Senior Assistant Mi dicnl
Officer, Fife and Kinross Asylum, Cupar, Fife.

1897. Fielding, James, M.D., Viet. Univ., Canada, M.It.C.S.Eng., L.R.C.P.
Edin., 18, The Crescent, Norwich.

1906. Fielding, Saville James, M.B., B.S.Durh., Medical Superintendent,
Bethel Hospital, Norwich.

1873. Finch, John E. M., M.A., M.D.Cantab., M.R.C.S.Eng., L.S.A.Lond.,
Holmdale, Stoueygate, Leicester.

1889. Finch, Richard T., B.A., M.B.Cantub., M.R.C.S.Eng., L.S.A.Lond.,
Medical Superintendent, Fisherton House, Salisbury.

18S9. Finlay, David, M.D., C.M.Glasg., Medical Superintendent, County
Asylum, Bridgend, Glamorgan.

1906. Firth, Arthur Harcits, M.A., M.D., B.Ch.Edin., Deputy Medical Super¬
intendent, Barnsley Hall, Bromsgrove, Worcestershire.

1903. Fitzgerald, Alexis, L.R.C.P. & S.T., District Asylum, Waterford.

1894. Fitzgerald, Charles E., M.D., M.Ch.Dubl., F.R.C.S.L, Surgeon-Oculist
to the King in Ireland, President of the Royal College of Physicians
of Ireland, 27, Upper Merriou Street, Dublin.

1888. Fitz-Gerald, Gerald C., B.A., M.D., B.C.Cantnb., M.P.C., Medical Superin¬
tendent, Kent County Asylum, Chartham, nr. Canterbury.

1903. Fitzgerald, James Francis, L R.C.P.&S.Irel., Assistant Medical Officer,

District Asylum, Clonmel, co. Tipperary, Ireland.

1904. Fleming, Wilfrid Louis Kcmi, M.R.C.S., L.R.C.P.Lond., Suffolk House,

Pirbriglit, Surrey.

1891. Fleury, Eleonora Lilian, M.D., B.Ch.ll.U.I., Assistant Medical Officer,
Richmond Asylum, Dublin.

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Members of the Association. xiii

1908. +Flynn, Tlios. Aloysius, L.R.C.P.&S.I., (County Asylum, Tliorpe,

Norwich) ; R.A.M.C.

1902. Forde, Michael J., M.D., B.Ch.R.U.I., Assistant Medical Officer, Port-
rane Asylum, Irelnud.

1911. Forrester, Archibald Thomas William, M.I)., B.S., M.U.C.S., L.R.C.P.

Lond., Senior Assistant Medical Officer, Leicester und Rutland
Counties Asylum, Narborough.

1913. fForward, Ernest Liouel, M.R.C.S., L.R.C.P.Lond. (Assistant Medical
Officer, The Coppice, Nottingham); Lieut. R.A.M.C., 2/2 East
Lancs. Field Ambulance.

1913. Fothcrgill, Claude Francis, B.A., M.B., B.C.Cantab., M.R.C S., L.R.C.P.
Lond., Iratnrfa Hospital, Malta.

1909. fFoulerton, Alexander Grant Russell, F.R.C.S.Eng., L.R.C.P.Lond.,

D.P.H.Cautab. ( County Medical Officer of Health for E. Sussex),
VVealdsidc, Lewes; Capt. R.A.M.C., British Expediiioimry Force.

1912. Fox, Charles J., M.R.C.S., L.R.C.P.Lond., The Moat House, Alnechurch,

Birmingham.

1881. Fraser, Donald, M.D., C.M.Glasg., F.R.F.P.S., 13, Royal Terrace
West, Glasgow.

1901. fFrench, Louis Alexander, M.R.C.S., L.R.C.P.Lond., “ Locksley,” Willing-

don, Eastbourne; Major R.A.M.C.

1902. Fuller, Lnwrence Otway, M.R.C.S.Eng., L.R.C.P.Lond., Medical Super-

intendeut. Three Counties’ Asylum, Hitclnn, Herts.

1914. +Gage, John Muni o, L.R.C.P.&S.I., M.P.C. (Eurlswood, Redhill, Surrey);
R.A.M.C.

1906. Gunc, Edward Palmer Steward, M.D.Durli., M.R.C.S., L.R.C.P.Lond.,
City Asylum, Willeiby, Hull.

1912. Garry, John William, M.B., B.Ch., N.U.I., Assistant Medical Officer,
Ennis District Asylum, Ireland.

1912. Gavin, Lawrence, M.B., Ch.B.Edin,, L.R.C.P.AS.Edin., L.R.F.P.&S.
Glasg., Superintendent, Mullingar District Asylum, Ireland.

1896. Geddes, John W„ M.B., C.M.Ediu., Medical Superintendent, Mental

Hospital, Middlesbrough, Yorks.

1892. Gemmel, James Francis, M.B.Glasg., Medical Superintendent, County
Asylum, Whittingham, Preston.

1914. Gettings,Harold Salter, L.R.C.P. & S.Edin.,L.R.F.P.&S.G., D.P.H.Birm.,
Pathologist, West Riding Asylum, Wakefield.

1899. Gilfillnn, Samuel James, M.A., M.B., C.M.Edin., Medical Superin¬
tendent, London County Asylum, Coluey Hatch.

1912. Gill, Eustace Stanley Hayes, M.B., Ch.B.Liverp., Shaftesbury House,
Formby, Liverpool.

1S89. Gill, Stanley A., B.A.Dubl., M.D.Durli., M.R.C.P.Lond., M.R.C.S.Eng.,
Shaftesbury House, Formby, Liverpool.

1904. fGillespie, Daniel, M.D. B.Ch.R.U.I., Dipl. Psych. (Wadsley Asylum,
near Sheffield); Maj. R.A.M.C., Wharncliffe War Hospital, Middle-
wood Road, Sheffield.

1897. Gilmour, John Rutherford, M.B., C.M., F.R.C.P.Edin., M.P.C., Medical

Superintendent, West Riding Asylum, Scalebor Park, Burley-in-
Wharfedale, Yorks.

1906. Gilmour, Richard Withers, M.B., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,
Homewood House, West Meon, Hants.

1878. Glendinning, James, M.D.Glasg., L.R.C.S.Edin. Hill Crest, Lansdown
Road, Abergavenny.

1898. Goldie-Scot, Thomas G., M.B., C.M.Edin., M.R.C.S., L.R.C.P.Lond.,

Crichton Royal Asylum, Dumfries, N.B.

1897. Good, Thomas Saxty, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬
tendent, County Asylum, Littlcmore, Oxford.

1889. fGoodall, Edwin, M.I)., B.S., F.R.C.P.Lond., M.P.C. (Medical Superin¬
tendent, City Asylum, Cardiff); Lt.-Col. R.A.M.C., The Welsh
Metropolitan War Hospital, Whitchurch, nr. Cardiff.

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xiv Members of the Association.

1899. Gordon, Janies Leslie, M.D., C.M.Abcrd., Medical Superintendent,

Fountain Temporary Asylum, Tooting Grove, Tooting Graveney,

S.W.

1905. Gordon-Munn, John Gordon, M.D.Edin., F.It.S.E., Heighain Hull,
Norwich.

1901. tdostwyck, C. H. G., M.B., Cli.B., F.R.C.P.Edin., M.P.C., Dipl. Psych.,
(Stirling District Asylum, Larbert) ; Lt., R.A.M.C., 31st General
Hospital, Mediterranean Expeditionary Force, c/o G.P.O.; StaHa
Lodge, A\ r.

1912. fGraham, Gilbert Malise, M.B., Ch.B.Edin., R.N., H.M.S. “ Emperor of
India.”

1914. fGraham, Norman Bell, B.A., R.U.I., M.B., B.Cli.Belfast, (Assistant

Medical Officer, District Asylum, Belfast) ; R.A.M.C.

1894. Graham, Samuel, L.K.C.P.Lond, Resident Medical Superintendent,
District Asylum, Antrim.

1887. Graham, William, M.D.R.U.I., L.It.C.S.Edin., Medical Superintendent,
District Lunatic Asylum, Belfast.

1908. Graham, William S., M.B., BCh.R.U.I., Assistant Medical Officer,

Somerset and Bath Asylum, near Taunton.

1915. Graves, T. Olivers, M.B., B.S., B.Sc.Lond., F.R.C.S.Eng., Medical Super¬

intendent, City and County Asylum, Burghill, Hereford.

1916. Gray, Cyril, L.R.C.P.&.S.Edin., Gateshead Borough Asylum, Stannington,

Newcastle-on-Tyne.

1909. Greene, Thomas Adrian, L.R.C.S.&P.Irel., J.P., Medical Superintendent,

District Asylum, Carlow.

1886. Greenlees, T. Duncan, M.D., C.M.Edin., F.It.S.E., Rostrevor, Kirtleton
Avenue, Weymouth.

1912. -f-Greeson, Clarence Edward, M.D., Ch.B.Aberd., Surgeon, R.N., c/o Messrs.
Holt & Co., 3, Whitehall Place, S.W.

1915. Griffith, Alfred Hume, M.D.Edin., D.P.H.Cuinb., Medical Superinten¬
dent, Liugfield Epileptic School Colony, The Homestead, Lingfield,
Surrey.

1915. Grigsby, Hamilton Marie, L.R.C.P.&S.Edin., 79, Victoria Road North,
Southsea.

1901. Grills, Galbraith Hamilton, M.D., B.Ch.R.U.I., Dipl. Psych., Medical
Superintendent, “ Elmwood,” Liverpool Itoad, Chester.

1900. Grove, Ernest George, M.lt.C.S., L.K.C.P.Lond., Bootham Park,

York.

1894. Gwynn, Charles Henry, M.D., C.M.Edin., M.R.C.S.Kng., co-Licensee,
St. Mary’s House, Whitchurch, Salop.

1894. Halsted, Harold Cecil, M.D.Durh., M.R.C.S., L.R.C.P.Lond., Manor
Road, Selsey, Sussex.

1903. fHanhury, Lang ton Fuller, M.R.C.S., L.R.C.P.Lond. (Medical Super¬

intendent, West Ham Borough Asylum, Ilford, Essex); on active
service.

1901. Harding, William, M.D.Edin., M.R.C.P.Lond., Medical Superintendent,
Northampton County Asylum, Berry Wood, Northampton.

1899. Harmcr, W. A., L.S.A., Resident Superintendent and Licensee, Redlands
Private Asylum, Tonbridge, Kent.

1904. fHarper-Smith, George Hastie, B.A.Cantab., M.Il.C.S., L.R.C.P.Lond.,

(Senior Assistant Medical Officer, Brighton County Borough
Asylum, Haywards Heath), May Cottage, Loughton, Essex;
R.A.M.C.

1898. Harris-Liston, L.,M.D.Brux.,M.R.C.S., L.R.C.P.Lond., L.S.A., Middleton
Hall, Middleton St. George, Co. Durham.

1905. Hart, Bernard, M.D.Lond., M.R.C.S.Eng., 29 b, Wimpolc Street, and

Northumberland House, Finsbury Park, N.

1886. fHarvey, Bagenal Crosbie, L.R.C.P.&S.Edin., L.A.H.Dubl., Reaideut
Medical Superintendent, District Asylum, Clonmel, Ireland.

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XV

Members of the Association.

1892. Haslett, William John H., M.R.C.S., L.R.C.P.Lond., M.P.C., Resident
Medical Superintendent, Halliford House, Upper Halliford, Shop-
perton.

1891. Havelock, John G., M.D., C.M.Edin., Little Stodham, Lisa, Hunts.

1890. Hay, J. F. S., M.H., C.M.Aberd., Inspector-General of Asylums for New
Zealand, Government nnildings, Wellington, New Zealand.

1900. Haynes, Horace E.. M.R.C.S.Eng., L.S.A., J.P., Littleton Hall, Brent¬
wood, Essex.

1895. Hearder, Frederic P., M.D., C.M.Edin., Medical Superintendent, York¬
shire Inebriate Reformatory, Whixley, near York.

1911. fHeffernan, Capt. P., I.M.S., B.A., M.B., B.CIi.C.U.l., Locock’s Gardens,

Kilpauh, Madras.

1916. Henderson, David Kennedy, M.D.Edin., Senior Assistant Physician,
Royal Asylum, Gartnavel, Glasgow.

1905. Henderson, George, M.A., M.B., Cli.B.Edin., 25, Commercial Road,

Peckbam, S.E.

1906. Herbert, Thomas, M.R.C.S.,L.R.C.P.Lond., York City Asylum, Fulford,

York.

1877. Hetberington, Charles E., B.A., M.B., M.Ch.Dubl., Medical Superin¬
tendent, District Asylum, Londonderry, Irelaud.

1877. Hewson, R. W., L.R.C.P.&S.Ediu., Medical Superintendent, Coton Hill,
Stafford.

1914. Hewsou, R. W. Dale, L.R.C.P.&S.Edin., L.R.F.P.AS.Glas., Coton Hill
Hospital, Stafford.

1912. Higson, William Davis, M.B., Ch.B.Liverp., D.P.H., Deputy Medical

Officer, H.M. Prison, Brixton; 7, Clovelly Gardens, Upper Tulse
Hill, S.W.

1882. Hill, H. Gardiner, M.R.C.S.Eng., L.S.A., Pentillie, Leopold Road,
Wimbledon Park, S.W.

1914. fHills, Harold William, B.S., M.B., B.Se.Lond., M.R.C.S., L.R.C.P.Lond.,
R.A.M.C.

1907. Hine, T. Guy Macaulay, M.A., M.D., B.C.Cantab., 37, Hertford Street,

Mayfair, W.

1909. Hodgson, Harold West, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Severalls Asylum, Colchester.

1908. Hogg, Archibald, M.B., Ch.B.Glas., 54, High Street, Paisley, N.B.

1900. Hollander, Bernard, M.D.Freib., M.R.C.S., L.R.C.P.Lond, 57, Wimpole

Street, W.

1912. Holyoak, Walter L., M.D., B.S.Lond., 45, Welbeck Street, W.

1903. Hopkins, Charles Leighton, B.A., M.B., B.C.Cantnb., Medical Superin¬

tendent, York City Asylum, Fulford, York.

1913. Hopwood, Joseph Stanley, M.B., B.S., M.R.C.S., M.R.C.P.Lond.,

Sunnvbank House, Cornholrae, Todmorden, Lancs.

1894. Hotehkis, Robert D., M.A.Glasg., M.D., B.S.Durli., M.R.C.S., L.R.C.P.

Lond., M.P.C., Renfrew District Asylum, Dykebar, Paisley N.B.

1912. Hughes, Frank Percival, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., The

Grove, Pinner, Middlesex.

1900. Hughes, Percy T., M.B., C.M.Edin., D.P.H., Medical Superintendent,
Worcestershire County Asylum, Barnseley Hall, Bromsgrove.

1913. Hughes, Robert, M B.Lond., M.R.C.S., L.R.C.P.Lond., M.P.C. ( School

Medical Officer, County Borough of Stoke-on-Trent). Address
uncommunicated.

1904. Hughes, William Stanley, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,

Medical Superintendent, Shropshire County Asylum, Bicton Heath,
Shrewsbury.

1897. Hunter, David, M.A., M.B., B.C.Cantab., L.S.A., Medical Superintendent,
The Coppice, Nottingham. ( Secretary for S.E. Divitiun, 1910-
1913.)

1909. fHunter, Douglas William, M.B., Ch.B.Glasg., Assistant Medical Officer,

10, Halllield Road, Bradford; R.A.M.C.

1912. fHunter, George Yeates Cobb, Colonel, I.M.S., M.R.C.S., L.R.C.P.Lond.,
M.P.C., c/o Messrs. Gritidlay & Co., 54, Parliament Street, S.W.

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Digitized by

xvi Members of the Association.

1904. Hunter, Percy Douglas, M.R.C.S., L.R.C.P.Lond., Three Counties

Asylum, Arlesey, Reds.

1882. Hyslop, James, D.S.O., M.B., C.M.Edin., Medical Superintendent, Natal
Government Asylum, Pietermaritzburg.

1888. Ilyslop, Tlieo. U., M.D., C.M.Edin., M.R.C.P.E., L.R.C.S.E., F.R.S.E.,
M.P.C., 5, Portland Place, London, W.

1915. Ingall, Frank Ernest, F.R.C.S.Eng., L.R.C.P.Lond., D.P.H., Tuc Brook
Villa, Liverpool.

1908. Inglis, J. P. Park., M.B., Ch.B.Edin., Assistant Medical Officer,
Catcrlmm Asylum, Caterham. Surrey.

1906. Irwin, Peter Joseph, L.R.C.P.&S.I., Assistant Medical Officer, District

Asylum, Limerick.

1911. Jackson, David James, B.A., M.D., B.Ch.R.U.T., 62, Thornsbeach

Road, Catford, S.E.

1914. fJames, George William Blomfield, M.B., B.S.Lond., 2, Charnwood
Street, Derby; R.A.M.C.

1908. Jeffrey, Geo. Rutherford, M.D., Ck.B.Glas., F.R.C.P.E., M.P.C.,

Medical Superintendent, Bootham Park, York.

1910. fJohnson, Cecil Webb-, M.B., Ch.B.Vict. (“ Crick lewood,” East Sheen,
S \V.) ; 10th Middlesex Regiment, Fort William, Calcutta, India.
1893. Johnston, Gerald Herbert, L.R.C.P.&S.Edin., L.It.F.P.&S.Glas., Brooke
House, Upper Clapton, N.

1905. Johnston,Thomas Leonard, L.U.C.P.&S.Edin., L.R.F.P&.S.Glas.,Medical

Superintendent, Bracebridge Asylum, Lincoln.

1912. Johnstone, Emma May, L.It.C.P. & S.Editi., L.R.F.P.&S.Glas., M.P.C.,

Dipl. Psych., Holloway Sanatorium, Virginia Water, Surrey.

1878. Johnstone, J. Carlyle, M.D., C.M.Glas., Medical Superintendent, Rox¬

burgh District Asylum, Melrose.

1903. Johnstone, Thomas, M.D., C.M.Edin., M.R.C.P.Lond., Annnndule,
Harrogate.

1880. Jones, D. Johnston, M.D., C.M.Edin. (travelling).

1879. Kay, Walter S., M.D., C.M.Edin., M.R.C.S.Eng. (The Grove, Starbech,

Harrogate) ; Ticehurst House, Ticehurst, Sussex.

1886. fKeny, John, M.D., C.M.Glasg., F.R.C.P.Edin. (Medical Superintendent,
Bangour Village, Uphall, Linlithgowshire); Lt.-Col., R.A.M.C.,
Edinburgh War Hospital, Bangour.

1909. fKcith, William Brooks, M.B., Cli.B.Aberd., M.P.C., Capt., R.A.M.C., T„

81st Field Ambulance, 27th Division.

1908. Kelly, Richard, M.D., B.Ch.Dub., Assistant Medical Officer, Stortlies
Hall Asylum, Kirkburtou, near Huddersfield.

1907. Keene, George Henry, M.I)., The Asylum, Goodmayes, Ilford, Essex.

1898. Kemp, Norali, M.B., C.M.Glas., Hill Rise, The Mount, York.

1899. Kennedy, Hugh T. J., L.R.C.P.&S.I., Assistant Medical Officer, District

Asylum, Enniscorthy, Co. Wexford.

1897. Kerr, Hugh, M.A., M. D.Glasg., Medical Superintendent, Bucks County
Asylum, Stone, Aylesbury, Bucks.

1902. Kerr, Neil Thomson, M.B., C.M.Ed., Medical Superintendent, Lanark

District Asylum, Hartwood, Shotts, N.B.

1893. Kershaw, Herbert Warren, M.R.C.S.Eng., L.R.C.P.Lond., Dinsdale Park,
near Darlington.

1897. f Kidd, Harold Andrew, M.R.C.S.Eng., L.R.C.P.Lond. (Medical Superin¬
tendent, West Sussex Asylum, Chichester) ; Lt.-Col. R.A.M.C.,
Graylingwcll War Hospital, Chichester.

1903. King, Frank Raymond, B.A.Cantab., M.R.C.S.Eng,, L.R.C.P.Lond.,

Medical Superintendent, Peckham House, Peckham, S.E.

1902. King-Turner, A. C., M.B., C.M.Ediu., The Retreat, Fairford, Gloucester¬
shire.

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Members of the Association. xvii

1899. fKirwan, James St. L., 11.A., M.B., B.Ch.R.U.I. (Medical Superintendent,
District Asylum, Ballinasloe, Ireland); Mont Clare Hotel, Clare
Street, Dublin R.A.M.C.

1915. Kirwau, Richard R., M.B., B.Ch. R.U.I., Assistant Medical Officer,
West Riding Asylum, Meuston, Leeds.

1915. Kitson, Frederick Hubert, M.B., Cb.B.Leeds, Assistant Medical Officer,
West Riding Asylum, Wakefield.

1903. Kougli, Edward Fitzndam, B.A., M.B., B.Ch.Dubl., Senior Assistant
Medical Officer, County Asylum, Gloucester.

1898. Labey, Julius, M.R.C.S., L.R.C.P., L.S.A.Lond., Medical Superin¬
tendent, Public Asylum, Jersey.

1902. Langdon-Down, Percival L., M.A., M.B., D C.Cantab., Dixlund, Hampton
Wick, Middlesex.

1896. Langdon-Down, Regiuald L., M.A., M.B., B.C.Cantab., M.R.C.P.Loud.,
Normansfleld, Hampton Wick.

1914. fLadell, R. G. Macdonald, M.B., Ch.B.Vict. (Shafton House, Holbeck,

Leeds) ; Lieut. R.A M.C., 1 /5th Norfolk Regiment.

1909. fLaurie, James, M.B., Ch.M.Glasg. ( Medical Officer, Smithston Asylum),
(Red House, Ardgowan Street, Greenock); Capt. R.A.M.C., T.F.,
3rd Scottish Hospital.

1902. Laval, Evariste, M.B.,C.M.Edin., The Guildhall, Westminster, S.W.

1898. Lavers, Norman, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Medical Super-

iutcudeut, Bailbrook House, Bath.

1892. Lawless, George Robert, F.R.C.S.I., L.R.C.P.I., Medicnl Superintendent,
District Asylum, Armagh.

1870. Lawrence, Alexander, M.A., M.D., C.M.Aberd., 26, Hough Green,
Chester.

1833. Layton, Henry A., M.R.C.S.Eng., L.R.C.P.Ediu., 26, Kimbolton Road,
Bedford.

1915. Leech, H. Brougham, M.D., B.Ch.Dublin, Assistant Medical Officer,

County Asylum, Hatton, Warwick.

1909. Leech, John Frederick Wolseley, M.D., B.Ch.Dubl., County Asylum,
Devizes, Wilts.

1899. Leeper, Richard 1L, F.It.C.S.I., L.R.C.P.I., M.P.C., Medical Super¬

intendent, St. Patrick’s Hospital, Dublin. {Hon. Sec. to the Irish
Division from 1911.)

1883. Legge, Richard J., M.D., II.U.I., L.R.C.S.Ediu., “ Comeragh,” Leck-
hamptou Road, Cheltenham.

1906. fLeggett, William, B.A., M.D., B.Ch. Dubl. (Assistant Medical Officer,
Royal Asylum, Sunnyside, Montrose) ; R.A.M.C.

1914. Lindsay, David George, L.R.C.P.&S.Kdin., Senior Assistant Medical
Officer, Dundee District Asylum, West Green, Dundee.

1903. Littlejohn, Edward Salteine, M.R.C.S., L.R.C.P.Lond., Senior Assistant

Medical Officer, London County Asylum, Cane Hill, Surrey.

1916. Lloyd, Brindley Richard, M.B., B.S.Loud., D.P.H.Lond., Assistant

Medical Officer, Peck ham House, S.E.

1903. Logan, Thomas Stratford, L.ll.C.P.&S.Edin., L.R.F.P.&S.Glas., D.P.H.,

Stone Asylum, Aylesbury, Bucks.

1898. fLoril, John R., M.B.,C.M.Edin. (Medical Superintendent, Horton Asylum,

Epsom); Lieut.-Colonel R.A.M. C., County of Loudon War Hospital,
Epsom, Surrey. {Co-Editor of Journal since 1911; Assistant
Editor of Journal, 1900-11.)

1906. Lowry, James Arthur, M.D., B.Ch., R.U.I., R.A.M.C., Medical Super¬
intendent, Surrey County Asylum, Brookwood.

1904. Lyall, C. H. Gibson, L.R.C.P.&S.Kdin., Leicester Borough Asylum,

Leicester.

1872. Lyle, Thomas, M.D., C.M.Glasg., 34, Jesmond Road, Newcastle-on-Tyne.

1906. fMacartbur, John, M.R.C.S., L.R.C.P.Lond. (Assistant Medical Officer,
Colney Hatch Asylum, London, N.); R.A.M.C., Mediterranean
Expeditionary Force.

1899. Macartney, William H. C., L.R.C.P.&S.I., Riverhead House, Sevenoaks.

b

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xviii Members of the Association .

1880 MucBryan, Henry C., L.R.C.P. & S. Edin., Kiugsdowu House, Box, Wilts.

1900. McClintock, John, L.R.C. P.&S.Edin., Resident Medical Superintendent,

Grove House, All Stretton, Church Stretton, Salop.

1901. MacDonald, James H., M.B., Ch.B., F.R.F.P.&S.Glusg., Govan District

Asylum, Hawkhead, Paisley, N.B.

1881. MacDonald, P. W., M.D., C.M.Aherd. (late Medical Superintendent,
now retired'), address for time being, Dorset County Asylum, Herri-
sou, Dorchester. ( First Hon. Sec. S.W. Division 1894 to 1905.)
(Pkesidknt, 1907-8.)

1911. fMucDonald, Ranald, M.D., Ch.B.Edin. (London County Asylum, Bexley,
Kent); Lieut. R.A.M.C.

1905. MacDonald, William Fraser, M.B., Ch.B.Edin., M.P.C., 96, Polworth
Terrace, Edinburgh.

1905. McDougall, Alan, M.D., Ch.B.Viet., M.R.C.S., L.R.C.P.Lond., Medical

Director, The David Lewis Colony, Suudlc Bridge, near Alderley
Edge, Cheshire.

1911. McDougall, William, M.A., M.B., B.C.Cantab., M.Sc.Vict., Foxcombe
Hill, Oxford.

1906. fMcDowall, Colin Francis Frederick, M.D., B.S.Durh. (Ticehurst House,

Ticehurst) ; Capt. R. A. 31. C., Military Hospital, MHghull, Liverpool.
1870. McDowall, Thomas W., M.D.Edin., L.It.C.S.E., Medical Su]>eriutendent,
Northumberland County Asylum, Morpeth. (Pkesident, 1897-8.)
1893. Macevoy, Henry John, B.A.(Douai), M.D., B.Sc.Loud., M.R.C.S.Eng.,

L. R.C.P.Lond., M.P.C., 19, Mowbray Road, Brondesbury, London,
N.W.

1895. Maefurlane, Neil M., M.D., C.M.Aber., Medical Superintendent, Govern¬
ment Hospital, Thlotse Heights, Leribe, Basutoland, South Africa.

1902. McGregor, John, M.B., Ch.B.Edin., Senior Assistant Medical Officer,

County Asylum, Bridgend, Glam.

1914. fMa'dtny, Magnus Ross, M.D., Ch.B.Edin., Capt. R.A.M.C..T.F., British

Expeditionary Force, France.

1899. McKclvey, Alexander Niel, L.R.C.P.AS.I., Costloy House, Epsom,
Auckland, New Ze tland.

1915. McKenna, Edward Joseph, M.B., B.Clt., R.U.I., Assistant Medical

Officer, Carlow District Asylum.

1911. Mackenzie, John Cossorat, M.B., Ch.B.Edin., County Mental Hospital,
Burutwood, near Lichfield.

1891. Mackenzie, Henry J., M.B., C.M.Edin., M.P.C.,Assistant Medical Officer,
The Retreat, York.

1903. Mackenzie, Theodore Charles, M.D., Ch.B., F.R.C.P.Edin., M.P.C.,

Medical Superintendent, District Asylum, Inverness.

1914. Macleod, J. R., L.R.C.P.AS.Ediu., L.'ll.F.P.&S.Glasg., 7, Mayfield
Gardens, Edinburgh.

1904. Macnainara, Eric Danvers, M.A.Camb., M.D., B.C., F.R.C.P.Loud., 87,

Harley Street, W.

1898. Mucnnughton, George W. F., M.D., F.ll.C.S.Edin., M.R.C.P.Loud.,

M. P.C., 33, Lower Bclgrave Street, Eaton Square, London, S.W.
1914. Macneill, Celia Mary Colquhoun. M.B., Ch.B.Edin. (Pathologist, North-

field, Prestonpaus); Leith War Hospital, Seafield, Leith.

1910. fMacPhail, Hector Duncan, M.A., M.D., Ch.B.Edin. (Assistant Medical
Officer, City Asylum, Goiforth, Newcastle - on - Tyne) ; Major
R.A.M.C., Northumberland War Hospital, Newcastle.

1882. Macphail, S. Rutherford, M.D., C.M.Edin., Derby Borough Asylum,
Rowditch, Derby.

1896. Mucpherson, Charles, M.D.Glas., L.R.C.P.&S., D.P.H.Edin., Deputy
Commissioner in Lunacy, 25, Palmerston Place, Edinburgh.

1901. McRae, G. Douglas, M.D., C.M.Edin., F.R.C.P.Ed., Medical Super¬

intendent, District Asylum, Ayr, N.B.

1902. fMacrae, Kenneth Duncan Cameron, M.B., Ch.B.Edin. (Bangour Village,

Dechmont, Linlithgowshire); Lieut. R.A.M.C.

1894. McWilliam, Alexander, M.A., M.B., C.M.Aber., Waterval, Odiham,
Winchfield, Hants.

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Members of the Association.

1915. Manifold, Robert Fenton, M.B., D.Ch.Dub., Senior Assistant Medical
Officer, Deubigh Asylum, North Wales.

1908. fMapother, Edward, M.D., B.S.Lond., F.R.C.S.Eng. (Assistant Medical
Officer, London County Asylum, Long-Grove, Epsom); Lieut.
R.A.M.C.

1903. Marinin, John, B.A., M.B., B.Ch.Dubl., Senior Assistant Medical

Officer, Second County Asylum, Gloucester.

1896. Marr, Hamilton C., M.D., C.M., F.R.F.P.&S.Glasg., M.P.C., Commis¬
sioner in Lunacy (46, Murrayfield Avenue, Edinburgh) ; (Hon.,
Sec. Scottish Division, 1907-1910.); R.A.M.C.

1913. fMarshall, Robert, M.B., Ch.B.Glas. (Assistant Medical Officer, Gartloch

Mental Hospital, Gartcosli, N.B.) ; Lieut. R.A.M.C., 19th General
Hospital, British Expeditionary Force.

1905. Marshall, Robert Macuab, M.D., Ch.B.Glasg., M.P.C., 2, Clifton Place,
Glasgow.

1908. Martin, Henry Cooke, M.B., Ch.B.Edin., Assistant Medical Officer,
Newport Borough Asylum, Caerleon.

1896. fMartin, James Charles, L.R.C.S. & P.I., J.P., Assistant Medical Officer,
District Asylum, Letterkcnny, Donegal; Lieut. R.A.M.C.

1908. Martin, James Ernest, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
Assistant Medical Officer, London County Asylum, Long-Grove,
Epsom.

1907. Martin, Mary Edith, L.R.C.P.&S.Ediu., L.R.F.P.&S.Glas., L.S.A.Lond.,
M.P.C.Lond., Bail brook House, Bath.

1914. fMartin, Samuel Edgar, M.B., B.Ch.Edin., Barrister-at-Lnw (Senior

Assistant Medical Officer, St. Andrew’s Hospital, Northampton) ;
Lieut. R.A.M.C., 40th Casualty Clearing Station, Biitish Medi¬
terranean Expeditionary Force.

1911. Martin, William Lewis, M.A., B.Sc., M.B., C.M.Edin., D.P.H., M.P.C.,
Dipl. Psych. (Certifying Physician in Lunacy, Edinburgh Parish
Council), 56, Bruntsfield Place, Edinburgh.

1911. fMathieson, James Moir, M.B., Ch.B.Aber, (Assistant Medical Officer,

Wadsley Asylum, Sheffield) ; Major R.A.M.C., The Wharncliffe
War Hospital, Sheffield.

1904. fMay, George Francis, M.D., C.M.McGill, L.S.A. (Winterton Asylum,

Ferry hill, Durham); Lieut. R.A.M.C.

1912. Melville, William Spence, M.B., Ch.B.Glas., Woodilec Mental Hospital,

Lenzie, Glasgow.

1890. Menzies, William F., M.D.,B.Sc.Edin., M.R.C.P.Load., Medical Superin¬

tendent, Stafford County Asylum, Chcddleton, near Leek.

1891. Mercier, Charles A., M.D.Lond., F.R.C.P., F.R.C.S.Eng., late Lecturer

on Insanity, Westminster Hospital; Moorcroft, Parkstone, Dorset.
(Secretary Educational Committee, 1893-1905. Chairman do. f rom
1905-12.) (President, 1908-9.)

1877. Merson, John, M.A., M.D., C.M.Abcr., Medical Superintendent, Borough
Asylum, Hull.

1871. Mickle, William Julius, M.D., F.R.C.P.Lond., 69, Linden Gardens, Bays-
water, W. (President, 1896-7.)

1893. Middlemans, James, M.A., M.D., C.M., B.Sc.Edin., F.R.C.P., M.P.C.,
Medical Superintendent, Borough Asylum, Ryhope, Sunderland.
1910. Middlemiss, James Ernest, M.R.C.S.Eng., L.R.C.P.Lond., Reginald
House, 131, North Street, Leeds.

1883. fMiles, George E., M.R.C.S., L.R.C.P.Lond., Lieut.-Col., R.A.M.C.,
D Block, Royal Victoria Hospital, Netley, Hants.

1887. Miller, Alfred, AI.B., B.Ch.Dubl., Medical Superintendent, Hatton
Asylum, Warwick. (Registrar since 1902.)

1912. fMiller, Richard, M.B., B.Ch.Dubl., Medical Superintendent, Naval Hos¬

pital, Great Yarmouth ; Fleet-Surgeon R.N.

1893. fMills, John, M.B., B.Cli., Dipl. Ment. Dis., R.U.I. (District Asyium,
Ballinasloe, Ireland) ; Lieut. R.A.M.C., Mediterranean Expedi¬
tionary Force.

1913. Milner, Ernest Arthur, M.B., C.M.Edin., Assistant Medical Officer, Royal

Albert Institution, Lancaster.

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XX

Members of the Association.

1911. Moll, Jail. Marius, Doc. in Arts and Med, Utrecht Univ., L.M.S.S.A'
Loud., M.P.C., P.O. Box 87 a, Pretoria, South Africa.

1913. Molyneux, Benjamin Arthur, B.A., M.D., B.Ch.Dubl., St. Helens

House, St. Helens, Hastings.

1910. fMonnington, Richard CnUlicolt, M.D., Ch.B., D.P.H.Edin. (Darenth

Industrial Colony, Hartford, Rent) ; Hopefield, Lowick, Ulverston ;
Lieut. R.A.M.C.

1915. Monrad-Krohn, G. H., M.B., B.S., M.R.C.P.Lond., M.R.C.S.Eng.,
Assistant Medical Officer, Bexley Asylum, Kent.

1914. fMontgomery, Edwin, E.R.C.S.I., L.It.C.P.I. Dipl. Psych. Manch.,

(Prestwich Asylum, Lancs.) ; Lieut. R.A.M.C., 77th Field
Ambulance, British Expeditionary Force.

1911. fMoon, George Bassett, L.R.C.P. & S.Edin., L.R.F.P.&S.GIasg. (Assis¬

tant Medical Officer, Surrey County Asylum, Netlierue); Surgeon,

R.N.

1885. Moore, Edw. E., M.D., B.Ch.Dubl., M.P.C., Medical Superintendent,
District Asylum, Letterkenny, Ireland.

1899. Moore, Win. I)., M.I)., M.Ch.R.U.I., Medical Superintendent, Holloway
Sanatorium, Virginia Water, Surrey.

1914. +Morres, Frederick, M.R.C.S.Eng., L.R.C.P.Lond. (Assistant Medicnl
Officer, Cane Hill Asylum, Coulsdon, Surrey); R.A.M.C., Lord
Warden Hotel, Dover.

1S96. Morton, W. B., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Wonford House, Exeter.

1896. Mould, Gilbert E., M.R.C.S., L.R.C.P.Lond., The Grange, Rotherham,

Yorks.

1897. Mould, Philip G., M.R.C.S.Eng., L.R.C.P.Lond., Overdale, Whitefield,

Manchester.

1911. fMoyes, John Murray, M.B., Ch.B.Edin., D.P.M.Leeds, Crichton Royal
Institution, Dumfries; R.A.M.C.

1907. Mules, Bertha Mary, M.D., B.S.Durh., Court Hall, Kenton, S. Devon.
1911. Muncaster, Anna Lilian, M.B., B.Ch.Edin. (County Asylum, Chester);

home address, 8, Craylockhail Terrace, Edinburgh; at present
serving with Serbian Red Cross Society.

1893. Murdoch, James William Aitken, M.B., C.M.Glasg., Medical Superin¬
tendent, Berks County Asylum, Wallingford.

1909. Myers, Charles Samuel, M.A., D.So., M.D., B.C.Cautab., M.R.C.S.,

L.R.C.P.Lond., Great Shelford, Cambridgeshire.

1903. fNavarra, Norman, M.R.C.S., L.R.C.P.Lond. (City of London Mcntnl
Hospital, near Dartford, Kent) ; R.A.M.C.

1910. Neill, Alexander W., M.D., Ch.B.Edin., Warneford Mental Hospitnl,

Oxford.

1903. Nelis, William F.,M.D.I)urh.,L.R.C.P.Kdin.,L.R.F.P.&S.GIasg.,Medical
Superintendent, Newport Borough Asylum, Cuerleon, Mon.

1873. Newington, H. Hayes, F.lt.C.P.Edin., M.R.C.S.Eng., The Gables, Tice-
hurst, Sussex. (Chairman Parliamentary Committee, 1896-1904.)
(President, 1889.) (Treasurer since 1894.)

1909. Nicoll, James, M.D., C.M.Edin., D.P. H.Lond., Woodside, King’s Langley,
R.S.O., Herts.

1869. Nicolson, David, C.B., M.D., C.M.Aber., M.R.C.P.Edin., F.S.A.Scot.,
201, Royal Courts of Justice, Strand, W.C. (President, 1895-6.)
1888. Nolan, Michael J., L.R.C.P.AS.I., M.P.C., Medical Superintendent,
District Asylum, Downpatrick.

1913. Nolan, James Noel Green, M B., B.Cli., A.B.Dub., The Hospital, Hel-
lingly Asylum, Sussex.

1909. tNorman, Hubert James, M.B., Ch.B., D.P.H.Edin. (Assistant Medicnl
Officer, Camberwell House Asylum, S.E.) ; Nnpsbury War Hos¬
pital, St. Albans.

1885. Oakshott, James A., M.D., M.Ch.R.U.I., Medical Superintendent,

District Asy linn, Waterford, Ireland.

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1903. O’Dohertv, Patrick, B.A., M.13., B.Ch.R.U.I., District Asylum,

Omagh.

1911. O’Flynu, Dominick Thomas, L.R.C.P. Sl S.I., Assistant Medical Officer,
London County Asylum, Hanwell, Middlesex.

1901. Ogilvy, David, U.A., M.D., ILCh.Dub., Medical Superintendent, London

County Asylum, Long Grove, Epsom, Surrey.

1911. Oliver, Norman H., M.R.C.S., L.U.C.P.Lond., Latchmere, Ham Common,
Surrey.

1892. O’Marn, Francis, L.R.C.P.AS.I., District Asylmn, Ennis, Ireland.

1868. Orange, William, C.B., M.D.Heidelb., F.It.C.P.Lond., M.R.C.S.Eng.,
11, Marina Court, Bexhill-on-Sen. (Pkesidknt, 1883.)

1902. Orr, David, M.D., C.M.Edin., M.l’.C., Pathologist, County Asylum,

Prestwicli, Lancs.

1910. Orr, James H. C., M.D., Ch.B.Edin., Rosslynlce Asylum, Midlothian.
1899. Osburne, Cecil A. P., F.ll.C.S., L.lt.C.P.Edin., The Grove, Old Catton,
Norwich.

1914. Osburne, Johu C., M.B., B.Ch.Dubl., Assistant Medical Officer, Lindville,
Cork.

1890. Oswald, Landel R., M.B., C.M.Glasg., M.P.C., Physician Superin¬
tendent, Royal Asylum, Gartuaval, Glasgow.

1905. fPaine, Frederick, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Clay bury Asylum,
Woodford Bridge, Essex ; R.A.M.C.

1898. Parker, William Arnot, M.B., C.M.Glasg., M.P.C., Medical Super¬
intendent, Gartloeh Asylum, Gnrtcosli, N. B.

1898. Pasmore, Edwin Stephen, M.D., M.R.C.P.Lond., Cbelslmm Houee,

Chelsham, Surrey.

1916. Patch, Charles James Lodge, L.R.C.P.AS.Edin., Assistant Medical
Officer, Renfrew District Asylum, Dykebar, Paisley; Lieut.
R.A.M.C.

1899. Patrick, John, M.B., Cli.B., R.U.I., Medical Superintendent, Tyrone

Asylum, Omagh, Ireland.

1892. Patterson, Arthur Edward, M.D., C.M.Aber., M.P.C., Senior Assistant

Medical Officer, City of London Asylum, Dartford.

1907. Peachell, George Ernest, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,

M.P.C., Medical Superintendent, Dorset County Asylum, Herrison,
Dorchester.

1910. fPearn, Oscar Phillips Napier, M.R.C.S., L.R.C.P., L.S.A.Lond., (Assis¬

tant Medical Officer, London County Asylum, Horton, Epsom) ;
Capt. R.A.M.C.

1915. Pennant, Dyfrig Huws, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, 21, Bovinton Street, Roath Park, Cardiff; (on active
service).

1913. Penny, Robert Augustus Greenwood, M.R.C.S., L.R.C.P.Lond., Devon
County Asylum, Exminster.

1893. Perceval, Frank, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,

County Asvlum, Prestwicli, Manchester, Lancashire.

1911. Perdrau, Jean "Rene, M.B., B.S., M.R.C.S., L.R.C.P.Lond., Senior

Assistant Medical Officer and Pathologist, Dorset County Asylum,
Dorchester.

1911. fPetrie, Alfred Alexander Webster, M.D., B.S.Lond., Cli.B., F.R.C.S.

Edin. (Assistant Medical Officer, Epileptic Co'.ouy, Epsom); Lt.
R.A.M.C.

1878. Philipps, Sutherland Rees, M.D., C.M.Q.U.I., F.R.G.S., The Beacon,
Exminster.

1875. Philipson, Sir George Hare, M.A., M.D.Cantab., D.C.L., LL.D., F.R.C.I’.
Loud., 7, Eldon Square, Newcastle-ou-Tvne.

1908. Philips, John George Porter, M.D., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,

M.P.C., Resident Physician and Superintendent, Bethlem Royal
Hospital, Lambeth, S.E. ( Secretary of Educational Committee
since 1912.)

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xxii Humberts of the Association.

1910. fPhillips, John Robert Parry, M.R.C.S., L.R.C.P. Bond. (Assistant Medical
Officer, City Asylum, Bristol); Maj. R.A.M.C., Beaufort War Hos¬
pital, Bristol.

Phillips, Nathaniel Richard, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Assis¬
tant Medical Officer, County Asylum, Abergavenny, Monmouthshire.
Phillips, Norman Routh, M.D.Brux., M.II.C.S., L.R.C.P.Lond., 67,
Billing Road, Northampton.

Pierce, Bedford, M.D., F.R.C.P.Lond., Medical Superintendent, The
Retreat, York. {Hon. Secretary N. and M. Division 1900-8.)
Pietersen, J. 1'. G., M.R.C.S., L.R.C.P.Lond., Ashwood House, Kingswin-
ford, near Dudley, Stafford.

Planck, Charles, M.A.Camb., M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent, Brighton County and Borough Asylum, Haywards Heath.

1912. fPlummer, Edgar Curnow, M.R.C.S., L.R.C.P.Lond. (Medical Superin¬
tendent, Laverstock House, Salisbury); Capt. R.A.M.C., British
Expeditionary Force.

Pope, George Stevens, L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., Medical
Superintendent, Somerset and Bath Asylum, “ Westfield,” near
Wells, Somerset.

Potts, William A., M.A.Camb., M.D.Ediu.&Birm., M.R.C.S., L.R.C.P.
Lond., Medical Officer to the Birmingham Committee for the Care
of the Feeble-minded, 118, Hagley Road, Birmingham.

Powell, Evan, M.R.C.S.Eng., L.S.A., Medical Superintendent, City
Lunatic Asylum, Nottingham.

Powell, James Fsrquharson, M.R.C.S., L.R.C.P., D.P.H.Lond., M.P.C.,
Assistant Medical Officer, The Asylum, Caterham, Surrey.

Prentice, Reginald Wickham, L.M.S.S.A.Loud., Beauworth Manor,
Alresford, Hants.

Pugh, Robert, M.D., Ch.B.Edin., Medical Superintendent, Brecon nnd
Radnor Asylum, Talgarth, S. Wales.

1904. fRace, John Percy, M.R.C.S., L.R.C.P., L.S.A.Loud., Journals nnd
notices to Winterton As\ lum, Ferryhill, Durlinm (Wheatley Hill,
Doncaster); R.AM.C.

1913. Rae, Harry Janies, M.A., M.B., Ch.B.Aber., Viewmont, Anderson Drive,

Aberdeen, N.B.

1899. Raiusford, F. E„ M.D., B.A.Dubl., L.R.C.P.I., L.R.C.P.&S.E., Resident
Physician, Stewart Institute. Palmerston, co. Dublin.

1894. fRambaut, Daniel F., M.A., M.D., B.Ch.Dub. (St. Andrews, Northampton);

Lieut. R.A.M.C., 40th Casualty Clearing Station, British Medi¬
terranean Expeditionary Force.

1910. fRankine, Surg. Roger Aiken, R.N., M.B., B.S., M.R.C.S.,L.R.C.P.Lond.,

M.P.C.

1889. fRaw, Nathan, M.D., B.S.Durh., L.S.Sc., F.R.C.S.Edin., M.R.C.P.Lond.,
M.P.C. (66, Rodney Street, Liverpool) ; Lt.-Col. R.A.M.C., Liverpool
Merchants’ Hospital, A.P.O.S. 11, British Expeditionary Force,
France.

1893. Rawes, William, M.D.Durh., F.R.C.S.Eug., Medical Superintendent, St.

Luke’s Hospital, Old Street, London, E.C.

1870. Rayner, Henry, M.D.Abcrd., M.R.C.P.Edin., Upper Terrace House,
Hampstead, N.W. (President, 1884.) {General Secretary,
1887-89.) {Co-Editor of Journal 1895-1911.)

1913. fRead, Charles Stanford, M.B.Lond., M.R.C.S., L.R.C.P.Lond. (Assistant
Medical Officer, Fisherton House, Salisbury) ; Royul Victoria
Hospital, Netley.

1903. Read, George F., L. R.C.S.&P.Edin., Hospital for the Insane, New
Norfolk, Tasmania.

181)9. Rediugton, John, F.R.C.S.&L.R.C.P.I., Portrane Asylum, Donabate,
Co. Dublin.

1911. Reeve, Ernest Frederick, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,

Senior Assistant Medical Officer, County Asylum, Rainhill, Lancs.
1911. fReid, Daniel McKinley, M.D., Ch.B.Glasg. (Royal Asylum, Gartnaval,
Glasgow); Lt., R.A.M.C., No. 25 General Hospital.

1889.

1913.

1876.

1910.

1908.

1901.

1900.

1905.

1891.

1888.

1896.

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Members of the Association. xxiii

1910. fReid, William, M.A.St. And., M.B., Ch.B.Edin. (Senior Assistant Medical

Officer, Burntwood Asylum, Lichfield) ; Lieut. R.A.M.C.

1887. Reid, William, M.D., C.M.Aberd., Physician Superintendent, Royal
Asylum, Aberdeen.

1886. Revington, George T., M.A., M.D., B.Ch.Dubl., M.P.C., Medical Superin¬

tendent, Central Criminal Asylum, Dundrnm, Ireland.

1899. Rice, David, M.D.Brux., M.R.C.S., L.R.C.P.Lond., D.P.H., Medical
Superintendent, City Asylum, Hillesdon, Norwich.

1897. Richard, William J., M.A., M.B., Ch.M.Glasg., Medical Officer, Govan
Parochial Asylum, Merrvflats, Govan.

1899. Richards, John, M.B., C.M.Edin., F.R.C.S.E., Medical Superintendent,

Joint Counties Asylum, Carmarthen.

1911. Robarts, Henry Howard, M.D., Ch.B.Edin., D.P.H.Glasg., Ennerdalc,

Haddington, Scotland.

1914. fRoberts, Ernest Theophilus, M.D., C.M.Edin., D.P.H.Camb., M.P.C.

(129, Bath Street, Glasgow)} Hawkstone, Cambuslang, Glasgow;
Lt .R.A.M.C.

1903. fRoberts, Norclifl'e, M.D., B.S.Durh., (Senior Assistant Medical Officer,
Horton Asylum, Epsom, Surrey); Major R.A.M.C., County of
London War Hospital, Epsom.

1887. Robertson, Geo. M., M.D., C.M., F.R.C.P.Edin., M.P.C., Physician-Super¬

intendent, Royal Asylum, Morningside, Edinburgh.

1908. Robertson, George Dunlop, L.R.C.S.&P.Edin., Dipl. Psych., Assistant
Medical Officer, District Asylum, Hartwood, Lanark.

1895. Robertson, William Ford, M.D., C.M.Edin., 60, Northumberland Street,
Edinburgh.

1900. Robinson, Harry A., M.D., Ch.B.Vict., 56, West Derby Street, Liverpool.

1911. fltobson, Capt. Hubert Alan Hir<t, I.M.S., M.R.C.S., L.R.C.P.Lond.,

c/o Messrs. Griudlay, Groome, Bombay, India.

1914. fRodger, Murdoch Mann, M.D., Ch.B.Glas., The Rowans, Bothwell,

Scotland; Lieut. R.A.M.C.

1908. fRodgers, Frederick Millar, M.D., Ch.B.Vict., D.P.II., Senior Medical
Officer, County Asylum, Winwick, Lancs.; R.A.M.C.

1908. Rolleston, Charles Frank, B.A., M.B., Ch.B.Dnb., Assistant Medical
Officer, County of London, Manor Asylum, Epsom.

1895. Rolleston, Lancelot W., M.B., B.S.Durh., Medical Superintendent, Mid¬
dlesex County Asylum, Napsbury, near St. Albnns.

1888. Ross, Chisholm, M.D.Syd., M.B., C.M.Edin., 151, Macquarie Street,

Sydney, New South Wales.

1913. Ross, Derind Maxwell,M.B.,Ch.B.Edin.,Morningside Asylum, Edinburgh.
1910. Ross, Donald, M.B , Ch.B.Edin., Argyll and Bute Asylum, Lochgilphead.

1905. Ross, Sheila Margaret, M.D., Ch.B.Edin., Assistant Medical Officer of

Health, 42, Carill Drive, Fullowfield, Manchester.

1899. Rotherham, Arthur, M.A., M.B., B.C.Cantab., Commissioner under
Ment. Defec. Act, Board of Control, 66, Victoria Street, West¬
minster, S.W.

1906. Rowan, Marriott Logan, B.A., M.D.R.U.I., Medical Superintendent,

Derby County Asylum. Mickleover.

1883. Rowland, E. D., M.B., C.M.Edin., The Public Hospital, George Town,
Demerara, British Guiana.

1902. fRows, Richard Gundry, M.D.Lond., M.R.C.S., L.R.C.P.Lond. (Patho¬
logist, County Asylum, Lancaster), Major R.A.M.C., British Red
Cross Military Hospital, Maghull, Liverpool.

1877. Russell, Arthur P., M.B., C.M., M.R.C.P.Edin., The Lawn, Lincoln.

1912. +Russell, John Ivison, M.B., Ch.B.Glasg. (Jeanfield, 18, Woodend Drive,

Jordan Hill, Glasgow; Lt. R.A.M.C.

1915. Russell, William, M.B., Ch.B.Edin., Dip.Fhyc.h.Edin., D.T.M.Edin.,

Assistant Physician, Pretoria Mental Hospital, S. Africa.

1912. fRutherford, Cecil, M.B., B.Ch.Dubl. (Assistant Medical Officer, Holloway
Sanatorium, Virginia Water, Surrey); R.A.M.C., No. 16 Standard
Hospital, Mediterranean Expeditionary Force.

1907. Rutherford, Henry Richard Charles, F.R.C.S.I., L.R.C.P.I., D.P.II., St.

Patrick’s Hospital, James’s St., Dublin.

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xxiv Members of the Association.

1890. Rutherford, James Mair, M.B., C.M.,F.R.C.l\Ediu., M.P.C., Brislington
House, Bristol.

1913. fRyan, Ernest Noel, B.A., M.D., B.Ch.Dub., R.A.M.C., 6tli London
Field Ambulance (T.).

1902. Sail, Ernest Frederick, M.R.C.S., L.R.C.P.Lond., Medical Superinten¬
dent. Borough Asylum, Canterbury.

1908. Samuels, William Frederick, L.M.&L.S.Dub!., Medical Superintendent,

Central Asylum, Tangong, Rambutan, Perak, Federated Malay
States.

1894. Sankey, Edward H. O., M.A., M.B., B.C.Cantab., Resident Medical
Licensee, Boreatton Park Licensed House, Baschurch, Salop.

* Sankey, R. II. Heurtley, M.R.C.S.Eng., 3, Marston Ferry Road,
Oxford.

1873. Savage, Sir Geo. H., M.D., F.R.C. P.Lond., 26, Devonshire Place, W.

( Late Editor of Journal.) (Phesidknt, 1886.)

1906. fScanlan, John J.,L.R.C.P.&S.Edin., L.U.F.P.&S.Glasg.,D.P.H. (1 Castle
Court, Cornliill, E.C.) ; Capt. R.A M.C., 5th London Field
Ambulance, 47th (London) Division, British Expeditionary Force.
1896. Scott, James, M.B., C.M.Edin.. 98, Baron’s Court Road, West Kensing¬
ton. W.

1915. Scott, James McAlpine, M.D., Ch.B.Glasg., Junior Assistant Medical
Officer, Stirling I)i>trict As\lum, Larbcrt.

1889. Scowcroft, Walter, M.R.C.S., L.R.C.P.I., Medical Superintendent, Royal
Lunatic Hospital. Chcadle, near Manchester.

1911. Scroope, Qeoffrei, M.B., B.Ch.Dub., Assistant Medical Officer, Ceutral

Asylum, Dundrum.

1860. Seccombe, George S., M.R.C.S., L.R.C.P.Lond., c/o Messrs. H. S. King
and Co., 65, Cornliill, E.C.

1912. Sergeant, John Noel, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, Newlauds House, Tooting Bee Common, S.W.
(Secretary Soulh-Eatlern Division from 1913.)

1882. Seward, William J., M.B.Lond., M.R.C.S.Eng., 15, Chandos Avenue,
Oaklcigh Park, N.

1913. tShnnd. George Ernest, M.D., Ch.B. Aberdeen ; (Senior Assistant Medical

Officer,City Mental Hospital, Winson Green, Birmingham); Journals
to Capt, li.A.M. C„ No. 6 Clearing Hospital, British Expeditionary
Force.

1901. fSliaw, B. Henry, M.B., B.Ch.R.U.I. (Assistant Medical Officer, County
Asylum, Stafford) ; R.A.M.C.

1909. fShuw, William Samuel J., M.B., B.Ch.R.U.I., Major Superin¬

tendent, North Veravola, Poona, India.

1905. Shaw, Charles John, M.D., Ch.B., F.R.C.P.E., Medical Superintendent,
Royal Asylum, Montrose.

1915. fSliaw, Hugh Kirkland, M.B„ Ch.B.Edin. (Assistant Medical Officer,
Stirling District Asylum, Larbert) ; Surgeon R.N.

1904. Shaw, Patrick, L.R.C.P.&S.Ediu., Senior Medical Officer, Hospital for
the Insane, Kew, Victoria, Australia.

1909. Shepherd, George Ferguson, F.R.C.S., L.R.C.P.Irel., D.P.H., 9, Ogle
Terrace, South Shields.

1900. Sliera, John E. P., M.D.Brux., L.R.C.P.&S.Irel., Somerset County Asylum,
Wells, Somerset.

1912. Sheridan, Gerald Brinsley, M.B., B.Ch.R.U.I., Assistant Medical
Officer, Portrane Asylum, Donabate, Co. Dublin.

1914. Sherlock, Edward Burball, M.D., B.Sc., D.l’.H.Lond., Medical Superin¬

tendent, Darenth Industrial Colony, Dartford.

1914. fShield, Hubert, M.B., B.S.Durli. (Assistant Medical Officer, Gateshead
Borough Asylum, Stannington, Newcastle-on-Tync); Cnyt.,R.A.M.C.

( T .), 1st Nottingham Fiold Ambulance, British Expeditionary Force,
France.

1877. Shuttleworth, George E., B.A.Lond., M.D.Heidelb., M.R.C.S. and L.S.A.
Lond., 8, Lancaster Place, Hampstead, N.W.

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Members of the Association. xxv

1901. fSimpson, Alexander, M.A., M.l)., C.M.Aber. (Medical Superintendent,
County Asylum, Win wick, Newton-lc-Willows, Lancashire); Lt.-Col.,
R.A.M.C., Lord Derby War Hospital, Warrington.

1905. Simpson, Edward Swan, M.D., Cli.B.Edin., East Hiding Asylum,
Beverley, Yorks.

1888. Sinclair, Eric, M.l)., C.M.Olasg., Inspector-General of Insane, Richmond
Terrace, Domain, Sydney, N.S.W.

1891. Skeen, James Humphry, M.B., Ch.M.Aber., M.P.C., Medical Super¬
intendent, Fife and Kinross District Asylum, Cupar, N.B.

1900. Skiuner, Ernest W., M.D., C.M.Edin., J.P., Mountsfield, Rye, Sussex.
1914. Slaney, Chas. Newnliam, M.R.C.S., L.R.C.P.Lond.,The Elms, Parkhurst,

l.W.

1901. Slater, George N. O., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Assistant

Medical Officer, Essex County Asylum, Brentwood.

1897. Smalley, Sir Herbert, M.D.Durh., M.R.C.S., L.R.C.P.Lond., Prison Com¬
mission. Home Office, Whitehall, S.W.

1914. Smith, Charles Kilrnnn, M.B., Ch.B.Aberd., Assistant Medical Officer,
Borough Asylum, Portsmouth.

1910. fSmith, Gayton Warwick, M.D.Lond., B.S.Durli., I).P. 11.Can tab.,

M.lt.C.S., L.R.C.P.Lond. (Assistant Medical Officer, Middlesex
County Asylum, Tooting, S.W.); Capt. R.A.M.C., Springfield War
Hospital, Tooting, S.W.

1905. Smith, GeorgeWilliam, M.B., Cli.B.Edin., Brislington House, near Bristo..
1907. Smith, Henry Watson, M.D., Ch.B.Aberd., Medical Superintendent,

Lebuuon Hospital for the Insane, Asfurujeh, near Beyrout, Syria.
1S99. Smith, John G., M.D., C.M.Edin., Herts County Asylum, Hill End, St.
Albans, Herts.

1885. Smith, R. Percy, M.D., B.S., F.R.C.P.Lond., M.P.C., 36. Queen
Anno Street, Cavendish Square, W. ( General Secretary, 1896-7.
Chairman Educational Committee, 1899-1903.) (Puebidbbt,
1904-5.)

1913. Smith, Thomas Cyril, M.B., B.Ch.Edin., County Asylum, Gloucester.

1911. Smith, Thomas Waddclow, F.R.C.S., L.R.C.P.Lond., M.P.C., Assistant

Medical Officer, Wonford House, Exeter.

1884. Smith, W. Beattie, F.R.C.S.Edin., L.R.C.P.Edin., 4, Collins Street,

Melbourne, Victoria.

1914. Smith, Walter II., B.A., M.D., B.Ch.Dub., Senior Assistant Medical

Officer, County Asylum, Shrewsbury.

1903. Smith, William Maule A., M.D., Cli.B.Edin., M.R.C.P.Edin., M.P.C.,
98, Dagger Lane, West Bromwich.

1901. Smyth, ltobt. B., M.A., M.B., Ch.B.Dubl., Medical Superintendent,
County Asylum, Gloucester.

1899. Smyth, Walter S., M.B., B.Ch.R.U.I., Assistant Medical Officer, County
Asylum, Antrim.

1913. Somerville, Henry, B.Se., M.R.C.S., L.R.C.P.Lond., F.C.S., Harrold,
Sharnbrook, Bedfordshire.

1885. Soutar, James Greig, M.B., C.M.Edin., M.P.C., Medical Superintendent,

Barn wood House, Gloucester. (Phesident, 1912-13.)

1906. Spark, Percy Charles, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,

London County Asylum, Baustead, Surrey.

1875. Spence, J. Beveridge, M.D., M.C.Q.U.I., Medical Superintendent, Burnt-
wood Asylum, near Lichfield. ( First Registrar, 1892-1899;
Chairman Parliamentary Committee, 1910-12.) (Phbsidbnt,
1899-1900.)

1913. Spensley, Frank Oswold, M.R.C.S., L.R.C.P.Lond., Senior Medical
Officer, Darenth Asylum, Hartford, Kent.

1891. Stansfield, T. E. K., M.B., C.M.Edin., Medical Superintendent, London
County Asylum, Bexley, Kent.

1901. Starkey, William, M.B., B.Ch.R.U.I., Assistant Medical Officer, Lanca¬
shire County Asylum, Prcstwich, near Manchester.

1907. fSteele, Patrick, M.D., Ch.B., M. If.C.P.Edin. (Assistant Medical Officer,

Bangour Village, Dechmont, Linlithgowshire); St. Colmer, Inver¬
ness; Lt. R.A.M.C.

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xxvi Members of the Association.

1898. Steen, Robert H., M.D.Lond., M.R.C.P.Lond., Medical Superintendent,

City of London Asylum, Stone, Hartford. (Hon. Sec. S.E. Division,
1905-10; Acting lion. Qen. Sec., 1915.)

1914. Stephens, Harold Freize, M.R.C.S.bond., L.R.C.P.Eng., The Royal
Earlswood Institution, Redhill, Surrey.

1914. fStevenson, George Henderson, M.B., Ch.B.Ediu., D.P.H.Lond. (Joyce

Green Hospital, Hartford, Kent) ; R.A.M.C.

1912. fStevenson, William Edward, M.B., B.S.Durh.; Lieut. 19th Battalion

Royal Welsh Fusiliers, Winncell Down Camp, Winchester.

1909. fSteward, Sidney John, M.H., H.S.O., B.C.Cantab., M.R.C.S., L.R.C.P.

Loud. (Assistant Medical Officer, Langton Lodge, Farncombe,
Surrey); Capt., R.A.M.C., T.R.

1915. Stewart, A. H. L., M.R.C.S., 72, Wirapole Street, W.

1868. Stewart, James, B.A.Belf., F.R.C.P.Ed., L.R.C.S.I., Killydonnell, 28,
Glebe Road, Barnes, S.W.

1913. fStewart, Ronald, M.B., Ch.B.Glasg. (Gartlock Asylum, Gartcosli,

Glasgow) ; Capt. R.A.M.C., 30ch Field Ambulance, 10th Division,
Mediterranean Expeditionary Force.

1887. Stewart, Rothsay C., M.R.C.S.Eng., L.S.A.Lond., Medical Superinten¬
dent, County Asylum, Narborough, near Leicester.

1914. fStewart, Roy M., M.B., Ch.B.Ediu. (Assistant Medical Officer, County

Asylum, Prestwich) ; Lieut. R.A.M.C., Moss-side, Maghull, Liver¬
pool.

1905. Stilwell, Henry Francis, L.R.C.P.&S.E., Hayes Park, Hayes, Middlesex.

1899. Stilwell, Reginald J., M.R.C.S., L.R.C.P.Lond., Moorcroft House, Hil¬

lingdon, Middlesex.

1897. Stoddart, William Henry Butter, M.H., B.S., F.R.C.P.Lond., M.R.C.S.

Eng., M.P.C'., Harcourt House, Cavendish Square, W. (Hon. Sec.
Educational Committee, 1908-1912.)

1909. fStokes, Frederick Ernest, M.B., Ch.B.Glasg., H.P.H.Cantab. (Assistant
Medical Officer, Borough Asylum, Portsmouth); Major, R.A.M.C.
(T.), 2/3 Wessex Field Ambuluuce.

Strathearn, John, M.H., Ch.B.Glasg., F.R.C.S.E., 23, Magdalen Yard
Road, Dundee.

Stratton, Percy Haughton, M.R.C.S., L.R.C.P.Lond., 10, Hanover
Square, W.

Street, C. T., M.R.C.S., L.R.C.P.Lond,, Haydock Lodge, Ashton,
Newton-le-Willows, Lancashire.

Stuart, Fiederick J., M.R.C.S., L.R.C.P.Lond., Senior Assistant Medical
Officer, Northampton County Asylum, Beirywood.

Sturrock, James Prain, M.A.St.And., M.H., C.M.Edin., 25, Palmerston
Place, Edinburgh.

Suffern, Alex. C., M.D., M.Ch.R.U.I., Medical Superintendent, Rubcry
Hill Asylum, near Broiusgrove, Worcestershire.

Sullivan, William C., M.H., B.Ch.R.U.I., Hampton Criminal Lunatic
Asylum, Retford, Notts.

1910. tSutherland, Joseph Roderick, M.B., Ch.B.Glasg., M.R.C.S., L.R.C.P.
Loud., H.P.H., County Sanatorium, Stonehouse, Lanarkshire.

Swift, Eric W. I)., M.B.Lond., Medical Superintendent, Government
Asylum, Bloemfontein.

Tattersnll, John, M.D.Lond., M.R.C.S., M.R.C.P.Lond., Assistant
Medical Officer, London County Asylum, Hanwell, W.

Taylor, Arthur Loudoun, ll.Sc., M.B., Cli.B., M.R.C.P.Edin., 30,
Hartington Place, Edinburgh.

Taylor, Frederic ltyott Percival, M.D., B.S.Lond., M.R.C.S., L.R.C.P.

Loud., Medical Superintendent, East Sussex Asylum, Hcllingly.
Thomas, Joseph I)., B.A., M.B., B.C.Cantab., Nortliwoods House, Winter¬
bourne, Bristol.

1911. fThomas, William Rees, M I)., B.S.Lond., M.R.C.S., M.R.C.P.Lond.,

M.P.C. (Mosside, Maghull, near Liverpool); Capt. R.A.M.C. British
Red Cross War Hospital, Maghull, near Liverpool.

1908.

1908.

1910.

1897.

1908.

1905.

1903.

1885.
1909.
1900.

1886.
1894.

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Mevibers of the Ansociation. xxvii

1880. fThomsou, David G., M.D., C.M.Edin. (Medical Superintendent, County

Asylum, Thorpe, Norfolk); Lieut.-Col. B.A.M.C., Norfolk War
Hospital, Thorpe, Norwich. (President, 1914-15.)

1903. Thomson, Herbert Campbell, M.D., F.lt.C.P.Lond., Assist. Physician
Middlesex Hospital, 34, Queen Anne Street, W.

1903. fTidbury, Robert,M.D., M.Ch. R.U.I. (Heathlands, Foxliall Road, Ipswich);
Lieut. B.A.M.C.

1901. Tighe, John V. G. B., M.B., B.Ch.R.U.I., Medical Superintendent,
Gateshead Mental Hospital, Stanuington, Northumberland.

1914. fTiadall, C. J. t M.B., Ch.B. (Crichton Royal Institution, Dumfries);

B.A.M.C.

1903. Tophnm, J. Arthur, B.A.Cantab., M.R.C.S., L.R.C.P.Lond., Comity

Asylum, Cbartham, Kent.

1896. Townsend, Arthur A. I)., M.D., B.Ch.Birm., M.R.C.S., L.R.C.P.Lond.,
Assistant Medical Officer, Hospital for Insane, Barnwood House,
Gloucester.

1904. Treadwell, Oliver Pereira Naylor, M.R.C.S.Eug., L.S.A.Lond., Fairfield,

51, Martin’s Avenue, Epsom, Surrey.

1903. fTredgold, Alfred F., M.R.C.S., L.R.C.P.Lond. (6, Dapdune Crescent,

Guildford, Surrey); Major, B.A.M.C., Mediterranean Expeditionary
Force.

1908. Tuach-MacKenzie, William, M.D., Cli.B.Aberd., Medical Superintendent,

Royal and District Asylums, Dundee.

1881. Tuke, Charles Molesworth, M.R.C.S.Eug., Chiswick House, Chiswick.

1888. Tuke, John Batty, M.D., C.M., F.K.C.P.Edin., Resident Physician,

Saughton Hall, Edinburgh; Linden Lodge, Loanhead, Midlothian.

1915. Tulluch, William John, M.D.St. Andrews, Director Western Asylums

Research Institute, 10, Claython Road, Glasgow.

1885. Tuke, T. Seymour, M.A., M.B., B.Ch.Oxon., M.R.C.S.Eng., Chiswick
House, Chiswick, W.

1877. Turnbull, Adam Robert, M.B., C.M.Edin., Corsewell, Colinton, Mid¬
lothian. {Hon. Secretary for Scottish Division, 1894-1901.)
(President-Elect, 1909-10.)

1906. Turnbull, Peter Mortimer, M.B., B.Ch.Aberd., Tooting Bee Asylum,
Tooting, S.W.

1909. Turnbull, Robert Cyril, M.D.Lond., M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, Essex County Asylum, Colchester.

1889. Turner, Alfred, M.D., C.M.Edin., Plympton House, Plympton, S. Devon.
1906. Turner, Frank Douglas, M.B.Lond., M.R.C.S., L.R.C.P.Lond., Medical

Officer, Royal Eastern Counties Institution, Colchester.

1890. Turner, John, M.B., C.M.Aberd., Medical Superintendent, Essex County

Asylum, Brentwood.

1904. Vincent, George A., M.B., B.Ch.Edin.,Assistant Medical Superintendent,

St. Ann’s Asylum, Port of Spain, Trinidad, B.W.I.

1894. fViuceut, William James N., M.B., ll.S.Durh., M.R.C.S., L.R.C.P.Lond.

(Medical Superintendent, Wadsley Asylum, near Sheffield); Lt.-Col.
B.A.M.C., Wharncliffe War Hospital, Sheffield.

1914. Vining, Charles Wilfred, M.D., B.S.Lond., M.R.C.P.Lond., D.P.H.,
M.P.C., Assistant Physician, Leeds General Infirmary, 40, Park
Square, Leeds.

1913. fWalford, Harold R. S., M.R.C.S., L.R.C.P.Lond. (Assistant Medical

Officer, Kent County Asylum, Banning Heath, Maidstone); Lieut.
B.A.M.C.

1914. Walker, Robert Clive, M.B., Ch.B.Edin., West Riding Asylum, Menston,

near Leeds.

1908. Wallace, John Andrew Leslie, M.D., Ch.B.Edin., M.P.C., The Hospital,
Gladesville, Sydney, N.S.W.

1912. Wallace, Vivian, L.ll.C.P. & S.I., Assistant Medical Officer, Mullingar
District Asylum, Mullingar.

Digitized by Google

Original from

PRINCETON UNIVERSITY

Digitized by

xxviii Members of the Association.

1889. Warnock, John, M.D., C.M., B.Sc.Edin., Medical Superintendent,
Abbasiyeh Asylum, nr. Cairo, Egypt.

1910. Waters, John Patrick F., B.A., M.B., Ch.B., R.U.I., Assistant Medical

Officer, County Asylum, Melton, Suffolk.

1895. Waterston, Jane Elizabeth, M.D.Brux., L.R.C.P.T.,L.lt.C.S.Edin., M.P.C.,
85, Parliament Street, Box 78, Cape Town, South Africa.

1902. Watgon, Frederick, M.B., C.M.Edin., Elm Lodge, Clay Hill, Enfield.
1891 Watson, George A., M.1L, C.M.Edin., M.P.C., Lyons House, ltainhill,

Liverpool.

1908. Watson,H. Ferguson, M.D., Ch.B.Gins., L.R.C.P.AS. E.,L.R.F.P.&S.Gins.,
Northcote, Edinburgh Road, Perth.

1885. Watgon, William Riddell, L.R.C.S. A P.Edin., 3, Tufncll Home, Anson
Road, Tufnell Park, N.

1911. Webber, Leonard Mortis, M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, Netherne, Merstbam, Surrey.

1911. fWhite, Edward Barton C„ M.R.C.S., L.R.C.P.Lond. (Senior Assistant

Medical Officer, Cardiff City Mental Hospital, Whitchurch) ; Major,
ll.A.M.C., Welsh Metropolitan War Hospital, Whitchurch.

1884. White, Ernest William, M.B.Lond., M.R.C.P.Lond. (Betlcy House, nr.

Shrewsbury). (Hon. Sec. South-Eastern Division, 1897-1900.)
(Chairman Parliamentary Committee, 1904-7.) (President
1903-4.)

1905. fWhittington, Richard, M.A., M.D.Oxon., M.R.C.S., L.R.C.P.Lond.,
(Downford, Montpelier Road, Brighton); Major, ll.A.M.C.,T.F.,
2nd East General Hospital, Biighton.

1889. Whitwell, James Richard, M.B., C.M.Edin., Medical Superintendent,
Suffolk County Asylum, Melton Woodbridge.

1903. Wigan, Charles Arthur, M.D.Durh., M.R.C.S.Eng., L.S.A.Lond., Deep-

dene, Portisbead, Somerset.

1883. Wiglesworth, Joseph, M.I)., F.R.C'.P.Lond., Springfield House, Wins-
combe, Somerset. (President, 1902-3.)

1913. tWilkins, William Douglas, M.B., Ch.B.Vict., M.R.C.S., L.R.C.P.

Lond. (County Mental Hospital, Cheddleton, Leek, Staff.);
ll.A.M.C.

1900. fWilkinson, H. B., M.R.C.S., L.R.C.P.Lond. (Assistant Medical Officer
Plymouth Borough Asylum, Bluckndon, lvybridgc, South Devon) ;
Lieut. ll.A.M.C.

1887. Will, John Kennedy, M.A., M.D., C.M.Aberd., M.P.C., Bethnal House,
Cambridge Road, N.E.

1914. Williams, Charles, L.R.C.P.AS.Edin., L.S.A.Lond., Assistant Medical

Officer, The Warneford, Oxford.

1907. fWilliains, Charles E. C., M.A., M.D., B.Ch.Dubl.; Capt. ll.A.M.C .,
No. 12 General Hospital, British Expeditionary Force, France.

1905. Williams, David John, M.R.C.S., L.R.C.P.Lond., Medical Superintendent.
The Asylum, Kingston, Jamaica.

1915. f Williams, Gwilym, Ambrose, L.R.C.P.Lond., M.R.C.S.Eng. (Pathologist

and Assistant Medical Officer, East Sussex County Asylum,
llellingly) ; ll.A.M.C., 27th General Hospital, Mediterranean
Expeditionary Force.

1912. Wilson, Samuel Alexander Kinneir, M.A., M.D., B.Sc.Edin., M.R.C.P.

Lond., Registrar, National Hospital, Queen’s Square, 14, Harley
Street, W.

1897. Winder, W. H„ M.R.C.S., L.R.C.P.Lond., D.P.H.Cantab., Deputy
Medical Officer, H.M. Convict Prison, Avlesbury.

1875. Winslow, Henry Forbes, M.D.Lond., M.R.C.P.Lond., M.R.C.S.Iing.,
164, Marine Parade, Brighton.

1899. Wolseley-Lewis, Herbert, M.D.Brux., F.R.C.S.Eng., L.R.C.P.Lond.,
Medical Superintendent, Kent County Asylum, Harming Heath,
Maidstouo. (Secretary Parliamentary Committee, 1907-12. Chair¬
man since 1912.)

1809. Wood, T. Outterson, M.D.Durh., M.R.C.P.Lond., F.R.C.P., F.R.C.S.
Edin., 7, Abbey Crescent, Torquay. (President, 1905-6.)

Google

Original from

PRINCETON UNIVERSITY

XXIX

Members of the Association.

1912. Woods, Janies Cowan, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Loud.,
10, Palace Green, Kensington, W.

1885. fWoods, J. F., M.D.Durli., M.R.C.S.Eng. (7, Harley Street, Cavendish
Square, W.) ; Cnpt. R.A.M.C.

1912. Wootton, John Charles, M.R.C.S.Eng., L.R.C.P.Loud., Haydock Lodge,
Newton-le-Willows, Lancs.

1900. fWorth, Reginald, M.B., B.S.Durh., M.R.C.S., L.R.C.P.Loud. (Medical
Superintendent, Middlesex Asylum, Tooting, S. W.); Maj. R.A.M.C.

1862. Yellowlees, David, LL.D.Glas., M.D.Edin., F.R.F.P.&S.Glasg., 6, Albert
Gate, Dowan Hill, Glasgow. (President, 1890.)

1914. fYellowlees, Henry, M.B., Ch.B.Glas., 6, Albert Gate, Dowan Hill,
Glasgow; Lt., R.A.M.C., 26th British General Hospital, British
Expeditionary Force.

1910. Younger, Edward George, M.D.Brux., M.R.C.P., M.R.C.S., L.S.A.Lond.,
D.P.H., Physician to the Finsbury Dispensary, 2, Mecklenburgh
Square, W.C.

Ordinary Members . 644

Honorary Members . 34

Corresponding Members . 18

Total. 696

+ Totnl number serving with H.M. Forces ... 133

Members are particularly requested to send changes of address, etc., to The
Acting Honorary General Secretary, 11, Chandos Street, Cavendish
Square, London, W., and in duplicate to the Printers of the Journal,
Messrs. Adlard Sf Son and West Newman, 23, Bartholomew Close,
London, E.C.

OBITUARY.

Members.

1862. Clouston, Sir Thomas S., M.D., LL.D.Edin., F.R.C.P., F.R.S.E.

1902. Douglas, Archibald R., L.R.C.P.&S.Edin., L.lt.F.P.S.Glns., M.P.C.

1874. Eager, Reginald, M.D.Lond., M.R.C.S.Eng., L.S.A.Lond.

1906. Ewens, George Francis William, Major I.M.S.

1908. Faulks, Edgar, M.lt.C.S., L.R.C.P.Loud.; Lieut. R.A.M.C. (Killed in

action .)

1861. Fox, Charles H., M.D.St. And., F.R.C.P.E., M.R.C.S.Eng.

1910. Gilfillan, William, M.B., Ch.B.Glasg.

1907. Jex-Blake, Bertha, M.B., Ch.B.Edin.

1909. Kellas, Arthur. M.B., Cli.B., D.P.H.Aberd., Lieut. R.A.M.C. (Killed

in action.)

1894. Lentaigne, Sir John, B.A., F.R.C.S.I., L.R.C.P.I.

1883. Macfarlane, W. H., M.B. and Cli.B.Univ. of Melbourne.

1878. Moody, Sir James M., M.R.C.S.Eng., L.R.C.P.Edin.

1892. Morrisou, Cuthbert S., L.R.C.P. & S.Edin.

1886. O’Neill, Edward D., M.R.C.P.I., L.R.C.S.I.

1912. Power, Pierce M. J., L.R.C.P. & S.I., Lieut. R.A.M.C. (Killed in action.)

1908. Stuart, Francis Arthur Knox,B.A.Cantab., L.S.A.Lond.

Original from

PRINCETON UNIVERSITY

XXX

Digitized by

List of those who have passed the Examination for the Certificate of Efficiency
in Psychological Medicine, entitling them to append M.P.G. (Med.-Psych.
Certif.) to their names.

Adams, J. Barfield.

Adamson, Robert O.

Adkins, Percy, R.

Ainley, Fred Shaw.

Ainslie, William.

Alcock, 13. J.

Alexander, Edward II.
Anderson, A. W.

Anderson, Bruce Arnold.
Anderson, John.

Andriezen, W.

Apthorp, F. W.

Armour, E. F.

Attegalle, J. W. S.

Aveline, U. T. S.

Balluntyuc, Harold S.

Barbour, William.

Barker, Alfred James Glanville.
Bashford, Ernest Francis.
Baznlgette, S.

Begg, William.

Belben, F.

Bird, James Brown.

Blackford, J. Vincent.

Black, E. J.

Black, Robert S.

Black, Victor.

Blackwood, John.

Blandford, Henry E.

7 Bond, C. Hubert.

Bond, R. St. G. S.

Bowlan, Marcus M.

Boyd, James Paton.

13 Boyd, William
Bradley, J. T.

Bristowe, Hubert Carpenter.
Brodie, Robert C.

Brough, C.

Brown, William.

Browne, Hy. E.

Bruce, John.

Bruce, Lewis C.

Brush, S. C.

Bulloch, William.

Calvert, William Dobree.
Cameron, James.

Campbell, Alex Keith.

Campbell, Alfred W.

Campbell, Peter.

Carmichael, W. J.

Carrnthers, Samuel W.

Carter, Arthur W.

Chambers, James.

Chambers, W. D.

Chapman, H. C.

Christie, William.

Clarke, Robert H.

Clayton, Frank Herbert A.
Clayton, Thomas M.

Clinch, Thomas Aldous.

Coles, Richard A.

Collie, Frank Lang.

Collier, Joseph Henry

Conolly, Richard M.
Conry, John.

Cook, William Stewart.
Cooper, Alfred J. S.

Cope, George Patrick.
Corner, Harry.

Cotton, William.

Couper, Sinclair.

Cowan, John J.

Cowie, C. G.

Cowie, George.

Cowper, John.

Cox, Walter H.

8 Craig, M.

Cram, John.

Crills, G. H.

Cross, Edward Jobu.
Cruickshauk, George.
Cullen, George M.
Cunningham, James F.
Dalgetty, Arthur B.
Davidson, Andrew.
Davidson, William.

6 Dawson, W. R.

De Silva, W. H.

UDevine, H.

Distin, Howard.

Dixon, J. F.

Donald, Win. D. D.
Donaldson, It. L. S.
Donelan, James O'Conor.
Douglas, A. R.

Downey, Augustine.
Drummond, Russell J.
Eager, Richard.

Rallies, Henry Marty n.
Earls, James H.

East, W. Norwood.
Easterbrook, Charles C.
Eden, Richard A. S.
Edgerley, S.

Edwards, Alex. II.

Elkins, Frank A.

Ellis, Clarence J.

English, Edgar.

Eustace, J. N.

Eustace, Henry Marcus.
Evans, P. C.

Ewan, John A.

Ezard, Ed. W.

Falconer, A. R.

Falconer, James F.
Farquharson, Wm. Fredk.
Fennings, A. A.

Ferguson, Robert.

Findlay, G. Landsborough.
Fitzgerald, Gerald.

Fleck, David.

Fortune, J.

Fox, F. G. T.

Fraser, Donald Allan.
Fraser, Thomas.

Frederick, Herbert John.

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Original from

PRINCETON UNIVERSITY

XXXI

2

Digitized by

Gage, J. M.

Gaudin, Francis Neel.

Gawu, Ernest K.

Gemraell, William.

Genney, Fred. S.

Gibb, H. J.

Gibson, Thomas.

Giles, A. 13.

Gill, J. Macdonald.

Gilinour, John R.

Goldie, E. M.

Goldschmidt, Oscar Bernard.
Goodall, Edwin.

Gostwyck, C. H. G.

Graham, Dd. James.

Graham, F. B.

Grainger, Thomas.

Grant, J. Wemyss.

Grant, Lacklan.

Gray, Alex. C. E.

Gray, Theodore G.

Griffiths, Edward H.

Haldane, J. R.

Hall, Harry Baker.

Halsted, H. C.

Haslam, W. A.

Haslett, VVilliam John Handfield.
Hassell, Gray.

Hector, William.

Henderson, Jane B.

Henderson, P. J.

Hcnnan, George.

Hewat, Matthew L.

Hewitt, D. Walker.

Hicks, John A., jun.

Hitchings, Robert.

Holmes, William.

Horton, James Henry.

Hotclikis, R. D.

Howden, Robert.

Hughes, Robert.

Hunter, G. T. C.

Hutchinson, P. J.

Hyslop, Thos. B.

Ingram, Peter R.

Jeffery, G. R.

Jagannadhan, Annie W.

Johnston, John M.

Johnstone, Emma M.

Keith, W. Brooks
Kelly, Francis.

Kelso, Alexander.

Kelson, W. H.

Ker, Claude B.

Kerr, Alexander L.

Keyt, Frederick.

King, David Barty.

King, Frederick Truby.

Laiug, C. A. Barclay.

Laing, J. H. W.

Law, Thomas Bryden.

Leeper, Richard R.

Leslie, R. Murray.

Livesay, Arthur W. Bligh.
Livingstone, John.

Lloyd, R. H.

Lothian, Norman V. C.

Low, Alexander.

Google

McAllum, Stewart.

Macdonald, David.

Macdonald, G. B. Douglas.

Macdonald, Johu.

Macdonald, W. F.

Macevoy, Henry John.

McGregor, George.

Maclnnes, Inn Lamont.

Mackeirzie, Henry J.

Mackenzie, John Cumming.

Mackenzie, T. C.

Mackenzie, William H.

Mackenzie, William L.

Mackie, George.

McLean, H. J.

Macmillan, John.

5 Macnaughton, Geo. W. F.

Macneice, J. G.

Macpherson, John.

Macvean, Douald A.

Mnllunnah, Sreenagula.

Marr, Hamilton C.

Marsh, Ernest L.

Marshall, It. M.

Martin, A. A.

Martin, A. J.

Martin, M. E.

Martin, Win. Lewis.

Masson, James.

McDowall, Colin.

Meikle, T. Gordon.

Melville, Heury B.

Middlemass, James.

Miller, R.

Miller, R. H.

Mitchell, Alexander.

Mitchell, Charles.

Moffett, Elizabeth J.

Moll, J. M.

Montcith, James.

Moore, Edward Erskine.

1 Mortimer, John Desmond Krncst
Munro, M.

Murison, Cecil C.

Murison, T. D.

Myers, J. W.

Nair, Charles R.

Nairn, Robert.

Neil, James.

Nixon, Johu Clarke.

Nolan, J. N. G.

Nolan, Michael James.

Norton, Everitt E.

Oldershaw, G. F.

Orr, David.

Orr, James.

Orr, J. Fraser.

Oswald, Landel R.

Owen, Corbet W.

Paget, A. J. M.

Parker, William A.

Parry, Charles P.

Patterson, Arthur Edward.

Patton, Walter S.

Paul, William Moncrief.

Peachell, G. E.

Pearce, Francis H.

Pearce, Walter.

Original from

PRINCETON UNIVERSITY

XXX11

Digitized by

Penfold, William James.
Perdrau, J. A.

Philip, James Farquhar.
Philip, William Marshall.
12Phillips, J. G. Porter.
Phillips, J. R. P.

Pieris, William C.
Pilkington, Frederick W.
Pitcairn, John James.
Porter, Charles.

Powell, James F.

Price, Arthur.

Pring, Horace Reginald.
Rainy, Harry, M.A.

Ralph, Richard M.

Rankiue, R. A.

Rannie, James.

4 Raw, Nathan.

Reid, Matthew A.

Renton, Robert.

Rice, P. J.

Rigden, Alan.

Ritchie, Thomas Morton.
Rivers, W. H. R.

Roberts, Ernest T.
Robertson, G. D.

3 Robertson, G. M.

Robson, Francis Wm. Hope.
Rorie, George A.

Rose, Andrew.

Ross, D. Maxwell.

Ross, Donald.

Rowand, Andrew.

Rudall, James Ferdinand.
Rust, James.

Rust, Montague.
lORutherford, J. M.

Sawyer, Jas. E. H.

Scanlon, M. P.

Scott, F. Riddle.

Scott, George Brebner.
Scott, J. Walter.

Scott, William T.

Seuwright, H. G.

Sheen, Alfred W.

Simpson, John.

Simpson, Samuel.

Skae, F. M. T.

Skeen, George.

Skeen, James H.

Slater, William Arnisou.
Slattery, J. B.

Smith, Percy.

Smith, T. Waddelow
Smith, William Maule.

Sinyth, William Johnson.
Snowball, Thomas.

Soutnr, James G.

Sproat, J. U.

Stanley, John Doucla*.

Staveley, William Henry Charles.
Steel, John.

Stephen, George.

Stewart, William Day.

Stoddart, John.

9 Stoddart, William Hy. B.
Strongman, Lucia.

Strong, D. R. T.

Stuart, William James.

Symes, G. D.

Taylor, W. J.

14Thomas, W. Rees.

Thompson, A. D.

Thompson, George Matthew.
Thomson, A. M.

Thomson, Eric.

Thomson, George Felix.

Thomson, James H.

Thorpe, Arnold E.

Trotter, Robert Samuel.

Turner, W. A.

Urnney, W. F.

Vining, C. W.

Walker, James.

Wallace, J. A. L.

Wallace, W. T.

Wnrde, Wilfred B.

Waters, John.

Waterston, Jane Elizabeth.
Watson, George A.

Welsh, David A.

West, J. T.

White, Hill Wilson.

Whitwell, Robert It. H.
Wickham, Gilbert Henry.

Will, John Kennedy.

Williams, 1). J.

Williamson, A. Maxwell.

4 Wilson, G. R.

Wilson, James.

Wilson, John T.

Wilson, Robert.

Wood, David James.

Wright, Alexander, W. 0.

Yeates, Thomas.

Yeoman, John B.

Young, 1). P.

Younger, Henry J.

Zimmer, Carl Raymond.

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10 To

11 To

12 To

13 To

14 To

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4

5

6

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(1892) was
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(1900) was
(1901) was
(1906) was
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(1913) was

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Google

Original from

PRINCETON UNIVERSITY

THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.']

No. 256 [ N1 N W 0 “^. IS ] JANUARY, 1916. Vol. LXII.

Part I.—Original Articles.

ON CAUSATION.

Through the kindness of Dr. Mercier we have been favoured with
an advanced copy of the first instalment of a new work recently
completed by him on the subject of Causation, with special reference
to causes of death and causes of insanity. Owing to conditions now
existing in consequence of the war, with, as a result, an extreme
scarcity of suitable literary material for publication, as explained in
the October number of the Journal, the Editors have had to face
quite unprecedented difficulties ; and they wish here to express their
acknowledgments to Dr. Mercier for so generously coming to their
aid in what may almost be termed a crisis in the history of the Journal.
The second (and final) instalment of Dr. Mercier's book will appear
in the April number.

LXII.

1

Digitized by Google

Original from

PRINCETON UNIVERSITY

1

Digitized by

Google

Original from

PRINCETON UNIVERSITY

Digitized by

CAUSATION

WITH

A CHAPTER ON BELIEF

BY

CHARLES A. MERCIER, M.D., F.R.C.P., F.R.C.S.

AUTHOR OF

'CRIMINAL RESPONSIBILITY’; ‘PSYCHOLOGY, NORMAL AND MORBID ’ ;
*A NEW LOGIC’; ‘CONDUCT AND ITS DISORDERS’; 'A TEXT-BOOK
OF INSANITY’; ‘CRIME AND INSANITY 1 ; ‘ASTROLOGY
IN MEDICINE ’ ; ETC., ETC.

Had I not continually exercised my judgement, the greater
part of the books on these subjects would have turned my brain.
This effect they have certainly had upon many who have not
used the same precaution. I know the advantage which I might
derive from perplexing the understanding by recurring to
abstruse reasoning and logical quibbles. But I wave it all. 1
shall speak nothing but common sense, and what may be under¬
stood by anyone, however slender his acquirements.

—Horne Tooke.

I myself frequently meditate by myself long and intently;
but in vain; unless I find an antagonist, I have no hope of
success.— Scaliger.

Coition

ADLARD & SON and WEST NEWMAN
BARTHOLOMEW CLOSE

1916

Google

Original from

PRINCETON UNIVERSITY

4

ON CAUSATION,

Digitized by

[Jan.,

CONTENTS.

CHAPTER I.

Some Theories of Causation. Hume, Mill, Mr. Welton, Professor
Pearson, Mr. Bertrand Russell, Dr. McTaggart.

CHAPTER II.

Effect, Reason, Result, Cause.

CHAPTER III.

Condition.

CHAPTER IV.

Causation.

CHAPTER V.

Subsidiary Problems.

Plurality of Causes.

Regression of Causes and Progression of Effects.

Radification of Causes and Ramification of Effects.
Co-operation of Causes.

The Law of Causation.

The Uniformity of Nature.

CHAPTER VI.

Methods of Ascertaining Causes.

CHAPTER VII.

Errors in Attributing Causation.

CHAPTER VIII.

Causes of Death. Causes of Insanity.

CHAPTER IX.

On Belief.*

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Original from

PRINCETON UNIVERSITY

r 9i6.]

BY CHARLES A. MERCIER, M.D.

5

PREFACE.

Exasperated by the fatuity of an expert in heraldry whom
he was cross-examining, Sir William Harcourt at length
exclaimed : ‘ Why, the silly man does not understand even
his own silly business! ’ The reader of a book on orthodox
Logic is constantly tempted to make the same comment. Every
book on Inductive Logic contains a chapter in which an attempt
is made to investigate the nature of Causation, to define it, and
to explain how causes are ascertained and assigned ; but why
Causatiod should be considered subject-matter of Logic, any
more than rotation or imitation, is hard to understand. The
proper task of Logic is to describe and explain the principles
and methods of reasoning, and causation is not a principle or
method of reasoning, nor is the definition of causation or the
ascertainment of causation a principle or method of reasoning.
These are applications of reasoning. They are examples of
reasoning. The results are arrived at by methods of reasoning,
but they are not themselves methods or principles of reasoning,
and are, therefore, no part of Logic. Mill says, and all sub¬
sequent writers have followed him, that causation lies at the
very root of Induction. It does nothing of the sort. It is
one of very many relations that may be discovered by Induc¬
tion, but it is no more the basis of Induction than rotation or
imitation is the basis of Induction.

However, logicians have appropriated to themselves the
examination of causation, and it is not surprising, therefore,
that its true nature has never been discovered, and that the
subject is entangled in confusion and contradiction ; for it is
thus that logicians leave the subjects they investigate. Mill
is the model and great exemplar, as well as the leader of
latter-day logicians, and though it may almost be said that men
of all sorts take a pride to gird at him, yet it may also be said
that he is not only confused and muddled in himself, but the
cause of confusion and muddle that are in other men. He
enumerates five Methods of Experimental Inquiry, and he calls
them four, and in seventy years not one of his commentators has
discovered the inaccuracy ; some of his most important terms,
such as effect and condition, he never defines at all; others,

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such as cause, causation, and conditionality, he defines over
and over again in senses that are different, incongruous, or
inconsistent; his Canons for discovering causes are cumbrous,
uncouth, and clumsy in expression, and in meaning are absurd.
They never have been used, and never could be used. It is
time, therefore, to take the matter out of the hands of logicians,
and investigate it by the light of common sense.

Everyone has an approximate notion, good enough for most
working purposes, of what is meant by causation, and by cause
and effect, but no one has been able to put that notion into a
verbal expression that will stand criticism, and some of the
attempts to do so have resulted in expressions that are pre¬
posterous beyond belief, as will appear when they are examined.
It may seem that if we know what we mean with sufficient
accuracy for working purposes, this is enough, and we need not
strive to attain pedantic precision ; but apart from the general
desirability of defining our terms, the approximate accuracy
which is enough for rough working purposes is not enough
when subtle, intricate, and important problems have to be
determined. Issues involving the determination of causes are
frequently brought before Courts of Law, and of late years such
issues have become much more frequent in connection with
causes of disease, of death, of accident, and of injury. In
trying such cases, judges have expressed the embarrassment
they have suffered from the want of a trustworthy definition of
cause. Many nice points of causation have lately come
before the Courts, and have been decided in the absence of
any clear or precise notion of what causation consists in,
without that guidance from philosophers which judges have a
right to expect. They have looked to philosophers for light
and order, and they have found Cimmerian darkness and
primaeval chaos.

Nor is it only in the determination of individual issues that
a knowledge of the nature of causation is important in law.
A definition of causation, or at least a clear knowledge of what
causation means and is, is the root and the basis of one very
important department of law, reference to which is made in
every case that is tried in the Courts. It is the basis of the
Law of Evidence. According to that very high authority, Mr.
Justice Stephen, the facts that may be proved in Courts of Law
are the facts in issue, and those facts that are relevant to the

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issue, and he defines relevancy thus : ‘ A fact is relevant to
another fact when the existence of the one can be shown to be
the cause, or one of the causes, or the effect, or one of the
effects, of the existence of the other,’ etc. Clearly, then, to
determine what facts are relevant, and this has to be determined
many times in the course of every trial, a knowledge of what
is meant by causation, and of the nature of cause and of effect, is
necessary. Mr. Justice Stephen, in fact, says that his work on
Evidence is founded on Mill’s Logic, and that a previous work
on the Law of Evidence is founded upon Locke’s ‘ Essay.’ As
to this previous work, I can give no opinion, but I am sure that
Mr. Justice Stephen was mistaken when he said his work was
founded upon Mill’s Logic, for his treatise on the Law of
Evidence is as clear and consistent as Mill’s Logic is the opposite.
Mr. Justice Stephen’s admission is important, however, as
showing that in his opinion the Law of Evidence does need a
foundation in a proper apprehension of Causation.

In other important matters also the need for a clear notion
of the meaning of cause and effect is imperative, and the want
of it leads to grave disadvantages. The instructions issued by
the General Register Office for assigning the causes of death
are such that no doctor can understand them, and their unintelli¬
gibility is owing to the want of a definite notion of cause. The
causes of insanity published in the annual tables of the Board
of Control are mostly guesses ; some of them are manifestly
not causes at all ; others may or may not be causes, but no
reason is given why they should be so considered ; and in the
absence of any definition of a cause, and of any trustworthy
method of assigning causes, no reason could be given.

It is always assumed by writers on the subject that the only
investigations that are worth making into the methods of
assigning causes are investigations into the methods pursued
by scientific workers, and that result in scientific discoveries.
These writers, following Mill, formulate five methods, which, as
1 have said, they count as four, which they say are used by
scientific workers. Scientific workers, however, never use these
methods, and could not use them, for they are utterly futile,
as will hereinafter appear. Moreover, the assumption that the
methods employed by scientific workers to discover causes are
in any respect different from the methods employed in every¬
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us, is quite groundless and mistaken. Men who work at science
have no monopoly of methods of discovering causes. Their
methods are not novel or peculiar, but are the same as those
that we all constantly use in the course of our daily lives. For
this reason I have not -followed the course usual in books on
Causation, of restricting my illustrative instances to examples
of discoveries in science.

The chapter on Belief has been added at the request of a
friend who, like most of us, has found himself often puzzled
what to believe and what to disbelieve. It makes no preten¬
sions to philosophical profundity, and to those who are
accustomed to the ponderous tomes that have been written on
the foundations of belief, and upon epistemology generally, it
will appear, I am afraid, a trifling performance. These books,
however, are scarcely accessible to the general reader, and if
they were, it is doubtful whether he would take advantage of
them. Some work accessible to him and intelligible by him
is sorely needed. It is curious that in an age that prides itself
before all things upon being scientific, there are as many pre¬
valent beliefs that are irrational, baseless, absurd, and self-con¬
tradictory, as at any former time of which we have any record.
We smile with confident superiority at the belief of our ances¬
tors in witchcraft, but there was a great deal of very cogent
evidence in favour of witchcraft, and it is little discredit to able
and cultivated men, like Sir Matthew Hale and Sir Thomas
Brown,* that they believed in it. Moreover, the age in which
they lived was a credulous age ; the age in which we live is
sceptical; and yet we now see men as eminent in their several
walks of life as Sir Matthew Hale and Sir Thomas Brown,
even men who are considered, not very unjustly, leaders in
science, holding beliefs much more irrational, and based upon
much less evidence, than witchcraft—beliefs in spiritualism,
telepathy, psycho-analysis, table-rapping, Christian Science, so
called, and the crazy phantasies of the orthodox logician.
When we witness these strange aberrations we may well wonder
whether credulity has not rather increased than diminished in
the last three centuries.

This book is not written for philosophers, and, indeed, it will
be scouted by them, for it is written in ordinary English, and

* Usually spelt Browne, but on the title-page of my copy of his works, dated
1686 , four years after his death, his name is spelt as in the text.

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is quite easy to understand. From St. John Erigena, the
first of the schoolmen, to William of Ockham, the last, and
with the exception of Roger Bacon, the greatest; from Francis
Bacon, the pioneer of scientific method, to Martineau, Herbert
Spencer, and Hughlings-Jackson ; the English nation has
produced a succession of great philosophers such as all other
nations put together would find it hard to equal, and impossi¬
ble to excel; yet during the last quarter of a century English
philosophers have been content to tie themselves like a tin
kettle to the tail of Germany, and to follow the cult of
obscurity and unintelligibility that passes for philosophy in
Germany, and now, alas ! in this country also. If I do not
write Germanised or Germanic philosophy, it is not because I
cannot. It would have been easy to fill my pages with stuff
like this :

Causation is the act by which the Form of a significant
idea presented in a content of Reality, recognised as such
by means of a real Identity, is referred to a subject in Reality
that is not really real or divergently diverse, but identical with
the diverse content of Reality.

It is as easy as pie to write like this when once you have
caught the trick of it. You have only to ring the changes
on the words content and form, reality and identity, and you
will pass for the most awe-inspiring and cogibundantly sub-
limificent philosopher; but my spiritual home is not in
Germany and I prefer to write in ordinary English for the
ordinary reader, whose notions of cause and effect are not as
definite as he could wish, who may be glad of some clear guidance
in methods of assigning causes, and who may welcome assist¬
ance in deciding what to believe, to disbelieve, and to doubt.

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CHAPTER I.

SOME THEORIES OF CAUSATION.

In the whole of philosophy, confused as it is, there is scarcely
any subject in such utter confusion as causation. There are
references to it in the writings of his predecessors, but Hume
was the first writer of note who discussed it at length, and he
got it into a tangle which has been worse and worse entangled
by subsequent writers, until the latest contributors to the dis¬
cussion have essayed to cut the knots by denying altogether
that there is such a thing as causation at all. Few writers
treat the subject without contradicting themselves, and none
without outraging common sense, a result which does not
trouble them, for the first qualification for a philosopher is to
set common sense at defiance. The consequence is that no
one who retains any remnant of common sense can rise from
the perusal of a discussion of causation without a feeling of
dazed perplexity. He finds long discussions in which the
cardinal terms are used in several different senses, and are
either defined in several different ways or never defined at all.
He finds things that are quite distinct, such as cause, condition,
and agent, confounded together ; he finds problems that are
quite distinct, such as the nature of causation and the univer¬
sality of causation, confounded together ; and through all the
discussions runs the difficulty inherent in examining and
defining a notion that is almost primitive.

Primitive notions are by their very nature impossible to
define or explain satisfactorily. They can only be described,
and even description is not always easy or always satisfactory.
Matter cannot be described except in terms of force, nor force
except in terms of matter. It is manifest that defining and
explaining more complicated notions in terms of simpler notions
cannot be continued indefinitely. The process reaches its
natural limit when at last we come to notions of primitive
simplicity, just as the chemical analysis of substances reaches
its natural limit when we have at last reduced them to elements.
The notion of causation is almost elementary. Cause and
effect, like matter and force, are terms that everyone under¬
stands more or less vaguely, more or less precisely, but that it

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is difficult to express more simply for want of simpler terms.
At any rate it has been found impracticable hitherto to ex¬
press them, for every effort that has been made to do so has
resulted in an expression that is either more obscure than
cause and effect themselves, or that does not truly express what
they mean.

Dr. Fowler says ‘ That a cause is ... ; that every event
has a cause ; that the same cause is always attended by the
same effect ; are obviously three different propositions, and
still there are few writers who in their treatment of the ques¬
tion of causation have not more or less confounded them.’
This is quite true, and he might have added a fourth—we derive
our notion of causation from ... or the origin of our notion
of causation is . . .

It is this fourth proposition that is the main theme of
Hume’s discussion, and he arrived at the conclusion, which is
no doubt correct, that we get our notion of causation from
witnessing repeated instances of it—that, in fact, as we should
say now, it is a generalisation from many individual experi¬
ences. So far no doubt he was right; but he went on to
assume, and his whole argument rests upon the assumption,
that because the notion of causation is a generalisation from
repeated experiences, therefore causation itself does not exist in
isolated or single instances, and, in fact, does not exist at all, but
is a mental fiction, without any corresponding relation in fact.

The common sense doctrine that Hume undertook to de¬
molish is ‘ that the idea of causation necessarily implies the
idea of power or necessary connection , that is to say, between the
cause and the effect, or power in the cause to produce the
effect.’ He set himself to show that power and necessary
connection had been illegitimately imported into the idea of
causation, and that what we call cause and effect is nothing
but casual antecedence and consequence. Antecedence and
consequence are all that we ever observe, or can observe ; but
when we have witnessed many instances of the same antecedent
being followed by the same consequent, we jump to the con¬
clusion, without any justification for doing so, that there is
between them a tie other and more than bare sequence—that
there is a power in the antecedent to bring about the con¬
sequent, and a necessary connection between them. Thus
Hume teaches.

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Briefly put, his argument is that all our ideas are in the last
resort analysable into simple ideas, which are themselves copies
of impressions or original sentiments, by which he seems to
mean what we now call percepts. ‘ These impressions are
strong and sensible. They admit not of ambiguity.’ Such
are solidity, extension, and motion, each of which we can per¬
ceive, so Hume teaches, in a single experience ; ‘ but the
power of force ... is entirely concealed from us, and never
discovers itself in any of the sensible qualities of body.’ He
means, apparently, that we cannot see it: ‘It is impossible,
therefore, that the idea of power can be derived from the con¬
templation of bodies in single instances of their operation;
because no bodies ever discover any power which can be the
original of this idea.’ Since, then, we obtain the notions of
force or power and necessary connection, not from single expe¬
riences, but by generalisation from many experiences, these
notions are fictitious, imaginary, and have no basis in fact,
neither have they any existence except in our own misguided
imaginations. This is Hume’s doctrine.

It is very curious that this doctrine should have been prac¬
tically accepted by every writer since Hume’s time, and that
no present-day philosopher should have detected any of the
fallacies in it. Modern psychologists are pretty familiar, I
should have thougnt, with the doctrine that every one of our
concepts of the simplest properties of bodies—solidity, exten¬
sion, motion, and the rest—is a generalisation from many
experiences, and is in no case derived from a single instance,
but is slowly built up in our early years under the guidance of
experience. As far and in the same way as solidity, extension,
and motion are revealed to us by experience, so far and in that
way is force or power; and if force or power is not revealed in
a single instance, neither is existence, extension, or motion.
The only force that exists wholly in the imagination, and is
without any counterpart outside it, is the force of Hume’s
argument.

‘ The generality of mankind never find any difficulty in
accounting for the more common and familiar operations of
Nature,such as the descent of heavy bodies . . . but suppose
that, in all these cases, they perceive the very force or energy of
the cause by which it is connected with its effect and is forever
infallible in its operation. They acquire, by long habit, such a

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turn of mind that upon the appearance of the cause they
immediately expect, with assurance, its usual attendant, and
hardly conceive it possible that any other event could result
from it.’ They do, undoubtedly ; but are they not justified
in so accounting for these operations of Nature? What is the
test ? What is the inexpugnable, infallible test ? It is that,
acting on this supposition, they should never meet with expe¬
rience that contradicts it ; and is not this test satisfied ? Hume
says that force or power is never revealed in a single instance ;
but, when the mind has been prepared by previous experiences
to entertain the notion, is not the single instance of carrying a
bucket of water sufficient to reveal the force or power of the
weight of the bucket ? If a breaking wave, thundering upon
the beach, and carrying away cartloads of shingle in the
undertow, does not convey the idea of force or power; if a
hurricane, uprooting great trees, unroofing houses, and whirling
haystacks into the air, does not convey the idea of force or
power ; if an avalanche, carrying away woods and villages, and
diverting the course of torrents, does not convey the idea of
force or power ; then no ‘ contemplation of any body in
single instances of its operation ’ can afford any idea of any
description.

Hume denies that we derive the idea of power from subjec¬
tive experience, from finding ' that by the simple command of
the will we can move the organs of our body or direct the
functions of our mind.’ He denies it on the ground that * we
learn the influence of our will from experience alone, and
experience only teaches us how one event constantly follows
another ; without instructing us in the secret connection which
binds them together and renders them inseparable.’ But why
should it ? We might as well deny that we derive from expe¬
rience the idea that glue sticks to wood, because we know it from
experience alone, and experience does not instruct us in the
secret connection which binds the glue and the wood together
and renders them inseparable.

Thus he summarises his conclusions : ‘ It appears that, in
single instances of the operation of bodies, we never can, by our
utmost scrutiny, discover anything but one event following
another, without being able to comprehend any force or power
by which the cause operates, or any connection between it and
its supposed effect. , , . All events seem entirely loose

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and separate. One event follows another; but we never can
observe any tie between them. They seem conjoined , but never
connected! Thus he virtually denies causation altogether, and,
as we shall see later, recent writers accept this conclusion, and
bring it forward as original with themselves ; but it is clear
that this is Hume’s position, though he never actually puts it
into these words. Having arrived at this conclusion, which is
a virtual denial that there is any such thing as causation, he
admits that when a man has observed several similar instances
of such conjoined events he ‘can readily foretell the one from
the appearance of the other ’ ; and then Hume astounds us by
defining a cause as * where , if the first object had not been , the
second had never existed! It would be difficult to put the
necessary connection between them in stronger terms, and
Hume seems frightened at having made the admission, for he
begins at once to hedge, and offers another, his third, definition
of a cause : an object folloived by another , and whose appearance
always conveys the thought to that other. Thus he removes the
reference from the world of things to the world of thoughts,
and places the matter on an entirely different basis. At length
he concludes : ‘ I know not whether the reader will readily
apprehend this reasoning. I am afraid that, should I multiply
words about it, or throw it into a greater variety of lights, it
would only become more obscure and intricate.’ In this he is
no doubt right. His argument is based on a premiss that is
thoroughly unsound, and leads to a conclusion that is repugnant
to universal experience, and that he is himself compelled to
repudiate. However, the mischief was done. He opened the
floodgates of confusion, and his successors have ever since been
floundering in the swamp.

Mill’s whole treatment of the problem of causation is a most
deplorable muddle, and that he should have been regarded as
an oracle for two generations is a startling proof of the
poverty of critical acumen and philosophic insight that has
prevailed since his Logic appeared. It is evident on the most
superficial perusal of his chapters on the subject that he has
never thought it out ; he wanders on from conjecture to
surmise, and from surmise to conjecture, stating his surmises
and conjectures as inexpugnable facts ; he defines cause and
causation over and over again in eighteen different ways, most
of them inconsistent with each other, and some of them contra-

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dictory of others, and neither he nor his commentators and
followers recognise the inconsistencies or the contradictions.
The only explanation of his astonishing and overwhelming
reputation is that amongst the blind the one-eyed is king ; but
even Mill’s one eye was purblind.

Mill first states Hume’s doctrine in its bare nakedness :
‘ The Lav/ of Causation ... is but the familiar truth,
that invariability of succession is found by observation to
obtain between every fact in Nature and some fact that has
preceded it.’ It may be noted in passing that however familiar
and however true this may be, it is certainly not found by
observation, and Mill’s study of Hume should have warned him
not to make so absolute an assertion ; for Hume says very
truly 1 on the discovery of extraordinary phenomena, such as
earthquakes, pestilence, and prodigies of every kind, they find
themselves at a loss to assign a proper cause,’ and there are
still innumerable facts in nature which baffle all our attempts
to discover their causes. However, Mill goes on : ‘To certain
facts, certain facts do, and, as we believe, will continue to
succeed. The invariable antecedent is called the cause ; the
invariable consequent, the effect.’ He does not recognise that
this statement differs very materially from the former. First
he says that every fact has an invariable antecedent, and then
he says that every fact has an invariable consequent, and he
regards the two assertions as equivalent. In his next statement
he goes back to his first position, and says : * The universality
of the law of causation consists in this, that every consequent
is connected in this manner [invariably] with some particular
antecedent, or set of antecedents.’ In this he airily gives away
Hume’s whole position, and introduces a new and vitally
important element, without in the least recognising that he is
doing more than restating his previous doctrine. The ante¬
cedent now not only invariably precedes the consequent, but
also is connected with it, a doctrine which Hume positively
denies, and which, when introduced into what is virtually a
restatement of Hume’s doctrine, requires at least some
justification or explanation ; but none is given.

As is well known, Reid demolished Hume’s definition of
causation as invariable succession by adducing the case of night
and day. Night invariably follows day, and day invariably
follows night, and yet neither is the cause of the other. Clearly,

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some qualification and addition is necessary, and Mill, though
he gives the expressions quoted above as complete and sufficient
statements of the nature and relation of cause and effect,
evidently recognises that some qualification and addition is
required, and supplies one, in fact, he supplies a good many, not
as successive approximations to a complete definition, not as
tentative proposals to be discarded when found inappropriate,
but all of them as final and complete definitions, which are
immediately superseded by others, which are superseded in their
turn.

It is very common, he says, when there are many antecedents
(as if there were ever an effect that had not many antecedents,
and he does not say invariable antecedents connected with the
consequent, though presumably he means such antecedents) to
single out only one of them under the denomination of cause,
calling the others merely conditions. ‘ But though we may
think proper to give the name of cause to that one condition,
the fulfilment of which completes the tale, and brings about
the effect without further delay ; this condition has really no
closer relation to the effect than any other of the conditions
has.’ This leads him to his fourth definition, different from all
the rest. 1 The cause, then, philosophically speaking, is the
sum total of the conditions, positive and negative taken
together; the whole of the contingences of every description,
which being realised, the consequent invariably follows.’

Having given this final definition of what the cause is,
philosophically speaking, he discusses it further, and finds that it
won’t do. He now finds it necessary ‘ to advert to a distinction
which is of first-rate importance,’ which, in spite of its first-rate
importance, has been omitted from his previous definitions.
Invariable sequence is not synonymous, he now finds, with
causation, unless the sequence, besides being invariable, is also
unconditional ; and this he says immediately after he has
defined the cause as ‘ philosophically speaking,’ the sum total
of the conditions. It is, therefore, philosophically speaking
conditional, and speaking otherwise unconditional. This leads
him to his fifth definition, according to which a cause is ‘ the
antecedent, or the concurrence of antecedents, of a phenomenon,
on which it is invariably and unconditionally consequent.’ Still
dissatisfied, as well he may be, he tries again, and gives a sixth
definition, * which confines the meaning of the word cause, to

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the assemblage of positive conditions without the negative, and
then, instead of unconditionally, we must say “ subject to no
other than negative conditions ” ’ ; and if this does not satisfy,
he has ‘ no objection to define a cause, the assemblage of
phenomena, which occurring, some other phenomenon invariably
commences or has its origin.’ So that after asserting in the
most positive terms that invariable sequence is not causation
unless the sequence, besides being invariable is also uncondi¬
tional, he now drops unconditionalness, and goes back without
a word of apology to invariable sequence.

It would be tedious and unprofitable to examine any further
the mass of confusion and contradiction contained in Mill’s
exposition of causation, but lest it should be thought that I
have at all exaggerated, I will set down here a series of extracts
from his Logic.

He prefaces his discussion of causation with the following
warning : ‘ The notion of cause being the root of the whole
theory of Induction [it is not], it is indispensable that this idea
should, at the very outset of our inquiry be, with the utmost
practicable degree of precision, fixed and determined.’ This he
says, and more than two hundred pages later he is still altering
his definition of cause ; more than three hundred pages later he
alters his definition of causation. This is how he fixes and
determines his notion of cause with the utmost practicable
degree of precision :—

‘ The Law of Causation ... is but the familiar truth
that invariability of succession is found by observation to obtain
between every fact in Nature and some other fact which has
preceded it.’ I, 376.

‘ The invariable antecedent is termed the cause, the invariable
consequent, the effect.’ I, 377.

‘ If it [the fact] has begun to exist, it was preceded by some
fact or facts with which it is invariably connected.’ I, 377.

‘The real Cause is the whole of those antecedents.’ I, 378.

‘ All the conditions were equally indispensable to the pro¬
duction of the consequent; and the statement of the cause is
incomplete unless in some shape or other we introduce them
all.’ 379 * Condition is not defined.

1 The cause, then, philosophically speaking, is the sum total
of the conditions, positive and negative, taken together ; the
whole of the contingencies of every description, which being
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realised, the consequent invariably follows.’ I, 383. Contin¬
gency is not defined.

‘ It is necessary to our using the word cause, that we should
believe not only that the antecedent always has been followed
by the consequent; but that, as long as the present consti¬
tution of things endures, it always will be so.’ I, 391.

‘ That which will be followed by a given consequent when,
and only when, some third circumstance also exists, is not the
cause, even though no case should have occurred in which the
phenomenon took place without it.’ I, 392.

* Invariable sequence, therefore, is not synonymous with
causation, unless the sequence, besides being invariable, is
unconditional.’ I, 392.

‘We may define, therefore, the cause of a phenomenon, to be
the antecedent, or concurrence of antecedents, on which it is
invariably and unconditionally consequent ’ ; or

‘ The antecedent, or the concurrence of antecedents, on which
it is invariably and subject to no other than negative conditions
consequent’; or

‘ The antecedent, or the concurrence of antecedents, in which
it is invariably and whatever supposition we may make about
things, consequent.’ I, 392.

‘ The series of the earth’s motions, therefore, though a case
of sequence invariable within the limits of human experience, is
not a case of causation.’ I, 394.

‘ I have no objection to define a cause, the assemblage of
phenomena, which occurring, some other phenomenon invariably
commences, or has its origin.’ I, 397.

‘ There is no Thing produced, no event happening in the
known universe, which is not connected by an uniformity, or
invariable sequence, with some one or more of the phenomena
which preceded it.’ I, 400.

‘ The state of the whole universe at any instant, we believe
to be the consequence of its state at the preceding instant.’
I, 400.

‘ The law of causation is, that change can only be produced
by change.’ I, 407.

‘ In this example we may go further, and say, it is not only
the invariable antecedent but the cause.’ I, 450.

‘ The cause of it, that is, the peculiar conjunction of agents
from which it results.’ I, 5 11.

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‘ That which would not be followed by the effect unless
something else had preceded, and which if that something else
had preceded, would not have been required, is not the cause,
however invariable the sequence may in fact be.’ II, 37.

* Fresh causes or agencies.’ II, 38.

‘The uniformity in the succession of events, otherwise called
the law of causation.’ II, 108.

From these dicta we may extract the following definitions or
descriptions of cause, and in repeating them I will put in
italics the words which are discordant or incongruous with
previous utterances.

A cause is :

(1) The invariable antecedent.

(2) The preceding fact with which the effect is invariably
connected.

(3) The whole of the antecedents.

(4) All the conditions.

(5) The sum total of the conditions.

(6) The whole of the contingencies.

(7) The antecedent which not only always has been
followed, but that always will be followed by the consequent;
although

(8) That which always has been and always will be followed
by the consequent is not necessarily the cause.

(9) The invariable unconditional antecedent.

(10) The antecedent on which the effect is invariably and
subject to no other than negative conditions consequent.

(11) The antecedent on which the effect is invariably con¬
sequent whatever suppositions we may make about other things.

(12) The assemblage of phenomena, which occurring, some
other phenomenon commences or has its origin.

(13) The peculiar conjunctioti of agents from which the con¬
sequence results.

(14) An agency.

Causation, or the Law of Causation, is :

(1) Invariability in succession.

(2) Invariable and unconditional sequence.

(3) Utiiformity in the succession of events.

(4) That change can only be produced by change.

In addition to the discordances in these definitions, account
must be taken of the following pairs of assertions :

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‘ Causation is invariability of succession.’

‘ The series of the earth’s motions, though a case of sequence
invariable within the limits of human experience, is not a case
of causation.’

‘ The cause is the invariable antecedent.’ 1 The invariable
antecedent is the cause.’

‘That which would not be followed by the effect unless
something else had preceded, and which if that something else
had preceded, would not have been required, is not the cause,
however invariable the sequence may in fact be.’

‘ Causation is invariability of succession.’

‘ Invariability of sequence is not synonymous with causation
unless the sequence, besides being invariable, is unconditional.’

The majority of writers since Mill have followed rather
slavishly in his footsteps, but a few recent writers have struck
out more independent courses, and some of these must be
examined. I confine the examination to the writings of Mr.
Welton, Prof. Karl Pearson, Mr. Bertrand Russell, and Dr.
McTaggart.

Mr. Welton accepts Mill’s doctrine that the cause is the sum
of the conditions, though he prefers to call it the totality of the
conditions, but he rejects altogether the time factor, or ante¬
cedence and consequence, which every previous writer on the
subject considers a necessary ingredient in our concept of
causation. ‘ The cause,’ he says, ‘ is not dependent on time
sequence. For if we analyse any case of causation we find that
time sequence is not an essential aspect of it.’ I am not so
sure. Gutta cavat lapidem. The continual dropping of water
wears away a stone, and surely this takes time. The ploughing,
harrowing, and sowing of the ground are causes of the subse¬
quent harvest, but the harvest is not simultaneous with these
operations. It gradually matures for months, and not until
months have elapsed is the effect produced. The admini¬
stration of an excess of food causes a pig to grow fat, but the
pig does not instantaneously explode into a state of obesity.
Perhaps, however, in giving these examples I should be tripped
up by the expression, ‘ essential aspect.’ What an essential
aspect may be I do not know, but whatever it is, I find it hard to
reconcile Mr. Welton’s assertion with his subsequent assertion
that the fact to be accounted for is change. Change, he says,
implies something which changes. So it does, but it implies

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something else also. It implies duration. We speak of
instantaneous changes, but in fact and in Nature there is no
such thing. Change implies duration. It implies an ante¬
cedent state from which, and a subsequent state to which, the
change takes place. If the fact to be accounted for is change,
which Mr. Welton says it is, and which it is sometimes, then
causation does imply sequence in time, and time sequence is
an 1 essential aspect ’ of it, if by an essential aspect of it Mr.
Welton means a necessary factor in it.

But he has another reason for rejecting time sequence as a
factor in causation. We cannot, he says, find the explanation
of change in preceding change ; for that would simply land
us in infinite regress ; by which he means that for each cause
we must find a preceding cause, and so ad infinitum. I do
not see the necessity. In following the chain of causes back¬
ward we can stop where we please, and we usually have a good
reason for stopping at a certain point; but supposing that
time sequence in causation does land us in infinite regress,
why not ? There is nothing inconsistent with our knowledge
of the universe in supposing that the causes of any change go
back to an infinity of past time. Infinite regress is no argu¬
ment against the time element in causation. Mr. Welton
might as well say that the explanation of night and day
cannot be found in the rotation of the earth, for that would
simply land us in a movable earth. No doubt it would, and
what then ?

Instead of sequence in time, Mr. Welton presents us with
contiguity in space as the necessary element, or, as he calls it,
the essential aspect, of causation ; for, he says, it is only under
the form of space that we can rationalise our experience of
the influence of bodies on each other. I must confess I cannot
fathom this cryptic reason. I do not know what the form of
space is, nor do I know how to rationalise an experience ; but
if by essential Mr. Welton means necessary, and if by con¬
tiguity he means contact, or even nearness in space, of an
acting body to a body acted on and consequently changing,
then I deny altogether that contiguity is essential to causation.
The instance that must at once occur to everyone is the action
of an astronomical primary in causing the motion of its satellite
to pursue a certain path. Mr. Welton sees this, and his way
out of the difficulty is a very extraordinary one. * How,’ he

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says, ‘ can we conceive a causal influence exerted on an object
distant in space from the agent ; as e.g. that of the sun on
the planets ? In reply to this it must be said that in one very
true and important sense of its reality a body must be thought
to be where its influence is felt : the power of exerting influence
is one of its properties, and where, therefore, that power is felt
there the agent truly is in this, the only applicable sense. Of
course in another sense of its reality—the sense in which
reality is identified with visible and tangible form and tangible
resistance—the body may be absent, but then that aspect of its
reality is, in this case, beside the mark.’ If Mr. Welton
succeeds in deceiving himself by thus juggling with the word
reality, the abracadabra of the philosophy that is made in
Germany, I know not whether he is more to be envied or
pitied, but I am very sure that he will not deceive anyone else
who has any appreciation of the meaning of words. He
might as well say that the German Emperor is omnipresent
throughout Central Europe, for that is where his influence is
felt. He might as well say, when a drunken man gives his
companion a black eye, that in a very true and important
sense of its reality the drink is in the black eye, for that is
where its influence is felt. Of course, in another sense of its
reality the drink is absent from the eye, but then that aspect
of its reality is beside the mark on the eye. Mr. Welton is, I
am afraid, not so thoroughly Germanised as he tries to make
out. No truly Germanised philosopher would spell the word
Reality without the capital, which makes it so much more
imposing. It will not, however, impose upon anyone who
looks to the meaning of words.

Cause and effect, says Mr. Welton, are not successive, but
simultaneous ; and to prove this he instances the formation of
water. ‘ The cause of the formation of water is the combina¬
tion in definite proportions of hydrogen and oxygen, but this
combination does not precede the formation of water, it is that
formation.’ Of course it is. He is juggling with words again.
The formation of water is the same thing as the combination of
the two gases. That is a truism. It is an identical expression.
It is expressing the same thing in two different sets of words.
But the combination of oxygen and hydrogen, which is the
formation of water, is not the cause of that formation. The
cause of the formation, or of the combination, is first the mixture

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of the gases, and then the passage of a spark through them.
And though the formation of water and the combination of
the gases is simultaneous, if, that is to say, a process can be
said to be simultaneous with itself, it is not simultaneous with
the mixing of the gases, nor is it simultaneous with the passage
of the spark. The mixing of the gases may precede the
combination by days, months, or years; and though the com¬
bination follows very rapidly on the passage of the spark,
they are not simultaneous. The combination begins in the
neighbourhood of the spark, and spreads throughout the
mixture, and this spreading takes time—a very short time, it
is true—but it takes time. The passage of the spark is ante¬
cedent, the formation of water is consequent.

‘ So it is,’ says Mr. Welton,' in every other case.’ I agree to
this extent, that in every other case of change in which he makes
out that the cause is simultaneous with the effect, either what
he calls the cause is not the cause, or what he calls the effect
is not the effect.

Mr. Welton continues thus : ‘We, then, arrive at this. Cause
and effect are not two but one.’ So we advance from con¬
tiguity in space to simultaneity in time, and from simultaneity
in time to identity ! How a body, supposing, as Mr. Welton
supposes, that a cause can be a body, can be contiguous in
space to itself, I do not know. I suppose that is another aspect
of its Reality. The question that arises in my mind is
whether the body is beside itself, or whether the person who
makes the assertion is beside himself.

A dropping of ink, says Mr. Welton, upon paper causes a
blot, but the blot is there as soon as the contact of ink and
paper is made : it is that contact. But on his own showing it
ought not to be. What he says is that cause and effect are one,
but the one he takes is neither cause nor effect. The cause is
the dropping of the ink : the effect is the blot. If cause and
effect are one, the blot ought to be the dropping of the ink ;
but Mr. Welton says it is not. It is the contact of the ink
with the paper. Such confusion and self-contradiction could
scarcely be found outside a book on logic. By a parity of
reasoning, when a man gets into bed, the getting into bed is
the man, or, if we take Mr. Welton’s second alternative, which
he does not recognise as an alternative, but asserts as the same
thing, then the contact of the man with his bed is the man. It

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ought not to be necessary to clear up such a very simple
matter, but seemingly it is necessary to point out that the blot
is not the contact of the ink with the paper : the blot is the
layer of ink in contact with the paper. And this layer of ink
on the paper does not appear simultaneously with the dropping
of the ink, it follows the dropping of the ink. The blot is not
on the paper until the dropping is arrested by the paper, is
over and done.

The fact to be accounted for, says Mr. Welton, is change ;
and the first example of causation that he adduces is that the
weight of the atmosphere is the cause of the height of the
mercury in the barometer. But the height of the mercury in
the barometer is not a change. Quite the contrary. The fact
to be accounted for in this case is not change, but the absence
of change. The fact to be accounted for is that the mercury
in the barometer does not sink. Perhaps the explanation is to
be found in another aspect of Reality, and it may be that in a
very true and important sense of its reality the absence of
change is the same as change. It is perhaps a Reality of
Identity, or an Identity in Reality, such as Mr. Bradley and Dr.
Bosanquet delight in.

‘ We, then, arrive at this,’ says Mr. Welton, 1 cause and
effect are not two, but one. That they are inseparable is indeed
recognised by the relativity of the terms themselves. A cause
without an effect, or an effect without a cause, is a contradiction
in terms and unthinkable.’ So it is, but it is not more un¬
thinkable than a cause which is identical with its effect, or an
effect which is identical with its cause. * But we must go
further,’ says Mr. Welton, ‘and say that in content they are
absolutely identical. It is only in form that they can be dis¬
tinguished.’ Here is the hoof—it is not a cloven hoof, but a
soliped—of Germanism again. Content is another of its
shibboleths or abracadabras. Content and form, reality and
identity, are its stock-in-trade, they are the four hoofs on which
it goes. Lug them in by head and shoulders, use them in any
sense or nonsense that you please, mix them up anyhow, and
you will pass for an up-to-date philosopher. Mr. Welton con¬
fines his illustrations to cause and effect, but it seems a pity so
to limit the application of such a fertile philosophical principle,
and I rejoice in being able to extend it to other pairs of relatives.
Parent and offspring are not two but one. That they are

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iseparable is indeed recognised by the very relativity of the
erms themselves. A parent without offspring, or an offspring
without a parent, is a contradiction in terms, and unthinkable.
Jut we must go further, and say that in content they are abso-
utely identical. If is only in form that they can be distinguished.
Vnd the same is true of higher and lower, outside and inside,
nurderer and victim, robber and robbed. In content they are
absolutely identical. It is only in form that they can be dis-
inguished. How charming is divine philosophy !

If cause and effect are not two, but one ; if they are abso-
utely identical (I leave out content, for I do not know what the
rontent of a cause is, or how it can have any content. A cause
s not a box or a bag); if, I say, they are absolutely identical,
iow idle it is to seek for causes or for effects ! The main
>ccupation of the whole human race, ever since it attained
he status of humanity, is founded on a chimaera. What is the
:ause of the alternation of day and night ? That silly man,
Copernicus, thought he had discovered it. What is the cause
if the spout of blood from a severed artery ? The stupid
Harvey thought he had discovered it. What is the cause of
he suppuration of wounds, of pyaemia, of septicaemia ? The
oolish Lister pretended that he had discovered it. What is the
:ause of malarial fever? of earthquakes? of Brown’s success in
growing roses? of Jones’ failure to secure the hand of Miss
Robinson ? What is the cause of mimicry in animals ? What
nakes the days warmer in summer than in winter?

What makes the price of corn and Luddites rise ?
What fills the butchers’ shops with large blue flies ?

\nd finally, what is the cause of philosophers writing nonsense?
Nothing could be clearer. Nothing could be plainer or more
nanifest. The chief, the most important, the most absorbing
•ccupation of mankind has always been the search for causes.
Vhat folly ! The causes were under their noses all the time.
They saw the effects, and the effects are absolutely identical
kith the causes.

Another recent writer on the subject is Prof. Karl Pearson,
. hose Grammar of Science has achieved a popularity remark-
ble for a work of the kind. It is disfigured by much uncouth
hraseology, and by the Papal infallibility that the author claims
)r his own doctrines, which he attributes to a personified

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science. On nearly every page he speaks of ‘ a routine of
experience,’ a ‘ routine of sense impressions,’ a ‘ routine of
perceptions.’ These are his fundamental terms, but he never
defines them, and we are left to conjecture what he means by
them. Far on in the book he speaks of the routine of perceptions
as equivalent to ‘ the uniform order of phenomena,’ and * the
uniformity with which sequences of perception are repeated ’ ;
but whether this is another name for causation, or whether it is
merely our old familiar friend the Uniformity of Nature, we are
left in doubt. Even if he does mean the Uniformity of Nature,
we are no better off, for no two philosophers agree on what is
to be meant by the Uniformity of Nature. The only thing on
which they agree, and when they do agree their unanimity is
wonderful, is that Nature is not uniform.

Much of the authority that Prof. Pearson’s Grammar oj
Science has unquestionably achieved is due to his habit of
attributing his own opinions to a personified science, a trick
that enables him to pose as infallible, while adroitly avoid¬
ing the appearance of arrogance that such a pose carries with
it. When he says that for science cause is meaningless, he
means that Prof. Pearson does not understand the meaning of
it; when he says that science can in no case demonstrate this
or that, he means that Prof. Pearson cannot demonstrate it ;
when he says that science can find no element of enforcement
in causation, he means that Prof. Pearson is too blind to see the
element of enforcement; and so on. This is an adroit method
of imposing on the gullibility of his readers, for who, in these
' scientific ’ days, would have the temerity to question the pro¬
nouncements of science? But I must confess to some surprise
that it has been so successful. I should have thought that it
might have occurred to some one that science in this sense is
only a name for a body of opinion ; a body of fluctuating
opinion, varying from time to time and from person to person,
so that what is science to-day was heresy yesterday, and will
be superstition to-morrow; what is science to one is stupidity
to another, and falsehood to a third. What is science to Prof.
, for instance, is nonsense to me.

Pearson belongs to the school of Hume and Mill,
them denies that there is any ‘ enforcement ’ of an
cause, or any necessary connection between them,
merely the antecedent, the effect merely the sub-

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sequent. The one happens to follow the other, but there is no
reason or necessity why it should do so : they are in no way
connected ; but when we see repeated instances of the same
succession of events, we deludedly jump to the conclusion that
the predecessor is the cause of the successor. Almost as soon
as it was stated, Reid blew this doctrine sky high by adducing
the instance of night and day. Day always precedes night, and
night always follows day, but no one supposes that day is the
cause of night or that night is the effect of day. And why
not ? Manifestly because they are merely antecedent and
subsequent; because there is no power in day to produce night;
because there is no enforcement of night by day. Prof.
Pearson bases his repudiation of enforcement on practically
the same ground as Hume does, viz., that our notion of force is
purely imaginary, and has no counterpart in the world outside
our imagination. In this he confuses, as Hume does, imaginary
with conceptual. Our concept of force, like all our concepts of
primitive things, such as motion, resistance, extension, duration,
and so forth, is a generalisation from many experiences of
individual instances ; and if we are to discard the one because
it is conceptual, that is to say, a generalisation, then we must
discard the rest for the same reason. In that case our minds
are left blank, and reasoning is impossible for want of pabulum.
In contradiction to this doctrine it is enough to appeal to
universal experience. By cause we do not mean mere ante¬
cedence, nor by effect do we mean mere succession. If we
did, we should accept day as the cause of night, and night as
the effect of day. If we did, the old and notorious fallacy,
post hoc, ergo propter hoc, would be no fallacy : it would be an
unassailable truth ; yet the same logicians who declare in their
Chapters on Causation and Induction that causation is nothing
but sequence, declare in their Chapter on Fallacies that it is
fallacious to argue from post hoc to propter hoc. But no incon¬
sistency or self-contradiction in a doctrine ever yet deterred
logicians from teaching it ; and no doubt they will continue to
teach this self-contradiction along with the rest, until the whole
silly pseudo-science is swept away, and goes to join Judicial
Astrology, Phrenology, and Humoral Pathology upon the
rubbish heap. In forming our idea of cause and of causa¬
tion, the enforcement of the effect by the cause enters as an
inseparable and necessary element into the notion, and if that

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element is extruded, that which appeared to be a cause is a
cause no longer. ‘ The necessity,’ says Prof. Pearson, * thus
lies in the nature of the thinking being, and not in the percep¬
tions themselves ; thus it is conceivably a product of the per¬
ceptive faculty.’ How it can be a product of the perceptive
faculty and not be a percept or perceived ; how that can be
perceived which is purely imaginary, and has no sensory impres¬
sion as a basis or provocation to perception, Prof. Pearson does
not inform us. His psychology is as hazy as his notion of
causation.

However, Prof. Pearson goes with the crowd, and quotes as
from Mill the definition that causation is uniform antecedence ;
and this definition, says Prof. Pearson, is perfectly in accord
with scientific concept—that is, with Prof. Pearson’s concept.
It may be a good definition, but when Prof. Pearson says it is
John Stuart Mill’s definition, he is mistaken. Among all of
Mill’s many definitions of cause and causation this one is not
to be found. In this instance ‘science’ is at fault.

‘ For science,’ that is, for Prof. Pearson, ‘ cause, as origi¬
nating or enforcing a particular sequence of perceptions, is
meaningless—we have no experience of anything which
originates or enforces something else.’ The most obvious
answer to this is that it is not true. It contradicts the whole
experience of the whole human race. Every time we move a
thing from one place to another we demonstrate the falsity of
the assertion. The word * originating ’ is used equivocally.
A change in anything is originated when the change begins ;
that is, when the thing begins to change. But it seems from
the context that Prof. Pearson denies that change—the
sequence of perceptions, as he calls it—is then originated,
because it can always be traced to previous change, and there¬
fore in this sense it is not ‘originated.’ This is an obvious
confusion. The particular change in the thing changing is
none the less originated, although it may be the effect of some
previous change in something else. What Prof. Pearson means
is that the total sequence of changes never originates, or, as I
should say, begins. It is the same difficulty that Mr. Welton
calls infinite regress, and which he takes as a conclusive argu¬
ment against the time element in causation, while Prof.
Pearson takes it, with equal inconsequence, as an argument
against causation itself. In so far as it is an argument at all,

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it is as much an argument against the existence of change as
against the existence of causation, or of a time element in
causation ; but it is no argument against either. Grant that
change generally, apart from individual changes, never begins,
but can be traced back until it is lost in the infinity of past
time, still that is no argument against causation. It merely
shows that every cause has itself a cause ; and so far from
abolishing causation, it renders causation more than ever
certain, and necessary, and universal. But I need not labour
the argument, for Prof. Pearson has himself refuted it. On
p. 9 he says, * the man who has accustomed himself to
marshal facts, to examine their complex mutual relations, and
predict upon the result of this examination inevitable sequences.’
Here he is evidently referring to himself, and if a sequence is
inevitable, it is enforced ; it is necessary ; it is not the mere
casual sequence that he says causation is. To say that a
sequence is inevitable, and to say that it is enforced, is to say
the same thing in different words.

However, Prof. Pearson sees what Hume did not appear to
see, and what Mill certainly did not see, that if we take away
from causation the element of enforcement, or of power in the
cause to produce the effect, causation vanishes with it, and the
only logical attitude is to deny altogether that there is any
such thing as causation. To this necessary result of their
teaching, Hume and Mill were blind ; but Prof. Pearson sees
it, and Mr. Bertrand Russell sees it, though they both see it
only in transitory and occasional glimpses, and for the most
part lose sight of it. They both deny that causation exists,
and they both define what it is—not what it means, but what
it is. Prof. Pearson asserts that the ‘ category of cause and
effect ’ is a fetish ; that the law of causation is a figment; that
no experience demonstrates causation ; that for science, that is
to say, for him, cause is meaningless ; and he asks whether
causation is anything but a conceptual limit to experience, a
cryptic question that, for my own part, I am unable to answer
until I know what it means. Having said this, he says he will
show how antecedents are true scientific causes ; he states the
law (which, by the way, is nonsense, as he himself in another
place shows, though he endorses the law) that the same set of
causes is always accompanied by the same effects; he says that
no phenomenon has only one cause ; and he even goes so far

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as to say we fail to comprehend a world to which the concep¬
tion of cause and effect would not apply. How he reconciles
these contradictions in his own mind I shall not speculate, but
I am very sure that he will not succeed in reconciling them in
the mind of anyone else, except, perhaps, in the minds of Mr.
Bradley and his followers, or in the mind of a German of the
school of Hegel.

The most popular doctrine of Prof. Pearson’s is his distinc¬
tion between how and why , a distinction which is either the
cause, or the chief effect, of his theory of causation. He denies
that we can ever discover why a thing happens, or explain it;
and limits our powers to saying how it happens, or describing
it. In this he is demonstrably wrong. It is often as impos¬
sible to describe how things happen as to explain why they
happen : it is often as easy to explain why they happen as to
describe how they happen. The fact is that both how and
why are equivocal words, having more than one meaning ; but
whichever meaning we take, what I have said is true. How
may mean in what manner, or it may mean by what means.
Why may mean for what purpose, or it may mean in obedience
to what law, in conformity with what rule. In any of the four
cases the answer may be easy, or difficult, or impossible ; and as
to either how or why , we may be able to answer one meaning
and not the other. If, for instance, we ask how, in the sense
of by what means, gravity acts, we cannot answer. It is im¬
possible to imagine by what means a body can attract another
through an immeasurab y great distance. It is only when we
ask how, in the sense of in what manner, gravity acts that we are
able to answer that it acts inversely as the square of the dis¬
tance. If we ask why, in the sense of with what purpose, the sap
circulates in the tree, we have no difficulty in explaining that
it is that the sap may be aerated, the tree nourished, its life
maintained, and its growth increased. It is only when we ask
why, in the sense of in conformity with what law, the sap cir¬
culates, that we are unable to answer. We do not know
whether it is capillary attraction or what it is.

A good example of the manner in which Prof. Pearson poses
as a superior being is the advice he gives to his readers,
to analyse what is meant by such statements as that the
law of gravitation causes bodies to fall to the earth. The
law, he says, really describes how bodies do fall. Of course

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it does ; but before Prof. Pearson gave this advice to his
readers, he should have shown some evidence that some one
besides himself had ever said such a silly thing. As far as I
know, no one has ever pretended that the law of gravitation
causes bodies to fall to the earth ; but if anyone should say
that the fact of gravitation—the fact that they attract each
other—causes bodies to fall to the earth, he would say what is
exactly and punctually true. The law of gravitation describes
how bodies fall: the fact of gravitation explains why they fall ;
and the explanation is as good and as valid as the description.
As far as I know, Prof. Pearson never answers the actual argu¬
ments of real antagonists ; and if he prefers the easier task of
answering silly arguments that he puts into the mouth of an
imaginary antagonist, then, whatever we may think of his
courage and sincerity, we cannot question his wisdom.

Mr. Bertrand Russell follows Professor Pearson in denying
the existence of causes. He says there are no such things.
He wants the word abolished, and regards the law of causation,
or, as he calls it, of causality, as a relic of a bygone age. To
prove this contention he selects from Baldwin’s Dictionary the
definitions given therein of Causality, of the notion of Cause
and Effect, and so forth ; he takes one of Mill’s definitions of
Causation, and an expression of Bergson’s, and analyses them
all destructively.

All these expressions assume, and Mr. Russell repeatedly in
his own expressions assumes, that repetition of instances is
necessary before we can identify causation, and I think it is
not too much to say that he regards recurrence or repetition as
a necessary element, either in causation itself, or in our idea of
causation. The definitions that he quotes all countenance
this supposition. They run : Whenever the cause ceases to
exist; whenever the effect comes into existence ; the Law of
Causation is invariability of succession ; the same causes pro¬
duce the same effects ; a certain phenomenon will not fail to
recur ; and so on ; and he himself says that an ‘ event ’ in the
statement of the law is obviously intended to be something
that is likely to recur ; and he makes this the basis of his
criticism. Criticism directed against such notions of causation,
however destructive of them it may be, is not relevant against
a definition of cause or of causation into which the element of
repetition or recurrence does not enter. To me, repetition or

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recurrence is not a necessary ingredient, either of causation
itself, or of my idea of causation, and therefore against my
definition Mr. Russell’s attack is not directed ; but even against
the definitions that he does attack, erroneous as I believe them
to be, his criticisms do not appear to me to be destructive, or
even damaging.

Thus he confutes the succession in time of cause and effect,
or that antecedence and consequence on which Mill and his
school lay so much stress : ‘ No two instants are contiguous,
since the time series is compact.’ I cannot see that the
conclusion follows from the premiss. It seems to me that the
more compact the time series, the more closely contiguous must
be its instants. If Mr. Russell means that time is continuous,
and not made up of instants separated from one another by
intervals that are not time, or in which there is no time, I
should agree with him ; but it is only in such an interrupted
time series that the instants would not be contiguous. An
instant, like an hour or a day, is a portion of time arbitrarily
divided by an imaginary limit from that which precedes and
that which follows, with both of which it is continuous or
contiguous. But if Mr. Russell is right, and no two instants
are contiguous, and if serial contiguity in time between cause
and effect is necessary to causation, then this settles the
question : then causation is impossible, and Mr. Russell’s
further argument is redundant, supererogatory, and unneces¬
sary. But he does not think so, for he goes on : ‘ Hence
either the cause or the effect or both must, if the definition
[Baldwin’s definition of Cause and Effect] is correct, endure
for a finite time . . .’ I agree that both the cause and the

effect must endure for a finite time, though I do not see how
this follows from the supposition that no two instants of time
are contiguous. ‘ But then we are faced with a dilemma : if
the cause is a process involving change within itself, we shall
require (if causality is universal) causal relations between its
earlier and later parts ; moreover, it would seem that only the
later parts can be relevant to the effect, since the earlier parts
are not contiguous to the effect. Thus we shall be led to
diminish the duration of the cause without limit, and however
much we may diminish it, there will still remain an earlier part
which might be altered without altering the effect, so that the
true cause, as defined, will not have been reached.’ This may

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or may not be an effective criticism of a definition of cause
and effect that defines them as contiguous in time, but to me
it is too much like the old problem of Achilles and the tortoise
to be convincing. Zeno proved quite satisfactorily that Achilles
could never overtake the tortoise—only he did ; and Mr.
Russell proves less satisfactorily that there is no such thing as
causation, but yet he, in common with the rest of us, always
acts on the supposition that there is such a thing, and, so
acting, he never meets with experience that contradicts the
supposition ; and this is for us the conclusive and inescapable
proof, first that the supposition is true, and second that Mr.
Russell is convinced that it is true.

He goes on to show that if cause and effect are not con¬
tiguous in time, then there must be an interval between them ;
and ‘since there are no infinitesimal time intervals’ this lapse
of time must be finite. But if there is a finite interval of time
between cause and effect, something may happen in that
interval to prevent the effect following the cause. It is all
very pretty word spinning, and for all I know it may apply
to the kind of ‘ causality ’ that occurs in the moon, or in a
universe of one dimension, but it has no relation whatever tc
causation as it is known on this earth. Mr. Russell assumes
that effect follows cause in the sense of what carpenters call a
butt joint, in the sense that the effect does not begin until the
cause has ceased to act. That may be what happens in some
other universe, but it is not what happens here. What happens
here is quite different, as Mr. Russell might have known if he
had considered an actual case of causation instead of specu¬
lating with e v e. 2 , . . . e n , and t lf t 2 , . . . t n , and r. When,
for instance, a man pushes a trolley, he causes it to move. The
pushing is the cause, the movement is the effect. But the
effect is not postponed until the cause has ceased to act. The
effect does not come suddenly into existence at an instant
contiguous to the cessation of the cause. The effect begins as
soon, or almost as soon, as the cause begins; thereafter,
cause and effect, the pushing and the movement, accom¬
pany one another, and proceed contemporaneously for a
certain time ; and at length, when the cause ceases, the
effect ceases. Cause is contiguous to effect in this case,
not end to end, but side by side for the greater portion of their
duration. The joint is not a butt joint but a fish joint ;
lxii. 3

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and all Mr. Bertrand Russell’s pretty word spinning goes for
nothing.

His own statement of ‘ causality,’ cannot, he says, be put
accurately in non-mathematical language ; the nearest approach
would be as follows : ‘ There is a constant relation between
the state of the universe at any instant, and the rate of change
at which any part of the universe is changing at that instant,
such that the rate of change in the rate of change is determinate
when the state of the universe is given.’ It is with diffidence
that I comment on this mysterious formula, but it seems to
me clear that if anything can be discovered by its means, it is
not the cause of a change, but the rate at which a change takes
place, or rather the rate of change in a rate of change ; which
may be a desirable thing to know, but by no perversity of
ingenuity can be twisted or tortured into a cause. But sup¬
pose the impossible to be true, and suppose that no cause of
anything can be discovered or assigned unless and until the
state of the whole universe is known ; then it is clear that no
cause of anything ever has been discovered or ever can be dis¬
covered, for we can never know the state of the whole universe.
But in fact many causes of many things are known, and more
are being discovered every day. I know, for instance, that
pushing a trolley is a cause of the movement of that trolley.

I know that reading such disquisitions as Mr. Welton’s, Pro¬
fessor Pearson’s, and Mr. Bertrand Russell’s, are among the
causes of the estimate I have formed of philosophers. Mr.
Bertrand Russell may be a great mathematician, Professor
Pearson a great statistician, and Mr. Welton a great authority
on education ; but there is a certain proverb about the cobbler
and his last that I would commend to the notice of all three.
It may be that I must determine the state of this earth, and
of everything upon it, in it, and around it ; of all its continents,
seas, rivers, lakes, and islands ; of all its minerals, from the coal
to the diamond ; of all its vegetables, from the bacillus to the
oak and the orchid ; of all its animals, from the spirochaete to
the whale ; of all its human inhabitants, from the Bushman to
Mr. Russell himself; and beyond this, of all the solar system,
with its planets, planetary streams, satellites, and comets ; of
all the stars which we call fixed, with their temperatures, posi¬
tions, sizes, movements, and chemical composition—it may be
that 1 must know all these things with accuracy before I can

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discover what it is that is tickling my nose ; but for my own
part I don’t believe it. In fact, I do not know all these things,
I know only some of them, and I have already discovered the
cause. No doubt Mr. Bertrand Russell knows best, but my
own private belief is that though mathematics cannot err,
mathematicians can.

The last view of causation that I shall examine is Dr.
McTaggart’s, which I select because it is the latest to be pub¬
lished, having appeared only last July. Like Mr. Russell, he
calls it causality, which, to be sure, is a more imposing term ;
but sometimes he fails to maintain the philosophical nomen¬
clature, and drops back into common causation. For thorough
mystification, and for the most extreme departure from plain
meaning and common sense, Dr. McTaggart runs Mr. Bertrand
Russell very hard. According to Dr. McTaggart, ‘ causation
is a relation of implication between existent realities—or to
put it more precisely, between existent substances.’ This does
not on the face of it afford us much help in understanding what
causation is, but unlike most philosophers, Dr. McTaggart defines
his terms, and for this one cannot be sufficiently grateful to him,
not only on general grounds, but also for the surprising meanings
that he shows lurk unsuspected in the most ordinary terms. A
substance, for instance, according to Dr. McTaggart, is anything
that can have qualities and relations ; so that, for instance, the
battle of Waterloo and a flash of lightning are substances in the
McTaggartian sense. This is a bit startling, but definitions are
so rare in philosophy that we must be thankful for any we can
get, even if they leave us more mystified than before. The
battle of Waterloo is presumably not only a substance but also
an existing substance in the McTaggartian world, though to the
rest of us it ceased to exist a hundred years ago. Causation,
then, is a relation of implication between such existing sub¬
stances as the battle of Waterloo and a flash of lightning; but
what is a relation of implication ? Here again Dr. McTaggart
comes to the rescue with a definition. A relation of implica¬
tion is a relation between two propositions, P and Q, such that
P implies Q, when, if I know P to be true, I am justified by
that alone in asserting that Q is true, and, if I know Q to be
false, I am justified by that alone in asserting P to be false.

So far, so good, but still we are a long way from attaining a
clear idea of causation ; but Dr. McTaggart is not done yet.

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‘ Strictly speaking,’ he says, ‘ implication is a relation between
propositions or truths [is a proposition, then, necessarily true ?]
and not between events. But it is convenient to extend our
use of it, so as to say that if one proposition implies another,
then the event asserted in the first implies the event asserted
in the second [but how if neither of them asserts an event ?].
It is in this sense that the cause implies the effect’—causes it,
in fact. The jump from propositions to events is a bit start¬
ling to those who are not accustomed to the proper meaning of
realities and substances, but interpreting these expressions to
the best of my ability, I gather that when we say the cause
implies the effect, we mean that if the cause is true the effect
is true, and if the effect is false the cause is false. But what
on earth is the meaning of a cause or an effect being true or
false ? It does not appear that by a true cause Dr. McTaggart
means the causa vera of the Schools, but what he does mean I
cannot conjecture ; and supposing this difficulty to be cleared
up, what is the meaning of a false effect ? Is it an effect that
never happens ? or is it an effect that is wrongly attributed
to a certain cause? or is it something else? It is to be re¬
gretted that Dr. McTaggart has not supplemented his definitions
with others, explaining the meaning of these terms. In this
difficulty the only practicable expedient is to clothe the expres¬
sion in circumstances—to apply the general rule to an individual
case.

I take, therefore, two propositions, Brutus killed Ccesar , and
Brutus and Ccesar were contemporaries, which stand in a rela¬
tion of implication ; for if P, or Brutus killed Caesar, is true,
then we are justified by that alone in asserting the truth of Q,
that they were contemporaries ; and if Q, or Brutus and Caesar
were contemporaries, is false, then we are justified by that alone
in asserting the falsity of P, that Brutus killed Caesar. This
specimen fulfils all Dr. McTaggart’s conditions. The relation
is undoubtedly a relation of implication ; and the killing of
Caesar by Brutus is a substance, for it can have qualities, such
as treachery, unexpectedness, rapidity, and so forth. It does
not seem to me to be an existing substance, it is true, but it is
as much an existing substance as the battle of Waterloo. The
contemporaneousness of Brutus and Ctesar is a relation, and
therefore this also is a substance, and to the same extent as
the other is an existing substance. All the conditions being

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satisfied, we may therefore predicate a relation of causation
between these two existing substances; but now our difficulties
begin, for I cannot understand whether the fact that Brutus
killed Caesar caused them to live at the same time, or whether
the fact that they were contemporaries caused Brutus to kill
Caesar. If the latter, why did not all his other contemporaries kill
Caesar? and why did not Caesar kill Brutus? If the former,
what caused Brutus and Caesar to have so many other contem¬
poraries ? I have puzzled over these problems till my brain
is almost turned, and I am no nearer a solution, and am
obliged to give them up. I doubt whether anyone but Dr.
McTaggart could solve them ; and a method which is useless
in the hands of everyone but its inventor is never likely to
become popular.

Dr. McTaggart arrives at certain other conclusions that are
interesting. He decides that there is no reason to believe ‘ that
a cause exerts an activity or an effect.’ What is meant by a
cause exerting an effect I do not know, and another definition
would be useful here ; but if Dr. McTaggart means that a
cause does not produce an effect, then I respectfully submit
that it is not a cause. Moreover, if a cause does not exert an
activity, it is only because it is an activity, or more properly an
action. Cause and activity can no more be divorced than heat
and motion, or solidity and resistance. Dr. McTaggart decides
that cause and effect are not identical, a discovery that will not,
I think, startle anyone but Mr. Welton ; that the effect is not
necessarily subsequent to the cause, and, indeed, he is not quite
sure that the effect may not sometimes come first, and the cause
follow after it; and at last he declares, in despair it seems to me,
that though cause and effect are not identical, yet there is no
means of knowing which is which, or at any rate, there is no clear
distinction between them; and therefore, though we may speak
of causal relations as existing between two terms, yet we ought
not to speak of one of those terms as cause, and of the other
as effect. I think we may legitimately complain that Dr.
McTaggart does not tell us what we ought to call them.
Ought we to call them both X, or the one X and the other Y ?
Ought we to call the one beef, and the other Yorkshire pudding?
Or ought we to call the one petticoat and the other trousers ?
Dr. McTaggart gives us no guidance, and the reader must
choose for himself.

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The lecture in which Dr. McTaggart expounded these views
was delivered at Newnham College, presumably to an audience
of young women, and I trust he developed to them his views of
the impropriety of naming the related terms when describing
relations. He convinced them, I trust, that it is convenient to
speak of the relation of marriage, but inconvenient (and per¬
haps improper), to speak of bride and bridegroom, or of husband
and wife ; that it is convenient to speak of parentage, but not
of parents or of children ; that it is convenient to speak of the
relation of cousinhood, but that they should never allow them¬
selves to use such expressions as Harry or Mary.

In concluding this survey of certain theories of causation, I
beg to assure the reader that they are stated with accuracy, in
the ipsissima verba of their authors. They are not garbled,
altered, or modified in any way. Everything material has been
stated, and nothing has been mis-stated. They are not the
theories of Laputa, nor are they the ravings of Bedlam. They
are not jokes, nor are they intended for caricatures. They are
the serious attempts of philosophers of position and repute to
solve a simple problem that every ploughman and artizan,
though he may not be able to put his solution into words, has
solved in practice for ages. Carlyle, in his genial way, charac¬
terised a certain philosophy as pig-philosophy. I should qualify
the philosophers’ treatment of causation with the name of
another domestic animal, unlike a pig in that its hoofs are not
cloven, nor its long ears drooping.

My view is that when we common people who are not
philosophers speak of causation, and, as we do in spite of Dr.
McTaggart’s warning, of cause and of effect, we attach to these
words very positive and downright meanings. We feel and
know that in seeking for causes, in noting effects, in trying to
identify causation, endeavours that occupy the greater part of
our lives, we are not pursuing an ignis fatuus , but we are doing
that without which it is impossible for men to live profitably,
nay, it is impossible for them to live at all. If we have no
very clear notion of what we mean by cause, effect, and causa¬
tion, this want of precision, which is largely due to the fog in
which they have been enveloped by philosophers, does not
interfere with our practical pursuit of them. If the plain man,
immersed in practical affairs, cannot precisely define what he
means by these terms, neither can he define precisely the

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meaning of capital, of labour, of rent, of interest, of life, of
death, of disease, or of hundreds of other terms that he uses in
his daily work, and that represent things of the utmost moment
to his welfare, his happiness, and his life. But because he can¬
not define them, is he therefore to say that the things they
stand for have no existence ? that they are empty words, that
represent nothing outside his own misguided imagination?
This is the conclusion to which philosophers are driven by their
inability to define cause and effect. On the same ground, and
for the same reason, they should deny the existence of life and
death. This is the result of living in the moon, and ignoring
all the efforts of the toiling millions of mankind. The only
way to discover the meaning of cause and effect is—to find
out what men mean by them ; and we shall not do this by
word-spinning ; by pretending a difference between connection
and conjunction ; by denying the existence of force ; by con¬
tradicting ourselves twenty times over ; by calling sequence
simultaneity, and simultaneity identity ; by posing oracularly
as embodied science ; by ingenious puzzles about the divisi¬
bility or indivisibility of time ; or by defining that which is easy
to understand by that which is impossible to understand. No.
To find the meaning of cause and effect, and of cognate terms,
we must come out of the moon, and go, not merely into the
laboratory and the observatory, but into the home, the kitchen,
the workshop, the factory, the garden, the field, and all the busy
haunts in which men and women are all day long seeking
causes, studying effects, and watching the course of causation.

Summary.

Hume’s denial that force or power exists, and that there is
any connection between cause and effect, is based on faulty
reasoning, and in the light of modern psychology cannot be
sustained. He himself so defines causation as to assert a
necessary connection between cause and effect.

Mill’s treatment of the subject is confused, wavering and
contradictory. He defines cause and causation many times
over, and never adheres to one definition. Generally, he follows
Hume in identifying causation with invariable antecedence and
sequence, but he does not adhere to this, nor to any, opinion.

Mr. Welton denies that antecedence or sequence, or any time

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element, enters into causation. In place of the time element
he asserts that contiguity in space is necessary to causation.
From this he argues that cause and effect are not in sequence,
but are simultaneous; and at length decides that they are
identical. His reasoning is inconsequent, and his conclusions
are opposed to universal experience and to common sense.

Professor Pearson follows Hume and Mill in denying any
enforcement of the effect by the cause, and in regarding causa¬
tion as invariable sequence. He also denies the occurrence of
causation, and says it is meaningless ; nevertheless, he quotes
with approval the law of causation, and asserts that some
sequences are inevitable. His treatment of the subject is as
self-contradictory as that of Hume and Mill.

Mr. Bertrand Russell, like Prof. Pearson, denies the existence
of causation, and like him formulates a law of causation, which
is not a law of causation. It is so expressed as to require,
before we can determine what Mr. Russell calls the cause,
which is in fact not the cause, of anything, a knowledge of the
whole universe.

Dr. McTaggart defines causation as a relation of implication
between existing substances. Application of the definition to
a test case shows that the definition is absurd, and affords no
guidance in practice*

In conclusion, it is suggested that the inability of philoso¬
phers to define causation in consistent and intelligible terms
argues, not that causation is imaginary, but that philosophers
are incompetent.

* Nevertheless, a leader of the Germanised school of philosophers refers to Dr.
McTaggart’s essay in the following terms: “The greater part of what he says
possesses, as one would expect from him, an almost convincing lucidity and
vraisemblance.” Lucidity and vraisemblance I Well, well! And convincing!
Heavens 1

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CHAPTER II.

EFFECT, REASON, RESULT, CAUSE.

The subject we are about to examine is the relation of
causation, and a relation comprises three things—the two
terms, and the link that relates them, and unites them in a
relation. The link is usually called a relation, which thus
becomes an ambiguous term, standing both for the link, and
for the triple whole of term—link—term. I have therefore, in
my New Logic, called the link the ratio. Mr. Bertrand Russell,
in a recent publication, calls it the relating relation, which is
possibly a better term, but is at any rate longer. The terms of
the relation w r e are about to examine are Cause and Effect, and
the ratio or link which binds them together and unites them in
a relation is Causation or Effectuation, according to the point
of view from which we regard it. It will be convenient to
begin our examination with the terms, and we may select
for this purpose either term we please. I shall begin with
effect.

The first thing, then, to settle is what is an effect ? What
do we mean, what do we think of, what have we in our minds,
when we use the term effect ? I think it is indisputable that
the idea of effect is inseparably connected with the idea of
change. Changes may be contemplated in and by themselves,
as changes and no more; and this is how we contemplate
changes to which we are well accustomed, such as the change
from day to night, and from night to day, the change from rain
to sunshine, and from sunshine to rain, the changes in the face
of the sky, the growth of herbage, the change from heat to cold
and from cold to heat, and all the customary changes of Nature.
These changes we may, and usually do, contemplate merely as
changes, without feeling any compulsion or need to regard them
as effects also, or to look behind them for their causes. But then
these changes are, in a sense, not changes to us. They are parts
of a routine, a changing routine, but a routine whose changes are
customary, and part of the routine ; a routine that, as a routine,
does not change, or changes but little. In such changes the
change to us is minimised, and the greater change would be if

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the regular routine should cease to change. The changes that
are changes to us, that impress us as changes, are not the
regular customary changes of the routine, but the breaks in the
routine. But any change that impresses us as change, any
break in our customary routine of changes, especially if it is
rapid, and more especially if it is sudden, carries the mind
irresistibly to the notion of cause, and impresses us as an effect.
In such cases change is identified with effect, or, if not iden¬
tified, is inevitably associated with effect. It is true that in
contemplation we can separate them. We can contemplate a
change either as change pure and simple, or as effect; but
though separable in contemplation, in occurrence they are
inseparable. Just so we may contemplate gold without taking
into account its specific gravity, or we may contemplate it with
reference to its specific gravity; but whether we choose so to
contemplate it or not, we know that its specific gravity is
inseparable from it. Whether we regard a change as simply a
change, or whether we regard it also as an effect, or whether
we regard it primarily as an effect, depends on the way we
choose to contemplate it. How close is the association between
change and effect is conspicuously displayed in the case of an
unaccustomed noise. When we hear a noise, especially a
sudden and loud noise, to which we are unaccustomed, the
natural and inevitable reaction is What’s that! And in putting
to ourselves this question, we do not mean, as the form of the
question seems to imply, What is the nature of that noise ?
That we already know. Our meaning is What is the cause of
that noise ? Instantly and inevitably the mind passes from
change to cause, and regards the change as an effect; and so
it is with every change to which we are unaccustomed, that is,
with every change that impresses us as change.

On the other hand, we do not, except in special cases that
will be examined directly—we do not seek for a cause for
things remaining unchanged, or regard want of change as an
effect. If, upon waking in the morning, or on entering a room,
we find the position of the furniture and all the other objects
the same as when we last saw them, we do not look upon their
unchanged position as the effect of anything, or seek for a
cause for it. When we come home after an absence, and find
the house, the trees, the bushes, the lake, and the distant hills,
all as we left them, we do not associate this want of change

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with causation, nor do we regard it as an effect. It needs no
accounting for, no attribution of cause.

This is the general rule. Every change may be contemplated
as an effect, and will be so contemplated in proportion as it is
unusual, for unusualness is what logicians would call the essence
of change; that is to say, it is the element in change that
attracts our attention, and impresses us. It is what to us
constitutes change. A change that happens continually soon
ceases to be contemplated as change. It becomes to us a
continuity, and the change to us is when it stops—when the
clack of the mill ceases, when the roar of the streets subsides,
when the train arrives at the terminus. But if we choose so to
regard it, every change is an effect.

It does not follow, however, that every effect is a change.
As a rule, no cause is assumed for the want of change, or for
things remaining the same ; but this rule has very important
exceptions, constituted by the circumstances we have just
considered. There are cases in which we do assume a cause
for the retention by a thing of its state unchanging, cases in
which we regard the absence of change as an effect. There are
two such cases.

When a change is customary, and yet does not take place,
we assume that the absence of change is the effect of some
cause. The weather, for instance, in this country changes so
frequently, and change in the weather is become so much a
part of our customary routine, that when a change in the
weather takes place, we forget to regard it as an effect; but
should the weather remain uninterruptedly stormy, or dry, or
wet, for six months together, we should at length be driven to
assume a cause for this want of change, for the want of change
would be itself a change in the routine to which we are
accustomed.

The second case is when we know of forces in operation
tending to produce a change which yet does not take place. In
such a case, if our attention is called to the operation of such
forces, we inevitably assume a counter-cause for things remain¬
ing unchanged, and regard this want of change, or unchange,
as an effect. If we pull the handle of a drawer, and the drawer
yields and opens, we regard the change in the position of the
drawer as the effect of the pull; but if we make no attempt to
open the drawer, we do not regard its remaining closed as the

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effect of anything. As there is no change, and nothing tending
to produce change, there is no effect. But if we pull the drawer
and it does not move, then the want of change, in circumstances
tending to produce change, at once becomes an effect, and
carries the mind irresistibly to the necessity of a cause. When
the mercury in a cup remains level, we do not regard the main¬
tenance of the level as an effect, for it is no change from the
customary behaviour of mercury; but when the mercury in a
Torricellian tube remains high above the level of that in the
cup, we do at once assume that this is the effect of some cause;
for the unchanging state, or briefly the unchange, is maintained
in spite of a cause—the weight of the mercury—that we know
is tending to change it.

We are driven by these considerations to regard change as a
necessary element in our concept of effect, and if we first for¬
mulate the definition that

An Unchange is the maintenance of an unchanging state in spite
of forces in operation tending to change it,

Then we may formulate our provisional definition of effect in
the following terms:

An Effect is a change or an unchange.

Reason.

Between these two kinds of effect there is a clear difference,
which is easily distinguished, which is generally felt, and which
is, in fact, embodied in language; for while we always call that
which produces a change the Cause of the change, we usually
do not give this title to that which opposes a change. This
latter we usually call a Reason. The variations in the height
of the barometer are caused by variations in the pressure of the
air; but the constant pressure of the air is the reason why the
mercury does not sink to the level of the cup. The pull we
exert on the handle of the drawer is the cause of the drawer

opening: the drawer being locked is the reason it does not yield
to the pull. It would be quite inappropriate to say that the
changes in the weather are due to some reasons: but it would
be quite appropriate to say there must be some reason why the
weather does not change. It would seem that the full force of

effectuation is felt only when the effect is change, and that
when it is unchange the effectuation is felt to be attenuated and
diminished ; so that we may add to our definitions the following:

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The cause of an unchange is called a Reason.

The definition of an effect as a change or unchange is
avowedly provisional, and needs to be completed. As already
explained, the nature of a thing, as it appears to us, depends on
the way in which we contemplate it. We may, if we please,
contemplate a change or an unchange in and by itself, merely
as change or unchange, without contemplating it as an effect.
In order to constitute it an effect, a change or unchange must
be contemplated from a special point of view, that is to say,
with reference to its causation. To become an effect it must
be associated in our minds with causation and a cause ; but as
we have not yet arrived at any definition of these terms, it
would not be legitimate to use them in defining effect. Still,
we may legitimately go as far as this: we need not, and do not,
always contemplate a change as an effect, but when we do regard
it as an effect we always contemplate it in relation with some
antecedent action on the thingchanged. We need not regard an
unchange as an effect, but if we do so contemplate it, we con¬
template it in relation with some action that maintains the thing
unchanged. We may therefore develop our definition into this:

An Effect is a change or an unchange connected with an action
on the thing changed or unchanged.

Still the definition is not complete. A cup may fall and
break. The fall of the cup is a change produced on the cup,
and is an effect. The impact of the cup on the floor is an action
on the cup, and is connected with the fall; but the impact of
the floor on the cup is not the cause of the fall; and why not ?
Evidently because it succeeds the fall. The cause of a change
must be sought in some action that precedes the change; it is
no use looking among the consequents for the cause. Most
writers on causation have been able to appreciate this, and
since the cause of a change must always precede the change,
they have muddled up causation with antecedence, and declare
that they are the same thing. They are not. Antecedence
often goes with causation, but there are many cases of causation
in which the cause does not precede the effect; and there are
many antecedents of a change that are not its causes; and to
identify causation with antecedence is a gross blunder, whether
the antecedence is invariable or not.

When the mercury in a Torricellian tube remains high above
the level of that in the cup, the pressure of the air, which is the

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action that maintains the unchange, does not precede the main¬
tenance of the unchange, which is the effect: it is continuous
with the unchange. It is contemporaneous with it. When the
action of the engine on the axles maintains the motion of the
motor car or the locomotive engine in spite of the forces in
action tending to arrest the motion, this action does not precede
the motion of the car or of the engine, but accompanies it.
The tension of a string that sustains a weight, and that is the
cause that prevents the weight from falling, does not precede
the suspension of the weight: it accompanies it. It begins at
the instant of suspension, it lasts while the suspension con¬
tinues, and it ceases the instant the string is cut and the weight
falls. It is true that the drawer may be locked long before and
long after it is pulled upon to open it; but it is not the drawer
being locked that is the cause of the unchange : it is the resist¬
ance of the tongue of the lock; and this resistance begins and
ends with the pull upon the drawer.

A time element, or time relation, of one kind or the other is
therefore a necessary and indispensable element in the definition
of effect, but the time relation is manifestly not the same in the
two kinds of effect, and therefore effect cannot be defined in a
single expression. The complete definition of effect must run
something as follows:—

An Effect is a change connected with a preceding action, or an
unchange connected with an accompanying action, on the thing
changed or unchanged.

Result.

* Some phenomena,’ says Mill, ‘ are in their own nature per¬
manent ; having begun to exist, they would exist for ever unless
some cause intervened having a tendency to alter or destroy
them ... no object at rest alters its position without
the intervention of some conditions extraneous to itself: and
when once in motion, no object returns to a state of rest
. . . unless some new external conditions are superin¬

duced. It, therefore, perpetually happens that a temporary
cause gives rise to a permanent effect. The contact of iron with
moist air for a few hours, produces a rust which may endure for
centuries ; or a projectile force which launches a cannon ball
into space, produces a motion which would continue for ever
unless some force counteracted it.’

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As usual, Mill founds a general statement upon the cnumeratio
simplex, without taking into consideration the instantia contra-
dictoria. It is not true of living animals that they never alter
their position without the intervention of some condition
extraneous to themselves: the mere internal accumulation of
energy is enough. But passing that, and making the necessary
qualification, Mill’s limitation of the assertion to some pheno¬
mena, as if it were not true of all, is utterly unjustifiable. If
the first Law of Motion is true, if Mill’s own Law of Universal
Causation is true, that no event happens without a cause, it is
difficult to see how any change can take place in any ‘ pheno¬
menon ’ whatever without a cause ; and it seems clear that
not some phenomena only, but all phenomena whatever, are in
their nature permanent, and having begun to exist will exist for
ever, unless some cause intervenes to alter them. Mill adduces
these instances as instances of permanent effects ; but here he
is evidently using the word effect, which he never defines except
as an invariable consequent, in a popular sense, and in a sense
which even popular usage does not always sanction. According
to my definition, a permanent state is not an effect unless it is
an unchange ; and none of these is an unchange. Once at rest,
a body needs no cause to keep it at rest, unless there is some
action on it tending to move it; and without such action, its
remaining at rest is neither a change nor an unchange, and is
therefore not an effect. A body at rest needs a cause to set it
in motion, and the setting in motion, the change from rest to
motion, is an effect: but once in motion, its continuing in
motion is not an effect. When iron rusts, the rusting is an
effect, for it is a change from metallic iron to oxide; but once
it is rusty, there is no cause in action tending to change it back
again, and therefore its remaining rusty is not an effect. In
none of these cases does the effect continue. None of them is
a permanent effect. What Mill means by a permanent effect is
that iron once rusted does not change back again, and that a
man once killed does not come back to life again. It is a
manifest misnomer to say that if an effect is not reversed, the
non-reversal is an effect. It is true that in common speech it
is a frequent practice, but by no means an invariable practice,
to say that an effect continues, even when the effect is a change,
and to speak of the state of death and the state of rust as effects;
but these are not accurate expressions, are eschewed by accurate

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speakers, and are utterly unpardonable in philosophical writing.
What persists when a body is brought to rest or set in motion,
when iron is rusted, or a man is killed, is not the effect, not the
change, but the changed state—the new state that has resulted
from the change. A change implies a state from which and a
state to which the change is made, and the state brought about
by the change is a very different thing from the change itself,
which alone is the effect. The changed state is not the effect,
it is the result , and thus we arrive at a sixth definition:—

A Result is the changed state of a thing on which an effect has
been produced.

Cause.

The definition of effect, as a change or unchange connected
with an action, points straight to the nature of cause. I do not
think it is possible to imagine any change or unchange that is
not produced by the action of some agent. Of course, it may
be said that things may exist or occur, although we cannot
imagine them ; but we are not here dealing with transcendental
possibilities. We are dealing with events in this world as we
know them in experience, and our experience is such that we
can no more imagine change to be produced or prevented
without action upon the thing changed, than we can imagine
resistance without extension, force without matter, or solid
without surface. In each case the one presupposes the other.
The only consideration that can be plausibly advanced against
this view is, I think, that we regard some changes as spon¬
taneous. But by a spontaneous change we do not mean a
change produced without action on the changing thing, we
mean a change due to the action of the changing thing itself,
as contrasted with change due to the action upon it of some¬
thing outside the changing thing.

The only formal repudiation of this doctrine is that of
Hume, which has already been examined. Hume taught that
there is no such thing as force or power, which I here call
action ; that it exists only in our imagination; that the notion
we have of it rests upon no evidence, and corresponds with
nothing in the external world. His reason for this opinion was
that we gain our notion of force or power not from any single
individual experience, but as a generalisation from many
experiences; and he thought that in this it contrasted with

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our notions of resistance, extension, and motion. We now
know that in this he was mistaken. All such notions are
generalisations from many experiences, and the notion of force
or power is not singular in this respect, does not differ in this
respect from other primitives, nor is it invalidated, as a true
representation of externals, by being a generalisation.

But all Hume’s discussion of its origin is beside the ques¬
tion. Whatever its origin, it is indisputable that we have this
notion of force, or power, or action, and that we regard it as
having a real existence in the world outside of us; and the
crucial test is this : that we act upon the assumption that it
does exist, and that the consistent action, on that assumption,
of the whole human race has never brought anyone up against
experience that contradicts the assumption. This is the ulti¬
mate and unimpugnable test of empirical truth. This test
being satisfied, it is quite out of our power to doubt that the
assumption is true. We may in words express a doubt, or
even a denial, for language was acquired by man in order that
he might deny his beliefs; but in fact we do not and cannot
doubt it. It is quite possible to deny in words that matter
exists, that there is an external world to be appreciated, and
that we have minds to appreciate it with ; it is quite possible
to deny that things that are equal to the same thing are equal
to one another; but the test of belief is action ; and when we
come to act, we act in conformity with the beliefs which we
deny, and prove by so doing that our denial is a sham and an
imposture—an imposture that does not impose even upon
ourselves.

We may take, therefore, as our first provisional definition of
a cause:

A Cause is an action.

Though we may speak of change and of unchange in isolation
and abstraction from other things, yet in thinking of change
or unchange it is impossible to expel from our minds the
notion of a thing that changes, or that is prevented from
changing. Change and prevention of change alike imply a
changeable thing. That which produces change in a thing
cannot be thought of otherwise than as an action on that thing
either from without or from within. That which keeps a thing
unchanged in spite of something that is trying or tending to
change it, cannot be thought of otherwise than as an action on

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or by the unchanging thing. Hence, by a cause not only do
we always mean an action, but we always mean an action on
a thing. It is quite possible to entertain the notion of action
without taking into account anything acted on, as when we
contemplate the rotary action of the arms of a windmill; but
when we so contemplate an action we exclude from our minds
the notion of cause. Cause always carries with it the notion,
not merely of action, but of the transference of action from the
acting agent to the thing acted on, or the initiation of action by
the changing or unchanging thing; and the notion of cause is
not complete unless this transference or initiation of action is
taken into account. Hence we arrive at a further stage in our
provisional definition of cause :

A Cause is an action upon a thing.

But not yet is our notion of cause complete. We may
contemplate an action upon a thing in and by itself, without
letting our contemplation run forward to the consequent
change or prevention of change in the thing acted on; and
unless we do thus extend our contemplation, our notion of
cause is incomplete and unformed. When we contemplate
the action of a breeze blowing upon a rock, we do not, or need
not, regard this action as the cause of any change or unchange
in the thing acted on. To complete our concept of cause, we
must add to the provisional definition a reference to the change
or unchange that is connected with the action on the thing, and
develop our definition of cause as follows :

A Cause is an action connected with a change or unchange in the
thing acted on.

The pressure of steam in a boiler is an action on the boiler:
the rise in temperature of the boiler is a change in the boiler—
the thing acted on—and is connected with the steam pressure ;
but the pressure of steam is not the cause of the rise in the
temperature of the boiler: it is the other way about. The
pressure of the air is an action on the locomotive engine, and
it is connected with the unchange—the running of the loco¬
motive—for it increases with the speed; but it is not the cause
of the unchange. Evidently some further qualification is
required in the definition. Why cannot the pressure of steam
in the boiler be the cause of the rise in temperature of the
boiler ? Manifestly because the steam-pressure does not
precede, but follows the rise of temperature. Why is not the

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pressure of the air the cause of the running of the locomotive ?
Manifestly because, the running being an unchange, the pressure
of the air is not contemporanous with it. The pressure exerted
its action before the running began, and continued after the
running had ceased. In order, therefore, to accommodate our
definition to these considerations we must modify it as follows :

A Cause is an action connected with a following change or a contem¬
poraneous unchange in the thing acted on.

There are some usages that conflict with this doctrine. One
of these is that we often give the name of cause to that which
is not an action. We say the cause of the stoppage of a motor
car is a broken sparking plug, a leak in the water circulation,
grease in the commutator, dirt in the carburettor, and so forth.
Similarly, we say the cause of a man’s death is failure of his
heart to act; the cause of the stoppage of the machinery is the
the stoppage of the engine; the cause of the stoppage of the
engine is the fire going out; and so forth. In each the cause
is not an action, but is the cessation of action, or the agent
which produces cessation of action; and in every such case,
the change, which is the effect, is the cessation of an unchange.
Now an unchange is the maintenance of a continuous state in
spite of the operation of forces tending to change it: and that
which we call the cause of the cessation of the unchange, or the
destruction of this continuous state, is not an actual cause, not
an action, but the removal or cessation of the cause of the
unchange. In each of the foregoing cases, what we call a
cause is really the removal or cessation of a cause. The un¬
changed motion of the car is caused by the action of the
sparking plug, of the water circulation, of the commutator, of
the carburettor; arrest any of these actions, and the running
of the car ceases, and ceases by the operation of causes—
friction, etc.—that were all along tending to stop it, and are now
permitted, by the cessation of the causes of the unchange, to
become effectual. Similarly, the life of man is an unchange,
maintained by the action of the heart in spite of causes in
action tending constantly to bring life to an end. Cessation of
the heart’s action does not kill the man, but allows him to die.
The movement of the machinery is an unchange, maintained,
in spite of causes tending to end it, by the action of the engine.
The stoppage of the engine does not stop the machinery, but
allows it to be brought to rest by friction and other resistances.

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It is scarcely consonant with our notion of cause to call the
cessation of action a cause, but, undoubtedly, in individual
cases that occur in experience, such as those that have been
instanced above, we do in fact regard the cessation of action
as a cause, although a stricter logic would compel us to look
upon it as the removal of a cause. If the latter view is to pre¬
vail, the last definition will stand as the final definition of Cause,
but if we are to fall in with current usage, our definition will
run:

A Cause is an action, or cessation of action, connected with a
sequent change or accompanying unchange in the thing acted on.

Another usage that conflicts with both of these definitions is
that of Mill and the logicians, as well as of other writers who
should know better, in speaking of things which are not actions
nor cessations of action as causes. It is fruitless to try to fix
responsibility for the practice, but I am afraid that ultimately
it might be traced to writers on Causation. A flagrant example
is afforded by writers on medicine, who still divide the causes
of disease into predisposing causes and exciting causes. Among
the predisposing causes it is usual to enumerate the age and
sex of the patient, the climate and locality of his residence, his
occupation, and so forth ; and none of these is an action, nor
is any of them a cessation of an action. Occupation is
indeed action, but it is not action upon the thing changed—
upon the patient. It is action by the patient, a very different
thing. It is evident that in calling these passive states causes
of disease, we are using the word cause in a very strained and
unnatural sense, and this is often acknowledged even by
medical writers themselves. Yet it is beyond doubt that these
states have an influence upon the effect. Certain diseases are
limited to a certain age ; others are limited to one sex ; others
are found to attack those only who live in certain localities or
pursue certain occupations ; and yet there is a felt and acknow¬
ledged incongruity in calling them causes. No one has ever
specified what it is that arouses this feeling of incongruity, but
I think there can be no doubt that it arises from the recognition
that they are neither actions nor cessations of action, and that
it is only to actions, and perhaps to cessations of action, that
the term cause can be properly applied. The connection that
these passive circumstances have with the effect, a connection
which is undoubted, and cannot be questioned for a moment,

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is that they are Conditions of the effect; and this leads us to
inquire into the meaning of Condition, and to ascertain in what it
differs from Cause.

Summary.

This Chapter is an examination of the relation of which the
two terms are Cause and Effect, and the ratio, or relating
relation, is Causation.

Effect is inseparably connected with the idea of change, and
every effect is that which impresses us as change or as the pre¬
vention of change. The latter is called an unchange. By
successive approximations we reach the definition that an Effect
is a change connected with a preceding action, or an unchange
connected with an accompanying action, on a thing.

The cause of an unchange is often called a Reason.

The changed state that is left when an effect has been pro¬
duced is called a Result.

By successive approximations we reach the definition that a
Cause is an action (or cessation of action) connected with a
sequent change or accompanying unchange of the thing acted
on.

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CHAPTER III.

CONDITION.

While it is generally understood that a cause and a con¬
dition are different things, and stand in different relations to
the effect, yet even in common speech and in practice they
are often confused, and writers on causation admit no dis¬
tinction whatever between them. Mill was the worst offender
in this respect, and his evil example has corrupted all subse¬
quent writers. I do not know of any writer on the subject
who formally distinguishes between cause and condition,
though all writers use both terms; but they jumble them up
together, sometimes using them interchangeably, and sometimes
assuming a difference without ever distinguishing them.

Whenever a distinction is made in common speech, we may
be pretty sure that it represents and indicates a distinction in
thought which the common user feels and appreciates, though he
is usually unable to formulate and define it. Not one person in a
thousand makes a mistake in the use of the phrases ‘ I did it ’
and ‘ I have done it,’ and not one person in a thousand could
formulate and explain the precise difference in the meanings
of the two. Whenever two different words or phrases are used
to express nearly the same thought, it will always be found
that they never express quite the same thought. It is, in fact,
impossible to keep two commonly used words in the same
language synonymous. They soon begin to take on different
meanings and to be used on different occasions, and gradually
the meanings diverge more and more. A familiar instance is
in the different meanings that now attach to large, big, great,
and gross. In the face of such common usage, the proper
attitude of a careful student of language and thought is not
to assume a haughty superiority to the commonalty who have
made the distinction ; not to assume, as Mill does, that it is
the mere confusion of ignorance and illiteracy, pretending a
difference where no distinction exists; but to examine, probe,
penetrate, and realise the thought that underlies the practice,
to discover the difference, and to clothe it in an appropriate
definition. Cotton stuffs are often confounded with woollen

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stuffs, to the disadvantage of the purchaser; but not on that
account ought the expert to persuade the purchaser that there
is no difference between cotton and woollen, and that he has
been all his life calling one thing by two names. A sure,
though not a clear, discernment has convinced him that there
is a difference, though he cannot say in what the difference
consists. A helpful guide would teach him how they are to
be distinguished. Mill, however, and every subsequent logician,
finding that the populace makes a distinction between cause
and condition, but is not very clear as to the nature of the
distinction, seek, not to find and formulate the difference
between them, but to persuade us that no difference exists.

That Mill did dimly, and in his fumbling manner, feel, rather
than recognise, that there is a difference between cause and
condition appears from his treatment of them. He says ‘ It
is very common to single out one only of the antecedents
under the denomination of Cause, calling the others merely
Conditions. . . . The real Cause is the whole of these ante¬

cedents: and we have, philosophically speaking, no right to
give the name of cause to one of them, exclusively of the
others.’ This, it may be observed, is his sixth definition of
cause, different from all the previous five. ‘ What, in the case
we have supposed [that of eating a particular dish and dying
in consequence], disguises the correctness of the expression,
is this : that the various conditions, except the single one of
eating the food, were not events, but states, possessing more or
less of permanency.’ Supposing this were the correct dis¬
tinction between causes and conditions, surely it is a distinction
worth making, and entitles them to separate treatment. Again,
he says f There is, no doubt a tendency to associate the idea
of causation with the proximate antecedent event rather than
with any of the antecedent states .’ If this is so, the obvious
duty of an investigator is to discover the reason and meaning
of this tendency, and this Mill seems to feel, for he gives a
reason, a very inconclusive reason, which explains nothing,
but still he gives one, ‘ the reason being that the event not
only exists, but begins to exist immediately previous ; while
the other conditions may have pre-existed for a considerable
time.’ * But though we may think proper to give the name
of cause to that one condition, the fulfilment of which com¬
pletes the tale, and brings about the effect without further

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delay; this condition has really no closer relation to the effect
than any of the other conditions has. All the conditions were
equally indispensable to the production of the consequent;
and the statement of the cause is incomplete unless in some
shape or other we introduce them all.’ ‘ The cause, then,
philosophically speaking, is the sum total of the conditions.’
Thus, after fluttering on the edge of finding a distinction
between cause and condition, he makes up his mind that they
are identical, and comes down with a flop on the wrong side.
It would be difficult to find an argument more perverse, and
the statements by which it is supported are nearly all of them
erroneous.

If, as Mill says, we think proper to give the name of cause
to one antecedent rather than to the rest, is it not manifest
that we do so because we recognise a difference between this
antecedent and the rest ? Why else should we single it out
for different treatment ? The bestowal of a separate and
different name is prima facie evidence that a difference is felt
to exist; and Mill, though he does not discover the true
difference, yet does discover a difference, and then treats it
as if it were non-existent. If a glass bottle is broken by the
blow of a stick, is it true to say that the blow of the stick has no
closer relation to the breaking of the bottle than the existence
of the stick, or the muscles of the arm of the man who struck
the blow ? And is the ‘ statement of the cause ’ of the fracture
of the bottle incomplete unless in some shape or other we
introduce the growth of the tree from which the stick was
cut, and the birth of the man who struck the blow ? for they
were * equally indispensable to the production of the conse¬
quent.’ ‘Nothing,’ says Mill, ‘can better show the absence
of any ground for the distinction between the cause of a
phenomenon and its condition, than the capricious manner
in which we select from among the conditions that which we
choose to denominate the cause.’ Never was assertion more
unwarrantable. As well might a man who is colour blind
assert that nothing can better show the absence of any ground
for the distinction between red and yellow than the capricious
manner in which we select from the yellows that which we
choose to denominate red. The distinction is there right
enough. Between cause and condition there is a distinction
that is perfectly clear and very useful, and that is none the

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less a clear and useful distinction because it is not always
observed; because we do not always need to observe it;
or because Mill and his successors are too blind to ob¬
serve it.

Mill says we have a ‘tendency’ to associate the idea of
causation with antecedent events rather than with antecedent
states. If this were so, it would be a distinction of sufficient
importance to warrant us in separating the events (causes) from
the states (conditions) and discussing them apart; and though
this is not the truth, yet it is an adumbration of the truth.
Mill would have been much nearer the mark, though he would
not have been within it, if he had said that we associate the
idea of effect with events. An event is that which comes out
of something else, and an effect is that which comes out of the
cause. An event, whatever else it may be, is a change, and as
we have seen, an effect is often a change, and is always asso¬
ciated with change. We do not necessarily associate the idea
of causation with either events or antecedence, but we may
associate it with an event if we contemplate the event as an
effect. Nor is it true that we associate the idea of condition
with * states possessing more or less of permanency ’ merely
because they are states and more or less permanent. The
state of activity of an engine is a state possessing more or less
of permanency, but we do not regard it as a condition of the
movement of the train. We regard it as the cause, and rightly
so regard it, because it is an action. A cause is an action, and
so to regard cause points to the difference between cause and
condition, for

A Condition is a passive state.

That is the true distinction between cause and condition.
Cause is active : Condition is passive. A cause is an action :
a condition is a passive state; not necessarily a permanent
state, though as a state it must have some endurance, even if the
endurance is but brief. One of the conditions of the discharge
of a gun is that the hammer must be at cock. This is a passive
state, but it is not a permanent state. It must, however, have
some endurance, even though the endurance may be but
momentary.

Clearly, however, the definition of a condition as a passive
state is not a complete definition with reference to any given
case of causation. There are many passive states of many

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things quite unconnected with the causation of any given effect.
The position of the hammer of a gun at half-cock is a passive
state, but it is not a condition of the occultation of Jupiter.
To complete the definition of a condition it is necessary to state
the connection of the passive state with the causation of the
effect. A cause is an action upon a thing, connected with a
change or unchange in the thing acted on. A condition is a
passive state: of what ? Of the thing acted on ? It would
seem so, for that is the only thing admitting of a condition
mentioned in the definition; and many instances can be adduced
of conditions which are passive states of the thing acted on.
The pulling of the trigger is the cause of the discharge of a
gun : the position of the hammer at full cock, and the presence
of a cartridge in the barrel, are passive states of the gun, the
thing acted on, and satisfy the definition of conditions. The
striking of a key on the piano is the cause of the sound of
the note. The tension of the wires and the integrity of the
mechanism are conditions of the occurrence of the sound : they
are passive states of the thing acted on. The application of
moisture to the flap of an envelope is a cause of the flap stick¬
ing. The presence of a film of gum on the flap is a condition
of the flap sticking: it is a passive state necessary to the occur¬
rence of the effect. In this case, we may regard the presence
of the film of gum as a state of the envelope itself, or we may
regard it, more accurately perhaps, as adjoining and in contact
with the envelope, but not a part of the envelope—a passive
state, not of the thing acted on, but of something about the
thing acted on. In other cases the distinction becomes clear.
The cause of a plant’s growth is the action of heat on the plant;
but the effect on the plant would not be produced but for a
condition—the existence of food within reach of the roots of
the plant. This condition is a passive state, not of the plant—
the thing acted on—but of the soil in which the plant grows,
that is, of something about the plant. The cause of the sound
of a bell is the action of the tongue on the bell: but this effect
would not be produced were it not that the bell is bathed in air,
and the existence of the air is a passive state, not of the bell,
but of something about the bell. The cause of a plant twining
up a support is the action of the plant in rotating about an
axis ; but the effect would not be produced but for the presence
of a support up which the plant could twine. The presence of

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the support is a condition of the effect, and is a passive state,
not of the plant, the thing which, acting on itself, produces the
effect, but of something about the plant. And so we find with
many other conditions, that they are passive states, not neces¬
sarily of the thing acted on, but of something about that thing.
Thus we must modify our first tentative definition of a condi¬
tion and say

A Condition is a passive state of or about the thing acted on by a
cause.

The definition is not yet complete, however. It requires
further limitation, for there are many passive states in and
about a thing acted on which yet are not conditions of any
effect produced by the action. The sun shines upon a wall,
and by its action warms the wall; and against the north side
of the wall rests a ladder. The presence of the ladder is a
passive state about the thing acted on, but it is not a condition
of the warming of the wall. A red-haired man takes medicine
in a room with a parquet floor and a painted ceiling. The
medicine produces its effect, but the red hair, the parquet
floor, and the painted ceiling, though they are passive states of
and about the thing acted on, are not conditions of the produc¬
tion of this effect. A fall of rain causes a road to be muddy :
the dust on the road is a condition of the road becoming
muddy, but the presence of a house by the side of the road,
though it is a passive state about the thing acted on, is not a
condition of the formation of mud. It is clear that a passive
state of or about the thing acted on need not be a condition
of the effect of that action, and is not a condition unless the
existence of the state is necessary to the effect, or material to
the effect. If a ship is careened by a gale, we may cause her
to right herself by taking in sail. The action of taking in sail
is the cause of the ship’s righting. But no taking in of sail
would cause this movement of the ship unless she were already
careened. The careening of the ship is a passive state of the
thing upon which the cause acts, and it is necessary to the
result. Being a passive state, it is not a cause ; and it will be
admitted that it would be an absurd misnomer to speak of the
careening of the ship as a cause of her righting herself. But
the careening is necessary to the righting. It is a condition,
an indispensable condition, of her righting herself. Hence we
arrive at the following complete definition.

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A Condition is a passive state of or about the thing acted on by
a cause, and material to the effect.

As an example of the confusion which he attributes to people
in general, but which really exists in his own mind, and scarcely
anywhere else but in the minds of his followers, Mill gives the
following example, which it will pay us to examine in some
detail:

* A stone thrown into water falls to the bottom. What are
the conditions of this event ? In the first place there must be
a stone, and water, and the stone must be thrown into the
water, but these suppositions forming part of the enunciation
of the phenomenon itself, to include them among the conditions
would be a vicious tautology.’ To include them all among the
conditions would certainly be erroneous, for the throwing of
the stone is not a passive state, but an action; and an action
directly concerned, as an action, with the effect. It is there¬
fore not a condition, but a cause. The existence of the stone
and of the water are certainly conditions, and are so according
to Mill’s own definition, for they are included in the sum total,

‘ the whole of the contingencies of every description, which
being realised, the consequent invariably follows.’ ‘ The next
condition is, there must be an earth : and accordingly it is
often said that the fall of the stone is caused by the earth; or
by a power or property of the earth, or a force exerted by the
earth, all of which are roundabout ways of saying that it is
caused by the earth ; or, lastly, the earth’s attraction ; which
also is only a technical mode of saying that the earth causes
the motion, with the additional peculiarity that the motion is
towards the earth, which is not a character of the cause but of
the effect.’ It would not be easy to find a better example of
Mill’s thorough muddleheadedness. No one with any sense of
propriety in the use of words, or with any attention to the
meaning of words, could possibly say that the earth was the
cause of a stone thrown into water falling to the bottom ; but
anyone who should say that the fall of the stone was caused by
a power of the earth, or by a force exerted by the earth, or by
the earth’s attraction, would assert precisely and accurately
what the cause is. These are not roundabout ways of saying
that the fall is caused by the earth : on the contrary, if anyone
were inaccurate enough, and slipshod enough, to speak of the
fall being caused by the earth, he would be using an elliptical

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expression, taking it for granted that his hearers would under¬
stand that he was using * the earth ’ for the sake of brevity,
instead of the power, or force, or attraction exerted by the
earth, or briefly, the action of the earth: in short, that he was
speaking of the agent as a cause when he meant the action of
the agent, a mistake not infrequent with uneducated people,
but one that makes us stare when we find it formally adopted
by the authoritative writer on causation.

‘ Let us now pass to another condition. It is not enough
that the earth should exist; the body must be within that dis¬
tance from it, in which the earth’s attraction preponderates
over that of any other body.’ Well, yes, so it must, for if not,
there would be no w'ater for it to sink in. At this rate a book
the size of Mill’s Logic would be needed to contain a list of all
the conditions necessary to the sinking of the stone. We should
have to go back to the geological conditions under which the
stone was formed: and so back to the primordial nebula that
gave rise to the solar system. ‘ Accordingly we say, and the
expression would be confessedly correct, that the cause of the
stone’s falling is its being within the sphere of the earth’s attrac¬
tion.’ It is cool of Mill to say that this expression would be
confessedly correct. I know not who has made the confession,
but I know that not the rack nor the thumbscrews would wring
such a confession out of me. Being within the sphere of the
earth’s attraction is not an action, and therefore cannot be a
cause of anything. It is a state, and for the purpose in hand
a passive state, and therefore is not a cause, but a condition.

‘ We proceed to a further condition. The stone is immersed
in water : it is therefore a condition of its reaching the ground,
that its specific gravity exceeds that of the surrounding fluid,
or in other w'ords that it surpass in weight an equal volume
of water. Accordingly anyone would be acknowledged to
speak correctly who said, that the cause of the stone’s going
to the bottom is its exceeding in specific gravity the fluid in
which it is immersed.’ Mill might make this acknowledgment,
but I doubt if anyone else would, and for my part I certainly
should not. According to the rule I have laid down, the
specific gravity, being a passive state and not an action, is a
condition, not a cause.

Mill sinned against the light. He was not ignorant of the
view here adopted: it was brought to his notice by a reviewer,

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*

and after examination he deliberately rejects it. The reviewer
says * we always apply the word cause rather to that element
in the antecedents which exercises force.' Thus he had the
temerity to defy Hume, and he came nearer than any other
writer to the view taken in this book. One of Mill’s instances
is ‘ The army was surprised because the sentinel was off his
post.’ He considers this as a justifiable and proper expression,
which no doubt it is, and that it means ‘ The cause of the
army being surprised was the sentinel’s being off his post,’
which it does not, or does not necessarily. Mill, though he
always expresses himself clearly, rarely expresses himself
accurately, and here he is inaccurate. ‘ Because ’ may indicate
a cause, a condition, or a reason. What Mill is contending
for is that it is correct to use the second expression about the
surprise of the army. The reviewer says, and I agree with
him, that it is incorrect, and I add that it is incorrect because
the sentinel’s being off his post is not an action, but a passive
state, and therefore a condition. The reviewer says, and again
I agree with him, that the allurement or force which drew the
sentinel off his post may rightly be called the cause of the
surprise of the army, and to this Mill objects that it can
scarcely be wrong to say the surprise took place because
the sentinel was absent; and right to say it took place because
he was bribed to be absent. This is ignoratio elcnchi. We are
dealing with causes only, and * because ’ may refer to causes,
conditions, or reasons, and Mill, like other logicians, never
uses a univocal word if he can find an ambiguous word to
serve his purpose. Let us put it into accurate language. It is
wrong to say the cause of the surprise was the sentinel’s being
off his post, for that implies a passive state and a condition.
It is right to say the cause of the surprise was the sentinel’s
going off his post, or deserting his post, for these imply action ;
and for the same reason the bribing of the sentry may properly
be called a cause of the surprise.

In every book on medicine we find age, sex, race, time of
year, climate, and so forth enumerated among the causes of
diseases. It is clear that none of these is an action. None
of them therefore can be a cause of disease. Occupation also
is called a predisposing cause of disease; but though the
occupation of the patient is an action, it is an action not on
the patient, the thing changed, but by the patient, which is

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a very different thing. When occupation is a factor in pro¬
ducing disease it is therefore usually a condition, not a cause;
but there are some cases in which it may properly be called
a cause. Dry grinding produces a quantity of irritating dust,
which is inhaled by the dry grinder, and irritates the delicate
walls of the air-cells of the lungs, in such a way as to produce
inflammation in them, which is called grinder’s phthisis.
In this case the occupation of the patient is an indirect cause
of the disease. It causes a result—the presence of dust in the
air—which is a condition of the disease.

A condition has been defined as a passive state . . . material
to the effect, or such that without it the effect would not have
been produced; and according to this definition, every con¬
dition must be necessary to the effect; yet we often speak of
favouring conditions, with the implication that they favour or
assist the production of the effect, which yet might be pro¬
duced without them. The expression * favouring condition ’
is a convenient expression, and is not inaccurate if it is
properly understood and defined. Under given conditions a
seed will germinate, and the plant will grow to maturity,
flower, and seed. All the conditions necessary to its life and
growth to maturity must therefore have been present; but
under other conditions of aspect, moisture, soil, and so forth,
it might have reached maturity sooner, might have attained
a larger growth, might have produced more flowers and more
seed, and might have lived longer. These other conditions
were not necessary to the life, growth, and maturity of the
plant; but they favoured its life, growth and maturity; and
though not necessary to the production of some effect, they
were necessary to the full or extra effect over and above that
produced in the first set of conditions. A favouring con¬
dition is, therefore, a condition without which some effect
will be produced on a given thing by a given cause, but with
which more of that effect will be produced, or the effect will
be produced more speedily by the operation of the same cause,
or both. With respect to the production of some effect, the
second condition is a favouring condition : with respect to the
production of the extra effect, or the earlier effect, it is a
necessary condition.

There is another sense in which the terms necessary condi¬
tion and favouring condition are contrasted. If in certain con-

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ditions a certain amount of an action is necessary to produce a
certain effect, and if, when a new condition is introduced, less
of that action will produce that effect, then this new condition
is called a favouring condition. It is not necessary to the pro¬
duction of the effect by a given intensity of action, but it is
necessary to the production of the effect by a less intensity of
action. Thus, though a condition is always necessary for the
production of an effect by a given action, yet it is convenient
and justifiable to distinguish between necessary and favouring
conditions if we bear in mind the conventional meanings of
* favouring.’

Frost, if sufficiently intense, will infallibly kill the blossom
of pepin fruits. A less degree of frost will not kill the blossom
if it is dry, but will infallibly kill it if it is wet. Wetness of
the blossom is a necessary condition to the destruction of the
blossom by this less degree of frost, but it is not a necessary
condition to the destruction of the blossom by frost in general.
It is called, and may justifiably be called, a favouring condition
of the killing of the blossom by frost.

Summary.

A condition has never hitherto been satisfactorily distin¬
guished from a cause. The true distinction is that a cause is
an action, a condition a passive state.

By successive approximations we reach the definition that a
condition is a passive state of or about the thing acted on by
the cause, and material to the effect.

The difference between a necessary and a favouring condition
is verbal. A condition is always necessary to the production
of a given effect by a given action; but, if, under an additional
condition, the effect would be produced sooner, or more of the
effect would be produced, or the same effect would be produced
by less of the action, then that additional condition may be
termed a favouring condition with respect to the general causa¬
tion of that effect, though it is a necessary condition with respect
to particular cases.

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CHAPTER IV.

CAUSATION.

We may now turn to the consideration of the third con¬
stituent in the relation. We have considered the terms—Cause
and Effect—and we now turn to the consideration of the link,
or * relating relation ’ which binds them together, and which I
call the ratio. The question we now have to discuss is What is
the nexus between cause and effect ? or, Given an action on a
thing,'and a following change or contemporaneous unchange in
that thing, what is it that converts this time relation into a
relation of causation ? in short, What is the mark or character
of Causation ?

Hume, after arguing at length that there is no connection at
all between cause and effect, astounds us by defining their rela¬
tion as * if the first object (the cause) had not been, the second
(the effect) had never existed,’ and thus declares not merely
connection, but necessary connection, between them. Mill, as
we have seen, proposes one definition after another, not as suc¬
cessive approximations to a final clarified expression, not even
as alternatives of equal value, but he wanders on, giving one
definition after another, not noticing that they are incompatible,
aud seemingly forgetting, when he formulates a new one, that
he had ever formulated one before. The two qualities on which
he most insists are invariableness and unconditionalness, but
he soon abandons invariableness, and he insists throughout that
conditions are necessary to causation. Dr. Fowler pins his
faith to invariableness of succession, but Mr. Welton denies
sequence as being necessary to causation, and in this no doubt
he is right; but he goes farther, and denies that sequence or
any time relation enters into causation, and in this he is
unquestionably wrong. According to him, ‘ the relation of
causation is found in the securing of those conditions, which
are, consequently, at once both cause and effect,’ not a very
illuminating statement, and not quite consistent with his defi¬
nition of cause as * a totality of conditions whose existence
secures the effect ’—causes it, in fact. Professor Carveth Read,

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whose pronouncements always deserve consideration, enume¬
rates five marks of causation, which it will be well to examine,
since one or more of them are adopted by most other writers.
* The Cause of any event, then, when exactly ascertainable, has
five marks: it is (quantitatively) equal to the effect, and is (quali¬
tatively) its immediate, unconditional, invariable antecedent .’

The quantitative equality of cause and effect is frequently
assumed and asserted, but it seems to me to rest upon a very
insecure foundation, and to be based upon very misty notions
of what a cause is, and of what an effect is. The instances
given are almost always chemical combinations, and it is said
‘ When oxygen combines with hydrogen to form water, or with
mercury to form red precipitate, the weight of the compound
is exactly equal to the weight of the elements combined in it.’
No doubt it is, but what are equated here are two weights, and
I do not see how it can be maintained that the weight of the
elements is the cause, or the weight of the compound the effect,
of the combination. The causes of the combination of oxygen
and hydrogen are first, the mixing of them, and second, the
passage of an electric spark through them; and I cannot see
that the mixing is equal to the effect, or that the spark is equal
to the effect, which is not the weight of the water, but the
formation of water. The effect in this case is a change—the
change from a mixture of gases to a liquid ; and there is nothing
in this change that is equal to the spark. The cause of the
maintenance of the mercury in a Torricellian tube is the weight
of the air, and the weight of the air is certainly equal to the
weight of the mercury; but the effect is not the weight of the
mercury, but the maintenance of the height of the mercury, and
this cannot equal the weight of the air. As another instance of
equality of cause and effect, Professor Carveth Read says the
numbers of any species of plant or animal depend on the food
supply, and no doubt they do in part, but the numbers are not
equal to the food supply. The number of lions in a district is
not necessarily equal to the number of antelopes in that district;
and if they were, the antelopes are not the cause of the lions.
Another instance of causation adduced by Professor Carveth
Read is still more to seek. * How learn to play the fiddle ?
Go to a good teacher (then, beginning young enough, with
natural ability and great diligence, all may be well).’ I am at a
loss to discover how the cause in this case can be quantitatively

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equal to the effect. No. I think the quantitative equality of
cause and effect is as idle a dream as the identity of cause and
effect : it is founded upon misapprehensions, and is not true,
nor even is it sense.

The next mark or character of causation is immediacy. The
relation of causation is said to be immediate, by which is meant
immediate sequence. Mr. Welton, as we have seen, confuses
immediate sequence with simultaneity. He takes it that an
effect which immediately follows a cause is simultaneous with
the cause, and from this he jumps to the further conclusion
that simultaneity means identity, so that an effect that imme¬
diately follows the cause must needs be identical with the cause.
I do not think that either of these views needs serious refuta¬
tion ; but the assumption that an effect must necessarily follow
immediately on a cause does require careful examination.
Certainly in common speech, and in the light of that common
sense which philosophers so much and so universally despise,
there is no such necessity; nor is there any necessity in law.
If a man wounds another, and if that other dies of the wound
at any time within a year and a day of the assault, the assault
is in law the cause of the death, and the assailant maybe guilty
of murder. Of course, philosophers are not bound to make
their definitions conform to the definitions of law; but it is
very desirable that philosophers should not live wholly in a
balloon of speculation, out of all touch with mundane and
practical affairs. The use of opinion is to be a guide to con¬
duct, a truth that philosophers rarely recognise; and lawyers
have this advantage over philosophers, that their definitions
are perpetually being put to the test of practical use; and if
they are found to be faulty from this point of view, the defini¬
tion must be discarded or amended. Philosophers are under
no such obligation. They can, if they please, define ‘the
Knave of Hearts as the Jackovarts,’ or that which depends on
conditions as unconditional, or sequence as simultaneity, or
simultaneity as identity, or causation as implication, or that
which cannot be perceived as a product of perception, or a battle
as a substance, and no one can prevent them ; nor are they under
any obligation to make their definitions square with their
practice; but when one is immersed in practical affairs, and is
writing for the guidance of those whose business it is to discover
and record the causes of actual occurrences, it is prudent to

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take into account the notions that are prevalent among men of
affairs, and not lightly to reject them.

The General Register Office is a department of the State
maintained at considerable expense, and engaged in collecting
and presenting to Parliament immense statistics of the causes
of death ; and the Registrar General has no hesitation in
admitting into his Tables, and presenting to Parliament, causes
of death that may have preceded the effect by weeks, months,
and years. Neither he, nor his staff of officials, nor the tens of
thousands of medical men who furnish him with items, nor the
High Court of Parliament, nor any of the multitude of scien¬
tific men who have used these tables, have ever made any
objection to them on the score that the alleged causes of death
are not causes of death because the result does not immediately
follow on the cause. The Tables are not immaculate: they
are open to objection, as I shall presently show; but they are
of very great value to Officers of Health and others in the
prevention of disease, even though it is from time to time
found that some of the alleged causes of death are, after all,
not causes ; but if immediacy is a necessary element of causa¬
tion, the alleged cause of death would be the true cause in
scarcely one of the millions of instances which the General
Register Office has recorded; and if the alleged cause were in
every case false, then the usefulness of the Tables would be
destroyed, and they would be of no value at all, either to Officers
of Health or to any other human being. The primd facie pre¬
sumption against immediacy as a quality or mark of causation
is therefore very strong.

As I have shown in the previous discussion, immediacy in
the strict sense of the term cannot obtain in any case of effec¬
tuation, for an effect is a change or an unchange, and an un¬
change by its very nature implies duration, and cannot be
immediate; while in experience every change takes time, how¬
ever short that time may be. Perhaps the nearest approach
to immediacy that we know is the effect of lightning upon our
mind the instant the flash passes; but this we know takes
time—time for the light to travel to our eyes, time for it to
traverse the media, time for a change to take place in the
retina, time for an impulse to travel to the brain, time for it to
produce its effect there. Strict immediacy between cause and
effect is unknown to us; but is not this pushing matters too

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far ? May there not be a practical immediacy that is required
for causation, although immediacy in the pedantically accurate
sense there cannot be ? In other words, ought we not to limit
our notion of causation to that change which appears to our
senses to follow immediately upon an action, even though in
strict accuracy some infinitesimal fraction of a second may
separate them ? Well, as has already been shown, even in such
a restricted sense immediacy is not required in the current and
accepted meaning of causation ; and if it is to be imported into
the philosophical meaning, then philosophy cuts herself off, in
this respect, finally and for all from utility and common sense ;
and this is inadvisable if it can be avoided. But there is no
earthly reason why philosophy should thus make a fool of her¬
self. One of the favourite maxims of logic is Nota notes, nota rei
ipsius. As a logical maxim it is of little or no value, but in
the present connection it has this value, that it effectually
estops logicians from objecting to the maxim that I here pre¬
sent to them :—Causa causes, causa rei ipsius. The cause of a
cause is the cause of the effect.

Ilavra pu : all things flow. The universe is a series of con¬
tinuous change. In this continuous series we may take, any¬
where we please, a longitudinal section of any length we please,
and call the first change the cause of all or any that follow, and
the last the effect of all or any that have gone before : or we
can call the first the cause of the last, and the last the effect of
the first. The process is familiar with us from childhood, and
was solved for us long before our infantine minds were sophis¬
ticated by reading books on logic. If the cat began to catch
the rat, the rat began to gnaw the rope, the rope began to hang
the butcher, and so on until the pig began to get over the stile, and
the old woman reached her destination, then the action of the
cat was the cause of the rope being gnawed, of the butcher
being in peril of death, and of all the other events in succession
down to the old woman getting home in time. The cat’s action
was the cause, immediately or mediately, of each effect, and it
was not less efficacious when it acted mediately than when
it acted immediately. It is just as scientific, and just as
philosophical, to attribute one man’s death to the bite of a
mosquito twenty years before, as to attribute the death of another
to the explosion of a shell which blew him to bits in a moment.

The third distinguishing mark of causation is unconditional-

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ness. Mill invented the term, and gives, as is his custom, several
definitions of it, each different from the rest. It is synonymous
with necessity ; it means whatever supposition we make about
all other things ; it means subject to no other than negative
conditions; it means as long as the causes do not vary; it
means, in short, pretty much what you please. Mill's discus¬
sion of unconditionalness is a striking example of his utter
muddle-headedness. Invariable sequence, he says, is not syn¬
onymous with causation, unless the sequence, besides being
invariable, is also unconditional, and this he says immediately
after he has defined the cause as ‘ philosophically speaking ’
the sum total of the conditions ! It is therefore philosophically
speaking conditional, and speaking otherwise unconditional.
This, however, is only a beginning. His fifth or sixth defini¬
tion of a cause ‘ confines the meaning of the word cause to the
assemblage of positive conditions without the negative, and
then, instead of “ unconditionally ” we must say “ subject to no
other than negative conditions.” ’ So that in the first place the
cause is the sum of the conditions, both positive and negative;
in the second place, it is the positive conditions without the
negative; and in the third place it is the negative conditions
without the positive. There is only one other possible alter¬
native, that the cause is neither the positive nor the negative
conditions, and this, which is the correct view, is the only one
that Mill does not give. Hume is inconsistent enough, good¬
ness knows, but Hume is a miracle of consistency in comparison
with Mill.

Professor Carveth Read adopts unconditionality as a mark
of causation, and his meaning of the term is quite different
from any of Mill’s, though he says it is what Mill means.
When Mill defines the cause of any effect as its unconditional
antecedent, he means, according to Professor Carveth Read,
that it is that group of conditions which, without any further
condition, is followed by the event in question. According to
this, when Mill said unconditional he meant un-further-condi-
tional; and it is possible that Mill may have had sometimes in
his mind some such meaning as this ; but the only thing we
can be sure of is that what he meant at one time was not what
he meant at another time, and there is no evidence or indica¬
tion that he had any definite meaning at all. However, there
are few writers on causation who do not adopt Mill’s assertion

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If this is the meaning, it is doubly wrong, for in the first place,
a cause need not be an antecedent, and in the second, if it is an
antecedent it may vary, and usually does vary. If the ante¬
cedent must not vary, then the pressure of the gas of an exploding
cartridge is not the cause of the propulsion of the projectile, for
the pressure of gas varies from moment to moment as the
projectile travels along the bore of the gun.

When it is said that the effect is the invariable consequent,
what ought to be meant, though I believe it never is meant, is
that the effect is that consequent which does not vary. If this
is the meaning, it is undoubtedly wrong, for an effect need not
be a consequent, and when it is a consequent, it may vary. If
the consequent must not vary, then the movement of a motor
car is not due to the action of the engine, for the speed varies
with the gradient, and with the surface of the road.

When it is said that causation is invariable sequence, what
ought to be meant is that the time and manner in which the
cause precedes the effect, or in which the effect follows the
cause, do not vary. But in the first place, causation need not
be sequence, and in the second, when it is sequence, it may
be variable. The time at which the report of a gun reaches us
does vary with our distance from the gun ; and the remittent
manner in which the light from the fixed stars reaches us varies
from the steady manner in which the light from the planets
reaches us.

But suppose, what I believe is the case, that writers on
causation express their meaning in this matter, as in other
matters, inaccurately, and when they say invariably they
mean always; is it true that there is no causation unless the
cause is always followed by the effect, and the effect is always
preceded by the cause ? Then how if cause and effect are
contemporaneous, as they are in the causation of an unchange?
If sequence is always necessary to causation, then such un¬
changes as the maintenance of the motion of a locomotive,
or the maintenance of animal life, or the suspension of a
weight by a cord, or the prolonged boiling of water, are not
caused. They are not effects, nor instances of causation. But
even supposing there is no causation except the sequence of
change on action, is it true that there is no causation unless this
sequence always happens? Then how if it happens once only ?
Once, as the boy said to the man who declared that he was once

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as active as the boy, ‘Once ain’t often.’ Still less is it always.
If I see a bottle of wine fall on a stone floor and smash, am
I to deny that the fall of that bottle on to the floor was the
cause of the smash ? It has happened only once and can
never happen again. * Oh, but,’ says the logician, * when
similar bottles have fallen on stone floors they have always
broken.’ Indeed ? I have it in mind that this very bottle
had previously slipped out of my hand and fallen a sixteenth
of an inch on to the very same stone floor, and yet was not
broken. * But then the cause was not the same, for the
bottle did not fall so far.’ Granted, but your definition says
nothing about the same cause, it says the cause is always
followed by the effect; and you now say that the cause of
the bottle breaking was its fall for a certain distance; but
I had previously let that bottle fall the very same distance on
to a truss of straw, and the bottle did not break. ‘ Ah yes,
but when I say the same cause I mean the same cause acting
in the same conditions.’ But if the same cause had acted in
the same conditions the bottle would have smashed before,
and you cannot be always smashing the same bottle, you
know. It seems to me that cadit ampulla, cadit qucestio. But
may we never predicate causation until an event has occurred
repeatedly ? Then how often must it be repeated before we
can say it always has happened ? how often before we can
say it always will happen ? Suppose a man hits me in the
eye, how many times must I get him to repeat the blow
before I can be sure that it is the cause of my eye turning
black ? ‘ But,’ says the logician, * a blow on the eye always

has been followed by the blackening of the eye, and always
will be followed by the same phenomenon.’ Has it ? What
do you know about black eyes amongst Mousterian or Nean¬
derthal men ? And will it ? Why ? ‘ Because the same cause

is invariably followed by the same effect.’

‘ My friend,’ I reply, ‘ you are a logician ; did you never hear
of the circultis in probando ? ’

I can imagine the tormented logician answering these
objections something in this way :—

* When I say invariably, of course I don’t mean invariably ;

I mean always. At least I don’t exactly mean always. You
are so confoundedly particular. You expect me always to
mean precisely what I say, and to say precisely what I mean ;

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and you expect me always to have a precise meaning to
express. You forget that I am a logician. When I say the
effect invariably follows the cause, I mean of course that it
follows unconditionally, that is to say, in certain conditions.’

* That,’ I should answer, ‘ is a curious meaning for uncon¬
ditionally ; but waiving that, what are these conditions ? ’

‘ Why, of course, the same conditions in which it happened
before.’

‘ But, ex hypothesi, it never has happened before.’

* Well then, the same conditions in which it would have
happened before if it had happened before.’

‘ Thank you very much, but on your own showing, the same
conditions never are, and never can be repeated.’

* Really, sir, I cannot bandy words further with a person
who knows nothing of logic. Allow me to bring to your
notice the well-known philosophical principle, of which you
have never heard, that all reasoning is through a universal.
I wish you a very good morning, and take my leave of you.’

It would be difficult for me to suppress Hamlet’s answer—
You cannot, sir, take from me anything that I more willingly
will part withal.

No, I am afraid invariability must go after equality and
immediacy and the rest of the marks that are supposed to
characterise causation, and with them must go the last of
Professor Carveth Read’s distinguishing marks of cause, that
of antecedence. It is manifest to everyone who is not wilfully
blind, that the cause of a change must be antecedent to the
effect, even when cause and effect are apparently simultaneous.
The fracture of a glass bottle by the blow of a stick seems
to be instantaneous, and no doubt the time consumed is very
short. But if the operation were photographed by a rapidly
moving kinematograph, and the film was to be put through
the lantern very slowly, we should see the glass yield and
bend before the pressure of the stick, and give way first on
the surface remote from the stick, and gradually spread until
it involved the whole thickness. We should see the splinters
separate, not simultaneously, but successively, and that the
whole operation took time. This, I think, is one answer to
Mr. Bertrand Russell’s contention that we can divide up the
cause, or the duration of the cause, into many successive
instants, of which the last only is entitled to the name of

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cause; and that it is this last division only upon which the
effect follows instantly, and with which the effect is virtually
continuous. These are not his words, but this is the meaning
of his doctrine as I understand it. It is not so. The cause
has a certain duration; and during every instant of that
duration it is a cause, and is in action, and is causing more
and more of the effect. The effect also has a certain duration.
As the cause begins to act, the change begins to occur; as the
cause continues, the change increases; when the cause ceases,
the effect reaches its maximum. As soon as the cause ceases to
act, the effect, as an effect, that is as a progressing change, also
ceases, and becomes a result. The total effect is not reached
until the cause ceases to act, and it is in this sense, and in this
sense only, that the effect succeeds the cause, and that cause
and effect are antecedent and consequent.

But when the effect is an unchange, the cause does not and
cannot precede, nor can the effect follow. In this case cause
and effect are contemporaneous ; the only exception, which is
but an apparent exception, being the delay due to inertia in the
starting and cessation of that unchange which is the motion of
a body, such as a cart, a motor car, or a railway train, that owes
its motion to continuous action.

What, then, is the quality which characterises and marks
causation ? It is not at all difficult to discover, and indeed it
was discovered and assigned long before the day of Hume, but
he took a violent prejudice against it, and all his successors
have been afraid of it. They have avoided it as if it were an
asp or a viper, and few of them even dare to mention it; and
yet there is nothing frightful about it, and if the nettle is firmly
grasped, it not only fails to sting, but even furnishes a grateful
and sufficient support.

Daily the tide rises on our coasts, and daily thereafter men
and women in this country marry ; and in some respects the
consequents are invariable. They invariably marry two at a
time and with some sort of ceremony. Moreover, this conse¬
quence always follows the antecedent: not a rise of the tide
occurs but some marriage follows it. As far as history goes
back, this consequent has always followed this antecedent ; as
far as we can foresee, the consequent will follow the antecedent
‘ as long as the present constitution of things endures ’; and
these are the conditions that are said to convert mere time-

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sequence into causation. But they don’t. No one but a lunatic
or a logician would regard the rise of the tide as the cause of
men and women marrying; and why not ? Ask the first man,
woman, or child (not being a lunatic or a logician) you may
come across why they do not regard the rise of the tide as the
cause of marriage, and he, she, or it will answer * Because there
is no connection between them.’ This is the obvious answer,
and it is a very good answer as far as it goes, though it is not
quite a sufficient answer.

There are two reasons why it is not quite a sufficient answer:
first, because things may be connected together in sequence
without being cause and effect, and second, because it does not
explain the nature of the connection.

Night always follows day, and the two are connected, but
yet night is not the effect of day. The flight of the projectile
always follows the recoil of the gun, and is connected with it,
but the recoil of the gun is not the cause of the flight of the
projectile. The sinking of the stone always follows the splash,
and is connected with it, but the splash is not the cause of
the sinking of the stone. Although, however, these instances
prove that mere connection in sequence does not constitute
causation, even when the sequence is constant (which is what
logicians mean by invariable) yet it is clear in each case that
the connection in sequence does depend upon causation. The
connection between day and night is that they have a common
cause, the rotation of the earth. The connection between the
recoil of the gun and the flight of the projectile is that they
have a common cause, the explosion of the charge. The con¬
nection of the sinking of the stone with the splash is that they
have a common cause, the fall of the stone into the water.
It is evident that we are getting ‘warm.’ If the connection
between antecedent and consequent does not itself constitute
causation, j'et it is evident that it is indispensable to causation,
and that we may say provisionally

Causation is the connection between cause and effect.

Although, however, this is true, it does not carry us much
forwarder. It does not display the nature of the connection.
In order to get a complete definition of causation, and to clarify
the concept, we must substitute for the terms cause and effect
the definitions of them at which we have previously arrived.
We shall then get the following definition :—

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Causation is the connection between an action and the following
change or accompanying unchange in the thing acted on.

If vve apply this definition to the foregoing test cases we find
that it fits, and satisfactorily explains why they are not cases
of causation although they are causally connected. Night
always follows day, and is connected with it; but night is not
the effect of day, and why not ? Because, although there is a
connection between them, the connection is not between an
action and a change in the thing acted on. Day does not act
upon anything to cause night. The recoil of the gun always
precedes the flight of the projectile, and is connected with it;
but the recoil of the gun is not the cause of the flight of the
projectile, and the reason is manifest—the recoil of the gun does
not act on the projectile, the thing in which the effect is pro¬
duced. Similarly, the reason the splash is not the cause of the
sinking of the stone is that the splash does not act upon the
stone, the thing in w'hich the change occurs.

The same formula satisfies all Mr. Welton’s difficult cases.
1 The dryness of a boy’s clothes before his immersion in water
is not the cause of their subsequent wetness.’ It certainly is
not, and I doubt if even a logician has ever suggested that it is;
* that cause can only be found in that spatial relation between
the clothes and the water which we call contact.’ It is true that
we may speak of the contact of the water with the clothes as
the cause of the wetness of the clothes, but what we mean, or
ought to mean, by contact, in this case, is not being in touch,
but bringing into touch. The cause of the wetness of the
clothes is the action of bringing water into contact with them,
and then the action of water upon them. Once the clothes are
wet, the continued contact of the water with them is not the
cause of their wetness, it is their wetness. The bringing of the
water into contact with the clothes is the cause, the effect is not
wetness, it is becoming wet. Wetness is not an effect, it is a
result. Mr. Welton’s statement is vitiated by two confusions.
He says wetness when he means becoming wet, and he says
contact when he means bringing into contact.

‘ A dropping of ink upon paper causes a blot, but the blot is
there as soon as the contact of ink and paper is made; it is that
contact.’ Here again there is confusion. The dropping of the
ink upon the paper is rightly called the cause of the blot, for
the dropping of the ink is an action on the paper, and the blot

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is the change in the thing acted on, and is connected with the
action. It is true that the blot is there as soon as the contact
is made, as every' effect is there as soon as the causing action is
complete; but I see no ground for asserting that the blot is the
contact. As well might we say when a man lies in bed, that the
contact of the man with the bed is the man. The blot is not the
contact. The blot is the layer of ink adhering to the paper.

There is yet one thing wanting to the definition of causa¬
tion. It is, we find, the connection between an action upon a
thing and the sequent change or accompanying unchange in
that thing; but we have yet to ascertain the nature of the con¬
nection. This cannot be put much better than in the words in
which Hume stultifies his whole previous argument,—‘ where,
if the first object had not been, the second had never existed.’
In other words, the connection is a necessary connection.
Much unnecessary verbiage has been wasted in discussing the
nature of necessity, which is perfectly clear to everyone but
philosophers. By necessary connection I mean that the action
is so connected with the change or unchange that if the action
had not taken place, the change or unchange would not have
occurred ; and the action taking place in the conditions in which
it did, the change or unchange connected with it was unavoid¬
able and unpreventable. That, I believe, asserts the true
nature of causation, which may be finally defined thus :—

Causation is the necessary connection between an action and the
sequent change or accompanying unchange in the thing acted on.

Mill boggles at the term necessary, and suggests that its
meaning is not clear. * If,’ he says, ‘ there be any meaning
which confessedly belongs to necessity, it is unconditionalness,'
and thus he substitutes for a plain clear word which everyone
understands, a word which no one else understands, and which
he does not understand himself. What he means by ‘ con¬
fessedly ’ it is difficult to surmise, for no one but himself has
ever defined necessity as unconditionalness, and not even his
followers confess that they mean the same thing. It is another
of his wandering and unwarrantable assertions, adopted, ap¬
parently, on the spur of the moment, without consideration or
justification. No one has ever confessed that necessity means
unconditionalness ; and it doesn’t. Whichever of Mill’s various
definitions of unconditionalness we adopt, it bears no resem¬
blance to necessity.

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But is causation the necessary connection that I have asserted
it is ? It may be said that if the severing of an artery which
causes a man’s death had not taken place, the death would still
have occurred sooner or later, and therefore the connection
between the cause and the effect was not necessary. The
obvious answer is that though the connection between the
severing of the artery and the death of the man was not neces¬
sary, the connection of the severing of the artery with his
death by haemorrhage at that time and place was necessary.
It was necessary to that particular effect. And it may be said
that the death did not necessarily follow, for if a surgeon had
been present, and had tied the artery, the man would not then
and there have died, so that the change was neither unavoidable
nor unpreventable; and this is true, but then the conditions
would not have been the same. The conditions being what
they were, the change followed necessarily, in the sense in
which I have defined necessarily, on the action ; and it is this
necessary connection between the cause and the effect that
constitutes causation.*

* A doubt, I find, is felt by a reader, whether the maintenance of the motion
of a locomotive can properly be called an unchange; for it may be said—Are not
all parts of the machinery continuously changing in position ? Animal life also is
a perpetual series of changes; how then can it be called an unchange? The
answer is that the nature of things as it appears to us, and as for our purposes it
is, varies according to the way in which we choose to contemplate them. An
unchange, as I have defined it, is a way of contemplating things, just as a class is
a way of contemplating things. No such thing as a class exists except in our
minds. When several individual things have some quality in common, such as
hardness, or whiteness, or motion, we may mentally group them together, and
contemplate them together as all possessing that quality; and by the possession
of that quality they are grouped together in our minds, and consolidated into a
single object of contemplation—a class of hard, or white, or moving things. They
are not grouped together in fact, or outside of our minds. Both the North Pole
and the South Pole are white, and may be contemplated together as adjoining
white things in the class of white things; but in fact they do not adjoin, but are
wide asunder. To call things a class is to contemplate them together; and to
separate them, not actually, but in contemplation, from other things that have not
the class-quality. Just in the same way, we may take all the successive changes
of a locomotive, both the internal changes of its parts, and the changes of position
of the whole with respect to its surroundings, and contemplate them all together,
as grouped and consolidated into a single object of contemplation, which we call,
not a class, but an unchange. We call it an unchange, or the maintenance of an
unchanging state, because, as movement, it does not change to rest, although there
are forces in action—friction, gravity, and so forth—tending to bring it to rest.
Each movement of the parts is a change, and may be so contemplated if we
choose; but we need not so contemplate it. The movement of the whole is
change of place with respect to surroundings, and may be so contemplated; but it
need not be so contemplated. We may, if we please, regard the movement, not in
contrast with surrounding things which remain at rest, but in contrast with its own
possible state of rest, or in contrast with its being brought to rest, which would be
a change of another kind, but still a change. So contemplated, the state of motion
is not a change, but the maintenance of the unchanging state of motion. In short,
it is an unchange.

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Summary.

This chapter examines the five characters or marks that are
said to be characteristic of causation, viz., equality of cause
and effect, immediacy, unconditionality, invariability, and
antecedence ; and shows that not one of them properly or
necessarily pertains to causation.

By successive approximations the definition is reached that
Causation is the necessary connection between an action and
the sequent change or accompanying unchange in the thing
acted on.

The meaning of ‘ necessary ’ in connection with causation is
defined.

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CHAPTER V
SUBSIDIARY PROBLEMS.

I. Plurality of Causes.

Mill is the inventor of the phrase Plurality of Causes, and he
gets into his usual muddle over it, a muddle which even his
followers have discovered to be a muddle, but which they have
only partially cleared up. It will be remembered that one of
his statements of the Law of Causation is ‘ that every conse¬
quent is connected in this manner [invariably] with some
particular antecedent, or set of antecedents. Let the fact be
what it may, if it has begun to exist, it was preceded by some
fact or facts with which it is invariably connected.’ It would
be difficult to put the statement more positively or more
strongly, and as he himself would say more unconditionally.
It is an unqualified assertion ; and yet in a subsequent Chapter
he says ‘ There are often several independent modes in which
the same phenomenon could have originated. . . . Many causes
may produce mechanical motion : many causes may produce
some kinds of sensation : many causes may produce death.’
Inconsistency is, as I have said elsewhere, with other people a
vice to be avoided. With logicians it is an end to be pursued
for its own sake. A writer on any other subject who should
thus stultify himself by self-contradiction would be discre¬
dited, but with logicians self-contradiction is rather a virtue
than otherwise.

It is clear that in this use the term Plurality of Causes is
wrong, and doubly wrong. In the first place it does not mean
that any single instance of effect is due to more than one cause,
and in the second it does not mean that more than one cause
may be necessary to produce a certain effect. What is meant
is that an effect of a certain kind may be due on one occasion
to one cause and on another occasion to another cause. This
is not Plurality of Causes: it is Alternity of Causes, or, as Pro¬
fessor Carveth Read calls it, Vicariousness of Causes. When
an effect is said to be due to a plurality of causes, what is meant
is that if several effects resemble one another in some particular,

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one may be due to one cause and another to another. The
death of A by drowning is due to one cause—drowning—and
no more. It is not due to a plurality of causes. The death of
B by shooting is due to a different cause, it is true, but then
it is a different effect. It is a different effect, occurring on a
different occasion, under different circumstances, to a different
person. Both effects include the element or ingredient of
death, but the effects are not death, but deaths; and when it
is said that many causes may produce death, what is meant is
that many different causes may produce many different deaths ;
which is not so very paradoxical.

When Mill said many causes may produce some kinds of
sensation, we may suppose that what he had in his mind was
sound, which is a kind of sensation. But sound in general is
not an effect: it is a generalisation from many individual
instances of sound, each of which was an effect, and an effect
of one single cause. Mill’s blunder consists in generalising
the effects without generalising the causes. If we generalise
many instances of sounds into the one concept of sound, and
call the generalisation a single effect, we should also generalise
the causes of all these sounds, and call the common ingredient
in them the cause of sound. Each separate sound will then
have its separate cause; and the common ingredient in them
all will have its common cause in aerial vibration. Similarly,
if we generalise the common ingredient in many deaths, and
call it death, we must generalise the common ingredient in all
the causes of these deaths and call it cessation of the heart’s
action. There is no such thing as Plurality of Causes in
Mill’s sense, unless we generalise the effects while leaving
the causes particular, which is not a very legitimate logical
operation.

It is of course perfectly legitimate, and may be very useful,
to investigate all the cases in which effects have a common
ingredient, such as deaths, or sounds, and to determine as
many as we can of the combined causes and conditions by
which the effects are produced that have this common ingre¬
dient : this is very proper, and may be very useful; but in such
cases we are seeking the- causes, not of an effect, but of a
common ingredient in many effects; and the plurality of causes
applies to the plurality of effects, and not to the common
ingredient in them, although for the sake of brevity and con-

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venience we may allow ourselves to speak as if it did. In any
case, Plurality of Causes is clearly a misnomer here; what is
meant is not Plurality of Causes but Alternity of Causes.

There is a sense in which plurality of causes is a perfectly
justifiable expression. There is a sense in which every event
has many causes, innumerable causes, and there are certain
effects that admit, and others that require, the cooperation of
more than one cause to bring them about. These we will
examine in their turn.

v

II. The Regression of Causes and the Progression

of Effects.

A cause is an action in certain conditions upon a thing :
an effect is a change or unchange in the thing acted on, and
leads to a result. In the physical world, action means the
transfer or liberation of energy. It is now a commonplace
that energy neither appears out of nothing nor disappears
into nothing, but that every manifestation of energy is the
release of energy from store or its transfer from one thing to
another. If it is expended from store, then at some past time
it must have been put into store by some action or other. If
it is transferred from place to place, such transfer is action, and
action was as necessary to put it into the place from which it
comes as to put it into the place to which it goes. In short,
action, which is cause, is also always either effect or result. It
is always produced by previous action.

The action of the pig in getting over the stile was caused
by the action of the dog in biting him. The action of the dog
was caused by the action upon it of the stick. The action of
the stick was caused by the action of the fire, which was caused
by the action of the water, which was caused by the action of
the ox, which was caused by the action of the butcher, and so
back to the action of the cat. There was a continuous regres¬
sion of causes from the last effect to the first action ; and a
continuous progression of effects from the first action to the
last effect.

What is true of this dramatic and perhaps fictitious series is
true of every other case of cause and effect. The actions
stretch backwards in series as far as we like to trace them, or
can trace them; and the effects proceed forwards down to the

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present moment in which, as actions, they are carrying on the
chain of effects into a futurity of indefinite duration.

The motion of a train is the effect of the action of the wheels
upon the rails, which is the effect of the action of the piston-
rods on the cranks, which is the effect of the expansion of
steam in the cylinders, which is the effect of heat upon the
water in the boiler, which is the effect of the combustion of the
coal, which is the effect of the action of the fireman in lighting
and stoking, which is the effect of the action of his immediate
superior in giving the order, which is the effect of the action of
his superior, and so back to the directors, whose action is deter¬
mined by the action of the travelling public in demanding
means of travelling, which is determined in the long-run by the
action of their predecessors in building up the complicated
structure of the nation with its needs for travel; and so we
might, if we had the knowledge and patience, pursue the series
of actions back to the time when men first wandered into this
country, to the time when men first were, to the beginnings of
life, to the beginnings of the solar system, and further back ad
infinitum. In this long precession every action was caused by
some previous action, and produced, as its effect, a subse¬
quent action; and the same is true of every other cause of
change and of every other change. Action once taken goes on
producing its effects in succession for ever.

It is a commonplace that the institutions of a nation are
the results of the past history of that nation. The Napoleonic
wars, the Revolution, the revocation of the Edict of Nantes,
the Great Rebellion, the discovery of America, the Hundred
Years’ War, the Norman, Saxon, Danish, and Roman invasions,
have each and all contributed to making our institutions what
they are, and to making us what we are. If Julius Caesar had
not invaded Britain, I should not now be writing on the
Regression of Causes, and should probably never have been
born.

It is evident, therefore, that although the phrase * Plurality
of Causes/ in the sense in which Mill used it, was a misnomer,
and rests upon a confusion of thought, yet there is a sense in
which every effect has a plurality of causes—has an indefinitely
great multitude of causes, stretching back in continuous series
to infinity of past time.

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III. The Radification of Causes.—Indirect Causes.

There is more than this, however. The series is not the
simple series that has just been sketched. It is a complicated
web of infinite intricacy. To take a very simple case, the
birth of every child is the effect, and the child is the result,
of the actions of its two parents. Two actions were necessary
to the production of the effect. The birth of each of these
parents was the effect of similar actions on the part of the
grandparents, and the parents are the results of these actions,
so that in the second generation upwards there were four
causes. In the third there were eight, in the fourth sixteen,
and at every step backwards, with every preceding generation,
the number of causes increases in geometrical progression until
it is controlled by the intermarriage of descendants of the same
pair. But for this, the number of causes, even in historical
times, would be unimaginably great.

It is the same with all other effects. An effect is produced
by action upon a certain thing in certain conditions; and for
the production of the effect, the thing and the conditions are
just as necessary as the action that is the immediate cause.
This thing and these conditions are themselves the results of
causes, which are therefore also necessary to the effect. In
order to produce the discharge of a gun, it is necessary to pull
the trigger. This action is the cause of the discharge. It is
the direct and approximately immediate cause; but every
action that went to build up the conditions necessary for the
discharge was a cause, more or less remote, more or less
indirect, of the discharge. A necessary condition of the
discharge is that the hammer should be at full cock. The
action of cocking the gun was the direct and immediate cause
of this result, and as the result is a condition of the discharge,
the cause of this condition is a cause of the discharge; an
indirect cause, but still a cause, and a cause not very remote.
Anyone who is accustomed to scrutinize carefully the meaning
of words must feel a certain incongruity in speaking of the
cocking of a gun as the cause of its discharge; but I think
that the incongruity is much diminished, if indeed it is not
altogether removed, but calling it an indirect cause. We may,
I think, formulate the following definition :—

An Indirect Cause is a cause of a condition.

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Though the trigger is pulled with the hammer at cock, the
gun will not be discharged unless it is loaded. The presence
of the cartridge in the barrel is a condition of the discharge,
and the action of loading the gun is the cause of the gun
being loaded, a result which becomes, with respect to the
discharge, a condition of the effect. The cause of this result,
the loading of the gun, is therefore another indirect cause of
its discharge.

It is a condition of the discharge of the gun on the pulling
of the trigger that the mechanism of the lock should exist in
good order: and the actions of making the lock, nay, on the
same principle, all the actions involved in making the gun,
are indirect causes of the discharge of the gun. There is
more than this, however. The gun is made of certain
materials; and the existence at hand of these materials is
a necessary condition of making the gun. The actions by
which these conditions were brought about, by which the
materials were made, prepared, and collected, are all indirect
causes of the discharge of the gun, and causes that are not
only indirect, but remote also. And so we may go back to
the growth of the tree of which the stock was made, to the
deposit of the ore from which the metal was extracted, to
the covering by alluvium of the forests which became the
coal wherewith the ore was smelted, to the growth of these
forests, and as much further back as we please. All these are
causes, more and more remote, more and more indirect, of the
discharge of the gun.

The action of pulling the trigger is a direct cause of the
discharge of the gun, but it is not the only direct cause. The
pulling of the trigger caused the fall of the hammer, which
caused the explosion of the detonator, and each of these actions
was a direct cause of the discharge of the gun. The soldier
had orders to fire as soon as the enemy should come within
a certain distance. The action of the officer in giving
the order was a cause of his pulling the trigger, and so a
direct, but a mediate cause of the discharge of the gun. The
action of the enemy in coming within the stated distance
was another direct cause, but a mediate cause, of the dis¬
charge ; and all the actions that led up to these causes were
causes of the discharge itself, direct causes, but causes more
and more remote as the number of actions between the cause

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and the ultimate effect increases. Thus we may carry the
line of direct causes back, through the orders of intermediate
officers on both sides to those of the generalissimos ; to the
causes of the war; to the multitudinous actions of the members
of the nations at war that produced their antagonism; and
so on. We have already seen that at a very early stage the
line of direct causes divides into two, the actions of the
soldier’s superiors on the one side, and the actions of the
enemy on the other; and it would be easy to show that
at each step backwards the causes multiply like the ancestry
of every individual man, until at length they become unimagi¬
nably multitudinous. They still remain direct causes, however
remote theymay become, as long as action produces action, and
the line is not interrupted by the interposition of a condition.

It is manifest from these examples that both the direct and
the indirect causes ramify, or rather radify (for causes are
evidently rather the roots than the branches of effects), as
we go backwards from the effect; and that the further back
we go, the more numerous they become. The conditions
may be many, and each may have many causes, depending
on other conditions, which again may be many, and so on.
The direct causes go back in series to an indefinitely remote
past; and not in single series, but in series that spread like
the spokes of a fan, and that divide and redivide and radify
indefinitely.

Yet out of all these different series of innumerable causes,
both direct and indirect, it is usual to select one, and to call
it the cause. On what principle is this selection made ? What,
for instance, is the cause of the kettle boiling over ? The
action of the fire, says the master. Leaving the kettle too
long on the fire, says the mistress. The neglect of the
kitchenmaid, says the cook. The cook sending me upstairs,
says the kitchenmaid. The cook’s forgetfulness in leaving
her apron upstairs, says the housekeeper. Every one of them
is right. Each of these is a cause ; but which is the cause ?

It may seem that, strictly speaking, we should limit the
cause to the direct immediate cause, to the action that is
nearest to the effect and immediately precedes it; as for
instance, in the case of the discharge of the gun to the pulling
of the trigger. But we find upon trial that this will not do.
In fact we very often assume, as the cause, an action that

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by no means immediately precedes the effect; and in fact we
often do not know the immediate cause, and when we do
know it, we often do not take it into consideration. It seems
at first blush that the pulling of the trigger is the immediate
cause of the discharge of the gun, but a moment’s thought
shows that it is not. Between the immediate cause and the
effect nothing can intervene, nothing can interpose; but the
trigger acts through the medium of the mechanism of the
lock, and if this mechanism is impaired, the discharge may
not follow. After passing through the mechanism of the lock
the action must reach the hammer, and cause it to fall; and
the action of the hammer is more nearly immediate than that
of the trigger. The fall of the hammer strikes the detonator,
but even this is not quite immediate, for the detonator may
not explode. The truly immediate cause of the discharge is
the explosion of the detonator, but this is never spoken of as
the cause of the discharge, and is rarely thought of as the
cause. We may put immediacy on one side, therefore: it
does not determine us in fixing on the cause. Even apparent
immediacy does not determine us, for we may as legitimately
look upon the order to fire as the cause of the firing as the
pulling of the trigger. What then should, and what does
determine us in fixing upon one among the innumerable causes
of an effect, and calling it the cause ?

It depends entirely upon the purpose in view, that is, upon
the aspect of the matter in which we are interested. The
master, the mistress, the cook, the kitchenmaid, and the house¬
keeper are each of them right about the cause of the kettle
boiling over, but they all look at it from different points of
view, and for different purposes. The master looks at the
matter from the point of view of the physicist, and to him the
cause is the physical cause, which happens also to be the
immediate cause. The women all look at the matter from the
point of view of responsibility, and for the purpose of fixing
the responsibility. According to the mistress, the cause was
such that someone was responsible. The cook seizes upon the
cause that makes the kitchenmaid responsible. The kitchen-
maid selects the cause that throws responsibility upon the
cook; and the housekeeper chooses the cause that not only
supports the kitchenmaid but throws a double measure of
responsibility on the cook.

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During shooting at the butts, a trespasser gets into the line
of fire, and is killed by a bullet. What is the cause of his death ?
That depends entirely on the point of view and the purpose of
the person who makes the enquiry. To the physiologist it is
arrest of the heart’s action ; to the pathologist it is the effusion
of blood round the heart which stopped the heart’s action; to
the student of ballistics it is the low trajectory of the bullet;
to the marksman it was the force of the wind, which deflected
the bullet from the line of aim ; to the ammunition expert it is
the issue of the new light bullet, which yields more to the force
of the wind than the men are accustomed to; to the squad
instructor it was the failure of the marksman to respond
promptly enough to the order ‘ Cease fire ’; to one leader-
writer it is the deplorable carelessness of the soldier; to another
it is the stupidity of the civilian in crossing the line of fire; and
so we could go on multiplying causes ad infinitum. The fact is
that everyone of these may quite legitimately be considered a
cause, but if we ask which is the cause it is evidently quite im¬
possible to reply until we know for what purpose the question
is asked. Is it to fix responsibility ? Is it to prevent similar
effects in future ? Is it to determine the mode of flight of the
new bullet? Is it to clear up a nice point in pathology? It
may be any of these, and according to the purpose of the argu¬
ment will be the answer to the question What was the cause ?

IV. The Cooperation of Causes.

Every effect is, as we have seen, the product of a long and
complicated web of causes stretching back into infinity, all
of which are necessary to produce the effect; and therefore
every effect is in a sense due to a cooperation of causes. There
are, however, cases in which an effect is due in a special sense
to a cooperation of causes. We have found that it is a fre¬
quent and a legitimate practice to single out one of the
multitude of causes to which a given effect is due, and to
call that the cause, which it is from a certain point of view,
and for a particular purpose. We call it the cause, because
it is that one of the causes in which we are for some purpose
interested, and because on that account we allow our con¬
templation to rest upon it to the ignoring of the rest. Just in
the same way, and for a purpose, we may select from a series

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of causes a certain length of the series, comprising a certain
number of successive causes, and limiting or extending our con¬
templation to them, we may regard them as in a special sense
the causes of the effect; and in such a case we regard them as
cooperating more closely and more specially with one another
to produce the effect than the other causes, which, for the pur¬
pose in hand, we leave out of our consideration. Or two actions
may simultaneously take place on one body, so that the changes
they severally produce are merged and blended in a single
change; and then we naturally contemplate them in association
with each other, and regard them as cooperating to produce that
change. Every effect is in fact due to the cooperation of many
causes, direct and indirect, immediate and remote; but according
to the purpose in hand we limit our contemplation to one, two,
or a limited number.

Thus regarding them, we may make several classes of co¬
operating causes, according, first, as the causes we consider are
like or unlike, and second, as they operate successively or simul¬
taneously.

Cooperation of Like Causes in Succession.

An instance of like causes cooperating in succession to pro¬
duce a certain effect is seen when a nail is driven home by
repeated blows of a hammer. Each blow produces a certain
effect on the nail, and drives it further in. In a sense, and
from one point of view, it is the final blow only that drives the
nail home; but if it is more convenient for any purpose to con¬
template the operation as a whole, then we may regard, not
each blow as driving the nail for a certain distance, but the
whole series of blows as causes cooperating in producing the
complete effect of driving the nail home.

Actions may be like in kind though they are unlike in sign.
The action of paying money into the bank is like in kind to the
action of drawing money out of the bank, since they are
both transfers of money with reference to the bank ; but
they are unlike in sign, the one kind adding to the balance
and the other diminishing it; but the two causes cooperate in
succession to bring about the result, the amount of the bank
balance.

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Simultaneous Cooperation of Like Causes.

The flow of a large body of water from the upper reaches of
a tidal river may coincide with an unusually high tide to pro¬
duce in the lower reaches a flood, that would not have occurred
but for the simultaneous cooperation of the two causes. The
simultaneous rush of all the passengers to the side of the boat
may cooperate to make the boat capsize. If a bullet or a bird
flies across in front of a photographic camera at the moment
the shutter acts, an image of the flying object will be formed
upon the plate. If the actions are not simultaneous, no such
effect will be produced.

Indifferent Cooperation of Like Causes.

Like causes may cooperate to produce an effect or a result
independently of whether they act successively or simulta¬
neously. If one force acts upon a body so as to move it to the
north, and another equal force acts upon it for an equal time
so as to move it to the east, the effect will be that the body will
reach a certain point to the north-east, which will be the same
whether the forces act simultaneously or in succession. If we
add the two components of a Seidlitz powder to a glass of
water, the effect is the same whether we add them simulta¬
neously or successively.

Successive Cooperation of Unlike Causes.

When unlike causes cooperate in succession to produce an
effect, it is almost always necessary that they should operate in
a certain order; and unless this order of succession is strictly
observed, the effect will not be produced. The great majority
of effects and results that are produced by human agency are
of this class. When a thing is to be made, the materials must
first be provided, and then one operation after another is fol¬
lowed in a certain order, and the effect and the result are looked
upon as due to the cooperation of all these processes. When
bread is to be made, the flour and water are first provided,
then the dough is mixed, then it is leavened, then kneaded,
then allowed to rise, divided, and baked ; and these operations
must follow one another strictly in this order if the effect is to

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be produced. The final effect, the production of bread, is due
to the cooperation of the various causes in orderly succession.
If any one is omitted, or done out of its turn, or bungled, the
effect is spoilt, the result is a failure. And so whenever any¬
thing is made by art of man, it is made by certain actions in
orderly succession, and the whole series of actions cooperate
to produce the thing made. There is actually no break in the
long chain of causes, direct and indirect, stretching back in-
definitelyinto the past; nor in the long chainof effects and results
stretching forward from the moment the thing was made; but
the beginning and ending of the making form convenient arti¬
ficial or conventional boundaries to the section of the chain to
which we limit our contemplation. We must limit the scope
of our contemplation, because of the limitation of our powers,
which cannot grasp an indefinite length of chain; and boun¬
daries must be placed somewhere; and the boundaries fixed by
the beginning and ending of the making of a thing are apt for
our purpose. In contemplating causes, no less than in every
other operation of mind and body, we have a purpose in view,
and it is their indifference to purpose, and their ignoring of it,
that render the speculations of the philosophers described in
the first Chapter so curiously detached, irrelevant, and point¬
less. Our purpose in investigating how a thing is made, or
comes to be, is to make it or prevent its being made, to cause
it or help it to be, or to prevent or hinder it being ; or in any
case to get some advantage out of our knowledge, even if it is
only the advantage of satisfaction in knowing more than wedid
before. The only causes we need take into consideration are
those that answer our purpose, whatever that may be : to con¬
sider more would only lead to confusion and embarrassment.
That is why, in grouping together as cooperating causes the
actions whereby a thing is made, or comes to be, we fix an
arbitrary limit beyond which we do not at the moment go. We
stop short at that stage, not because we imagine that the causes
began at that stage, but because it is among the causes subse¬
quent to that stage that we expect to find those that we can
initiate, facilitate, hinder, or destroy. For the purpose in view,
the group is a natural group, and the limits are convenient
limits, and none the less so because for some other purpose we
may find it desirable to extend or to contract them.

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Simultaneous Cooperation of Unlike Causes.

Unlike as well as like causes may cooperate simultaneously
or contemporaneously to produce an effect which, but for their
simultaneous or contemporaneous cooperation, would not have
been produced. Plants will not thrive except under the com¬
bined action of light, warmth, and moisture. Without light
they will grow, but they will not thrive. Without some degree
of warmth, varying with the nature and habits of the plant, it
will not thrive, or even live ; neither will it thrive if desicca¬
tion is carried beyond a certain point, or live if it is
carried beyond a certain further point. Iron rusts under
the simultaneous cooperation of moisture and of oxygen. In
dry air it will not rust, though constantly in contact with
oxygen. Immersed in water free from dissolved oxygen it will
not rust, although it is kept constantly wet. It requires the
simultaneous operation of the two causes to produce the effect.
A man who refuses to do a thing under threat of punishment
for non-performance, and refuses to do it for reward, may yet
be induced to do it by combining the threat of punishment
with the promise of reward. When a glass tube is held
horizontally in a flame until it softens, it will bend ; and the
bending is the effect of the cooperating action of heat and
gravity acting simultaneously. The running of a motor car,
the action of an engine, are the effects of numbers of causes
acting contemporaneously.

Indifferent Cooperation of Unlike Causes.

Finally, unlike causes may cooperate to produce an effect
when it is immaterial in what order the causes act, or whether
they act simultaneously or in succession. A business firm may
be ruined by the cooperation of the defalcation of a clerk and
the failure, either at the same time, or before, or after, of a
debtor for a large amount. A man’s death may be due to the
cooperation of several diseases, which would have effectually
killed him in whatever order they attacked him, together or
successively. Rain and frost combine to produce the fall of a
mass of earth from a cliff, and in what order they act upon the
cliff is immaterial.

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V. The Law of Universal Causation.

We are now done with the first of Dr. Fowler’s propositions,
and may consider the second, that every event has a cause.
This is what is known as the Law of Universal Causation, and
not only do logicians commonly confuse it, as Dr. Fowler points
out, with the definition of cause, and with the Uniformity of
Nature, but also it comprehends within itself four distinct
problems which are usually confused together. They are as
follows:—Does everyone believe that every event has a cause ?
If so, what is the warrant for the belief? Is it true? and
How do we come by it ?

In the first place, what is meant by an event ? I think we
may say without fear of objection that an event is that which
happens, and inevitably implies a change ; and as we have seen,
the idea of change is necessarily bound up in the idea of effect.
But changes are not the only effects. The prevention of change
equally demands a cause for its existence; and, with some
straining of the sense of words, unchanges may be included in
events. Taking this to be the meaning of event, then it is
evident that events are synonymous with effects; or, if un¬
changes be excluded from the denotation of events, then event
is synonymous with one of the two classes of effect. The first
question then becomes Does everyone believe that every effect
has a cause ? or Does everyone believe that a particular kind
of effect has a cause ? It seems to me that these questions
must necessarily be answered in the affirmative. Effect implies
cause, as husband implies wife, or any other relative implies its
correlative. They are of course separable in thought, as, indeed,
they are separable in fact, but, being correlative, their constant
association in fact cannot be denied.

Moreover, I think there is abundant evidence that not only
human beings, but many of the lower animals also, assume
causation for every change which is a change to them—which
is appreciated by them as change. Horses shy, dogs bark, birds
and animals of various kinds rush away, when events occur to
which they are unaccustomed, that is to say, which are out of
their ordinary routine, and to them imply change. And I think
we may safely assume that when horses shy and dogs bark at
such things they do so because they apprehend danger, which

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is as much as to say that they have causation in their minds.
They apprehend the causation of harm to themselves. In the
same circumstances all timid animals either bolt, or conceal
themselves, or behave otherwise in a way that indicates that
they apprehend danger. In all such cases the change is viewed
as the effect of some cause, and the cause of that effect may
produce other effects, and effects detrimental to the witness.
Of all the changes in surroundings that excite in both animals
and man the danger reaction, none is more potent than an un¬
expected noise; and no one apprehends danger from noise.
The apprehension is that, as there is a noise, there must
be an agent to cause the noise, and that what has caused
this effect may cause other effects. I think therefore that the
evidence is that every man does believe that every event has a
cause.

This opinion is corroborated by considering the way by
which we come into possession of it. I do not say that it
is the only way, but I do not think it can be disputed that
the chief source of this belief is as follows:—Man, and all his
ancestors throughout an immeasurable past, have lived by
action; and every act of theirs has been an instance of
causation. It has been an action on something, and has
produced or prevented a change in the thing acted on. It
has been a cause, and has produced an effect. Hence the
notion of causation is in every individual of very early origin,
and with respect to his own action is inescapable and per¬
petual. Contemporaneous with this enormous body of positive
experience, is the negative experience, equally inescapable,
and equally perpetual, that we cannot produce or prevent
change in anything without acting on that thing, either
directly or indirectly. Hence experience, from the dawn of
consciousness to its last oblivion, perpetually enforces upon
us the conviction that change or prevention of change cannot
occur without action of or on the thing changed; in other
words, that every event has a cause. I think, therefore, that
the evidence warrants us in saying that everyone who is
capable of forming the notion of causation does believe that
every event has a cause, and that he derives this belief from
experience. It may be well to point out that though I hold
the empirical origin of this belief, I do not found it upon the
supposition that the will is the cause of bodily movements.

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Whether this is or is not a case of causation, it does not enter
into the demonstration.

The next question is, Granted that we do entertain this
belief, what is our warrant for it ? The warrant has already
been indicated. It is in experience. It is experience repeated
with incalculable frequency without a single contrary instance.
When I say without a single contrary instance, I do not mean
that in every case of change or prevention of change we are
able to assign a particular cause, or identify the cause; that
of course would be directly contrary to experience. I mean
that in no case of change or prevention of change that has
ever occurred in experience are we able to exclude a cause,
or to be certain that no cause has acted. As I have said
elsewhere, this is the conclusive test of truth for us—that
conduct founded upon a supposition never brings us up against
experience that contradicts the supposition. This is the
highest warrant we can have. Granted that the experience
is obtainable, granted that actions on the supposition are
incalculably numerous and diverse, then the fact that expe¬
rience has never shown the supposition to be false, not merely
warrants us in believing that it is true, but compels us to
believe it is true. The belief is inescapable; and however
strongly we may in words deny it, the first time we act we
shall prove our belief in it by acting upon it.

The third of the four questions put at the beginning of this
section was Is it true ? Apart from our belief in it, is it true
that every event has a cause ? After the foregoing discussion,
this question ceases to have any meaning. If we have in
support of a supposition, and based upon it, incalculably
numerous experiences, not one of which has ever contra¬
dicted the supposition, then for us that supposition is true.
It is certain. We are precluded from doubting it. We may
put together the words expressing a doubt, but those words
have no answering relation in our minds. That every event
has a cause is true in the sense that we cannot doubt it.
Whether it is noumenally true we cannot know, and it would
not matter if we did. It is true for us. It is true as far
as we are concerned. To ask whether it is really true is to
ask whether there is a higher degree of certainty than certainty
itself—whether that which is true for us may not be false in
some sense which we cannot clearly conceive, and with which

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we are not concerned. The importance of knowledge is its
influence upon conduct; and in the influence they respectively
exert upon conduct there is no appreciable difference between
that which is universally true to all men, at all times, in all
places, and that which is noumenally true.

VI. The Uniformity of Nature.

The Axiom of Causation.

We are now arrived at the third of those propositions which
Dr. Fowler justly says few writers have not more or less
confounded, that the same cause is always attended with the
same effect. Dr. Fowler calls this the Law of the Uniformity
of Nature, and the title may as well be retained, though other
writers use it in other senses. In this case again there are
four different problems comprised in the one proposition; that
is to say, Do men universally believe that the same cause is
always attended by the same effect ? If so, How do they
come to believe it ? Is it true ? and What is their warrant for
believing it ?

Does every man believe * that the same cause is always
attended by the same effect ’ ? This is the way in which
the problem is stated by Dr. Fowler, but Mill puts it
differently, and few writers seem to appreciate the difference.
Mill puts it that every consequent has an invariable ante¬
cedent ; by which he probably means that the same effect is
always due to the same cause; which is the converse of
Dr. Fowler’s problem ; and as we have seen, Mill says this
although he has a whole Chapter on the Plurality of Causes,
by which he means that the same effect may be due to very
different causes.

It is clear that the answers to both of these questions must
depend upon the definitions that we adopt of cause and effect,
and will be very different if we adopt one definition from
what they will be if we adopt another; but most of all they
will be influenced by our definition of the word ‘ same,’ which
most writers on this subject, I think I may say all, interpret
so that it includes ‘ different.’ It is perhaps this uncertainty
about the meaning of the chief terms employed that is respon¬
sible for the differences of different writers on the subject.

VOL. XLII. 7

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Some assert that Nature is uniform ; some deny that Nature
is uniform ; some neither assert nor deny it; some, like Mill,
both assert and deny it; and few of them mean by it the
same thing. In this chaos I shall follow Dr. Fowler, who
does at any rate say clearly what he means in this, as in most
things.

His reading of the Law of the Uniformity of Nature is
that the same cause is always attended by the same effect.
Is this true ? As I have already said, it depends on what
we mean by the chief terms employed. If a cause means
the invariable antecedent of an effect, and if an invariable
antecedent means an antecedent that is the same in every
case, then whether or no the same effect always is attended
by the same cause, it does not follow that the same cause
is always attended by the same effect, and Mill’s Plurality
of Causes forbids us to suppose that it does. In Mill’s sense
of cause, therefore, Nature is certainly not uniform in Dr.
Fowler’s sense. Whether it is uniform in Mill’s sense we
cannot tell, for Mill muddles up the Uniformity of Nature
with the Law of Universal Causation. To Mr. Welton,
cause and effect are the same thing, and in this meaning of the
word ‘cause’ of course Nature is Uniform, for the same cause
must always be attended by itself, which is the same effect;
and the same effect must always be attended by the same
cause—by itself. Professor Karl Pearson denies the existence
of both cause and effect, but yet his expressions * a routine
of perceptions,’ ‘a routine of experience,’ ‘a routine of sense
impressions ’ appear, when taken with their context, to mean
what other writers mean by the Uniformity of Nature. If,
however, there is no cause and no effect, of course there can
be no Uniformity of Nature in Dr. Fowler’s sense. Mr.
Bertrand Russell’s statement of * causality ’ includes the
assertion that there is a constant relation between the state
of the universe at one instant, and a certain rate of change
at that instant. The constancy of the relation would seem
to imply that the nature of the universe is uniform; but as
Mr. Russell denies that the law of causality (whether his own
or only that of others I do not know) is anything but a relic
of a bygone age, it would seem that he does not admit that
Nature is uniform in Dr. Fowler’s sense. All that Dr.
McTaggart can conclude after an exhaustive discussion is

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that it is impossible to prove empirically that the law does
not hold universally. Here I will leave the authorities, and
discuss the matter on the basis of my own definitions.

Does the same cause always produce the same effect ? That
is the problem we have to solve. According to my first provi¬
sional definition, a cause is an action. Does the same action
always produce the same effect ? Take the blow of a hammer
for instance: does the blow of a hammer produce the same
effect whether it falls on the head of a nail, or the side of a bell,
or a man’s fingers, or a bale of wool, or a sheet of water ?
Clearly, in this sense of the word ‘cause ’ the same cause does not
always produce the same effect, and Nature is not uniform.
But this definition of cause was provisional only. It was sub¬
sequently elaborated into this: that a cause is an action upon a
thing; and the question now becomes Does the same action on
the same thing always produce the same effect ? Again let us take
our hammer and strike with it our sheet of water. The effect
is a splash. Now let the same water be frozen, and let us strike
it again. The same effect is not produced. It may be objected
that the thing on which the cause acts is no longer the same
thing, but it is quite arguable that it is the same thing. It is
certain, however, that it is not for the purpose of the argument
the same thing. Then in what respect does it differ ? Liquidity
and solidity are, for the purpose of the argument, passive states
of the thing acted on by the cause, and according to the defini¬
tion already given, a passive state of the thing acted on by the
cause is a condition. It is evident, therefore, that the question
we are discussing, Does the same cause always produce the
same effect ? must be answered in the negative unless we amend
it by inserting a reference to the conditions ; and the question
ought to be put in the form Does the same cause in the same
conditions always produce the same effect ? But this is an
instance of the fallacy erroneously called the fallacy of many
questions, which should be called, as it is called in my New
Logic, the fallacy of the previous question. It implies that
a previous question, which has not been answered, has been
answered. It implies that the same action can take place for
a second time upon the same thing in the same conditions;
and this is not only impossible, but is acknowledged to be im¬
possible by many of those who insist that the same cause always,
or as they say invariably, produces the same effect.

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flai/ra pit, ‘All existence,’ says Mr. Welton for instance, ‘is
continuous and uninterrupted transition,’ and * uniformity itself
is not to be taken to mean resemblance. It is in identity alone,
not in mere resemblance, that we can find a firm basis of infer¬
ence.’ But if all existence is continuous and uninterrupted
transition, or change, it is clear that a state of things once
passed can never in all respects be reproduced, unless time
should flow backwards, and of this we have no experience ; and
it is a commonplace that the same state of things never is repro¬
duced. To get the same effect, the same cause must act on
the same thing in the same conditions, and the cause is never
the same, the thing is never the same, and the conditions are
never the same. Therefore cadit qucestio. In this sense, there
is certainly no such thing as Uniformity in Nature.

Yet the aphorism that the same cause invariably produces the
same effect, clumsily though it is asserted, and untrue though
it is, is the adumbration of a truth, and of a most valuable
truth. It is not true in any sense that the same cause invariably
produces the same effect; but if we recognise what logicians are
groping after, and put it into precise and accurate language, we
can assert a very important truth, upon which all our methods
but one of ascertaining causes are founded, a truth without
which but few causes would ever be discovered. It is this, that
Like actions on like things in like conditions produce like effects; and
The more nearly alike the actions, the things acted on, and the con¬
ditions, the more closely alike will the effects be. We may put the
same thought more concisely in the following aphorism :— Like
eauses in like conditions produce like effects.

I do not think this aphorism needs proof. I doubt whether
it is susceptible of proof. It seems to me to bean axiom. As
soon as its meaning is grasped, it claims and secures our assent.
Its contradictory, if not actually inconceivable, is certainly
incredible. Whether its truth is manifest a priori or is based
upon experience I do'not care to speculate. The universal
experience of mankind goes to show that, whether of empirical
origin or not, it is empirically true ; and if we like to call it an
instance, or an example, or a proof, of the Uniformity of Nature,

I don’t know that any harm will be done—or any good. We
may, if we please, call it a proof of the Uniformity of Nature,
just as we may call the axiom that things that are equal to the
same thing are equal to one another, and the axiom that two

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straight lines cannot enclose a space, proofs or examples of the
Uniformity of Nature.

Whether it is or is not the principle of the Uniformity of
Nature, or an example or a proof of this principle, the aphorism
is the fundamental Axiom of Causation, and upon it all our
reasonings about causation are founded, and all but one of our
means of ascertaining causes are based. In practice it is one
of the most important guides of life, and is employed continually
throughout life by everyone, either in the fundamental form in
which it has been stated, or in one or other of its very numerous
variants and derivatives. Of these, that which is perhaps most
frequently employed is the axiom Like effects in like conditions
are due to like causes; but as I have said, the derivatives are
numerous, and every one of them is of frequent application. It
would be tedious to cite them all, but the following are samples,
and we may, if we please, call each of them an instance or a
statement of the Uniformity of Nature.

Like causes in like conditions produce like effects.

Like causes in unlike conditions produce unlike effects.

Unlike causes in like conditions produce unlike effects.

Like effects in like conditions are due to like causes.

Unlike effects in like conditions are due to unlike causes.

If like causes produce like effects the conditions are alike.

If like causes produce unlike effects the conditions are unlike.

And so on.

Summary.

There is no such thing as Plurality of Causes in Mill’s sense.
What he meant was that in different cases different causes
produce different effects that have some element in common,
and this common element he called the effect, and said that it
might have many causes. His error was in generalising the
effects without generalising the causes.

But every effect is due to a series of causes stretching back
into infinity.

And this series is not single, but every effect requires both
a cause and conditions, and the conditions are themselves
the results of causes; every effect is therefore due to an in¬
definitely large number of series of causes converging on the
effect.

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The cause of a condition is an indirect cause.

The cause of a cause is a direct, but more or less remote
cause.

The cause of an effect is that cause in which for a certain
purpose we are most interested.

To produce an effect, causes may cooperate in any of the
following ways.

Like causes may cooperate in succession, simultaneously, or
indifferently.

Unlike causes may cooperate in succession, and then must
preserve a certain order ; or simultaneously ; or indifferently.

The Law of Universal Causation has, in the books, several
incompatible meanings. It appears to be indisputable that we
believe that every event has a cause, and that this belief is shared
with us by many of the lower animals. This belief is founded
upon the constancy of our experience, and is true, or at any
rate is inescapable.

The Law of the Uniformity of Nature, as stated in the books,
is nonsense. Neither the same cause nor the same effect is ever
repeated. The true Axiom of Causation is that Like causes in
like conditions produce like effects, and the more closely alike
the causes and the conditions, the more closely alike will be the
effects. On this axiom all our reasonings with respect to
causation are founded.

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CHAPTER VI.

METHODS OF ASCERTAINING CAUSES.

When we have discovered an action upon the thing changed
or maintained unchanged, and have determined that the action
precedes the change or accompanies the unchange, we have
still not ascertained the cause ; we have only cleared the ground
in preparation for doing so. The cause is not ascertained until
we have established a necessary connection between the action
and the effect. This is what Mill’s Methods of Experimental
Enquiry are designed to secure. Mill assumed, and the assump¬
tion is adopted from him by subsequent writers on the subject,
that the only way to discover causes is by experiment, and that
the only aim of experiment is to discover causes. Both assump¬
tions are manifestly and transparently false, and are contradicted
by everyday experience. Some of the methods described by
Mill himself as experimental are not experimental, indeed he
admits that one of them is not; and some of the instances he
gives of the determination of causes are instances of the deter¬
mination not of the causes of things, but of their existence, or
their nature.

Logicians as a rule know nothing of natural science except
what they mug up for the purpose of finding instances where¬
with to illustrate Mill’s five methods, which he and they all call
four. They have therefore no means of knowing whether these
methods are used or not; but they accept Mill’s confident
assertion that in scientific investigations these methods and
no others are used. But though logicians know nothing of
natural science or of its methods except what they learn from
Mill, they cannot help, in common with the rest of the world,
assigning causes for the various events they meet with in their
daily lives; nor can they help seeing that in thus ascertaining
causes, none of Mill’s methods is ever used. They naturally
conclude that the methods of science and the methods of daily
life are utterly and totally different; that when a man enters
his observatory or his laboratory he strips himself at the door
of all the methods he is accustomed to use, and employs an

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entirely new set, a set of methods that are mysterious, recon¬
dite, and complicated, that logicians regard with awe, and
do not venture to criticise. To these methods they give the
name of the Logic of Science, and they suppose that non-
scientific people have to be satisfied with a different and very
inferior Logic. This is all moonshine.

I assert, and the present chapter is designed to prove, that
the methods by which scientific men ascertain the causes of
those phenomena that are called scientific are precisely and
exactly the same as those by which the cook ascertains the
cause of the dinner being spoilt, and the child ascertains the
cause of its toy being broken. I assert, and will presently
prove, that the methods so clumsily and uncouthly described
by Mill are in fact never employed; that they never could be
employed, for they are absurd, and when applied to actual cases
result in futility; and I assert that when we seek to ascertain
the causes of things, and when we do ascertain them, we look
for an action upon the thing on which the effect is produced,
that is, on the thing changed or maintained unchanged; and we
are guided in our search, as well as determined in our choice,
by one or more of the following considerations :—

I. Instant sequence of the effect on the action.

II. Subsumption of the case in hand under a general law.

III. Assimilation of the case in hand to a known case of
causation.

IV. Association of the action with the effect.

V. Concurrent and proportional variation of the action and
the effect.

VI. Common rarity of the action and the effect.

VII. Correspondence of a quality in the effect with a quality
in the agent.

VIII. Coincidence in space of an action or a condition with
the effect.

IX. Coincidence in time of the action with the effect.

The fifth of these methods, that of establishing an association
between the action and the effect, is further divisible into four
subordinate methods; so that altogether there are at least
twelve methods of ascertaining causation; and these we may
now proceed to examine.

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I. Instant Sequence.

When an action upon a thing is instantly followed by a change
in that thing, we are irresistibly driven to conclude that the
action is the cause of the change.

When a china cup falls to the ground and breaks at the
instant of its impact on the ground, we do not need to witness
‘ two or more instances in which the phenomenon occurs ’ or
‘two or more instances in which the phenomenon does not occur *
before we can make up our minds that the action of the impact
was the cause of the breakage. We are driven to the conclusion
that this action was the cause of this effect; and the main, if
not the only reason for our conclusion is the instant sequence
of the effect on the action. As already said, the writers
upon causation seem to think that causes never are attri¬
buted, and that there is no need for the discovery of
causes, except in the laboratory or the observatory, or in
matters that are called, with more or less justice, scientific.
There was never a greater mistake. We are all of us
engaged daily, hourly, and almost momentarily, in the ascer¬
tainment and attribution of causes; and it is much more
important to each of us in our lives to attribute causation cor¬
rectly in matters that pertain to our immediate welfare, than
that we should ascertain the causes of the perturbation of a
planet, or of the mimicry of butterflies. Among the means by
which we ascertain causes in our daily work, the instant
sequence of an effect upon an action is perhaps the most
frequent, and is by no means the least important. Nor is the
employment of this means confined to trivial matters of daily
occurrence. It is just as important and just as trustworthy in
the laboratory. When the chemist adds one clear liquid to
another, and a precipitate is instantly formed, he concludes at
once that the addition of the reagent was the cause of the
formation of the precipitate; and he forms this conclusion
because of the instant sequence of the turbidity of the liquid
on his action in adding the reagent.

If we see a match applied to a thing, or a blow struck upon
it, and that thing instantly explodes, we attribute the explosion
to the application of the match or the striking of the blow ;
and this we do without any need of two or more instances in
which the phenomenon occurs, and two or more instances in

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which it does not occur. The instant sequence of the change
on the action assures us that they are effect and cause. Anyone
quite ignorant of military evolutions who should see the troops
alter their formation immediately on hearing a bugle call,
would instantly regard the call as the cause of the movement.
If we pour oil into the bearings of an engine, and the engine
instantly increases its speed, or if we do the same to a foot-
lathe, and the lathe instantly runs easier, we have no hesitation
in attributing the change of speed, or the easier working, to
the action of lubrication. If a horse’s head is turned towards
home, and he instantly improves his pace, we inevitably
connect the improvement causally with the change of direc¬
tion. If a bell rings or a whistle sounds in a factory, and the
workmen all instantly drop their tools, we cannot help regarding
the cessation from work as the effect of the sound; and similarly,
when the air is thick with the chirruping of birds, if a gun is
fired, instantly a dead silence ensues. We cannot help attributing
the sudden occurrence of the silence to the report of the gun.

In some of these cases there may be other reasons which
corroborate our judgment, and in fact our judgment of
causation is seldom formed upon one method alone. Usually
two or more methods corroborate one another, and the third
method, the Method of Similarity, is seldom quite absent; but
in others of the cases that have been instanced it is clear that
the conclusion was based upon the instant sequence of the
effect on the action, and upon no other method. One who
had never before seen a galvanometer, and knew nothing of
electric action, who should see the needle move the instant the
key was depressed, could scarcely avoid attributing the change
to the action.

Of course, the method is not infallible. In this imperfect
world few methods are infallible. In some cases it needs
corroboration or testing by some one or more of the other
methods. But for all that, it is a method; it is a method
that is constantly in use ; it is a method that by itself may
lead to a perfectly reliable conclusion ; and it is a method-that
is not mentioned by any previous writer on the subject. Its
fallibility is shown by the familiar instance by which a child
is made to believe that he can cause the cover of a watch to
fly open by blowing on it; but what is more important, the
same instance shows how very early in life the conclusion is

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thrust upon us, that a change that follows instantly upon an
action is the effect of that action.

Mill and his commentators must each of them have used
this method thousands of times, but they none of them record
it, whether because it is difficult to put it into cumbrous and
obscure language, or because they do not consider it sufficiently
‘ scientific,’ I do not know.

II. Subsumption.

The second method of establishing a causal connection
between an action and an effect is by subsuming the instance
in hand under a general law. If this can be done, causal
connection is assured, and neither Mill’s Canons nor any other
device is required to assure us of the necessary connection
between the action and the effect.

Whether the tides were associated with the moon before the
discovery of gravitation I do not know; but as soon as gravi¬
tation was discovered, and was applied to the action of the
moon upon the seas, it must have become apparent at once
that the moon’s attraction must be the cause of tidal changes
in the level of the seas; and if tides had never before been
observed they would now be looked for. The action of the
moon on the sea, and the sequent change in the level of the sea,
are subsumed under the general causal law of gravitation, and
this subsumption gives us the assurance that the action is the
cause of the change.

When our waterpipes burst in winter, we find the cause
at once by subsuming the case under the general law that
water in freezing expands with immeasurable force; and by
this subsumption the action of the frost and the bursting of
the pipes are connected. When the cook goes to the cupboard
for a pot of jam, and finds it is not there, she says at once
* Someone must have taken it.’ She subsumes this instance
under the general law that inanimate things do not move from
their places without external agency. When the price of fish
rises, and we hear of gales in the North Sea, we assume a
causal connection between the action and the change, and we
do so on the strength of the general law that, other things
remaining the same, restriction of supply raises prices; and
we know that gales in the North Sea do restrict the supply

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of fish to this country. If the river overflows its banks, we
assume, unless it is a tidal river, that there has been much
rain in its catchment basin, and we make this assumption on
the strength of the general law that caeteris non mutandis, the
level of a river depends on the rainfall in the catchment area.
If we find an object of gold or silver that shows signs of having
been melted, we assume at once that it has been subjected to
great heat, for it is a general law that great heat is necessary
to the melting of gold and silver. If we find iron rusty, we
assume that it must have been damp, for it is a general law
that dry iron does not rust. When we are seeking the cause
of a rare disease, and we find that it affects the members of
several families in conformity with the laws of Mendel, we
have no hesitation in concluding that the cause is hereditary
transmission.

Neither in these cases do we look for two or more instances
of the phenomenon, and ask if they have only one circumstance
in common, nor do we look for two or more instances in which
the phenomenon does not occur, and ask if they have nothing
in common but the absence of the phenomenon. What we do
is to subsume the case in hand as an instance under a general
law applicable to such instances ; and if the subsumption is
good, then the causal connection is made out to our satisfaction
This method, which is distinct enough in cases like the tides
and the Mendelian inheritance of disease, is in other cases less
pronounced, and graduates and merges into the next.

(To be continued.)

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I 9 1 6 .] CONVERSION OF ASYI.UM INTO HOSPITAL.

109

A Descriptive Record of the Conversion of a County
Asylum into a War Hospital for Sick and Wounded
Soldiers hi 1915C 1 ). By Lieut.-Col. D. G. Thomson,
M.D., President of the Association, Officer in Charge of
the Norfolk War Hospital.

Ladies and Gentlemen, —I wish your President, especially
as you are condemned to abide under his aegis for a second
year, had been a man able to enthrall you with some lofty
theme appropriate to this time of stupendous events.

There is a trite saying, however, that it takes all sorts of
people to make a world. We cannot all be a Hughlings-Jack-
son, a Mercier, a Maudsley, or a Savage, but many of us can
act as scribes or chroniclers, and having an uneasy conscious¬
ness of my own limitations I have adopted that humble role in
my recent appearances before you. I assumed it last year—
how long ago it already seems !—in my Presidential Address,
when I reviewed the history of Psychiatry during the last
hundred years, and I propose, with your permission, to read
you another chapter of Chronicles to-day.

I can lay no claim to this chronicle being of scientific medical
interest, but my administrative bent of mind suggested that it
would be proper and fitting that there should be some record
on our tablets of what happened to many of our Public Institu¬
tions for the Insane in the time of the great European war of
1914 and onward.

If we look back to August, 1914, on the 4th of which month
war with Germany was declared, it is not surprising that a
maritime nation like Great Britain pictured to itself great naval
engagements rather than battles by land, and that probably
large numbers of wounded would be landed on our North Sea
coasts from ships of war, whereas our naval hospitals existed
on the south coasts far from the changed venue of action. This
point of view prompted Norfolk, the nearest part of England
to the German naval bases, and itself a maritime county, so
early as the 5th of August, or the very day after the war w'as
declared, to offer to the Admiralty 100 beds, and to erect tents
for 150 more, in the Norfolk and Norwich Hospital.

This early and patriotic offer was accepted, but, as we now

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know, not made use of, so that on the 3rd of September the
offer was transferred to the War Office, and on the 17th of
October the first convoy of 100 sick and wounded was sent to
that Hospital.

We learn from this date when it first became evident that
the Base Hospitals of the British Expeditionary Force in France,
and the existing military hospitals in this country could not
cope unaided with the great and sudden influx of wounded.

In the last week of October, or shortly after the Norfolk
and Norwich Hospital received its first convoy, there is evidence
that the War Office became seriously concerned as to the dis¬
posal of the large numbers arriving from the battles of the
Marne and Aisne, for all public asylums in England and Wales
received a letter from the Board of Control stating that the
War Office would be'glad to have knowledge of those asylums
in which facilities could, if required, be obtained for the treat¬
ment of wounded soldiers, and offers of fifty beds and upwards
were asked for. The Norfolk County Asylum replied on Novem¬
ber 23rd to this inquiry by offering 100 beds, the plan I recom¬
mended to my Committee and approved by them being to vacate
one block of buildings at the extreme western end of the Main
Asylum, which could be easily cut off from the Asylum gene¬
rally, and the seventy patients in which could be distributed
throughout other wards of the Asylum. On the 15th of Decem¬
ber the Board of Control wrote that, so far as they could ascer¬
tain, no actual urgency in this matter existed at present, that it
seemed unnecessary at the moment to put in motion any definite
arrangements for setting apart accommodation for wounded
soldiers, and that they were merely collecting information as
to possible accommodation in the asylums for sick and wounded.
This corresponds with the period of comparative inaction at
the western front during December and January.

Towards the end of January, 1915, there was a very general
impression that the Allies contemplated an advance against the
enemy in the spring, that such an advance would be very
costly, and that it would be necessary to provide additional
hospital accommodation on a large scale, whereupon the War
Office invoked the assistance of the Board of Control, the Local
Government Board, and the Board of Education, all Govern¬
ment Departments controlling institutions, asking them to
provide at least 50,000 beds.

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1916.] BY LIEUT.-COL. D. G. THOMSON, M.D. Ill

Accordingly, on January 29th, a letter was received from the
Board of Control, expressing a desire to use determined efforts
to provide 15,000 beds in asylums by clearing some asylums
entirely of their ordinary patients, and distributing them in
other asylums. On February 1st a preliminary conference was
held at the Offices of the Board of Control, attended by Drs.
Bolton, Cassidy, Goodall, Kidd, Macdonald, Spence, and
Thomson, whereat the Commissioners outlined the scheme they
had in view, viz., to hand over to the War Office certain
asylums in the neighbourhood of large towns, where operating
surgeons would be readily available, evacuating these institu¬
tions of their usual patients, who would be sent to neighbouring
asylums. This scheme was generally approved by the Medical
Superintendents present, and, of course, many difficulties which
naturally and at once occurred to them were mentioned, inter
alia, the safeguarding of the position and interests of the
asylums staffs, the financial arrangements as between the War
Office and the asylums taken over on the one hand, and as
between the vacating and receiving asylums on the other.
However, the Commissioners intimated that this was merely a
preliminary conference, and that those matters would be debated
at a subsequent meeting.

This latter was held at the deputation room at the Home
Office, under the Chairmanship of Sir William Byrne, on
February 8th, and there were present members of the Com¬
missioners of the Board of Control, the Chairmen, Clerks to
Visitors, and Medical Superintendents of about twelve county
and borough asylums.

Sir William Byrne described the scheme of his Board for pro¬
viding in the asylums 15,000 beds for sick and wounded soldiers,
as follows : He proposed that the public asylums of England
and Wales be divided into nine groups, viz .—

Group 1.—Northumberland, Newcastle-on-Tyne, Durham,
Gateshead, Sunderland, Cumberland, York City, Clifton, and
Middlesbrough.

Group 2.—Wakefield, Wadsley, Menston, Scalebor Park,
Storthes Hall, Beverley, Hull, Bracebridge, Kesteven, Notts,
Nottingham, Leicester and Rutland, and Leicester City.

Group 3.—Lancaster, Rainhill, Prestwich, Whittingham,
Winwick, Chester, Parkside, Denbigh, Derby County, and
Derby City.

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Group 4.—Stafford, Burntwood, Cheddleton, Salop,Warwick,
Winson Green, Rubery Hill, Oxford, Northampton, Powick,
and Barnsley Hall.

Group 5.—Norfolk, Norwich, Suffolk, Ipswich, Brentwood,
Severalls, West Ham, Cambridge, Three Counties, Herts, and
Bucks.

Group 6. — Gloucester, Hereford, Monmouth, Newport,
Glamorgan, Cardiff, Carmarthen, and Brecon and Radnor.

Group 7.—Hants, Portsmouth, Berks, Chichester, Hellingly,
Barming Heath, Chartham, Canterbury, and Isle of Wight.

Group 8.—Dorset, Wilts, Wells, Cotford, Devon, Exeter,
Plymouth, Cornwall, and Bristol.

Group 9.—Banstead, Bexley, Cane Hill, Claybury, Colney
Hatch, Hanwell, Horton, Manor, Colony, and Long Grove.

That one asylum in each Group be offered to the War Office,
viz .: Bristol, Cardiff, Chichester, Newcastle, Norfolk, Wads-
ley, Winwick, Horton, and Rubery Hill, and that all the
patients in these asylums, numbering some 12,000, be removed,
transferred to or boarded out in the other asylums of the respec¬
tive groups. Assuming the receiving asylums to be full they
would under the scheme be overcrowded to the extent, in round
numbers, of ten per cent., or in an asylum of twenty wards by
five patients per ward, no serious hardship for staff or patients
under national emergency.

Sir William Byrne urged the chairmen of committees of
public asylums present to convene a meeting in their respective
areas of the chairmen, clerks to visitors, and medical super¬
intendents of asylums of each group, to discuss the scheme
proposed, and come to mutual agreement on the provisions.

As a basis of discussion at these meetings he enunciated
several main points, which a day or two later were circulated
in the following memorandum :

Suggested Arrangements.

(Vacating certain asylums for War Office use.)

(a) No asylum should seek to make any profit out of patients
received from a vacated asylum.

( b ) The rate of maintenance charged by a receiving asylum
to a vacated asylum for patients sent from the latter asylum

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1916.] BY LIEUT.-COL. D. G. THOMSON, M.D. I I 3

should be that of the ordinary pauper rate obtaining for the
time being in the receiving asylum.

(c and d) Details referring to private patients.

(e) That the entire clerical staff, the laundry, kitchen, and
farm employees, and the steward’s staff, and as many as pos¬
sible of the nurses and attendants and of the medical staff of
the vacated asylums should remain, and be utilised by the
War Office, and that wherever possible the Visiting Committees
of these asylums should, in conjunction with the War Office,
undertake the equipment of the asylums so far as may be neces¬
sary' for the purpose of a military hospital, augmenting the
staff with a sufficient number of surgeons and trained hospital
nurses. The clearing of the asylum of all patients, except those
who are gravely ill, and perhaps a certain number of farm work¬
ing patients, should be absolute.

(/) The Board further think that contracts, transfer orders,
notices of admission, reception orders, medical statements, etc.,
rendered necessary by the scheme, should be simplified as much
as possible. They will be glad to consider any suggestions
made to them in relation to this.

(g) All documents required for the transfer of patients, and
all arrangements with railway companies for the transfer of
patients, should as far as possible be made well in advance.

(h) As speedily as possible after the termination of the war,
all patients should be returned to the asylums they vacated.

After various questions had been put and replied to from
the chair, and discussion, the meeting pledged itself to approval
of the Board’s scheme, and undertook to hold the necessary
local conferences. In regard to item ( b ) on the memorandum
the meeting expressed itself against any charge being made for
rent or interest on capital.

On leaving this Conference I was “given furiously to think.”
First to arise in the mind was the overawing national emer¬
gency necessitating such unexpected and revolutionary pro¬
ceedings, then the natural pride in actively assisting, and the
desire to do so, in the national need, added to this the personal
feeling that my life’s occupation and interests were slipping
from under me, and that somewhat late in my career I was to
face and undertake new and unfamiliar responsibilities. Since
passing the pensionable age-Rubicon I have at times pictured
the painful but inevitable process of some day bidding adieu to

VOL. XLII. 8

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my patients, but never in my wildest dreams did I picture them
all filing out of the Asylum bidding me farewell and leaving me
stranded and alone.

The next step in carrying out the scheme of the Board of
Control was the holding of the local conferences, calling together
the representatives of the asylums of each particular group, and
inducing agreement among them to vacate one asylum in the
group, and to receive the patients so removed in the remaining
asylums of the group.

The first conference of the kind was held by the East Anglian
group on February 17th, 1915, in the Shirehall, Norwich.
This was attended by the chairmen of the various Committees,
Clerks, and Medical Superintendents of the eleven asylums of
the group, and by Dr. Marriott Cooke, a Commissioner of the
Board of Control. It was resolved unanimously to approve of
the scheme in general, and of its local application, whereby the
Norfolk County Asylum was to be emptied, and its 1,050
patients received into the nine other asylums in the group.
An exception was made in the case of the Norwich City
Asylum, which offered to take all the cases of insanity occurring
or arising in the county. This arrangement was welcomed by
Norfolk, as from the patients and their friends’ point of view,
as well as that of the Guardians and their officers, it was a great
boon to have the Norwich City Asylum, which is as near and
as convenient of access to them as the County Asylum at
Thorpe itself. Further, that as these cases accumulated, the
incurable residuum would be drafted off to other asylums of
the group from time to time.

The various headings in the memorandum given above were
then discussed, and (a) ( b ) (c) and ( d) were agreed to, it being
understood that the receiving asylums should charge the
vacating asylums the actual cost of maintenance, and that no
charge should be made in respect of the Building Fund/ that is
to say rent, upkeep of buildings, and interest on capital.
Items ( e) (/) ( g ) and ( h) were left to be settled between the
War Office, the Board of Control, and the Norfolk County
Asylum, so as to avoid the inconvenience and difficulty of
holding further conference.

It must be said that this Conference carried out its object
with commendable expedition, unanimity, and patriotism, and
touched but lightly on the barbed wire that lay in its path, such

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1916.] BY LIEUT.-COL. D. G. THOMSON, M.D. IIS

thorny questions as cost v. charge, the charging of rent by
receiving asylums, and last, perhaps not least, where so many
patriotic spirits were present eager for more active work in the
assistance of the country, no cavil or jealousy at the selection
by the Board of Control of the particular asylum to be vacated.

It must not be supposed that to so many men, well versed in
the administration of asylums, schemes alternative to that of
the Board of Control had not suggested themselves, e.g., in our
then state of knowledge of the whole subject it appeared to
some that a less drastic and thorough emptying of one asylum
and congestion of others might have sufficed, resulting in less
general upheaval and cost, by devoting some detached block,
say, of one hundred beds, at every asylum in the county, to
military hospital purposes. The question of sentiment, how¬
ever, was strongly against placing our sick and wounded soldiers
in even wholly separated parts of the same institution as the
insane, in fact, any advice tendered to the War Office as to the
economic policy of retaining women working patients, for
kitchens and laundry, was met with decided refusal, the only
concession made in this direction being that a few farm and
garden working patients might be retained, if they could be
housed at some separate farmhouse or other building. Now that
I am familiar with all the military requirements as to records,
invaliding Boards, and the endless clerical and administrative
dealings with the invalid soldier, and also with the necessarily
elaborate provisions for operative and X-ray work requisite for
military surgery, I am fully convinced that the scheme planned
by the Board of Control is far and away the best.

General principles having been determined, it now only re¬
mained to carry them out. It was intimated to us on March 2nd
that the matter was urgent, that the War Office hoped to be in
possession of the 15,000 beds at the nine receiving asylums in
six weeks time, i.e., by April 15th, and that with this end in
view certain outstanding matters would be adjusted as soon as
possible, such as the details of the reimbursement which the
War Office undertook to make to the asylums, and the
suggested forms of contract between the vacating and the
receiving asylums.

On February 18th a conference of Medical Superintendents
of public asylums was held in the Association rooms in London,
and various matters bearing on the subject were discussed.

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On March ioth the two following documents, “A” and “B,”
were sent to the asylums by the Board of Control.

“A” is the scheme prepared by the Board of Control as to the
general terms of the conversion, and the details of reimburse¬
ments which the Board of Control state the War Office will
undertake to make to vacating and receiving asylums. Of this
scheme the War Office, we were informed, generally approved,
but, in addition, the Army Council sent out a document or state¬
ment of their own, Document “ B,” setting out various points, so
as to arrive at a clearer understanding, and the Board of Con¬
trol gave it as their opinion in a letter of March ioth that there
was nothing conflicting in the case as stated in Document “A”
on the one hand, and in Document “ B ” on the other.

In the letter quoted above, covering these two documents,
we were assured how much the Army Council appreciated, not
only the willingness of the authorities and staffs of these
institutions to place them at their disposal, but also the hearty
co-operation of the authorities and staffs of all the receiving
asylums, without which they realised the scheme would not
have been practicable.

(a) Use of Asylums as Military Hospitals.

Scheme , prepared by the Board of Control, for the General Administra¬
tion of the vacated Asylums, and the details of the reimbursement
which the War Office undertake to make to the receiving and vacated
Asylums.

I. Charges arising from the maintenance and treatment of sick and
wounded soldiers in asylum buildings, which the Army Council under¬
takes to meet.

i. Vacated asylums:

( a ) Charges in connection with buildings and equipment.

(i) Necessary adaptations of the buildings for hospital purposes.

(ii) Maintenance and repairs of premises.

(iii) Reinstatement of premises at end of occupation by Army Council.

(iv) Additional equipment found to be necessary, e.g., hospital
requirements, extra beds, etc.

Note. —All extra equipment purchased at the expense of the War
Office which remains in stock at the conclusion of the war, is to be
regarded as the property of the War Office, but may, if the asylum
authorities so desire, be taken over by them wholly or in part at a
valuation.

(b) Charges in connection with the maintenance of staff and of
soldier patients.

(i) Salaries and wages, including fees to surgeons and other experts,

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1916.] BY LIEUT.-COL. D. G. THOMSON. M.D. 117

and remuneration of other persons called in to supplement ordinary
staff.

(ii) Victualling on scales laid down by Army Council.

(iii) Uniform for staff and clothing for patients.

(iv) Furniture and bedding. (Renewals and repairs.)

(v) Medicines, surgical appliances and instruments.

(vi) Fuel, lighting, washing, and other necessaries.

(vii) Rates, taxes and insurance.

(viii) Incidental expenses, including travelling, burials, etc.

2. Receiving asylums:

Charges in connection with the maintenance of lunatics.

(i) Additional weekly cost of maintenance, if any.

(ii) Equipment and stores required for additional numbers and extra
cost of maintenance and depreciation.

(iii) Any necessary slight structural alterations necessitated by increased
numbers, extra wear and tear and reinstatement of premises.

3. Cost of all necessary travelling and conveyance of lunatics.

II. General arrangements.

r. The War Office will be solely responsible for the medical care and
treatment of the soldiers and the management of the hospital.

2. The asylums will be handed over as going concerns with the
whole of their staff, medical, engineering, stores, farm, etc., and such
part of the nursing and attendant staff not needed to accompany the
patients to the receiving asylums. The portion of the nursing staff
retained at the asylum should be that portion best suited to take up or
assist in the care of the sick and wounded.

3. The War Office will appoint the additional medical and nursing or
other staff required for the hospital. The Visiting Committee and the
Medical Superintendent will generally, from their local knowledge, be
able to suggest suitable persons for employment in addition to those
already in War Office service.

4. Subject to the directions of the Committee, the Medical Superin¬
tendent is the head and director of the asylum administration, and in
most instances, no doubt he will be appointed by the War Office to be
the officer in charge of the hospital. If so appointed he will continue
to exercise the general control over the institution and its staff and
working, for which his experience specially qualifies him. The other
medical officers of the asylum will ordinarily be qualified and willing to
become part of the medical staff of the hospital, and to share the duties
with the additional professional staff sent by the War Office.

5. The whole of the asylum staff is in the employment of the Visiting
Committee, by whom they are appointed and by whom they can be
dismissed. They are in established pensionable service, and it is
necessary that their asylum service should be unbroken, except for
misconduct. If in any instance it is expedient that the head of the
hospital should be an officer other than the Medical Superintendent, it
is desirable that he should delegate the lay administration of the institu¬
tion to the Committee which, from experience and local knowledge, is
the authority best qualified to carry it on. The Medical Chief will
thus be relieved from many laborious administrative tasks. The dele¬
gation may be subject to such conditions as are thought reasonable.

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6. The War Office has decided that military rank shall be conferred
on the members of the medical staff. If an officer of higher rank than
the Medical Superintendent is sent to the hospital, it is desirable that
the general administration of the institution should be delegated to the
Medical Superintendent, or at any rate in practice left in his hands. As
regards the male attendants, it may be thought necessary, as has been
done at the State institution at Moss Side, to incorporate them in the
Red Cross organization.

7. The Committee will continue to make contracts for supplies, and
otherwise carry on the business side of the administration, will open a
fresh banking account from the date when the War Office are in posses¬
sion, and the Clerk will each month present to the War Office an
account, certified as the War Office may require, of the expenditure
incurred. These accounts will be audited as heretofore by the asylum
auditors with any additional precautions which the War Office may
require. They should be transmitted to the War Office through the
Board of Control who, after such inquiry—if any—as they think neces¬
sary, will append their certificate that the claim is a proper one to be
made on the War Office.

The Committee will be informed by the War Office what stores, etc.,
can be supplied by that Department, and what must be contracted for
locally.

The necessary funds to meet expenditure on structural alterations,
additional equipment, expenses on travelling and conveyance, etc., will
be advanced by the War Office as soon as a decision is come to that an
asylum is to be vacated.

Claims for such advances should be transmitted through the Board
of Control.

(b) Use of Asylums as Military Hospitals.

Observations by the War Office supplementary to their general confirma¬
tion of the scheme prepared by the Board of Control:

1. Vacated asylums:

(a) Charges in connection with buildings and equipment:

(ii) Maintenance and repairs of premises.

In case of considerable repairs constituting permanent structural
improvements, the Board of Control will no doubt be prepared to
advise to what extent credit can be given to the War Department for
these in the final settlement.

(iii) Reinstatement of premises at end of occupation.

It is presumed that a complete inventory will be taken before occu¬
pation.

(iv) Additional equipment.

It is presumed that complete accounts will be kept of equipment
furnished by, or purchased at the expense of, the War Department.

(b) Charges in connection with the maintenance of staff and of
soldier patients :

(i) Salaries and wages.

It is presumed that the Visiting Committee will actually pay (at War
Department expense) the present salaries of the retained asylum staff,

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1916.] BY LIEUT.-COL. D. G. THOMSON, M.D. 119

and any persons temporarily engaged, and that the War Department
will pay direct its own officials. This is merely a matter of machinery,
and will be pursued in the communication referred to in paragraph 7
below. The rates to be paid for any persons temporarily engaged will
be settled by the War Office.

(ii) Victualling.

Presumably consumable stores taken over will be valued and the cost
credited to the asylum authorities.

It is presumed that appropriate accounts of consumables, etc., whether
supplied by War Department or purchased on their behalf by the
asylum authorities, will be kept, and that these accounts will be avail¬
able for inspection, if desired.

Medicines and medical and surgical equipment when not taken over
with the asylum will be provided by the War Office or under arrange¬
ments approved by them.

Receipts generally.

It is presumed that the produce of asylum farms will be available for
use, and that the War Department will be allowed credit for produce
sold. Also that the War Department will receive credit for the grants
received by the asylum authorities in respect of any harmless patients
retained for work on farms or grounds, since they will be maintained
out of general maintenance of which War Department is bearing the
cost, and generally that any receipts arising out of the ordinary working
of these institutions while they are in use by the War Department will
be taken in reduction of the working expenses chargeable against the
War Office.

2. Receiving asylums.

(1) Additional weekly cost of maintenance, if any.

It is presumed that the authorities of the vacating asylum will
continue to draw their grants in respect of patients transferred, and of
patients who would be sent there but for War Department occupation,
that the vacating asylum will pay to the receiving asylum the weekly
cost of maintenance therein, and that the War Department will refund
to the vacating asylum the excess in cases where their grant is less than
the weekly cost in the receiving asylum.

In cases in which the weekly cost is less, this Department would not
propose that the saving should be taken into account unless the saving
is of material amount, in which case the charge under (ii) below should
apparently be abated.

(ii and iii) Equipment and stores required.

It is presumed that an account will be kept of the additional equip¬
ment, and that such equipment may be taken over on evacuation at a
valuation as in case of vacating asylum. This Department will readily
fall in with your views as to the manner of payment for these services.

General arrangements.

(2) If a portion of the staff is transferred to a receiving asylum, it is
presumed that the salaries will not be a charge for the War Department.

(3) After "nursing” in line 1, add “or other.”

(4) After “ War Office ” in line 3, add “ under the General Officer
Commanding-in-Chief of the Command concerned.”

(6) Delete the first 3 lines and substitute, “ If the War Office in any

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CONVERSION OF ASYLUM INTO HOSPITAL, [Jail.,

given case should appoint an officer of senior rank to the hospital, it is
desirable that the general ...”

(7) It is suggested that when an asylum is taken over, an advance be
made by the War Department on the recommendation of the Board of
Control, on the basis of a month’s (or quarter’s) estimated expenditure
(plus initial costs in the first instance) and that periodical accounts
should be rendered to the War Department through the Board of Control
as suggested. A further communication will, however, be addressed to
the Board of Control as regards the procedure in rendering accounts,
but this Department will be prepared to make advances as soon as
desired.

All these matters having been settled, the contracts between
the vacating and receiving asylums committees were drawn
up and signed, and it was now possible to set about transferring
the patients from the vacating to the receiving asylums. To
facilitate the procedure and clerical work attendant thereon
the Board of Control issued the following memorandum of
suggestions.

Suggestions offered by the Board of Control in order to

SIMPLIFY THE MEDICAL AND CLERICAL WORK IN CONNECTION WITH

EMPTYING CERTAIN ASYLUMS, WITH A VIEW TO THEIR USE BY THE

War Office. (March ioth, 1915.)

The Commissioners desire to simplify, as much as is compatible with
safety, the work entailed in keeping the medical records, both at the
moment of emptying the selected asylums (which, for brevity’s sake will,
in what follows, be denoted by “V”) and at the time when the patients
are returned to them from the grouped asylums (which will be denoted
by “R”). With this object, they offer the following suggestions.

a. When transferring patients from V to R, send with them (a) the
original reception orders (or copies in the cases of patients who had been
received into V as a transfer); ( b) corrected addresses of friends and
relatives; (e) brief particulars as to character, eg., whether suicidal,
dangerous, epileptic, degree of supervision at night required, how
employed, existence of any important physical disorder necessitating
caution ; and ( d ) in those instances in which V has adopted the loose-
leaf system of case-book, the folios corresponding to the patients ; these
should be adequately secured, either in proper loose-leaf binders or
other satisfactory means.

B. Notices to Board of Control of admission to R. —In the case of
patients transferred from V to R, these need indicate only the patient’s
full name, date of reception order, date of admission to R, and evidence
(if any) of recent injuries or severely impaired health.

c. Entries in Registers and Case-books. —(i) It is suggested that the
statutory registers (civil, medical, register of discharges and transfers, and
register of death) belonging to V be not closed, but continue to be
entered up by the retained clerical staff of V, in the manner to be
presently indicated.

(2) Each receiving asylum (R) to establish a simple form of register

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igi6.]

BY LIEUT.-COL. D. G. THOMSON, M.D.

I 2 I

of all the patients received from V, indicating name, date of reception
order, dates for its continuation, date of admission to R, any other facts
of importance thought desirable, and providing provision to record dis¬
charge or transfer (with particulars of such) or death (with cause thereof,
verification by P.M., and other particulars).

(3) Each receiving asylum also to establish a loose-leaf form of case¬
book in respect of the cases received from V. This, in those instances
where V already uses the loose-leaf system, will be made up of the loose-
leaves sent from V; if Udoes not use this system, it should purchase
a sufficient number of folios for its patients and send them, adequately
secured together, to the several asylums (R) receiving its patients.

(4) That the frequency and amount of note-taking for these case¬
books should be left to the discretion of the medical officers ; and that
it be understood that adhesion to the Commissioners’ Rules as to this
matter will not he expected, so long as due care is taken to record
really important facts as they occur from time to time.

(5) That on the discharge, transfer (elsewhere than back to V) or
the death of a patient in R, received there at the emptying of V, a full
entry be made on the case-book loose-leaf, comprising, besides the usual
facts noted in a case-book, all particulars necessary to complete the
columns in the corresponding register; that this loose-leaf be then sent
to V, where the registers can then be duly filled in and the loose-leaf
fixed in its appropriate place, either in the loose-leaf system or gummed
in the case-book. The usual copy of notice of death should also be
sent to V. The results of any post-mortem examinations, made in
respect of any of these patients, could easily be made also on loose
sheets, which would be sent to V with the above documents.

D. On the re-opening of V. —Items (a), (b), and (c), indicated above,
should be sent from R to V, together with the case book folios. Notices
of re-admission to V would only require to be in the simple form set
out in “b” of the above headings.

E. Direct admissions to R which, under normal circumstances , would
have been sent to V. —It is suggested that it would not be expedient to
make any attempt to modify the usual clerical procedure in these cases,
as regards either their admission to R or their subsequent transfer to V,
particularly if all the receiving asylums bore their proportionate share;
if, however, one asylum in each group were selected for the purpose, a
certain amount of clerical simplification might perhaps be possible.

Documents were made out at the vacating asylum for the
transfer of the patients, in accordance with the suggestions of
this Memorandum. Norfolk Board of Guardians were notified
that on and after March 4th, 1914, the asylum would be
closed for the reception of patients, and directing the Union to
send all cases of insanity arising in their area to the Norwich
City Asylum at Hellesden, that the patients belonging to a
particular Union would be transferred to one or more of the
asylums of the group, that the particular asylum to which each

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patient had been sent would be notified later, and that all
accounts in respect of maintenance would be sent in future to
the Union from the vacating asylum, in this case the Norfolk
Asylum, as heretofore.

Printed notices were also sent to one or more relations or
friends of every patient notifying them of the intended transfer
and destination, giving opportunity of daily visiting any day
before the patient left. In some sixty suitable cases the friends
were encouraged to make application for the patient’s discharge
under Sec. 79. The fact that fifty-three patients were dis¬
charged in this way relieved the pressure on receiving asylums
by one-twentieth ; a few of these were granted an allowance
under Sec. 55 (1 and 2) which is being indefinitely prolonged.
This is the only attempt I have ever made at the Scotch system
of boarding out, which is said not to be a success in England,
and probably it has only been a success on this occasion by
reason of the fact that the friends of the patient were stimulated
to make the effort to avoid the necessity for patients being sent
out of the county.

Eventually the various parties of patients for the different
asylums were made up, due regard being had to the various
classes of patients, of which each party was constituted, e.g.,
the recent, acute, sick, infirm, epileptic, turbulent, convalescent,
and working. It was no easy matter to ensure fair and even
distribution among the receiving asylums, regard even being
paid to patients’ predilections for particular asylums, near which,
perhaps, lived some relative, as a recompense for expatriation.

When all the transport arrangements by road and rail had
been made, the accompanying staff arranged for, all the docu¬
ments, including each patient’s “ case ” from the loose leaf case¬
books, made up and distributed, not at all so simple or light a
matter as it sounds, parties of patients and staff began to leave
on March 19th, and by March 31st, or in twelve days, 960, or
an average of over 100 per week-day, were safely and without
the least mishap or accident, transferred to the following
places: Ipswich, Melton, Colchester, Brentwood, Aylesbury,
St. Albans, Arlesley, Goodmayes, and Cambridge.

Forty patients remained, twenty-three permanently as farm
workers and thirteen too ill to move till two or three weeks later.

The scenes on departure aroused varying emotions in myself,
my medical colleagues, and the nurses. It was all interesting,

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123

some of it most amusing, and much sadly pathetic. To many
the asylum had been their home for many years, some for over
fifty years, some since childhood; many even had never been in
a railway train: the Norfolker is insular and homestaying, he
rarely goes “ foreign,” as he calls the shires and even neigh¬
bouring counties, so it will be readily believed that the whole
gamut of emotion was exhibited by the patients on leaving,
ranging from acute distress and misery, through gay indifference,
to maniacal fury and indignation. Personally I met with the
experience of most asylum medical officers, viz., that I did not
realise the strong mutual attachment till it was severed. The
great and pressing work now before one was to convert a set of
buildings designed and well adapted for the insane into a hospital
for sick and wounded soldiers, and that in a space of six to
eight weeks.

At an interview with the Director General of the Army
Medical Service, Sir Alfred Keogh, at the War Office, I learned
in a general instruction that the asylum tradition, and character
of the institution, was to be as completely transformed for the
time as possible, and that everything in the way of the highest
medical and nursing skill, and of appliances was to be provided.

The following are the former names and present approved
names of the various converted asylums :

Asylum.

Hospital.

Officer in charge.

I

Newcastle-on-Tyne City
Asylum, Gosfotth

The Northumberland War
Hosp., Gosforth, New¬
castle-on-Tyne

Col. G. G. Adams.

2

West Riding of Yorks
County Asyl., Wadsley

The Wharncliffe War
Hospital, Middlewood,
Sheffield

Lt.-Col. Vincent.

3

Lancashire County Asyl.,
Winwick, Warrington

The Lord Derby War
Hospital, Warrington

Lt.-Col. Simpson.

4

Birmingham City Asyl.,
Rubery Hill

The 1 st Birmingham War
Hospital, Rubery Hill

Lt.-Col. Suffern.

5

Birmingham City Asyl.,
Hollymoor, Birmingham

The 2 nd Birmingham
War Hospital, Holly¬
moor, Birmingham

Lt.-Col. S. J. Thom¬
son, C.I.E., I.M.S.

6

Norfolk County Asylum,
Thorpe, Norwich

The Norfolk War Hosp.,
Thorpe, Norwich

Lt.-Col. Thomson.

7

Cardiff City Asylum,
Whitchurch, Cardiff

The Welsh Metropolitan
War Hospital, Cardiff

Lt.-Col. Goodall.

8

West Sussex Asylum,
Chichester

The Graylingwell War
Hospital, Chichester

Lt.-Col. Kidd.

9

Bristol City Asylum,
Fishponds, Bristol

The Beaufort War Hosp.,
Bristol

Lt.-Col. Blachford.

10

London County Asylum,
Horton, Epsom

The County of London
War Hospital, Epsom

Lt.-Col. Lord.

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The names of the special hospitals in connection with the
Napsbury Asylum and the Wandsworth Asylum are respec¬
tively :

As) lum.

Hospital.

Officer in charge.

11

12

Middlesex County Asyl.,
Napsbury, St. Albans
Middlesex County Asyl.,
Wandsworth, near Toot¬
ing, S.W.

The Napsbury War Hosp.,
St. Albans

The Springfield War
Hospital, Wandsworth,
near Tooting, S.W.

Major Rolleston.

Major Worth.

It will be seen from the above list, that an additional asylum,
viz., that of Birmingham City Asylum, Hollymoor, has been
converted into a War Hospital, and that the London County
Asylum, Horton, Epsom, has been taken over, instead of
Long Grove, as originally intended.

As I write this, I hear that the Northamptonshire Asylum,
Berrywood, has also been taken over by the War Department.

I propose in this descriptive record to deal, first, with the
necessary structural changes involved in the conversion of an
asylum into a military hospital, or if I offend in my terminology
some of my younger colleagues, shall I say, a mental hospital.
It will tend to conciseness if I take the principal changes
seriatim, which were much more numerous and important than
I ever anticipated, and cost altogether about £16,000.

(1) Doors : Every door in the asylum actuated by lock only,
and there are hundreds, has to have an inside and an outside
rim-lock or latch handle fitted; it is not necessary to remove
the existing lock, but if a spring lock, it must be put out of
action.

Every door, or doorway, that won’t easily admit a stretcher
party must be removed or widened. The road or garden
approaches to outside main entrances or doorways have to be
so widened and curved as to admit long chassis’d cars,
ambulance or private.

(2) Windows : All window locks or stops, upstairs and down,
have to be opened or removed so as to allow of full opening of
window sashes.

(3) Corridors and passages: These must all be tested practi¬
cally by a stretcher party to ensure that such can pass easily

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125

and without tilting the stretchers, the whole way from the main
entrance to any bed in any ward in the hospital; this applies
more particularly to staircases and landings. I was rather sur¬
prised that this could not be done in some even of the more
modern staircases of the asylum, and I had to install three Way-
good-Otis hand-power lifts at a cost of £150 each. At first I
thought this could be avoided by putting stretcher cases on
ground floor wards and “ walkers ” or “ sitters” upstairs, but apart
from this being unfair to the surgeons and nurses of first floor
wards, it would not do, because a “ sitter ” may become at any
time a stretcher case, with or without operation, and frequent
ward transfers are impracticable. All this wide and easy access
is necessary, not so much when taking in the weekly convoys as
they arrive, as for the incessant traffic between the wards and
the operating and X-ray theatres.

(4) The Wards : The actual dayrooms and dormitories of the
asylum need no structural alteration; the larger and more plainly
rectangular they are the better, so that a large barrack-like
plain ward of from forty to sixty beds, without bays or recesses,
makes the best hospital ward, whereas the smaller, cosier
wards, well broken up into bays and recesses, so suitable for
insane patients, as in the old main asylum at Thorpe, were not
so serviceable, and cut up most uneconomically for bed space.

At the Norfolk War Hospital, a small ward on each side of
the “ centre ” of the main hospital had to be vacated, so as to
make room for various administrative departments, for which
there was no accommodation in the “centre,” such as Regis¬
trar’s office, his clerks’ office, dental room, electro-therapeutic
room, chief orderly’s room, inspecting officer of auxiliary hos¬
pitals office, lady medical officer’s quarters, post office, inquiry
office, etc. This involved the sacrifice of some fifty beds which
would otherwise have been available for soldier patients.
Against this some twenty beds have been gained by the provision
of open-air sleeping shelters.

I found by experience that only about one-third of the
patients were on an average confined to bed, so that the reten¬
tion of a dayroom or gallery, or some room in each ward, was
necessary as a play, mess, or sitting-room for those able to be
up. This being the case, I found the accommodation in beds
amounted in round numbers to the same as in the pre-conver¬
sion days, viz., 1,050, and that all the tables, chairs, and dayroom

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furniture I had put away in store had to be brought back again,
and that the pianos, bagatelle tables, and all the usual asylum
dayroom amusements were invaluable.

As to the adnexa of the wards, however, it was a very
different matter. All the sanitary spurs, containing baths and
lavatories, were ample and suitable for soldier patients, with the
additions of special bed-pan sinks and minor nursing fittings,
but a considerable number of these essential conveniences had
to be provided altogether away from the wards for the nursing
staff. The sculleries, too, or ward kitchens, as the hospital
people call them, had to be supplied with gas and gas stoves;
gas also had to be laid into all the wards for heating ward
sterilisers. I resented this as much as anything, having rejoiced
fifteen years ago in abolishing gas and all its abominations in
favour of electricity. A sitting-room for the Sister, or charge
nurse of each ward, called the duty room, must be pro¬
vided opening off, or close to, each ward. No attendants’ or
nurses’ sleeping rooms opening off wards or galleries can be
made use of for nurses’ sleeping quarters, and this must be
borne in mind by those asylum medical officers who contemplate
nursing their male patients by women nurses.

Nurses may be housed in the following ways:

(1) In the nurses’ home, if there is one; in any case it will
only be one-quarter large enough as regards single bedrooms.

(2) By billetting the nurses out in neighbouring houses.

(3) By dividing up wards into cubicles by partitions or screens;
in my opinion an extravagant and undesirable method.

(4) By building rows of hutments with or without adjoining
mess and association rooms.

Numbers 1 and 4 were adopted at the Norfolk War Hospital,
and I am more than satisfied, as are also the nurses, with the
result. There are four rows of red-tiled hutments of fifty
separate bedrooms each, well warmed and lighted, built in an
adjoining field at a cost of £30 per bed ; in normal times they
would have cost probably one-third less. These hutments are
entirely detached from the hospital building, but the additional
mess and association rooms, which are also temporary buildings,
open off the kitchen corridor. This arrangement obtains at
each of our two hospitals, the main and the annexe.

In some converted asylums the entertainment hall has been
utilised for nurses’ mess, but so far I have been able to reserve

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127

this most useful place for the entertainments, which are almost
daily events. Cycle sheds to accommodate 250 cycles have also
been provided. The existing asylum mess-rooms have to be
given to the large additional numbers of house, kitchen, and
laundry servants who have to be engaged, housed, and fed, to
supplant the lost asylum patients’ labour. All male attendants
have been enlisted in the Royal Army Medical Corps and act
as orderlies; there being no accommodation for them in the
hospital they have found lodgings in the village and neighbour¬
hood, and have been granted board money.

Quarters comprising mess-, ante-, and bed-room accommoda¬
tion, had to be found for fifteen resident medical officers, a
matter of no little difficulty.

The only other important structural additions were the
operating and X-ray theatres. As already mentioned, there are
two hospitals on the asylum estate of equal size, the main
hospital and the annexe, having in round numbers 525 beds
each. These are one-third of a mile apart, so a theatre was
necessary at each. They are temporary buildings, each situated
directly off the main corridor in the most central and acces¬
sible position possible, and I can recommend the design and
ground plan to anyone building such an important department
of a hospital. Armed with the standard army plan of such a
building, as also the plans of similar temporary buildings at
other hospitals, also by visiting, e.g., the Royal Herbert Hospital
at Woolwich, the temporary hospital at Cambridge, and the
second Scottish General Hospital at Edinburgh, an eminent
military surgeon, my own surveyor of works, and I evolved a
plan omitting the defects and developing the good points of
each of those. I am assured by those who work in our operating
and X-ray blocks that they could not be improved upon. They
are of wood framing covered with asbestos sheeting and rub-
beroid outside, and lined with lath and plaster, white enamelled
inside, the white deal floors covered with polished linoleum,
with the ample lighting, daylight and electric, warming and
ventilation, well under control. They contain in all five
operating rooms, two X-ray rooms, and waiting rooms, with
developing rooms, main sterilising room, surgeons’ and sisters’
rooms, two anaesthetising rooms, and drug, instrument, and
linen rooms. They cost £1,000 each.

The pack-store, which in a military hospital in war-time

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receives sick and wounded from overseas, deals with the recep¬
tion, disinfection, washing, and ultimate reissue of soldiers’
clothing ; important department as it is, it does not necessarily
involve any structural alteration except the provision of 1,050
pigeon-holes, in spline racking, 18 inches cube, round the walls
and centre of a large room, for each soldier’s kit. It is con¬
venient that it be adjacent to the laundry, but, except for the
actual washing of the clothes which pass through it, it is entirely
separate from the laundry as to buildings and personnel. At the
Norfolk War Hospital it is a temporary building set up on the
laundry drying ground between the steam-disinfector and the
laundry proper.

If a properly equipped pathological laboratory is not one of
the existing resources of the asylum of course one must be
instituted. A large room must also be devoted to, and fitted
up as, a physical and electro-therapeutic department. Exten¬
sive additions to the dispensary must also be found for the
necessarily large stocks of drugs, dressings, and surgical appli¬
ances, splints, etc.

Equipment .—All the equipment necessary for an ordinary
civil general hospital, and, in addition, the special equipment of
a military hospital, are obtained on requisition, or “ indent ” as
it is termed, from various military departments, the initial
standard outfit from the medical department of the War Office,
and subsequently on indents through the District Assistant
Director of Medical Services (A.D.M.S.), local or private pur¬
chase, except in rare emergency, not being allowed. I need not
mention the innumerable articles which have to be obtained,
as this would be a mere recital of the catalogues of surgical and
scientific instrument makers and hospital furniture dealers. It
can, however, be imagined that, owing to the great and sudden
demand all over Europe for surgical, X-ray, and electro-thera¬
peutic instruments, drugs, and furniture, my anxiety to obtain
these essentials was considerable, but it was evidently shared
by the medical officers in high places at the War Office, for
their uniform courtesy, business-like methods, and promptitude
resulted much sooner than I expected in a first-rate equipment.

I must now proceed in my record to the probably more
interesting question of staff—doctors, nurses, orderlies, and
domestics. The general scheme of the medical staff is as
follows:—There is a resident staff and a visiting staff, as in any

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civil general hospital. Taking the latter first, one of the reasons
for the selection of this asylum in the East Anglian group is its
proximity to an important and modern general hospital, the
Norfolk and Norwich Hospital, and the staff of this hospital
was appointed en bloc as the civilian visiting physicians and sur¬
geons of the Norfolk War Hospital, including a radiologist,
oculist, pathologist, and dentist; the terms of appointment as
to pay being £i on each day that the hospital is visited.

The finding of a resident medical staff seemed to present
great difficulties. One heard on all sides of the dearth of the
younger medical men in hospitals and asylums, even as
“ locums,” or in private practice. Before stating how this was
surmounted I will shortly describe the constitution of the
resident medical staff. There are six commissioned residents.
The Officer in Charge is the officer responsible to the Committee
of Visitors and to the military authorities for the general
administration and management of the hospital. In all con¬
verted asylums except one the existing medical superintendent
of the asylum was appointed to this office, and given temporary
military rank as a Lieutenant-Colonel in the Royal Army
Medical Corps while serving in the hospital.

Next to the Officer in Charge comes the Registrar. This
important officer, the homologue of an adjutant in a regiment,
is responsible for all the military and medical records—and they
are not a few in a military hospital. He arranges for the
reception of convoys and the allocation of the patients to the
various wards, makes all returns of vacant beds, admissions,
discharges, and deaths to the War Office, keeps a regimental
record of offices and depots, arranges all the business of medical
boards held in the hospital, all discharges and furloughs, and>
as this has recently been created the central hospital for Norfolk,
to which all auxiliary, Red Cross, and convalescent hospitals
are affiliated, the Registrar is in charge of all the correspondence,
records, and accounts of these hospitals, which vary in size
from one to one hundred beds. He issues the daily “ Hospital
Orders ” in the name of the Officer in Charge, which are posted
up in every ward and department of the hospital. He holds
the rank of Major in the R.A.M.C., and has a staff of twelve
men and women clerks. Finally, he acts as deputy to the
Officer in Charge in his absence.

At each of our two hospitals there is a chief resident surgeon,

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with the rank of Major in the R.A.M.C.; each is a Fellow
of the College of Surgeons, and has full surgical charge of one
hospital.

In charge of the fewer medical wards at both hospitals is
the Chief Resident Physician, also ranking as a Major in the
R.A.M.C. He is the Senior Assistant Medical Officer of the
former asylum regime.

An additional officer of the R.A.M.C. has been attached to
this hospital for the special duty of inspecting the auxiliary
hospitals affiliated to us, which number some fifty.

In addition to these six commissioned officers there are ten
resident civilian medical men who, speaking generally, corre¬
spond as regards their duties to house-surgeons and house-
physicians in civil hospitals, a proportion of i per cent, to
patients.

There is also a resident lady-pathologist, who works in a
well-equipped laboratory, and who deals with, and reports on,
all clinical specimens sent to or collected by her.

The securing of such a highly qualified and numerous staff
was only possible by obtaining the services of men medically
unfit for active service and yet physically fit for the less
arduous indoor duties of a hospital; also by the fact that two
of the number are Belgian refugee doctors, one a Canadian,
and one a lady, the pathologist.

The pay of the commissioned officers, other than the former
asylum medical officers, is £i 4s. 6 d. per diem and all found,
while the pay of the civilian residents is £1 per diem and all
found. The few who are married live on the estate or close
at hand, and have extra pay in lieu of board and lodging.

I next come to the nursing staff. Fortunately our Matron
under the asylum regime was approved and appointed matron
of the hospital. The two assistant matrons of the asylum were
appointed to aid her in the housekeeping part of her work,
and an assistant matron was appointed at each of our two
hospitals to help the matron in the nursing department.
This organisation yielded the great advantage of one supreme
female officer with paramount authority, under the Com¬
mittee of Visitors and the Officer in Charge, over all
nursing and domestic affairs of the hospital. I have always
been a strong advocate of this in asylum organisation, although
I am aware it postulates a highly capable but benevolent despot;

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the system of dual control by housekeepers and chief nurses
which obtains in some asylums has never appealed to me;
dual control by medical officers and stewards is bad enough,
but dual female control is anathema.

There are no probationers in military hospitals proper, but
only the two ranks, sisters and staff nurses, the former corre¬
sponding to our charge nurses; both these ranks must possess
the certificate of training gained in a hospital to which a
nurses’ training school is attached. At the time of conversion
it happened that none of our nurses possessed this certificate,
so they could only be given the position of probationer as this
term is understood in a civil hospital.

There was no difficulty in obtaining sisters, the proportion
necessary being one to each ward of between thirty-five and
fifty-five patients for day duty, one superintending night-sister
for each hospital, and one sister each for the operating and
X-ray theatres, one in charge of massage at each hospital,
and one for each of the two electro-therapeutic departments.

Staff nurses were more difficult to obtain. They are in the
proportion of one, two, or even three to each ward or special
department according to its size; and probationers two, three,
or four in the same way for day duty to each ward or depart¬
ment ; the complete nursing staff in this hospital of, say, 1,000
beds being as follows :

Nurses.

Day.

Night.

Total.

Wards.

Special

Departments.

Sisters.

24

6

2

32

Staff nurses ....

35

3

26

64

Probationers ....

7 1

7

50

128

Total

130

•

l6

78

224

Also ten masseuses.

It will be seen that the proportion is in round numbers, one
nurse to every four and a half patients, or exactly double the
asylum proportion, which may be taken as one to nine. The
number of nurses required would probably be less in one
hospital of a thousand beds.

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The majority of the existing asylum nurses loyally took
service in the humble ranks of the probationers, some few left
the service at the conversion, and some of the senior charge-
nurses were given special jobs in the housekeeping department,
in sewing and stockrooms, pack-stores, etc., or in charge of
housemaids, day-workers, etc. Newcomers from all parts of
the country, and in various stations of life, were engaged to
make up the necessary numbers of probationers. I cannot
speak too highly of the way our experienced and capable
mental nurses returned to the foot of the ladder, a very similar
ladder after all, and worked under strangers, sisters, and staff
nurses, who in a sense had usurped their positions in the
asylum.

The pay of the sisters and staff nurses is fixed by the War
Office at £50 and £40 respectively. They wear a grey uniform,
the sisters at this hospital being distinguished by red bands
round the upper part of both sleeves. Only members of the
Queen Alexandra Imperial Nursing Service wear the scarlet
shoulder cape, which, by the way, it is said was introduced by
Florence Nightingale to subdue the charms of the female form
divine. The probationers are paid and uniformed as those who
used to join the asylum service, viz., £20 per annum, with
washing, dresses, etc., and wear such M.P.A. nursing or other
badges as they may possess.

Orderlies: At all military hospitals, there being no proba¬
tioners or wardmaids, the orderlies are a numerous and
important body of men. At some converted asylums, War
Hospitals, this is also the case, at least one company of the
R.A.M.C. being stationed in the hospital as the guard, sentries,
ward orderlies, and in other capacities. At the Norfolk War
Hospital I had the male attendants enlisted in the R.A.M.C.
and placed one of them as orderly in each ward, and have no
guard or sentries. We have under 100 orderlies, whereas the
regulation number for a hospital of this size is 200. If ever I
had to open another hospital I would have no ward orderlies
at all; of course, a few are necessary as porters, bathmen, or
barbers, just as in a civil general hospital. My opinion is
that the fewer men there are about a hospital the better. In
hospitals with grounds, such as the converted asylums, a few
R.A.M.C. men as military police are necessary to see that rules
as to “ bounds ” are obeyed, and that the grounds are not

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despoiled. The orderlies are under the command of the former
head attendant, now a staff sergeant-major.

With a few words as to some of the other permanent
officials of the asylum regime I will conclude the references to
staff. The chaplain has been given the rank, and wears the
uniform of Captain, as fourth-class army chaplain ; he conducts
an early communion service at 8 a.m. and a “parade” service
at 10 a.m. every Sunday, and visits the wards daily.

The steward naturally continues his ordinary duties as steward,
or quartermaster, which duties I may mention are enormously •
increased.

The clerk of the asylum not only continues his much
lessened duties as asylum clerk, but acts as assistant registrar,
and is paymaster and chief accountant of the hospital. His
duties, like those of the steward, have much increased and are
onerous and responsible. Salaries or wages are not paid by
the Army Pay Department, as in a military hospital, but I
indent for money by submitting a monthly estimate to the chief
paymaster of the Eastern command, through the Board of
Control; a cheque is sent to the county treasurer and the Com¬
mittee of Visitors draw on this for salaries and wages, and the
payment of such goods as are not supplied by the War Depart¬
ment, for which latter the Committee contract as they did under
the asylum regime. Separate banking accounts were opened
on April 1st, 1915, the beginning of the asylum financial
year.

Domestics : Owing to the loss of all the valuable labour of
the asylum patients our staff of domestics, such as laundresses,
cooks, kitchenmaids, housemaids, cleaners, etc., has much
increased, numbering no less than close on 100 women.

I will conclude my descriptive record by a few general obser-
vations which may be of interest alike to my asylum and War
Hospital colleagues.

After the asylum was vacated I naturally endeavoured to qualify
myself for my prospective new duties, for, although similar to
my former ones, they were far from identical, perhaps as far apart
as the duties of a banker are from those of an insurance manager
or stockbroker. There are differences in ways of dealing with
patients as there are of dealing with money. I spent, therefore,
a week at the Royal Herbert Hospital, Woolwich, by authority
of the War Office; I also visited military territorial hospitals

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at Cambridge and at Edinburgh. I also made myself familiar
with the inner working of a civil general hospital receiving
military patients, the Norfolk and Norwich Hospital. The
matron, the clerk, and the steward had the same privilege as
regards Woolwich and Cambridge hospitals.

I would have liked to give some comparative figures regard¬
ing the cost of maintenance as between the institution as an
asylum and as a war hospital, but this unfortunately is not yet
possible, at all events at present. Our worthy and careful
• steward becomes increasingly anxious at the comparatively
huge receipts and issues of stores, such as milk, eggs, chickens,
and bacon—all expensive and difficult items to obtain in large
quantities even at any price ; for example, a thousand eggs at
twopence halfpenny each, as a mere breakfast adjunct, is
alarming!

I am often asked about the amenities existing between the
former mental nurses and the hospital-trained newcomers. I
have already commented on the admirable and loyal way in
which even the experienced among our former staff have
subordinated many of their privileges and their rank in the
service to the good of the hospital. On the whole, there has been
very little friction between the old and the new staff, certainly
less than I expected ; moreover, in a hospital only six months
old one cannot expect a scratch team to be animated by the
esprit de corps and great traditions of a permanent hospital, such
as Guy’s, St. Bartholomew’s, or the Edinburgh “ Royal.”

The discipline of soldier patients in hospital is effected much
on the same lines as that of the insane patients in asylums.
No punishment can be meted out to them except, pace
Dr. Mercier, negatively by the deprivation of privileges, such
as the withdrawal of permission to go to entertainments,
concerts, motor drives, walking parties, etc. For grave
offences, such as escapes, drunkenness, or assaults, the sending
of a soldier when well enough to his depot with an offence
report, without furlough, is the only action one can take.
The conduct of the men is on the whole excellent, and prac¬
tically one has no trouble as to discipline. They are an
agreeable, cheery lot, and it is very interesting to note the
various temperamental characteristics of the natives of all
parts of the British Isles whence our patients originally come.
Of course there are the usual few “ grousers ” and inveterate

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grumblers among the new as among the former patients. I
attribute the general contentment largely to the ample and
well-cooked food, plenty of occupation and amusements, and
the reduction to a minimum of all irritating and really
unnecessary restrictions.

I cannot close this imperfect account of the revolutionary
upheaval which has taken place in 10 per cent, of our asylums
during the past nine months without voicing a tribute from the
Presidential Chair to the arduous work of the two Commis¬
sioners of the Board of Control, Dr. Marriott Cocke and Dr.
Hubert Bond, to whom that Board delegated the important duty
of acting as intermediaries in all the negotiations between the
War Department and the vacating and receiving asylums. It
is not for me to appraise the value of that work, but the small
portion of it affecting the institution of which I have charge
gives me some idea of the magnitude and high quality of their
task to which they must have devoted long and laborious
hours.

(*) Read at the Quarterly Meeting of the Medico-Psychological Association in
London, November 23rd, 1915.

The Biological Significance of Delusionsl}) By Henry
Devine, M.D., Medical Superintendent, Portsmouth
Mental Hospital.

The purpose of this paper is to develop the thought that
delusional formations fulfil a definite function ; they are the
expression of certain underlying trends in the individual, and
they satisfy certain needs. At the present time there is a
reaction against the tendency to regard classification as the
ultimate aim of clinical psychiatry. While the separation of
mental disorders into certain broad groups has its obvious
uses, it is being recognised that classification in itself is not a
very vital point, and it does not take us far in the understand¬
ing of our cases. Not only is each case a member of a parti¬
cular group, but in a certain sense it is an entity in itself;
the odd behaviour, the delusions and hallucinations, have an
individual significance ; they are the outgrowth of personal
conflicts and aspirations, and the whole psychosis is no more
than one form of reaction to experience.

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The general significance of some delusional conditions may
be indicated by reference to certain normal mental activities,
such as day-dreams or reveries, which have not only a
similar psychological structure to delusions, but the same
biological function. Every individual possesses needs or im¬
pulses which seek gratification ; these constitute the motives
for conduct. Thus everyone has desires for wealth, fame, or
knowledge, all of which may be included under the term
“ ambitious complex.” In the highest type of mental organisa¬
tion these desires are co-ordinated with reality, and the indi¬
vidual maintains a constant struggle to attain his ends. Such
adaptation to reality is, however, the most difficult psychic
operation, and this high level of conduct cannot always be
maintained ; there is a tendency, therefore, to turn away from
facts as they exist, and to gratify inner tendencies by seeking
refuge in inferior mental operations. Thus the tired man after
the work of the day seeks distraction at the theatre. As a
spectator at the musical comedy he lives in an atmosphere of
romance, which forms a contrast to his commonplace existence,
and thus gratifies certain hidden desires and ambitions. He
identifies himself with the hero of the play, and shares his
troubles and triumphs. The same aetiology is seen in the
case of day-dreams. The tendency to reveries in children is
favoured by circumstances which render external conditions
monotonous and difficult, and the same tendency is seen in
the case of psychasthenics, who, owing to an inability to adapt
themselves to their social environment, often elaborate extremely
complicated, romantic, and ambitious reveries. Thus the bio¬
logical function of these mental operations is to afford an
escape from reality, to gratify wishes which are impossible of
fulfilment under the actual conditions of existence. Further¬
more, the less the individual is able to gratify his ambitious
complexes by efficient action, the more will he tend to seek
compensation by falling back into these inferior modes of
mental activity.

Delusional states have, not infrequently, a similar signifi¬
cance. An individual is placed in a situation to which he
cannot adapt himself, and he unconsciously seeks refuge in a
psychosis, the content of which shows clearly the mechanism
of “ wish-fulfilment.” Thus a congenital deaf-mute, stunted,
deformed, and ugly, who has been brought up in the workhouse,

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develops the following delusions. She imagines she had been
stolen away at birth, and is really the daughter of certain
exalted personages. Those around her are malignant perse¬
cutors with the exception of the medical officer, on whom she
proposes to bestow her hand. She relates various indignities
to which she has been subjected, but in spite of these she sits
all day long with a rapturous expression and a smile of
superiority. She explains that her ugly appearance is only a
disguise due to a spell which has been cast upon her by her
enemies ; before long she will be “ infruated,” this neologism
meaning that the spell will be removed, and she will emerge as
a beautiful girl, with long golden hair. Reality in this case is
summed up by a hideous form, deaf-mutism, with its hindrance
to companionship, and the grey outlook of workhouse life.
Contrasted with all this, however, she possessed just the same
natural desire for admiration, craving for affection, and instinct
for maternity as any ordinary girl. These hidden desires had
obtained gratification by invading and transforming the person¬
ality. The patient had sought refuge in a psychosis.

Other instances might be cited in which there is an obvious
antagonism between desire and circumstance, but this example
suffices to indicate that in some psychoses (defence psychoses )
there is quite obviously an attempt at adjustment to external
difficulties in the direction of “wish-fulfilment.” It is by no
means usual, however, to establish such an obvious correlation
between the situations to which an individual has been sub¬
jected and the delusional content. In dementia pra;cox, for
instance, the casual observer gains the impression that the
ideation is utterly chaotic and meaningless, and that the
delusions expressed are a haphazard array of fantastic notions.

When these cases are investigated, however, it is found that
such an opinion is scarcely justified. It has been demonstrated
that there is no diminution of mental activity or actual des¬
truction of psychic functions, such as occurs in plainly organic
disorders, of which dementia paralytica is an example, in cases
of the dementia praecox group, but merely a direction of the
the thoughts inward, with a corresponding lack of interest in
external affairs. When analysed it is found that these patients
have only adopted a peculiar view of their own, and that the
delusions have a meaning and purpose analogous to the
inferior forms of mental activity which have already been cited.

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The obscurity and incoherence of thought in the precocious
dement is thus not due to dementia in its narrow sense, but is
accounted for as follows : In the first place, the individual
suffering from dementia praecox does not of necessity succumb
to circumstances of any particular difficulty, but, owing to
internal conflicts, he is unable to adjust himself to ordinary
situations. The fault lies in the make-up of an individual
rather than in his circumstances. It follows, therefore, that
the delusions are subjectively determined, and they relate
to intimate personal matters, the nature of which is not
apparent on the surface. In the second place, the inner
tendencies which seek expression do so in such a distorted
manner that their meaning is far from obvious. Just as the
manifest content of dreams is only the symbol for some hidden
concrete thought, so the delusions in dementia praecox are the
expression of actual impulses or desires which obtrude them¬
selves indirectly into consciousness ; the indirect expression
being due to the repressive force exercised by the normal
personality, or such remnants of it as exist unimpaired.
Thus, when one of Jung’s patients said, “ I am the double
polytechnic irretrievable,” she meant, “I am the best tailoress.”

To make these points clear I propose to give some extracts
from the analysis of an actual case, the study of which has
recently been engaging my attention. The analysis has been
undertaken by means of “word-association” tests and the method
of “free association,” upon the lines indicated by Jung, to
whom, of course, we owe much of our knowledge of the psycho¬
logical factors in dementia praecox. The subject of this
investigation, a single man, aet. 32, has been in the asylum for
four and a half years. The following facts of his history were
elicited : At the age of 8 the patient lost his father, and his
mother was left a widow with six children to support. The
patient was the fourth child and the oldest son. He was des¬
cribed as “ never very strong,’’ and dull and reserved in
character. He did well at school, and upon leaving he worked
until the age of 19 at one situation. After this his work was
most irregular, and for some time before entering the asylum
he did practically nothing. He was then aged 28, and two
years previously his mother had become insane, and she is still
an inmate of the asylum. The patient was certified owing to
delusions of persecution. He thought people were talking

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about him, and he became strange and erratic in conduct. At
the present time he is quiet and inoffensive, he does a little
light work, interests himself to a moderate extent in the
activities of the ward, and apparently lives a contented exist¬
ence. He is ready to converse on general topics and displays
a considerable knowledge of current events, but he soon
diverges off the subject into fantastic delusional statements.
He explains in a thoroughly cheerful manner that he is under¬
going terrible torture from subconscious force, nature is hypno¬
tised, his mind is filled with Chinese hypnotic supernature, he
suffers from reflex action, bestiality is forced through him,
moral agony is concentrated upon him, he has to be engulfed
in the centre of gravity, and numerous other ideas of a like
character. The diagnosis is obviously one of paranoid
dementia praecox.

Now though these curious notions are loosely organised,
with considerable pains it is possible to piece together a co¬
herent delusional line of thought. This is briefly as follows :
The whole of humanity, Nature and God Himself are under
the influence of some malevolent “ superomnipotent ” power.
This power takes the form of a “hypnotic supernature.” Its
effect is to destroy freedom of action in humanity, forcing
people to act against their desires and making them constrained
and ill at ease. The patient traces evidence of this in current
movements, wars, plagues, labour unrest, and social injustice,
detecting in general a tendency towards racial deterioration.
Furthermore, this force has prevented the souls of men from
dying, and thus there is a quantity of floating consciousness in
Nature. Because the patient is a “ moral degenerate with a
pliable mind,” he has been selected to play the chief role in
this curious state of affairs. These living souls—chiefly
Chinese—are now located in his consciousness, and inflict
numerous tortures and indignities upon him. They inflict him
with moral agony, and force bestiality through him. What are
delusions to other people are made to him “ a frightful reality.”
Thus, if another patient thinks he has a woman inside him,
they actually put the spirit of a woman inside the patient
himself. This state of affairs will shortly culminate in a
“ hypnotic war,” and all the evil which is in him will be let
loose on society. Five months of suffering will ensue, during
which the world will be more or less disorganised, and the

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patient himself will be regarded as the cause of all the trouble.
He illustrates this by a concrete instance. Any sexual thoughts
which have been forced into his mind will obtain actual fulfil¬
ment, women will become prostitutes, and will trace their
downfall to him. Actually, however, he is only the chief
victim, he is the medium through which the regeneration of
society will be brought about. When the evil force has
inflicted sufficient agony, it will be dispersed, and the patient
will be free to wage an “ inspiration moral war.” Society will
be purged through his sufferings. He will be the master power,
the new Messiah. This brief outline indicates that the patient
has constructed a complicated drama in which he is the central
figure. The main theme is obviously regeneration through
conflicts and suffering. Now, when this phantasy is analysed
it becomes apparent that it represents the patient’s own
internal conflicts and aspirations. This will become clear if
we study the most prominent delusional ideas, giving a few of
the associations which appeared in the analysis.

The patient reiterates frequently the phrase, “ I am hypno¬
tised by subconscious force of supernature.” The following are
some of his associations : “ I am forced to do what I otherwise
would not do. I once saw some Chinese wrestlers ; one held
the other down. I have always been held down. I never had
any free will. It wasn’t a disease, it was lack of will. I
struggled against self-abuse ; they would not let me give it up.
I wished to break my self-consciousness, but the more I
thought of my bad habit the more it became fixed on my
mind ; I lost the power of my nature, it was all from hypnotic
force ; I lacked power of action. It was an effort to walk in
the street, a terror to ask for a job. If I had made one big
moral effort the weight would have gone. I was never
allowed to tell anyone. I daren’t talk to a woman ; if I had
the pressure would have left me, I should have become a man.
I could not prevent the wrongs and injustice about me.” From
these associations we see that when the patient says he is
hypnotised, he refers to his volitional incapacity. The process
is one of rationalisation—by a method of outward projection
the responsibility is placed on some external agency. The
following concrete reactions which the patient exhibits illustrate
this mechanism quite clearly.

(a) When asked to work, the patient shows much hesitation

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and says, “ They put the hypnotic-idle-atrophy upon me, I
can do nothing.” He here rationalises the feelings of incapacity
which are so common in psychasthenics when any form of
activity is required.

(1 b ) When he plays a game of billiards he says, “ They put
the hypnotic pressure on, and turn my eyes the least bit, so
that I cannot hit the ball right.” Here he rationalises feelings
of self-consciousness which arise in the performance of delicate
co-ordinations, and which, of course, prevent a completely
efficient action. It means attention to movements which
should be automatic, and is a common experience in nervous
persons.

(c) In the word-association experiments, and sometimes in
conversation, the patient fails to react at all ; no word comes to
his mind, or he loses the thread of his conversation. He
explains in these instances, “ They put the hypnotic break on
me, and make my mind a blank.” This “ thought deprivation ”
is always found to be due to reminiscences about which the
patient does not wish to think, and indicates the existence of
submerged complexes. Such moments of obstruction to his
thought were, no doubt, common enough in his daily life. As
before, he explains them by reference to external agencies.

( d) Lastly, there is a tendency for his thoughts to become
automatic. He loses control over them, and they appear in
consciousness against his will. These forced reveries, to which
he has been subject for many years, constitute one of the chief
reasons for his notion of being hypnotised. The expression,
“ Nightmares are forced on to me,” illustrates this. These
experiences will be further elucidated when his hallucinations
are considered.

A further notion which the patient expresses is one relating
to the Chinese. Thus he says, “ I have Chinese souls in my
mind." These are some of his associations : “ I have been
submitted to a drumhead trial from Chinese Machiavellis. It
was a trial without defence ; they could accuse me of what
they liked, there was no retaliation. What the Chinese have

been through as a nation corresponds to me as an individual.

The Chinese believe in the transmigration of souls. They

were hypnotised under opium, it distorted their minds and

took away the death agony ; I have driven my thoughts in
with cigarettes, it eased my fears, but forced me to dream

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bestial nightmares; if a man smokes it forces bad habits
(masturbation) on to his mind, he cannot give them up.
Cigarettes destroy life by taking away a little bit of super¬
happiness. The Chinese are small, their houses and trees are
stunted, they are hypnotised like me with opium. The Chinese
were trodden upon by European nations, they had to work
other people’s minds like me. The Chinese were allowed to go
to ruin ; no one was allowed to help me, they were manipulated
against it. The Chinese are descended from Hagar, a bond-
woman ; my mother is the mother of Chinese, she was left a
widow to fight for herself. Before the revolution the chief
power of China went to America. I was afraid to take any
risk ; my brother, who had more courage, went to America,
and struck out a new line for himself.” The patient, however,
has some more hopeful associations. He describes how, since
the revolution, the Chinese are breaking their bad habits,
cutting off their pigtails, and so on. This is connected with
the thought that the patient himself is going through a
struggle or revolution, the effect of which is to purge him of
his bad habits and vices. The underlying notion is expressed
in his constant observation, “When a man is on the downward
path and pulls himself up, he is a better man for his struggling
and experience ; he can tell others how to act.”

The Chinese delusion is thus a process of identification.
When he says his mind contains a Chinese spirit, he really
means there are certain analogies between that nation and
himself. He refers to the fact that cigarette smoking has
stunted his growth, weakening his will-power ; that he has
been oppressed by others ; that he has been allowed to drift
on the downward path, a widow’s son with no one to advise
him, and so on.

Another form of persecution which requires elucidation is
contained in the phrase, “ They concentrate moral agony on
me .” When analysed this exaggerated mode of expression is
found to refer to the little difficulties in life to which every
individual is subjected. Thus, he says, “It’s persecution, spite
and malice ; I’m to be trodden down ; it’s not the thing in itself,
it’s cumulative ; it’s all this sense of injustice, the little personal,
petty things. It’s the side, swank, and swelled head of people
which is agony to me. These things are trivial if you are not
held down.” The patient illustrates his expression by a wealth

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of concrete details. They all consist of everyday worries
common to every working man—little annoyances in the insti¬
tution, a bullying foreman, low wages, inability to obtain work,
little aches and pains. All these things, of course, assume
traumatic significance because of his inability to react effec¬
tively to situations which present themselves.

We now come to the consideration of the patient’s halluci¬
nations and allied phenomena. These consist of actual
“ voices,” “ forced ” thoughts which he refuses to acknowledge
as his own, or sometimes actual dreams of a peculiarly vivid
character. These experiences relate almost exclusively to his
family. Thus the voices say to him, “ Should his sister tell ? ”
This refers to the fact that one of his sisters had a child
before her marriage, and the voices are asking if she should
acquaint her husband of the fact. Further associations of an inti¬
mate character are also aroused. The patient exhibits a strange
dislike of his sister’s husband, explaining it on trivial grounds.
He states that on the day of her wedding he could not bring
himself to attend the ceremony, but went off to work. The
thought of the couple as man and wife caused a great distur¬
bance in his mind. These thoughts lead back to other concrete
reminiscences of childhood, relating to infantile experiences of
a sexual character with his sister. The voices also accuse his
mother and sister of being prostitutes, and we find that at the
“ drumhead trial,” to which reference has been made, this is
especially the taunt which was levelled at his head. When he
says he had no defence against this accusation, the significance
of the remark is obvious. The “ bestiality ” which is “ forced ”
into him consists, in the main, of unveiled images of an inces¬
tuous nature. The content of these phenomena is again deter¬
mined by definite experiences of childhood and youth. Owing
to the narrowness of their circumstances, the patient occupied
the same room as his mother, such a state of affairs persisting
until after puberty. This naturally led to the development of
premature sexual curiosity, impulses, and thoughts, which had a
considerable influence upon the subsequent development of the
patient.

Thus it is seen quite definitely that the hallucinations owe
their origin to a series of infantile experiences. This aspect of
the case will be referred to subsequently. For the moment it
is sufficient to note the existence of what may be called the

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BIOLOGICAL SIGNIFICANCE OF DELUSIONS, [Jan.,

“ family complex,” which includes a series of sexual memories,
with impulses or compulsive tendencies in a special direction.

Having now in some degree elicited the meaning of the
persecutory delusions, some attention must be given to the
expansive side of the psychosis. This aspect is not nearly so
prominent as the persecutory. The patient speaks of the
future with diffidence and reluctance, and he always follows his
delusional assertions by the remark, “ They can make me a liar
if they wish, they can make these things hypnotic delusions.”
The following associations denote the general trend of the
ambitious phantasies: “The hypnotic war is to put Nature
right again, afterwards I shall tell what I have learnt ; I am
the ultimate redemption which follows this bestiality, the
transformation of the race will be done through me and doctors.
The future is mental and moral redemption. They tell me the
cause of epilepsy, consumption, and cancer. Not doing to
others as they would be done by. Swank, I call it. The
patient S. boasts that he has tobacco at 8d. an ounce ; that
boasting affects the mind and causes epilepsy. Epilepsy is
not being decent to a man, it’s being high and mighty ; swank
unbalances the nature. I shall have the inspiration, I shall be
the master-power, and cure all this by saying the right thing.
When I have omnipotent power I shall redeem things, I shall
tell people what they need. They tell me I shall be king of
kings, my mother will get freedom through me. I cannot do
anything now, I am held down. As much moral force as I
have had drawn away I shall have back again. My suggestion
will be moral strength. They make me believe I shall have
seven wives ; seven is the natural number,” etc.

These expansive ideas are of considerable interest. They
refer almost exclusively to the patient’s endowment with
knowledge and moral power, and they contain no reference to
wealth, rank, and titles. He explains, “ I shall be myself,
plain S.” Even his reference to the king of kings only means
superiority in a volitional and moral sense. The following
examples indicate that he will be endowed more especially with
qualities and attributes which he actually lacks.

(i) He will have "the inspiration”; after giving various
mystical meanings of this he suddenly remarks, “ It is complete
concentration, a total loss of self, and a power of forgetting
your surroundings. An engine-driver has the inspiration when

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he sees the signals subconsciously ; his eyes are fixed in front,
so that he can pull up directly with danger. A man who has
that is a superman, he is just a perfect being, he could over¬
come trouble and sickness.” This rather remarkable statement
from an uneducated man expresses accurately the quality which
he as a hesitating, perplexed, and ruminating individual had
always lacked.

(2) He will “ give society a good hiding by suggestion.”
He here means that he will be able to retaliate for his former
rebuff in a manner he has hitherto lacked courage to do.

(3) A similar notion is expressed in his views on disease.
He has for many years been preoccupied about his health, and
thought he was consumptive, but he knows now it was due to
“ lack of will.” He, therefore, generalises, and ascribes a mental
causation to all maladies. “ Cancer is due to puffing of the
breast with pride. Habits which seem nothing lead to epilepsy.
If I could speak my mind I could cure all these. They are
due to little spiteful tricks.” It is to be noticed that he lays
stress on faults in others which have been especially irritating
to his sensitive nature, so that when he talks of curing diseases
the underlying thought is that he will reprove those who have
annoyed him by their overbearing conduct.

(4) Somewhat cruder are his “ wish-fulfilments ” in regard
to marriage. He is to have seven wives, his nature will be
restored, etc. He goes on to show how he will produce
children under perfect eugenic conditions ; but space forbids
further reference to these notions. Such ideas are of obvious
significance in a man who was obsessed by the thought that he
was impotent.

Now though the ultimate psychological roots of the various
delusional thoughts have probably not been completely elicited,
sufficient material has been obtained from the analysis to justify
certain conclusions. In the first place, it is seen that each
delusional thought has numerous relations or associations which
serve to indicate its special meaning and significance ; in the
second place the special conflicts to which the patient had to
adjust himself have been elicited ; and, in the third place,
insight has been obtained into the constitutional characteristics
of the patient, or the peculiar setting which constitutes the basis
of the psychosis.

It is apparent that the character of the patient betrayed

VOL. LXII. 10

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abnormal traits from puberty. The patient grew up shy,
diffident, and reserved. He lacked courage, was afraid to
take any responsibility, and became increasingly unable to get
into contact with his surroundings. Though troubled and
unhappy, he felt unable to tell others of his difficulties, and he
was keenly sensitive to his own incapacity. These constitu¬
tional deficiencies, taken together, represent what August Hoch
has described as the “ shut-in personality,” and they are often
found as the basis of dementia praecox.

Now in these defects of the personality I think we see what
is best described as a failure in psycho-sexual evolution, using
the term sexual in its widest sense. However one may hesi¬
tate to accept Freud’s sexual theories in the schematic manner
in which he presents them, there is no doubt that the sex-
impulse or libido constitutes the most potent biological force
in the individual, and further, that defects in its development
lie at the root of many psycho-neurotic disturbances. I think
we may also say that this libido or psycho-physical energy is
not only expended in sexual activities, in their narrow sense,
but flows outward, is sublimed into other channels, and
becomes the motive force for the manifold activities of ordinary
life. It is interesting to note how this notion was expressed
by Mercier quite clearly some years ago. He says, referring
to the development of sexual activity at puberty : “ In man at
this period not only does the special activity find ready outlet,
since to him belongs by ancient and prescriptive custom the
initiation of the overtures of love, but at the same period of
life he is usually provided with abundant outlets for the
general activities of his nature, which then receive so marked
an accession to their vigour. . . . He can enter freely into
clubs or societies of various kinds, can take up a special study
or pursuit, a science or an art, and find in such pursuits
channels of escape for the activities which are so copiously
generated within him.” At puberty, therefore, in the healthy
individual the libido expresses itself by transference to objects
outside his own family ; the youth finds pleasure in mixed
society, he falls in love, and so on ; and also the impulse flows
into other channels (sublimination), and becomes the motive
for ambition and creative activities generally.

No such normal, healthy development is seen in the case of
our patient. Before puberty the surroundings and circum-

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BY HENRY DEVINE, M.D.

1 47

stances of the patient had been of such a character as to
arouse premature sexual tendencies in an abnormal direc¬
tion. The normal affection for his mother and sisters became
associated with concrete sexual desires, impulses, and curiosity,
the significance of which it is impossible to ignore. With
the growth of moral and ethical standards these impulses
were submitted to a rigid repression, but the subsequent
development of the patient indicates clearly that the free
expression of the libido was hindered, the repressed impulses
exerted an unconscious influence, and served to prevent a
normal psycho-sexual evolution.

Then at puberty, though a normal intellectual development
occurred in the volitional sphere, defects soon became apparent.
These have already been detailed, and indicate a failure of sub¬
limation. In the definitely sexual sphere there is a complete
failure of transference to object love. He develops an abnormal
shyness, and later a definite dislike for mixed society. This
afterwards becomes almost an obsession, and he says: “ I
would walk a mile out of my way to avoid passing a woman.”
His conscious sexual life is confined to auto-erotic tendencies,
vague fancies about women, and a morbid curiosity comprised
under the expression “ spying on lovers.”

Now, in addition to these strangled sexual impulses, asso¬
ciated with a general volitional incapacity, indicative of a
failure of transference and sublimation, certain special reactions
indicate the specific influence of the “ family complex.” Thus
all his life the patient had shown an abnormal bias towards his
home, an undue dependence. His own words indicate this :
“ Home is final, there is nothing past that; you are your own
master, your thoughts are at rest, it’s always a refuge for me ;
a chap who couldn’t fend for himself and has to depend on
home if he is turned out is practically killed.” Another
reaction indicative of the abnormal kind is seen in his dislike
of his brother-in-law. When analysed this feeling was shown to
be due to jealousy associated with childish experiences which
have been already detailed.

The delusional content shows the influence of this complex
still more clearly. Not only is this the case in the hallucina¬
tions, the peculiar content of which has been described, but
also in numerous fantastic notions relating to the patient’s
mother. The following is characteristic: “ The hypnotic

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spirits mix me up with my mother; they pervade me with her
consciousness. They make me think she is mother-earth.
The earth has consciousness ; they will give my mother con¬
sciousness of the thoughts which are forced into my mind.
There is special enmity to my family.” These thoughts are
very obscure, but they obviously mean a mystical union of the
souls of his mother and himself; a realisation on his part of
the peculiar thoughts he has about her, and also a general ten¬
dency to place her on an exalted plane.

It has been necessary to consider the personality of the
patient in some detail, because without such knowledge the
significance of the psychosis is quite obscure. It is clear that
the psychosis does not depend on any notably severe external
stresses, but rather upon defects in the make-up of the patient,
which prevented him from reacting effectively to ordinary
situations. The patient aptly expresses his own defect in the
phrase “ I never grew up.” This is quite true. While his
intellectual growth was probably beyond the average, the
development of his libido, that “life force” which serves to
create healthy external interests, and forces an individual
into contact with the world, was hindered and unable to find
free expression. Thus the patient becomes a solitary, brooding
figure ; nourishing ambitions he cannot gratify, and isolated in
a world which must of necessity assume an aspect hostile and
malignant. This is the soil upon which the psychosis develops.
The delusional phantasy is a method of compensation—it is a
substitute for efficient action.

A brief review of the content of the psychosis will make this
clear. In the first place there is the mechanism of wish-fulfil¬
ment. The shy, diffident, hypochondriacal youth, afraid of
responsibility, unable to retaliate and conscious of his own
incapacity, is to become the great healer by moral force, he is
to purge society, he is to transform the world into a Utopia
and put right those social conditions against which he has
struggled so ineffectively. He is to have “ the inspiration ”—
perfect efficiency. In the sexual sphere his strangled impulses
become fantastically realised, and we find “he outrages females
by hypnotic transference.” His auto-erotic fancies assume a
definitely illusory form, and he becomes endowed with the
“ face and form of a woman.” How his suppressed incestuous
impulses force their way into consciousness in the form of

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1 9 1 **•]

BY HENRY DEVINE, M.D.

149

hallucinations and obscure delusional thoughts has already been
described ; and on a more elevated plane of thought the patient
pictures himself as the father of a numerous healthy progeny,
born and bred under perfect eugenic conditions.

In the second place there is the mechanism of projection.
The analysis has shown that the patient ascribes to some
external agency all his feelings of incapacity, all his inferior
attributes and qualities, and all his thoughts and desires which
do not harmonize with his ethical and moral standards. Such
thoughts and feelings are not his at all, his real personality is
the one which is “ held down,” the perfect being which will
emerge at the termination of the hypnotic war. This method
of adjustment is no more than an exaggeration of a mechanism
which is common enough in everyday life. The incompetent
man is always ready to regard himself as the victim of circum¬
stances ; because in this way he avoids looking into his own
mind, and discovering the painful fact that his failure results
from his own inefficiency. It is obvious that an elaborate,
persecutory, delusional scheme may originate in this manner.
This mechanism is of particular interest in regard to hallucina¬
tions. An individual refuses to acknowledge these isolated
images as belonging to himself because they are out of harmony *
with the general trend of his personality. Thus, one of my
patients, who was afflicted with “ voices ” which made amusing
but vulgar remarks to her, denied strenuously that they could
be her own thoughts, because she could never under any cir¬
cumstances entertain such coarse notions. In the same way
one patient not only gratifies his less creditable desires, but he
is able to absolve himself of all responsibility in the matter.
Instead of struggling against his thoughts, he can now give
himself up to them, and he is able to explain in a detached and
complacent manner that they do not belong to his own per¬
sonality at all.

Lastly, we see in this delusional phantasy the erection of a
pretentious philosophic scheme which serves as a complete
substitute for an incapacity in action. Such a defensive
mechanism is quite usual. Individuals who fail to adjust them¬
selves to reality often tend to fall back into rumination upon
the meanings of things, and are apt to adopt a pretentious
manner of speech. I cannot refrain from giving an excellent
example in one of my own patients who has shown an in-

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150 BIOLOGICAL SIGNIFICANCE OF DELUSIONS. [Jan.,

creasing incapacity to manage his own affairs. He is now
becoming very superior and detached, and recently he wrote as
follows : “ In a world in which nothing is an indefinite some¬

thing there is much ground for hope, and one may view with
calmness the progress towards final night of those who use
distributed negatives to inconceivability, and betake oneself to
a cold peak of learning which sees humanity concluded under
a barren negative ; and like the wayfaring man to formulate
the advance of a nation of strong negatives over a nation of
weak positives in such a way as to cause the influx of a united
people of a far continent.” There is no doubt that these
phrases seem perfectly rational to the writer himself, though
the actual relation between the words and the concrete thoughts
they are designed to express is decidedly obscure. They
certainly give him a great deal of pleasure and infuse him with
a delicious sense of intellectual superiority.

This superior attitude is very obvious in our patient, and it
is readily understood how, detached from the external world of
reality, he naturally fell back into the contemplation of all kinds
of obscure subjects—social problems, religion, hypnotism, the
yellow peril—which afforded all the necessary material for the
psychosis. The less efficient the patient becomes the more his
ego expands, and eventually he feels that he has arrived at the
solution of every problem which presents itself. From a state
of uneasy rumination and doubt he has attained a position of
positive belief, and he is able to watch the fruitless struggles of
his fellow'-creatures with an air of complacent detachment. As
the patient interprets his own actions, so he interprets those of
other people. He sees in humanity a mass of struggling souls,
manipulated by an unseen force, each striving against the other
—a topsy-turvy world which he alone can put right. Thus
prevented by defects in his personality from an energetic
application to reality, and unable to mould his circumstances
in accordance with his desires, the patient gratifies his inner
tendencies by the construction of a delusional phantasy. The
psychosis has therefore a definite biological significance,
analogous to other inferior mental operations in normal mental
life. It is a method of adjustment by means of which the
patient attains a state of equilibrium, and compensates himself
for a life of conflict and failure.

*) A paper read at the Section of Psychiatry, Royal Society of Medicine.

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AFTER-CARE REPORT OF EPILEPTICS.

151

After-care Report of Epileptics following Colony
Treatment. By A. Hume Griffith, M.D., D.P.H.
Superintendent and Medical Officer, Epileptic Colony,
Lingfield. Communicated by Sir G. Savage.

Hitherto a difficulty in forming a just opinion as to the
value of the colony treatment of epileptics has been the
inability to keep trace of the patients after they have left
the Colony. In connection with the Lingfield Colony (which
has nearly 300 epileptic patients), an attempt has now been
made to follow up, and obtain a report upon, those patients
who have left the Colony during the last 4! years. To this
end a circular was sent to the different local authorities asking
for their co-operation in this investigation, and thanks are due
to them for their prompt response. The number of cases
inquired into totalled 101. The number of reports actually
received was 100, but 20 of these were blank, the patients
having disappeared without leaving an address. Eighty cases
altogether have therefore been available for consideration as
follows :

(1) Arrest of Fits.

Eighteen (or 22‘5 percent.) are still free from fits, the period
of arrest being as follows :

1 year ....... 3

2 years ....... 1

3 ». 4

4 » ■ • • • • • 7

5 ». 3

18

(2) Length of Time away from Colony.

Less than 1 year .

.

r

.

• 17

1 year .

■

•

•

. 24

2 years

•

•

•

. 24

3 » •

•

•

•

1 2

4 » • • •

•

•

3

80

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152 AFTER-CARE REPORT OF EPILEPTICS, [Jail-,

Only 3 patients out of the 80 had been away from the
Colony for four years. It is hoped to make this investigation
five-yearly, so that each successive period should yield more
definite results.

(3) Number Wholly or Partially Self-supporting , 22 (27'5

per cent.).

This is satisfactory, as 10 percent, is considered the average.
But it must be remembered that practically all leave colony
life and treatment against medical advice. Public authorities
are naturally anxious to get suitable cases off their hands as
quickly as possible. Parents insist on parental rights. The
epileptic patient, even when the disease is confirmed, is usually
of the opinion that if given a chance he could do anything or
everything, so that altogether it is uphill work to be always
insisting that epilepsy is a very serious disease, that inter¬
missions for a larger or shorter period are quite common, even
without treatment, that, even when the disease is arrested, it is
unwise to talk of a cure. Dr. Alden Turner’s dictum is
probably a sound one, vis., “that the disease may be said to
be arrested when there has been no fit for nine consecutive
years, and that in 10 per cent, of the cases thus arrested a cure
may be more or less confidently expected.”

Thus out of the 22 reported wholly or partially self-
supporting, the latter are still having fits, and, therefore, would
not be likely to be employed through fear of the Workmen’s
Compensation Act. It is interesting to notice that i8(8i - 8 per
cent.) out of these 22 cases had passed through our school,
which is conducted on open-air lines.

(4) Nature of Occupation.

Shop, 3 ; army, 6 ; not mentioned, 11 ; handyman, 1 ;
chemical works, 1.

It is noticeable that, with the possible exception of the
army, none of the occupations given are suitable for epileptics,
even when the disease has been arrested. They need an
open-air life, free from strain or anxiety. At present they
take any job that offers, and go from one situation to another.
They have been carefully looked after for years, taught, dieted,
disciplined, even had their games organised, only to be pitch-

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*9*6.]

BY A. HUME GRIFFITH, M.D.

1 5 3

forked into the outside world, to sink or swim. Education
Committees are more and more waking up to their responsibility
in dealing with epileptic children, by sending them to special
schools, but suddenly, when the age of sixteen is reached,
that responsibility ceases, and, unless he or she can be trans¬
ferred to a Board of Guardians, the child is withdrawn, lives
in unsuitable surroundings, the treatment is stopped, often
suddenly, and it is not remarkable that many who have had no
fit for quite a long period relapse, and become confirmed
epileptics. The crying need is co-ordination and co-operation
between the Board of Education and the Local Government
Board, so that automatically an epileptic child at the age of
sixteen may pass from the care of a teaching body to the control
of a Guardian Committee, who will be prepared to take an
intelligent and sympathetic interest in his case for many years,
if not to the end of his life. The revival of the old apprentice¬
ship system would be excellent, provided that some means
could be devised of safeguarding employers from any penalty
under the “ Compensations ” Act whem employing epileptics.

Six of the patients have joined the army. Most of these
are now on active service. One has been recommended for
the D.C.M. for bravery under fire in carrying dispatches. At
the outbreak of the war some of the worst cases in our adult
male home absconded and enlisted. Two were old soldiers.
Their stay in the army has usually been a short one. Their
fits have been discovered, and they have been promptly
discharged, and have drifted back to the workhouse, or gone
“ on tramp.”

(5) Ntwiber still having Fits , 38 (47'5 per cent.).

Nearly half, and most of these were withdrawn at the age
of sixteen, the local Education Committees ceasing to be respon¬
sible for their maintenance. In a few cases the parents have
removed the child in opposition to all advice. In no case
has the medical officer in charge more than ordinary advisory
power, and his advice is more often rejected than accepted,
particularly by parents, who naturally like to have their child
home, particularly if the patient is likely to bring in a few
shillings extra to the family exchequer. Often the patient
himself gets unsettled. He naturally wants to see the world,

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154 AFTER-CARE REPORT OF EPILEPTICS, [Jan.,

believes in his own power to accomplish great things, threatens
to abscond, and probably does so, and then starts life in the
great outside world handicapped by a false step.

Out of the 38 cases still reported as having fits, 29 went
through the school (*. e., were admitted as children). Most of
these were Education Committee cases, and then had to be with¬
drawn at the age of sixteen, although still suffering from fits.

(6) Number who Died since Leaving , 8(10 per cent.).

The annual death-rate of the Coldly is low ; last year being
under £ per cent. With the best will in the world it would be
impossible to give patients the same care outside.

Of the 8 deaths 3 occurred in asylums ; and in only one
(an asylum case) was the cause stated, death having been
certified as due to status epilepticus. The danger of suddenly
stopping treatment is well known, and in some cases it may
well be that status is actually induced by such stoppage.

(7) Number of Cases who have had to be Certified since leaving
the Colony, 20 ( or 25 per cent.).

This is far from encouraging, but quite a number of these
cases were confirmed epileptics, who had been allowed to
remain at the Colony for some years, as it was felt they were
better off there than anywhere else. It is doubtful whether
they would now gain admission, as most of them were decidedly
mentally deficient, and would now come under the provisions
of the Mental Deficiency Act. Out of the 20 cases certified
1 5 had been through the school, and 5 were over school age
on admission.

Ten out of the 20 were still having fits when they left the
Colony.

In conclusion it is interesting to contrast the medical
history and record of the patients when resident in the Colony,
who are now partially or wholly self-supporting, with the records
of the 20 unfortunates who had to be certified, with regard to
the following points :

(1) Type of fit.

(2) Date of first fit.

(3) Supposed cause.

(4) Morbid family history.

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BY A. HUME GRIFFITH, M.D.

155

(5) Mental age, as tested by the Binet-Simon tests.

(6) Monthly incidence of fits.

(7) Educability as shown by six-monthly reports.

(8) Conduct, as shown by six-monthly reports.

(9) Average daily dose of bromide.

(10) Length of time in Colony.

(11) Frequency of fits before admission.

(12) After-care report.

(1) Type of Fit.

(a) Certified cases. — Out of the 20, 13 are “combined” major
and minor. All but 2 of these are noted “ chiefly major,”
one as “ serial.” Three suffered from major fits only. In two
cases the type is not recorded. One only suffered from minor
fits, combined with night terrors.

This is interesting, as “ petit j/ial” is considered to bring
about mental deterioration more quickly than the “major” type.
On the other hand, many epileptics change their type of fits
from year to year, as is well known.

(b) Non-certified cases ( self-supporting ). —Out of the 22 cases
only 5 are “ combined,” 8 major, 4 minor, and 5 not recorded.
The “combined” type, therefore,seems more favourable to mental
deterioration than either the “ major ” or the “ minor ” alone.

(a) Certified Cases.

Infancy to 3 years of age
3 to s years
5 to 10 years
Over 10 years of age
Not recorded

20

The figures are remarkably
value.

(b) Non-certified Cases.

Infancy to 3 years of age 4
Between 3 and 5 years . 5

Between 5 and 10 .5

Over 10 years of age . 5

Not recorded . . 3

22

even, and yield no deductions of

(2) Date of First Fit.

6

3
6

2

3

(3) Supposed Cause.

(a) Certified Cases.

Unknown . . . . . -9

Heredity ...... 3

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156

AFTER-CARE REPORT OF EPILEPTICS,

[Jan.,

Injury to head by fall or blow (i instru¬

ments used at birth) . . . .5

Sunstroke ...... 1

Convulsions three days after birth . . 1

Fright ....... 1

20

Probably most of the five cases supposed to have been
caused by a blow or fall could be added to the nine unknown.

(is) Non-certified ( Self-supporting ) Cases.

Unknown . . . . . .16

Heredity ...... 1

Fall on head . . . . . .2

Sunstroke ...... 1

Excessive cigarette smoking . . 1

Dentition ...... 1

22

(4) Morbid Family History.

(a) Certified Cases.

Healthy family history . . . . 1

History of cancer in near relation (mother) 3
Epilepsy in near relatives . . .6

Insanity in near relatives . . .2

Phthisis in near relatives . . .3

Hysteria in near relatives . . .2

Alcoholic in near relative . . 1

Unknown ... ... 2

20

(b) Non-certified {Self-supporting) Cases.
Healthy . . . . . .6

Cancer ....... 1

Epilepsy.5

Insanity . . . . . o

Phthisis ...... 4

Alcohol ....... 1

Convulsions ...... 1

Unknown . . . . . -4

22

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BY A. HUME GRIFFITH, M.D.

1 57

In (b), as one would expect, there are more healthy family
histories, but epilepsy is recorded in nearly as many family
histories of (b) as (a), so that the prognosis for patients with a
history of epilepsy in the family is nearly as good as for other
cases where there is none.

(5) Mental Age (as tested by Binet-Simon tests).

(a) Certified Cases. (b) Non-certified ( Self-support¬

ing ) Cases.

Under 10 years . .12 Under 10 years . . 1

10 to 16 years . . 4 10 to 16 years . . 6

Adult . . . .2 Adult . . . .11

Not taken . . .2 Not taken . . -4

20 22

This is as one would expect. The mentally sound cases are
the ones that are likely to prove self-supporting.

(6) Monthly Incidence of Fits while under Treatment.

(a) Certified Cases.

Average o a month . . . . .1

Average 2 to- 3 a month . . . .6

Average 3 to 6 a month .... 3

Average 6 to 10 a month . . . .5

Average 10 to 20 a month . . . .2

Average 20 to 30 a month . . . .2

Night terrors ...... 1

20

(b) Non-certified ( Self-supporting ) Cases.

No fit while under treatment . . . .6

No fit for 1 to 2 years before withdrawal . . 5

No fit for 3 to 5 years before withdrawal . . 2

No fit for over 5 years before withdrawal . . 2

Average 2 to 3 yearly . . . . . I

One fit in 3 years ...... 1

Average 4 fits a month ... . 1

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158

AFTER-CARE REPORT OF EPILEPTICS,

[Jan.,

Average 6 to 7 a month .... 1

Average 2 in 3 months . . . . .1

I fit in year before withdrawal . . .2

22

These records are interesting. They clearly show that the
hopeful cases are those that quickly react to treatment before
the convulsive habit becomes established. According to Dr.
Aldren Turner’s dictum, already quoted, “ No case of epilepsy
can be considered arrested unless there has been no fit for nine
consecutive years, and then in about 10 per cent, of these
arrested cases a permanent cure may be hoped for.” As many
of our patients come to us at an early age for education in our
special school, and do not leave until they reach the age of
sixteen years, we are able to keep records covering a lengthened
period of residence in the Colony.

Not only the relatives of patients, but even local authorities,
are apt to think that a patient who has been free of fits for
a year or two should be removed from the Colony as cured, yet
these are the promising cases with respect to which one may
hope, if only they are allowed colony treatment for a sufficient
number of years, that the disease may be permanently arrested.
The epileptic himself is a born optimist, and gets very restive
under colony life if the fits have stopped even for a few months.
So between the patients, his relatives, guardians and friends,
the unfortunate doctor who tries to do his duty is apt to get but
scanty gratitude, and is usually accused of selfish motives.

(7) Educability (as shown by half-yearly reports).

(a) Certified Cases. (b) Non-certified Cases.

Improving .

. 8

Improving

• 1 7

Stationary .

• 9

Stationary

• 5

Deteriorating

. 2

Deteriorating

. 0

Uneducable .

. 1

Uneducable .

. 0

20

22

In (a) it is surprising that eight should be returned as
“ improving ” in educability, but the explanation is that, in
dealing with defectives, a slight improvement is quickly

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BY A. HUME GRIFFITH, M.D.

1 59

detected and appreciated. It is improvement from a low
standard.

In list (b) five patients are noted as “ stationary,” but here it
is the opposite when, for instance, a boy who usually is bright
and intelligent has a dull interval.

(8) Conduct (as shown by half-yearly report).

(a) Certified Cases.

Excellent
Good .

Poor .

Bad to fair .

Bad

Troublesome

20

(b) N on-certified ( Self-support¬
ing) Cases.

Excellent . . .2

Good . . . .13

Poor . . . .5

Bad to fair . . . o

Bad . . . . o

Troublesome . . 2

22

7

1

9

3

(9) Average Daily Dose of Bromide.

(a) Certified Cases.

No bromide

Not exceeding 10 grs.

Not exceeding 20 grs.

Not exceeding 30 grs.

Over 30, not exceeding 60
Over 60 grs. per diem

(b) Non-certified ( Self-support¬
ing ) Cases.

. I

•

. 8

. 0

1

. 2

. 6

I

. 2

• 15

• 5

. I

. 0

20 22

Potassium bromide has been the usual drug given, and
ammonium and sodium bromide in a few cases, # each patient
receiving individual attention. The sight is tested for refractive
errors. The teeth are carefully overhauled by a dental surgeon.
Digestive errors are corrected, and a special dietary is followed.
School is held in the open air as much as possible, play and
work hours are all regulated ; in fact, a healthy colony life is
followed, which is probably of greater importance than the giving
of bromide. In some cases benefit has been obtained by giving
digitalis in combination with bromide. Arsenic prevents acne.

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l6o AFTER-CARE REPORT OF EPILEPTICS, [Jan.,

Fifteen out of the 20 patients in (a) class had daily doses of
over 30, but not exceeding 60 grs. of bromide. The anti¬
bromide enthusiast might say “ that proves that bromide causes
mental deterioration.” But it would be a rash conclusion, as
from Table 5, it is apparent that 12 out of the 20 patients
were under 10 years of age mentally, as tested by the Binet-
Simon tests, and there is no proof that the moderate dose of
bromide, while helping to control the frequency of the fits,
hastened the brain deterioration.

(10) Period of Residence in Colony.

(a) Certified Cases.

Under 1 year

• 3

(b) Non-certified ( Self-support¬
ing ) Cases.

Under 1 year . . 3*

1 to 3 years.

. 8

1 to 3 years

. 6

3 to 5 years.

• 5

3 to s years

• 9

Over 5 years

. 4

Over 5 years

• 4

•

20

* One absconded.

22

It is well to point out that very few cases leave the Colony
with the consent of the medical officer. They are withdrawn
by their relatives against advice, or, if maintained by Educa¬
tion Committees, that support ceases when they reach the age
of sixteen years.

(11) Frequency of Fits before Admission.

(a) Certified Cases.

Not stated ....... 1

Not stated, but occur both day and night . . 9

Occur by day only ...... 2

Occur by night only . . . . 1

8 to 14 daily ...... 3

1 to 8 weekly . . . . . .3

I in 3 weeks ....... 1

20

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19 I 6.] BY A. HUME GRIFFITH, M.D. I 61

(b) Non-certified Cases, Partially or Wholly Self-supporting.
Not stated, but infrequent . . .3

Not stated, but occur by day and night . . 4

Occur by day only . . . . .5

Occur by night only . . . . .5

8 to 12 daily . . . . . .0

5 to 6 daily ....... I

1 to 2 a week ...... 1

Fortnightly ....... 1

2 to 3 monthly ...... 1

1 in 6 months ...... 1

22

From Table (b) it appears as though the prognosis is more
favourable the less frequent the fit, and also when the fits occur
at a definite time, either by day or night, and less favourable
when they occur both by day and by night.

(12) After-care Report.

(a) All the certified cases have been transferred to asylums.

(b) Non-certified Cases, Partially or Wholly Self-supporting.

Occupation not stated . . . . .8

Enlisted in army . . . . . .6

Joiner ........ 1

Working at Royal Arsenal . . . 1

Handyman ......•!

Greengrocer ....... 1

Clerk in office ...... 1

Employed at chemical works . . . . 1

Sign writer ....... 1

Gardener ....... 1

22

Partially self-supporting, but still having fits . 7

Partially self-supporting, but no fits . . .1

Wholly self-supporting and no fits . . .10

Wholly self-supporting, but have occasional fits. 4

22

VOL. XLII. 1 1

Digitized by Google

Original from

PRINCETON UNIVERSITY

AFTER-CARE REPORT OF EPILEPTICS, [Jan.,

Twenty Certified

set. 12 on
admission

A. L.M—,
set. 12

A. G—,
male, set. 6

G. E—,
female, set.
12

W. J-,

male, set.
34

S. D—,

female, set.
13

J.H—,
male, set.
16

E. G—,
female,set.
12

A. M. R—,
female, set.

11

A- J—,

W. H—,
male. set.
II

female

(I)

(2)

( 3 )

( 4 )

( 5 )

(6)

Combined, but
chiefly at
night

8 years
old

Fall on
head

Cousin epileptic,
father choreio as
boy, paternal
uncle phthisical

N.

2-3 a month

Not

known

Not known

Unknown

Back¬
ward 2
years

2 a month

—

6 mos.
old

Unknown,
but instru¬
ments used
at birth

Healthy

Not

taken

Before admis¬
sion 8-9 daily,
after, 2 a
month

Combined

(serial)

7 years
old

Sunstroke
at 2 years
of age

Mother had
cancer

IO

Serial. One
series of over
200 fits in 48
hours ; ave¬
rage 8-9 per
month

Major (day)

19 years,
then long
interval
of 8 years

Unknown

2 sisters epileptic,
father intempe¬
rate

14

3 a month

Combined, with
excess of major
and tendency
to mania

7 years

Fall ?

Healthy, but
mother had cancer
of stomach

Not

tested

Average 25-
30 a month

Chiefly major

3 mos.

Convul¬
sions 4days
after birth

Healthy, but
mother died of
cancer

12

4-5 a month

Combined,
chiefly major

Un¬

known

Unknown

Unknown

8

6-8 a month

Combined, with
excess of major

5-6

years

Knocked
down by
bicycle

Maternal aunt
died of phthisis

10

6-7 a month

Minor, and
night terrors

2 years

Dropped
on head
when 18
mos. old

Maternal uncle
and aunt died of
phthisis, 1 sister
died of wasting
disease act. 9 mos.

7

Night terrors
and occa¬
sional minor
fits

Combined

5 years

Fright ?

Mother hysterical

5

26-30 a
month

Combined, with
excess of major

3 years

Heredity

Mother and sister
epileptic

7

16 a month

Combined with
excess of major

2 mos.

Heredity

Epilepsy on
father’s side

5

6-10 a month

Combined, with
great excess
of majors

3 years

Unknown

Father and pater¬
nal grandfather
died of phthisis

5

8 a month

Digitized by Google

Original from

PRINCETON UNIVERSITY

*9*6.]

BY A. HUME GRIFFITH, M.D.

*63

Cases .

( 7 )

(8)

( 9 )

(10)

00

(12)

Improving

Fair,

very

excitable

55 gr-

5 years

Not stated, but
fits returned

Certified March 17th, 1913.

Stationary

Bad

40 gr.

1

1 year

Frequency not
stated, occur by
day and night

Transferred to Tooting Bee
Asylum on Feb. 5th, 1914;
from there transferred to
Fountain Asylum on Feb.
23rd, 1915.

Unedu-

cable

Fair

20 gr.

6 mos.

8-9 daily

Is in Graylingwell Asylum.

Stationary
for last
year of
residence

Good

70 gr.

4! years

Not stated, but
both by day and
night

Inmate of East Riding Asy¬
lum, Beverley.

Improving

Good,
but a bad
moral
case

45 gr-

7 mos.

Frequency not
stated, but nearly
all by day

Certified March 6th, 1912,
and again Feb. 7th, 1913.
Slight fits every 2-3 days,
bad attacks every 2-3 mos.

Stationary

1

Poor

40 gr.

3 i y ears

Frequency not
stated

Certified Feb. 22nd, 1912,
and died in asylum, Jan.
nth, 1915.

Stationary

Good

60 gr.

i year 8
mos.

Always one a
week, but both by
day and night

Died in asylum, Jan. 8th,
I 915 -

Stationary

Bad to
fair

20 gr.

2 \ years

Frequency not
stated, but by day
only

In Colney Hatch Asylum.

Improving

Bad to
fair

60 gr.

s years 4
mos.

As many as 12 in
a day, longest
interval a week

Has frequent fits, August 3rd,
1914, sent to Tooting Bee
Asylum, transferred to Leam¬
ington Asylum in Oct., 1914.

Improving

Fair

25 gr.

54 years

Occur both by
day and night,
chiefly “ terrors ”

Certified Feb. 12th, 1914,
now at Darenth Asylum.

Stationary

Good

50 gr.

4 years 8
mos.

Frequency not
stated, but occur
both by day and
night

Fits about twice a week, now
in Waterford Asylum.

Improving

Bad

60 gr.

64 years

Frequency not
stated, but chiefly
at night

Certified March, 1914, and
inmate of Cane Hill Asy¬
lum.

Stationary

Fair

60 gr.

18 mos.

8 weekly

Transferred to Tooting Bee
Asylum April nth, 1914,
and on Sept. 18th, 1914, to
Darenth.

Improving

Fair

50 gr.

4 years

Frequency not
stated, but occur
both by day and
night

Certified Sept. 15th, 1913,
now in Leavesden Asylum.

Digitized b;

*Go

Original from

PRINCETON UNIVERSITY

164

AFTER-CARE REPORT OF EPILEPTICS, [Jan.,

—

(0

(2)

( 3 )

( 4 )

( 5 )

(6)

C.W.J-,
male, ret. 7

Combined
chiefly major

Not

known

Unknown

1 brother died of
epilepsy

12

4 a month

C. C-,
male, ret. 11

Major

4 years

Unknown

Mother hysterical,
step-sister in
asylum

Not

taken

None since
admission

C. F. W—,
male, set.

Combined
chiefly major

12 mos.

Unknown

Father alcoholic

8

2-3 a month

R. S—,
female, set.

11

Combined
chiefly major

Between

7-8

Not known

Father alcoholic,
maternal father
phthisical

10

6 a month

A. E. L—,
male, set.
10

Combined
chiefly major

9

Not known

Maternal father
had fits, also pater¬
nal grandmother.
Father phthisical

7

2-3 a month

R. T. H—,
male, set.
20

Major

12

Heredity

Mother epileptic,
father insane,
sister also

Adult

2-3 a month

Twenty-two Cases Partially

F. W. F—,
male, set.
12

S. S. H—,
male, set.
16

Major

Minor

10

15

Heredity ?

Excessive

cigarette

smoking

Father epileptic

Brother, set. 3, died
in convulsions,
grandmother died
of cancer

Adult

Not

taken

None since a
month after
admission
Nil while at
the Colony

M. A—,
male, set.
26

Combined

14

Unknown

Father alcoholic,
mother fainting ?
fits

II

4 a month

H. T. M—,
male, set.

—

6

Fall from
a swing

2 brothers died
from convulsions

N.

—

W.ILS-,
male, set. 9

Combined

5

Unknown

A brother and
sister epileptic

14

2-3 yearly

W.R.W—,
male, set.
17

Combined

Not

given

Unknown

Unknown

IS

6-7 a month

R. W—,
male, set. 7

Minor

S

Unknown

Unknown

No

record

No fit for 3
years before
discharge

W. L—,
male, set.
11

Said to be
serial

Since

infancy

Sunstroke

4 brothers and
sisters had convul¬
sions, father and
mother had con¬
sumption

Normal

No fit since
admission

Digitized by Google

Original from

PRINCETON UNIVERSITY

T91 6 .]

BY A. HUME GRIFFITH, M.D.

165

(7)

( 8 )

( 9 )

(10)

(n)

(12)

Stationary

Good

60 gr.

i year

At intervals 1-19
days, once 4 in
24 hours

Sent to Long Grove Asylum
Nov. 16th, 1914, and he
died there Feb. 20th, 1915.

“ Status epilepticus."

Stationary

Fair

Nil

2 years

Frequency not
stated, but both
by day and night

In the Mental Hospital, Upper
Warlingham.

Deterio¬

rating

Bad to
fair

40 gr.

3 years

Not stated, but
occur both by day
and night

Has sometimes 3-4 fits a day.
Now in Hellingly Asylum,
Jan. 1st, 1915.

Deterio¬

rating

Bad

40 gr.

18 mos.

6-10 a day, largest
interval 18 mos.

Sentasan imbeciletoTooting
Bee Asylum June 8th, 1914,
transferred to Darenth July
15th, 1914.

Improving

Good

40 gr.

6 years

Frequency not
stated, but occur
in groups both
night and day

Certified insane and removed
to Hants County Asylum
April 6th, 1914.

Improving

Good

40 gr.

8 mos.

Frequency not
stated, but occur
both by day and
night

Is in the Wilts County
Asylum.

or Wholly Self-supporting.

Improving

Excel¬

lent

20 gr.

6 years

Frequency not
stated, but more
frequent at night

Apprenticed to joiner at
Yatton near Bristol.

Improving

Trouble¬

some

20 gr.

4 mos.

Frequency not
stated, but occur
both by day and
night

Whollyself-supportingat pre¬
sent. Present health good.
Has enlisted on two occa¬
sions, but was discharged as
result of fits. Parents last
heard of him from Sailors’
Home, Portsmouth.

Stationary

Good

50 gr.

10 mos.,
withdrawn
against
medical
advice

Fits occurred
fortnightly

Partially self-supporting, has
occasional fits ; health poor.

Improving

Good

Nil

4 years

Fits infrequent

Working at Royal Arsenal,
getting £1 a week. Health
good, no fits.

Stationary

Good

45 gr.

3 years

Fits occur at
all times

Earning 4-5 shillings weekly
as a handyman. Present
health good. Fits average
one a week.

Improving

Fair

60 gr.

1 year

1-2 a week

Self-supporting, no fits, pre¬
sent health good. Has

joined the R.H.A., and is
now said to be in France.

Stationary

Fair

10 gr.

7 years

Frequency not
stated, but occur
in the early
morning, slight

Partially self-supporting. Pre¬
sent health good. No fits.

Improving

Good

Nil

\

5 years

Fits occur several
in succession,
chiefly in bed

Is in the army, health has
been good, but is wounded
and is coming home. Had
only one fit after leaving
the Colony.

Digitized by Google

Original from

PRINCETON UNIVERSITY

AFTER-CARE REPORT OF EPILEPTICS,

[Jan.,

166

—

(0

(2)

( 3 )

( 4 )

( 5 )

(6)

A. L—,

Major

Not

Not given

Grandfather epi-

N.

No fits for

male, aet.

given

leptic

3 years

13

R. E—,

Major

Not

'Jot known.

Healthy

11

1 in 3 years

male, aet.

11

A. B—,

given

1

%

?

18 mos.

Dentition

1 brother died of

Not

None since

male, aet.

convulsions

taken

admission

12

H. D—,

?

11

Unknown

Healthy

N.

None since

male, aet.

admission

12

G. L—,

Minor

6 weeks

Unknown

14

None for a

male, aet.

old

year before

11

withdrawal

F. M—,

Major

9

Not given

Paternal grand-

Adult

None for 18

male, aet.

father died of

mos. before

13

phthisis

withdrawal

H. G. S-,

7

Not given

Healthy

Adult

No fit for

male, aet.

11

7 years

H. S—,

Major

18

Unknown

Healthy

Not exa-

2 in 3 mos.

male, aet.

mined

27

W. H. B—,

Major

10

Not known

Paternal grand-

Normal

No fits since

male

father was epileptic

admission

G. W—,

Combined

Not

Not known

None

10

I minor in

male, aet.

given

the year

22

S. If. W—

—

15 mos.

Not known

Father had con-

7

No fit since

male, aet.

sumption of bowels,

admission

11

mother fainting ?
fits, 2 aunts had fits

C. K—,

Combined

10

Blow on

Grandfather (pa-

N.

No fits for 2

male, aet.

head

ternal) phthisical

! years before

>3

| discharge

W. S—,

Major

5

Unknown

An uncle had fits

N.

No fits for 2

male, aet.

years before

12

discharge

R. H. C—

Minor

2

Unknown

Healthv

Not exa

No fit for 6

male, aet. 9

mined

mos. before

|

leaving

Digitized by Google

Original from

PRINCETON UNIVERSITY

i 9 16.]

BY A. HUME GRIFFITH, M.D.

167

( 7 )

(8)

( 9 )

(10)

do

(12)

Improving

Good

Nil

4 years

Fits infrequent,
usually at night

Partially self-supporting,

greengrocer, street trading.
Health fair, fits at intervals
of 5-6 weeks.

Improving

Good

20 gr.

4i years

Fits infrequent

Engaged in office.

Improving

Good

Nil

4 years

5-6 daily by night
and day

Partially self-supporting. Few
and slight fits, usually at
night; generally good health.

Improving

Good

Nil

4 years

Has fits in groups,
not very severe,
used to occur in
bed, now in the day

Wholly self-supporting. No
fits since leaving Colony.
Health excellent. Enlisted
in the Territorials, now at
the front.

Improving

Good

20 gr.

5 years

Frequency not
stated, but occur
in the daytime

Self-supporting. Health good,
free from fits. On leaving
the Colony went to sea as
steward. Joined the army
on outbreak of war, and is
now in France.

Improving

Improv¬
ing, good

15 gr-

4 years

Frequency not
stated, but occur
in the daytime

Capable of being partially
self-supporting. Health very
good ; has fits frequently in
groups, then an interval of
a few weeks. Was under
detention once for 14 days.

Improving

Good

20 gr.

9 years

Frequency not
stated, but occur
always at night

Self-supporting. Health ex¬
cellent, no fit since leaving
the Colony. Has enlisted
and is now at the front.
Left Colony with consent of
Medical Superintendent.

Improving

Abs¬

conded

45 gr.

3 mos.

Fits in groups,
severe. Was in
the army 2 years,
discharged unfit

Still has fits. Partially self-
supporting. Present health
good.

Improving

Excel¬

lent

Nil

2 years 10
mos.

Fits occur in
groups by day
only

Self-supporting, working at
chemical works, having no
fits.

Stationary

Fair

So gr.

1 year

2-3 at a »ime,
monthly

Partially self-supporting. Pre¬
sent health good, fits every
fortnight.

Improving

Fair

Nil

3i years

Average I in 6
mos.

Earns 12 shillings weekly.
Health at present good.

Improving

Good

Nil

3 years

Fits occur while
patient is asleep

Self-supporting as a sign
writer. Enlisted in Terri¬
torials, now at the front.

Improving

Good

30 gr.

7 years

Fits occur by day

Went to a situation as under
gardener, stayed 18 mos.,
and gave satisfaction. Then
took to drink and fits re¬
turned. Cannot now be
traced.

Stationary

Fair

30 gr.

2 years

Fits occur both
by day and night

Is an only son, much spoilt.
Said to be “ all right.”

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Original from

PRINCETON UNIVERSITY

i68

CHOLESTEROL CONTENT OF THE SERUM, [Jail.,

The Cholesterol Content of the Serum in Mental Diseases.

By J. Cruickshank, M.D., and C. J. Tisdall, M.B., Ch.B.,

Crichton Royal Institution, Dumfries.

WITHIN recent years a considerable amount of work has
been done upon the bio-chemistry of cholesterol, and valuable
information has been acquired which has thrown light upon
the important part which this substance plays in numerous
physiological and pathological states. It will be of value in con¬
nection with the results described in this paper to shortly review
some of the more outstanding facts which have been discovered.

It has been known for some time that cholesterol is a
constant constituent of every cell in the body, and that sub¬
stances of closely allied chemical composition are widely
distributed in plant tissues. In certain organs it is
very abundant, for example, in the white matter of the
central nervous system, where it is present to the extent of
IO per cent, of the dried substance, and in the cortical portion
of the suprarenals. As a rule it is present in two forms: (i)
free cholesterol, and (2) cholesterol combined with various fatty
acids, e.g ., cholesterol oleate, palmitate, stearate, etc. The
general term cholesterol-ester is applied to the latter form.
In blood serum cholesterol is chiefly in the form of cholesterol-
ester, only a small amount of free cholesterol being normally
present. It is an important constituent of bile, in the form of
free cholesterol, and the different forms in which cholesterol
exists in the two fluids, serum and bile, should be noted, as
this fact is of importance in the study of cholesterol meta¬
bolism. The work of Dor£e, Gardner, and others (1) has
suggested that in the metabolism of cholesterol there is a very
definite circulation of a conservative nature, the free cholesterol
of the bile being reabsorbed in the intestine, probably as
cholesterol-esters, and carried by the blood stream to various
tissues to be made use of in the building up of new cells. The
changes which occur in cholesterol metabolism in various
pathological states have been widely investigated (2). It has
been found that the cholesterol content of the blood, bile, and
suprarenals may vary within very wide limits. Normally, the total
cholesterol (that is to say, both free and combined cholesterol)
of the blood serum is from 1*5 to r8 grm. per litre, of the
bile 1 '5 to r6 grm. per litre. In pregnancy the content in

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Original from

PRINCETON UNIVERSITY

1916.] BY J. CRUICKSHANK, M.D., AND C. J. TISDALL, M.B. I 69

the blood may rise to 4^25 grm. per litre, and, associated with
this, there is corresponding increase in the amount of free
cholesterol in the bile. It has been suggested that the
increased cholesterol content in the pregnant state is due to
disturbance of the ovarian functions. An increase in blood
cholesterol also occurs in cases of adiposity, diabetes mellitus,
xanthoma, arteriosclerosis, chronic nephritis, eclampsia, and
chronic jaundice. The amount of cholesterol in the bile in cases
of gall-stone is unusually large, and the formation of gall-stones
(which are frequently composed of almost pure cholesterol) is
now regarded as a direct sequence of this increase.

Of the total cholesterin in the body the great bulk is,
however, localised in the central nervous system, particularly
in the white matter of the brain. The function of this very
considerable amount of cholesterol is unknown. Lorrain
Smith and Mair (3) found that in general paralysis there is
practically no diminution of the amount of cholesterol, and
that in the development of the brain the amount of cholesterol
relative to other lipoids remains remarkably constant.

In cerebro-spinal fluid cholesterol may be found in many
psychoses, both in the form of crystals and by means of the
Liebermann colour test. In a recent paper Weston (4) describes
the presence of cholesterol in the spinal fluids from a great variety
of psychoses, the average amount of cholesterol in cases of
epilepsy, dementia praecox, and organic dementia being greater
than in general paralysis, senile dementia, and in manic-depres¬
sive psychoses. Crystals of cholesterol-esters, which are readily
recognised by means of the polarising microscope, may also be
found. In a case of optic atrophy examined by us the spinal
fluid was distinctly turbid from the presence of such crystals.

It seemed to us that a systematic examination of the amount
of cholesterol in the sera of cases of mental diseases might be
of interest, particularly if the results were associated with
observations on the cholesterol content of the suprarenals and
the bile. For the estimation of cholesterol two methods are
at present in general use. The first, which is extremely
accurate, is the digitonin method of Windaus (5), and is
employed where larger amounts of cholesterol can be obtained.
This" method depends on the fact that digitonin, a glucoside
of the digitalis series, combines under suitable circumstances
with cholesterol to form a stable crystalline compound, digitonin-

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Original from

PRINCETON UNIVERSITY

170 CHOLESTEROL CONTENT OF THE SERUM, [Jan.,

cholesteride. The amount of cholesterol present in this com¬
pound is constant and in the ratio of one part in four parts of
digitonin-cholesteride. This method is the most convenient
for the estimation of cholesterol in brain and other tissues.
The second method, a colorimetric one, is suitable for the
estimation of small amounts of cholesterol, and has been used
by us in combination with a Konisberger-Autenrieth colori¬
meter. The method, as we have used it, is as follows : Blood
to the amount of about io c.c. is drawn off from the median
basilic vein and allowed to clot ; the serum is separated ;

1 c.c. of serum is pipetted off, placed in a small flask, 20 c.c.
of 2 per cent, caustic soda added, and the flask heated on the
water-bath for two hours. As a result of this treatment with
caustic soda the cholesterol-esters are saponified, and the
cholesterol separated as free cholesterol. The fluid in the
flask is now transferred to a separating funnel and shaken fora
period of two or three minutes with two to three times its volume
of ether. The mixture is allowed to settle, the ether drawn
off, and the fluid again shaken with a fresh amount of ether.
The ether extracts are accumulated in an evaporating basin
and the ether driven off on the water-bath. The residue in
the basin is dissolved in 20 c.c. of chloroform. Five c.c. of this
solution are carefully pipetted into a small test tube, and

2 c.c. of acetic anhydride and cri c.c. of strong sulphuric acid
are added. The tube is shaken to ensure thorough mixture
and placed in a dark cupboard for twenty-five minutes. The
depth of colour of the fluid is then compared with the standard
coloured fluid in the colorimeter, and the amount of cholesterol
calculated by reference to a curve which has previously been
made by the use of known amounts of cholesterol in com¬
bination with the standard fluid of the colorimeter. This
method in our hands has given very uniform results. The
accuracy of the colorimetric method has been on occasion
controlled by comparison of the findings with those obtained
by the use of the digitonin method.

The estimation of the “free” cholesterol of the serum is carried
out with another sample of the serum. One c.c. of the serum
is diluted with 20 c.c. of water and extracted with ether. The
procedure is then similar to that described above. The amount
of “combined” or ester-cholesterol is obtained by subtracting
the amount of “ free” cholesterol from the total cholesterol.

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Original from

PRINCETON UNIVERSITY

1916.] BY J. CRUICKSHANK, M.D., AND C. J. TISDALL, M.B. I 7 I

The total number of sera examined was about 120. The
accompanying tables give a sample of the kind of results
which were obtained. Unfortunately it is not possible for us
to give in detail the results of the examination of the whole
120 sera. Owing to a serious outbreak of fire in the
laboratory at the institution, practically the whole of the
records of this work, the colorimeter, and the stock of standard
coloured fluid, were destroyed. The results shown in the
tables were fortunately in another part of the laboratory, and
are the only details of these experiments which escaped
destruction. An examination of the tables shows that, on the
whole, the cases of general paralysis had a very low cholesterol
content and the cases of dementia pnecox a content con¬
siderably higher than normal. The majority of the other
cases gave figures which were slightly under normal limits. A
few cases of chronic mania gave readings as low as some of the
cases of general paralysis. In one case of mania, in which
extreme excitement had continued for a period of seven
months, there was a progressive fall in cholesterol from r8
grm. at the beginning of the attack to 0 2 grm. per litre at the
end of the attack. All the epileptics gave practically normal
readings. With the exception of early cases of dementia
praecox there is, therefore, on the whole a distinct tendency in
cases of prolonged mental disease for the cholesterol content of
the serum to fall. The cases of general paralysis with one
exception were in the second or third stage of the disease.
In the exceptional case, in the first stage, the cholesterol
content was o’8 grm. per litre.

Attention has been drawn above to the fact that the
cholesterol content of the suprarenals increases or decreases
with the cholesterol of the blood. With regard to the
increased cholesterol in cases of dementia praecox it should
be noted that several observers have found that hypertrophy
of the suprarenals frequently occurs in this disease.

Attention should also be drawn to the contrast which
exists between the high cholesterol content of the serum
reported in cases of chronic nephritis and arteriosclerosis,
and the low content observed in our cases of general
paralysis, a disease in which diffuse degenerative changes in
the blood vessels are well marked. We have in all our cases
endeavoured, as far as possible, to select for examination only

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172 CHOLESTEROL CONTENT OF THE SERUM, [Jail.,

those cases which showed no pronounced renal or arterial
changes.

VVe would suggest that a possible explanation of the above
results may be found in the different degrees of activity of the
sexual and reproductive tissues in the different psychoses.
The high content of cholesterol in the dementia pnecox cases
would thus be an expression of an unusual degree of activity
of the sexual glands, the low content of cholesterol in the
advanced general paralytics an index of great loss of functional
activity of the same organs.

It was our intention when this work was commenced to
examine, in addition to the blood, the cholesterol content of
suprarenals and bile. Owing, however, to the destruction of
our material by fire, and to the interruption of research w'ork
by the war and the departure of Dr. Tisdall on military service,
we have thought it advisable to put on record at the present
time this preliminary note of the serum examinations alone.

Case.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Table I.

Mental disease.

General paralysis
ditto
ditto
ditto
ditto
ditto
ditto
ditto
ditto
ditto

Dementia prsecox
ditto
ditto
ditto
ditto
ditto
ditto
ditto
ditto
ditto

Total cholesterol
in grm. per
litre of serum.

0-4

0-4

o-8

02

0*2

0-4

o‘6

0‘2

0‘8

0*2

2-5

2‘2

2-6

3‘5

2-8

2‘2

3' 1

r6

2'2

r8

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19 I 6.] BY J. CRUICKSHANK, M.D., AND C. J. TISDALL, M.D. I 73

Table II.

Total cholesterol

Case.

Mental disease.

in grm. per
litre of serum.

21

. Chronic melancholia .

r8

22

. ditto

ri

23

ditto

ro

24

. Agitated melancholia .

2 'I

25

Chronic mania

0 - 2

26

ditto

o-8

27

ditto (mild type)

11

28

Alcoholic insanity (chronic)

06

29

ditto (acute)

r8

30

ditto (acute)

ro

31

• Epileptic insanity

r 3

32

ditto

r 4

33

. ditto

1*2

34

ditto

35

Terminal dementia

. 1*0

36

ditto

0'3

37

. ditto

ri

38 .

Confusional insanity .

ro

39

ditto

11

40

. ditto

. 2 "I

References,

(1) Dor^e, Gardner, Ellis, etc.—Various contributions to Proc. Royal
Soc., London, 1908 to 19x2.

(2) For full bibliography on Cholesterol Metabolism see paper by
McNee, Quart. Journ. Med., 1914, vol. vii, No. 27.

(3) Lorrain Smith and Mair.— -Journ. Path. Bacteriol ., ign, vol. xvi,
p. 131, and ibid., 1912, vol. xvii, p. 123.

(4) Weston.—; Journ. Med. Res., 1915, xxxiii, p. 119.

(5) Windaus.— Ber. d. deutsch. c/ierrt. Gesellsch., 1909, Bd. xxxii,
P- 254.

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174

USE OF ASYLUMS AS MILITARY HOSPITALS, [Jan.,

Use of Asylums as Military Hospitals. By Lieut.-Col.
William Vincent, M.D., R.A.M.C., Wharncliffe War
Hospital.

The South Yorkshire Asylum, Wadsley, near Sheffield, was
offered to the War Office by the West Riding Asylums Board
under the scheme prepared by the Board of Control.

The transferring of the inmates—nearly 1,700—was com¬
menced on March 16th, 1915, and completed on March 30th.
The institution was thus cleared in a fortnight. The great
majority of the patients (some 1,400) were transferred to the
sister asylums—Menston, Storthes Hall, and Wakefield—by
motor char-a-bancs. The remainder were sent to various out-
county asylums—Hull, Leicester, Nottingham, Lincoln, etc.
The private class of male and female patients was transferred
to Scalebor Park and Menston Asylums respectively. All
the patients were transferred without mishap. Twelve patients
only were retained at the farm residence.

With the approval of the War Office the institution was
named the Wharncliffe War Hospital.

It was at first assumed that the hospital would afford
accommodation for some 2,000 sick and wounded soldiers.
This was found impossible. Not only would there have been
undue overcrowding, but part of the building had to be set
aside in order to provide accommodation for the large staff of
sisters and staff-nurses, and for the R.A.M.C. personnel.

The number of beds available at present is 1,500, but it is
not improbable that this number will eventually be exceeded.

The structural and other alterations necessary in order to
adapt the institution for the purpose of nursing sick and
wounded soldiers were considered by the Committee of
Visitors, and the architect of the Asylums Board and the
clerk of works were instructed to carry them out. The work
is now practically complete.

An “ Emergency and Consultative ” Committee was formed,
in addition to the General Committee, before the chairman
and members of which all recommendations and suggestions
made by the administrator or inspecting officers are placed.

Authority was given by the War Office, through the Board
of Control, for the committee to carry out such structural
alterations as were deemed necessary.

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1916.] BY LIEUT.-COL. WILLIAM VINCENT, M.D.

175

The difficulties associated with the difference of level of the
various buildings have been overcome as far as possible. A
temporary wooden bridge in the male division has proved
very useful. A small electric service lift has been placed in
position. If lifts for conveying patients, supplies, etc., to the
upper floors had been approved, a smaller staff of orderlies
would have been required than is at present the case. A
very considerable amount of work was necessary in order
to adapt the various wards and dormitories. In the upper
floor dormitories extra baths and sculleries, with an adequate
water supply, were added, and additional lighting in all
dormitories and side-rooms was quickly carried out. Gas
for heating purposes, for boiling water, and for sterilising
instruments, etc., was introduced where required on all
floors.

A small dormitory and a day-room were fitted up, and two
excellent operating theatres were thus obtained. A commodious
“X-ray” department is in close proximity to one of the operating
theatres, so that patients can readily and safely be subjected
to X-ray examination when under the anaesthetic, if necessary.
The want of electric light was met by having a special cable
laid from the nearest point available on the Sheffield city
boundary. Electricity was thus obtained from the Sheffield
supply for the operating theatres and offices, the X-ray depart¬
ment, and for lighting the stage and hall during entertainments
—thus eliminating a possible source of danger from fire.
Additional precautions against fire have also been taken, and
hand fire extinguishers have been placed where deemed
necessary.

All day-rooms and corridors are occupied as wards—the
corridors leading to the operation rooms excepted—and one
large day-room has been fitted up as a billiard-room for con¬
valescent patients.

Three blocks with 1,158 beds are reserved for surgical
cases, and one block, with 342 beds, for medical cases. The
total number of beds available for sick and wounded soldiers
will probably remain at 1,500, but 220 additional beds could
be placed in position should necessity arise.

Suitable accommodation for the matron, the sisters and
staff-nurses, and R.A.M.C. orderlies was provided by the fol¬
lowing arrangements. The whole asylum staff of attendants

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176 USE OF ASYLUMS AS MILITARY HOSPITALS, [Jan.,

and nurses was permitted to live out, the latter living with
relatives or friends in close vicinity to the hospital. The
nurses’ residence, together with the patients’ laundry residence,
afford accommodation for the matron and nursing staff. These
buildings, in which over 100 beds are available, are apart from
the hospital, but connected by corridors. The dormitories of
the laundry residence were divided up into cubicles containing
one, two, and in some instances three, beds. A separate kitchen
and offices, dining and recreation rooms have been found for
the nursing staff appointed by the War Office. The whole is
under control of a “ home sister ” appointed for this duty by
the matron.

The asylum nurses are acting as “ probationer nurses.” All
except ten live out, and come on duty at 7 a.m. A large
day-room in the laundry residence is placed at their disposal
as a recreation room when they are off duty during the day.

The asylum attendants are enlisted for “ home and local ”
service, and are employed in the wards, offices, laundry, and
gardens.

The R.A.M.C. personnel , N.C.Os. and men, are at present
occupying the upper floor of one of the detached blocks. This
floor, which accommodates 21 o men, thus becomes a barracks
for both the day and night staffs. This arrangement has
saved the cost and trouble of erecting hutment barracks for
these men, but has, naturally, restricted the accommodation
which otherwise would have been available for sick and
wounded. It, however, has met with approval from head¬
quarters and may continue.

The loss of patients’ labour in the kitchens, laundry, out¬
working parties, and gardens has been met by the appointment
of a temporary staff who are employed under the housekeeper,
second chief nurse, head gardener, farm bailiff, and other
asylum officials. The retention of twelve patients at the farm
has proved useful. Our chief nurse has taken charge of the
sewing-room and mending department. A temporary staff of
women is employed in the kitchens and laundry, and women
are also employed as ward-cleaners. This enables us to employ
a smaller staff of men. The entire staff of nursing sisters, pro¬
bationers, R.A.M.C. and institution orderlies, and temporary
workers in the kitchens, laundry, and gardens totals up to
over 650. The greatly increased demand on workers in both

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1916.] BY LIEUT.-COL. WILLIAM VINCENT, M.D.

I 77

the kitchen and laundry departments has been met with credit
to those in charge.

The Clerk of Works’ Department remains unchanged. Work
is carried out under the supervision of the architect to the
Asylums Board, and clerk of works. None of the artizans
has been required to enlist.

The clerk and steward (who has not been accorded military
rank) has charge of, and is responsible for, all supplies, and
also for the payment of salaries and wages of all the visiting
and resident medical and other officers, and the asylum
employees and temporary staff. A very great amount of
work has thus fallen upon the clerk and steward’s department,
and under very different conditions and requirements. Two
clerks are retained in his office in order to carry out necessary
work relating to the patients, as under the Lunacy Act this
institution is still an asylum.

The work of the stores department has been adequately
met by an increased staff Considerable change was necessary
to meet the military requirements, and enormously increased
output. This department has risen to the occasion in a manner
that merits very great praise.

The R.A.M.C personnel and the masseurs are paid by the
quartermaster appointed by the War Office, who is acting as
company officer. The former tailors’ shop, now the clothing
department, and the shoemakers’ shop, the “ pack stores,”
are under his control.

The changes in" the kitchen department have been very
great. The whole system has been re-organised. For the
nursing staff appointed by the War Office a separate kitchen
is available under the supervision of the matron. All cooking
for the remaining staff, R.A.M.C. personnel, and patients is
done partly in the main kitchen, under the direction of the
housekeeper, and partly in the smaller kitchen attached to the
medical block.

The isolation hospital is kept prepared for the reception of
any case of an infectious nature should such arise.

The clothing of all men coming from the Front is passed
through the disinfector at the isolation hospital immediately
on arrival, and before being received into the pack stores.

The medical staff consists of six operating surgeons, three
visiting physicians, and an ophthalmic surgeon, while four

VOL. XLII. 12

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178 USE OF ASYLUMS AS MILITARY HOSPITALS. [Jan.,

operating surgeons, with six medical and surgical assistants
and a pathologist are resident.

An X-ray expert and a sufficient number of anaesthetists
attend daily ; dental surgeons twice weekly. The local medical
officer of health attends as sanitary expert when required, and
all cases of an infectious nature are placed under his care.
Excellent massage work is carried out by three ladies and two
masseurs.

The War Office was considered in possession of the
institution on April 1st, and the work of adapting it as a
hospital was sufficiently complete in six weeks to enable sick
and wounded to be received. The first convoy was received on
May 2 1st. The number of convoys received to date has been
16, with a total number of 2,592 overseas men. The dis¬
charges have been 1,670. Of these 1,647 have been discharged
fit for duty, 23 as unfit for further service, and 15 have died.

The transport of the wounded from the station to the
hospital (a distance of four miles) is carried out most
effectually. The whole of the transport arrangements originally
organised by Col. Connell, of the 3rd Northern General Hospital,
have been placed at our disposal. Over 80 stretchers are
available.

The duties of the Registrar have been taken over by the
Senior Assistant Medical Officer, Dr. D. Gillespie, to whom a
temporary commission with rank of major has been accorded.

This hospital, in conjunction with the other hospitals in
Sheffield, receives help from the “ Soldiers’ Personal Comforts
Depdt,” organised and carried out by ladies of Sheffield and
the surrounding districts. Breakfasts and teas, and various
invalid dainties, hospital requisites, clothing, tobacco, etc., are
distributed among the men. A "Soldiers’ Comforts Fund,” to
which many people have kindly subscribed, has proved in¬
valuable, as means are thus found to meet small requirements,
the money for which would otherwise have been difficult to
obtain.

The work of converting this asylum into a hospital for the
reception of sick and wounded soldiers has necessarily involved
much anxiety, but results have shown that it has in every way
justified the expense and labour which have been incurred.

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of Sekhem-uatch-taui-Ra, King of Egypt, about B.c. 20

To illustrate paper by Dr. R. H. Steen

Ad lard «5r» West A

PRINC

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1916.

Mahu, Director of Works, and his wife Tuat. XIXth Dynasty.
To illustrate paper by Dr. R. H. Steen.

W. A. Mansell&* Co., photo.

Ad lard West Xauwan.

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1916.

Amenhetep III. XVIIIth Dynasty.

To illustrate paper by Dr. R. H. Stken.

ll'\ A . Mansell & Co., photo.

Ad lard <5r* West Newman.

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1916.]

CLINICAL NOTES AND CASES.

179

Clinical Notes and Cases.

A Characteristic Attitude assumed by many Cases of
Dementia Prcecox. By R. H. Steen, M.D.Lond.,
M.R.C.P.Lond.

The accompanying photograph illustrates an attitude when
sitting frequently adopted by many cases of dementia praecox.
The point to which special attention is directed is the position
of the arms and hands. The arms are held close to the
trunk, with, as a rule, the elbow-joint in a condition of
stiff extension and the hands in pronation, and resting on
the lower part of the thighs, or even on the knees. When the
photograph was taken there was no special posing for the
purpose of this note, the subjects merely being told to sit down.
In the wards I have seen these particular patients as well as
others maintain this position for hours at a time. They sit,
as a rule, rigidly upright, for example, in the case of the man
shown, whose head is erect with the eyes staring forwards. In
other cases the body and head may be bent slightly forwards.
Most frequently the feet and knees are found to be close
together, but, as in the case of the woman on the extreme
right, the legs may be kept apart.

I believe in most cases the muscles of the arms are in a
condition of rigidity, but when I try to test the point the
patient at once relaxes. The hands are slightly cedematous
and of bluish colour, indicating bad circulation. The patients
are all cases of dementia praecox of long standing, with the
exception of the man, whose illness has lasted only twelve
months. I am unable to suggest any explanation of this
phenomenon. It is possible that it is an example of reversion.
It is certainly well seen in the statues of ancient Egypt (see
illustrations). I have therefore named it the “ Ancient Egyptian
attitude.” I am drawing attention to the matter, as it does not
appear to be described in any text-book, and may be of interest
to the readers of the Journal.

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CLINICAL NOTES AND CASES.

[Jan.,

I 80

A Case of “ Status Epilepticus ” and Death due to
Cerebral Cysts of Cysticercus Celluloses {Laivcs
of Tcenia solium ). By G. E. Peachell, M.D., B.S.

Loud., M.R.C.S., L.R.C.P., Medical Superintendent, Isle
of Wight County Asylum.

As this is a fairly rare condition, the following case is
considered worth publishing :

R. P—, £et. 39, married, a private in the R.F.A., was admitted to the
Isle of Wight County Asylum on January 2nd, 1915, from a Red Cross
Hospital in a condition of status epilepticus. The history obtained
from his wife was interesting. He joined the Army when about 18, and
spent six years in India. He took part in the South African War for
fifteen months. He returned to England in 1903, married, and had
several healthy children, and had lived at Dorchester for the last ten
years. At the outbreak of war he was called up on the Reserve, and
sent to France with the B.E.F., and was in the battle of the Aisne.
Early in October he developed “epilepsy,” and was invalided to
England. He had always been strong and healthy till then, and never
had a fit previously. Under treatment he improved, and was on sick
furlough, when in November he had a severe epileptic attack, and was
readmitted to a military hospital. He then became sullen, drowsy,
and irritable, with occasional slight fits till December 20th, when he
had three severe attacks, but came round from them, and was able to
write a clear letter to his wife on December 26th. On January 1st,
1915, he started having severe fits, and these continued up to his
admission twenty-four hours later.

Condition on admission .—Well developed and strongly built. Marked
brown pigmentation of almost the whole of the trunk. Temperature
102 0 F. ; pulse weak and rapid. The fit was rather of Jacksonian type,
commencing in tonic spasms, followed by clonic convulsions of the left
facial muscle group ; it then spread to the left arm and leg. The right
side of the body was affected later, but only in slight degree. There
was right conjugate deviation. It was hard to estimate whether there
was any sensory change, but in the brief intervals between the fits he
was able to articulate in a low voice, and in a fairly coherent manner.
The eyes were examined with difficulty, but there was no apparent
optic neuritis or ocular cysts. The fits became more frequent, and
for the last six hours before death were continuous. He died thirty-six
hours after admission.

Post-mortem .—The skull cap and dura mater were normal. The
vessels of the pia-arachnoid were congested, and springing from the
membrane were numerous, small, oval, and rounded encapsulated cysts,
mostly the size of a pea, which were scattered over both hemispheres,
and to a lesser extent over the cerebellum. They were about seventy
in number, and for the most part were attached to the pia, and dipped
down into the cortex, but in some cases the cysts were actually in the

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*9*6.]

CLINICAL NOTES AND CASES.

I 8 I

grey matter; there were no surrounding inflammatory changes in the
brain-tissue. They were most numerous in the right Rolandic area, this
probably accounting for the convulsive fits starting and being mostly
confined to the left side. There were no cysts in the ventricles or
basal ganglia. The brain, which weighed 45 oz., appeared otherwise
normal. All the other organs of the body appeared healthy, and there
were no signs of cysts in the muscles or elsewhere, only in the brain.
The stomach and intestines were normal. There was no sign of a
tapeworm. The spinal cord was not examined.

Pathological examination .—To the naked eye, and examined with a
lens, the cyst wall was composed of an outer hard chitinous layer, and
an inner thin lining membrane, with villous processes in several instances;
some of the contents were cheesy and the others of a harder calcified
nature. I submitted specimens to my friend, Dr. B. H. Spilsbury,
Pathologist to St. Mary’s Hospital, to whom I am much indebted for
kindly examining. He reports : “ I have no doubt they are examples
of Cysticercus cellulosae. They all have a thick fibrous capsule with a
little round-celled infiltration outside it. One cyst appeared completely
occupied with granulation tissue, but others were filled with an amorphous
debris containing cholesterin crystals, and showing early calcification.
In some there is necrotic structure which I believe to be a scolex, and
in teased fragments of the cyst contents I have found portions of
hooklets.” I have only once previously met with such a case.

Through the kindness of Dr. Tattersall, Assistant Medical
Officer of L.C. Asylum, Hanwell, and of Dr. Elgee, Acting
Medical Superintendent of the Epileptic Colony, Epsom, I
am able to record another case of epilepsy due to the same
cause :

E. J. B—, at present a patient in the Epileptic Colony, Epsom, started
having epileptic attacks when fighting in the South African War, and
was admitted to Hanwell soon after the war. He had various cystic
nodules on the arms, legs, and tongue, and one removed and sectioned
showed it to be Cysticercus cellulosae. Blood examination showed a
marked excess of eosinophiles (7 25 per cent.). He was admitted on
three occasions to Hanwell, and under treatment his fits greatly
diminished, so that he only had one on rare occasions. On his discharge
he usually took to drink, and his fits increased again. The fits were
accompanied by complete unconsciousness, but on one occasion the
convulsive attack was of the Jacksonian type— i.e. he stated that he
was quite conscious, and that he felt pins and needles on left side of
tongue, followed by contractions of left angle of mouth and side of face.
He was transferred to the Epileptic Colony on April 12th, 19:2. Dr.
Elgee reports in August, 1915 : “He is a weak-minded man, rather
grandiose, lacking in self-control, and often quarrelsome. During the
last six months he has had twenty-two fits, and they were all of the
major type. He is in quite good health, and the only evidence of
cysticercus he hns presented since being here is a small cyst on the
right under surface of his tongue which is still present.”

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OCCASIONAL NOTES.

[Jan.,

182

I have heard of another case which was trephined at a London
hospital for cerebral tumour producing localising symptoms,
when several cysts of this nature were met with. The case I
have recorded suggested the diagnosis of a localised cerebral
tumour.

Occasional Notes.

A Statistical Intermission.

Among the many duties of life which have had to be thrown
overboard in consequence of war strain is that of recording and
tabulating facts connected with asylum experiences. It cer¬
tainly would be undesirable that a process, which at the best
of times is but a burden to many, should be continued when
the asylum, more than any other class of institution, is heavily
stressed by an increase in function accompanied by a notable
decrease in the means of performing function. Nevertheless it
cannot be denied that a breach in a long continued series of
medical observations is in itself somewhat of a misfortune.

The Board of Control, in a recently published circular, has
informed those hitherto responsible forcertain returnsthat, while
the civil register of admissions must be rigorously kept going, the
medical register of admissions may be completely jettisoned.
The same treatment has been extended to the death and dis¬
charge registers, that is to say, the civil facts must be preserved,
while those parts of the record which have to do with the
medical aspects of insanity maybe dispensed with. If there is
no need to note the latter, we fear that there will be a general
disposition to let them lapse altogether. We, however, suggest
that a valuable portion of the medical facts can be preserved
at the cost of exceedingly little trouble.

There are two phases of statistical work, the one of ascer¬
taining and recording experiences as they arise, the other of
summation and elaboration at stated intervals. The latter can
safely be entirely abandoned. A great point about a register,
which was made when our statistical system was proposed,
was that, given the entry of facts, those facts could be worked

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1916.]

OCCASIONAL NOTES.

183

up years after, the register going to sleep in the meantime.
Now, if we throw all tabulation, summation, elaboration, and
correlation to the winds for the present, where is there any
difficulty in recording, say, the aetiology and classification of
each case admitted? We take it that no physician can pos¬
sibly form a satisfactory estimate of the nature and prospects
of a case until he has come to some conclusion in his own mind
with respect to each of these two factors. The trouble therefore
is reduced to the mere putting down his formed ideas in a space
already prepared for them—a piece of purely ministerial work,
which could well be done by those who have no longer to bear
the burden of preparing the much heavier load of statistics.
We quite recognise that some caution will be called for in
accepting at full value any records made during the absence on
war work of so many skilled observers. But we may anticipate
that those skilled observers who are left necessarily to conduct
the asylums will be prepared to take some little extra trouble
to this end, just as there were men who recorded many things
of interest in asylum life for years before statistics were thought
of as a regular part of psychiatry.

If statistics are of worth at any time, surely the present is a
time when they should be most valuable. Strikes, famines, and
other stresses have yielded valuable returns to earnest observers;
shall the present opportunity afforded by the operations of the
greatest stress that has ever fallen on this or any other nation
be wasted ? We may confidently anticipate that the many
good men who have been called up from our ranks to take
charge of those on whom war stress has fallen most directly
will think it incumbent on them to render some generalised
account of their experiences; we may trust also that those who
have been left behind will not neglect to note and report on
their cases, which have only indirect relations to the stress, in
such a manner as to advance psychiatry. To give true value
to the work of either some enumeration is absolutely needful.

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184

REVIEWS.

[Jan.,

Part II.—Reviews.

First Annual Report of the General Board of Control for Scotland.

Edinburgh: H.M. Stationery Office; London: Wyman & Sons,

Limited; or Dublin: E. Ponsonby. Pp. lxxxiii and 162.

Price ij.

Under the Mental Deficiency and Lunacy (Scotland) Act, which
came into force on May 15th, 19T4, the former General Board of
Commissioners in Lunacy for Scotland was merged in the General
Board of Control for Scotland; and the present Bluebook is the first
annual report of the new Board. Iri its re-constitution the personnel of
the Board was increased by one medical commissioner and two deputy
medical commissioners (of whom one must be a woman); and, in addition
to the duties incumbent on it under previous lunacy statutes, the Board of
Control is now charged with the general superintendence of matters
relating to the supervision, protection, and control of mental defectives.
The first section of the report deals with these new duties, and shows
the scheme of the Act by reviewing the powers given to the various
authorities recognised or constituted under its provisions. These may
be shortly sketched as follows :—

It is the duty of the parents or guardians of children between five
and sixteen years of age, who are defectives within the meaning of the
Act, to make provision for the education, proper care, and supervision
of such children. When there is no known parent or guardian the
Parish Council acts in loco parentis. While an idiot or imbecile may
be placed by his parent or guardian in an institution for defectives, or
under guardianship with the consent of the Board, upon the certificate
of two duly qualified medical men, a defective whose condition is not
such as to amount to idiocy or imbecility cannot be similarly dealt
with except at the instance of his parents, and then only if he is under
twenty-one years of age. When the guardian is unable to make adequate
provision for the education and care of a defective child between five
and sixteen years of age, the School Board must act as the local
authority concerned, either under the Education of Defective Children
Act (1906-1908), or under the Mental Deficiency Act. The School
Board has to decide (a) whether a child is, owing to mental defect,
permanently incapable of receiving proper benefit from instruction
in ordinary schools, and (h) whether such a child is capable of receiving
benefit, or further benefit, from instruction in special schools or classes,
or of receiving such instruction without detriment to the interests of
other children. If a defective child is capable of receiving benefit
from instruction in special schools or classes it is the duty of the School
Board to make provision accordingly. As, however, the great majority
of School Boards possess no such facilities for the education of mentally
defective children, the Scotch Education Department has, by circular,
indicated that in such circumstances children who would otherwise be
suitable for special schools or classes may be sent to certified institu¬
tions under the Mental Deficiency Act. The School Board has also

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the duty of ascertaining what children within its area are defective
within the meaning of the Act, and of notifying to the Parish Council
and the General Board of Control the names of such children as are
incapable of being educated in special schools or classes, or of obtaining
benefit from special institutions. The School Board has also to intimate
in a similar way the names of defective children whose discharge from
the special arrangements made for them by the School Board is impend¬
ing by reason of their attaining the age of sixteen years, in whose
cases the School Board is of opinion that it would be to their benefit
that they should be sent to, or remain in, an institution, or be placed or
continued under due guardianship. When a defective child passes out
of the care of the School Board, either on account of being ineducable or
on attaining the age of sixteen, the Parish Council (if there is no parent
or guardian able to act) becomes the local authority responsible. It is
also the duty of the Parish Council to ascertain what persons of sixteen
years or over, within their parish, are defectives subject to be dealt with
under the Act, otherwise than at the instance of their parents or guardians,
and to take steps for placing them in institutions, or under guardian¬
ship. With the consent of parents or guardians all defectives under
twenty-one years of age for whom Parish Councils are responsible may
be placed by them in institutions, or under guardianship, without a
judicial order; in all other instances the Parish Council must obtain a
judicial order before they can deal with a defective under the Act.
Regulations have also been made for dealing with mental defectives
who are violent or dangerous, or who are found in criminal institutions,
such as prisons or reformatories, or who are neglected or cruelly
treated.

Defectives committed to care in the statutory manner may be placed
in (a) Certified Institutions, (?>) Certified Houses, ( c) State Institutions,
(d) Private Dwellings, or ( e) Places of Safety. The duty of providing
accommodation for defectives sent to institutions is imposed on the
District Boards of Control, which take the place of the former District
Boards of Lunacy. The constitution of these Boards has been altered
by the addition of representatives from the Parish Councils to the extent
of one-third of all the members of the Board, and by the enactment that,
if there are no women on the Board, women (not more than two) shall
be co-opted in addition to the existing members. Just as the District
Lunacy Boards provided the necessary institutional accommodation for
the insane in their districts, the District Boards of Control have to
provide the institutional accommodation required for the mental defec¬
tives ; and these buildings, being sanctioned by the General Board, are
certified institutions. A certified house is a house or institution
provided by a society or private individual for the reception for profit
of private patients which has been certified by the General Board. A
State institution is an institution for the care of defectives of violent or
dangerous propensities, established by the authority of the Secretary for
Scotland, and managed by the Prison Commissioners, and two of the
paid Commissioners of the General Board of Control. Private
dwellings may be used for the reception of defectives placed under
guardianship. Not more than one defective may be received under
guardianship into any private dwelling, unless the occupier of such

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dwelling holds a license from the Board. Such a license may permit
the occupier of the house to receive not more than four defectives at
any one time. A place of safety means any place of detention, such as
a poorhouse, police station, hospital, etc., the occupier of which is
willing to receive temporarily persons who may be taken there under
the Act.

The judicial order for the detention of a defective is obtainable upon
an application to the Sheriff by petition. A parent or guardian, a local
authority concerned, the procurator fiscal, or the Board may present the
petition. The authority for detention given by the order ceases at
certain definite periods, unless it is duly renewed under the statutory
regulations. The Act confers upon the Sheriff the same power as
regards the citation of the defective and others, the summoning and
examination of witnesses, the administration of oaths, the awarding of
expenses and otherwise, as if he were acting in the exercise of his
ordinary civil jurisdiction. This is in sharp contrast to the more or
less administrative duty performed by the Sheriff in granting orders for
the confinement of lunatics, where the validity of the medical certificates
and the conformity of the vaiious parts of the schedules to the require¬
ments of the statute have alone to be considered.

The number and distribution of certified mental defectives on
January ist, 1915, was as follows: In certified institutions for adults,
51; in certified institutions for juveniles, 156 ; and in private dwellings,
88. Except 16 private cases, all of these were “aided ” patients. Up
to the same date six institutions had been certified for receiving mental
defectives under the Act. Of these, the two institutions at Baldovan
and Larbert, which have been in existence for many years, and were
well known as institutions for the Care and Training of Imbecile
Children, have now become institutions for the Care and Treatment of
Juvenile Defectives. The Waverley Park Home at Kirkintilloch,
which was founded by the Glasgow Association for the Care of the
Feeble-minded, is certified for the reception of juvenile female defectives
of school age, and capable of benefiting by'education. The three other
institutions-namely, Grierson Hall, Middleton Hall, and Stoneyetts—
are for the care of adult defectives, and are connected respectively
with the Crichton Royal Institution (Dumfries), the Edinburgh District
Board of Control, and the Parish Council of Glasgow. Under the
power given by the Act, the General Board of Control have obtained
through the Scotch Education Department returns from School Boards
shewing all children ascertained to be mentally defective. About 1000
children were thus intimated, and are being visited and reported on by
the Deputy Commissioners. In addition, numerous defectives, both
children and adults, have been reported by Parish Councils, and are
under the consideration of the General Board. The suitable cases
requiring non-institutional care are certified, and placed under guardian¬
ship in private dwellings.

The portion of the Blue-book dealing with lunacy gives the usual
statistical and other information in regard to the insane. On January
ist, 1915, exclusive of insane persons maintained at home by their
natural guardians, there were in Scotland 19,557 insane persons, of
whom the General Board had official cognizance. That figure includes

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those inmates of training schools for imbecile children who have not
been certified under the Mental Deficiency Act, and the inmates of the
Criminal Lunatic Department of Perth Prison. Of the total number,
2,621 were maintained from private sources, 16,870 by parochial rates;
and 66 at the expense of the State. As the number on January 1st,
1914, was 19,346, an increase had taken place during the past year of
211.

In training schools for imbecile children the number resident under
the Lunacy Acts is 82 less than last year. This decrease is accounted
for by the certification under the Mental Deficiency Act of many of the
inmates who were in residence on May 15th, 1914, and their consequent
transfer to the corresponding register. The criminal lunatics in Perth
Prison are 4 more than last year. These two classes constitute the
non-registered lunatics. Among registered lunatics—that is, those in
rojal, district, and other asylums, in lunatic wards of poorhouses, and
in private dwellings—the following changes are noted : (1) There was
a total increase of 289, due to an increase of private patients by 31,
and an increase of pauper patients by 258. (2) The total increase of

289 arose from an increase of the number in establishments by 347, and
by a decrease of the number in private dwellings by 58. (3) The

increased number of 347 in establishments arose from an increase of
24 private patients and an increase of 323 pauper patients. Of pauper
patients in establishments, the average annual increase during the pre¬
ceding five years w’as 202, and the increase during the year 1914 has
therefore been much above that figure. Decreases in the number of
pauper lunatics chargeable, amounting in all to 84, occurred in fourteen
counties and urban areas, while increases, amounting in all to 342, have
taken place in twenty-two counties and urban areas.

The total number of patients admitted to establishments during the
year 1914 was 3,755 (private 569, pauper 3,186). This is the highest
number admitted in Scotland in any single year since the institution of
the Lunacy Board, and represents a proportion of 79*1 per 100,000 of
the population. The number discharged recovered was : Private 222
(being 39'o percent, of the admissions), and pauper 1,183 (37" 1 P cr
cent, of the admissions); total, 1,405 (37 4 per cent.). The number
discharged unrecoveied was: Private 123, pauper 347; total, 470,
being respectively private 5 2, pauper 2 6 per cent, of the average
number resident. These figures show that the admission rate still has
an upward tendency, that the recovery rate tends to fall—this being
largely due to the more unfavourable nature of the admissions, as
indicated in previous reports—and that the rate for unrecovered dis¬
charges was lower even than formerly. Simple transfers from one
establishment to another are not included in the figures given above;
of these there were 410 during the year.

The number of voluntary patients admitted in 1914 was.’T8i, being
a marked increase (70) on the average number admitted per year during
the ten years 1905-14 (hi). They are not certified and not registered
as lunatics, and are therefore not included in the figures given above,
but a record is made of their names, and other particulars regarding
them. The General Board continues to be of the opinion that it is a
useful provision of the law which permits persons who desire to place

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themselves under care in an asylum to do so in a way which is not
attended with troublesome or disagreeable formalities. Simple as the
process used to be, a certain amount of time had necessarily to elapse
before application could be lodged, and sanction issued ; and, though
the delay involved was short, it had serious consequences on more than
one occasion. Power has therefore been obtained under the recent
Mental Deficiency and Lunacy (Scotland) Act for a person to be
received into, and kept in, an asylum for three days on his own written
application to the superintendent, provided the sanction of the Board
be at once applied for in the usual way on admission, and that no
voluntary boarder be retained for any longer period than three days
without such sanction.

The number of patients who died in establishments during 1914 was:
private 188, and pauper 1345; total 1533. Calculated on the
average number resident, the proportion is: for privates 7^9 percent.,
for paupers 9^9 per cent. ; and for both classes together 9'6 per cent.
During the last three years the death rate has been higher than in
previous years, the increased mortality, as compared with earlier periods,
being no doubt due to causes similar to those which have already been
noted as tending to lower the recovery rate.

An interesting table is given tracing the progressive history of 2539
patients who were admitted for the first time into asylums in 1898, and
showing the number of re-admissions which occurred among those of
them who were at any time removed from asylum care. At the end of
ten years 618 had been re-admitted once, and 22 had been re-admitted
twice. The total number of re-admissions during the sixteen years to
which the table is extended is equal to 32^4 per cent, of the original
admissions. During the first two years the cases discharged recovered
amounted to 42'i per cent., discharged unrecovered io'2 per cent., and
died 16 per cent., the removals from all causes thus representing 68 2,per
cent, of the original number admitted. During the last two years of the
table the removals from all causes amounted to only 27 per cent, of the
original admissions, and at the close 440 of the original cases were still
resident in asylums.

In addition to those in establishments, the number of registered
patients provided for in private dwellings in Scotland on January 1st,
1915, was 2885. Of these the private cases numbered 117 (being an
increase of 7 on the previous year), and pauper cases 2768 (a decrease
of 65 on the previous year). The total number shows, therefore, a
decrease of 58 since January 1st, 1914. Of the pauper patients in
private houses about one-third are under the care of relatives, and about
two-thirds are boarded with unrelated guardians. The highest number
of pauper patients provided for in this way (2909) was reached in the
beginning of 1913, and the considerable fall which has taken place in
each of the two last years has been sudden and unexpected, and has had
the effect of making a number of vacancies in guardians’ houses. The
decrease has taken place most markedly among the pauper insane
boarded with unrelated guardians, the number of which had previously
been steadily rising; and as the reports of the Deputy Commissioners
show that the care of the patients continues to be in general quite
satisfactory, and is advantageous in various ways, it is probable that the

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decline will be merely temporary. The desirability is urged of taking
advantage of the present surplus accommodation and skilled guardian¬
ship while it exists. Many of the cases which are at present being
visited and examined under the Mental Deficiency Act will also, no
doubt, be provided for in private dwellings.

Reference is again made in the Blue-book to the want of accommoda¬
tion for the poorer class of private patients. The Royal Asylums give
some assistance in this direction. In the District Asylums the number
of private patients has been steadily increasing, and at January 1st, 1915,
stood at 335 ; and in addition to these there is a considerable number
who are in the asylums as pauper patients, but who repay the cost of
their maintenance to the parishes to which they are nominally charge
able, and who therefore should properly appear as private patients. The
number in this last class at May 15th, ^14, was 233. There can be
no doubt that the small number of private patients in District Asylums
has hitherto been due to the necessity for refusing to receive such
cases, or for calling for their removal, when the accommodation is
required for parochial cases. It is anticipated, however, that the
number of private patients will now tend to increase, as one of the
sections of the Mental Deficiency Act provides that private patients
having a presumptive settlement in any parish of the district shall not
be liable to be removed from the District Asylum upon the sole ground
that the beds occupied by them are required for the use of pauper
patients.

The usual information regarding the expenditure for lunacy purposes
for the last financial year is given in considerable detail. Hitherto, in
District Asylums the “ Capital ” expenditure (for providing land and
buildings) has been met by the District Lunacy Boards, while the whole
“Maintenance” expenses (for feeding and clothing the patients,
supplying medical care, etc.) for patients in District Asylums, as well as
the entire cost of supporting pauper patients in Royal Asylums, in
lunatic wards of poorhouses, and in private dwellings, has fallen upon
the Parish Councils. The capitation grant received annually from
Government, and contributions given by the relatives of patients, go to
the Parish Councils to assist in meeting the maintenance expenses.
Under the Mental Deficiency Act a new allocation of the lunacy
expenses comes into force. The District Boards of Control continue to
be responsible for the capital expenditure in providing District Asylums,
and have also to provide the Certified Institutions required under the
new Act. The maintenance expenses for all pauper patients—whether
in asylums, lunatic wards of poorhouses, or in private dwellings—as well
as the maintenance of the aided defectives, now fall (after deduction of
the sums received from Government and other sources) as to one-half
upon the District Boards of Control, and as to the other half upon the
Parish Councils and School Boards concerned. As the last complete
financial year covered by the Blue-book ended on May 15th, 19T4, just
before the new Act came into force, the financial information in the
present report is given in the old form. It shows that the average
cost of “providing” District Asylums in Scotland last year was
^15 1 8s. 7 d. per patient, and that the average cost of “ maintenance ”
of the patients in these asylums was ^27 9$. 3d., making a total cost

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for the year of ^43 7 s. tod. per patient. For pauper patients in
lunatic wards of poorhouses the average expenditure for the year was
£22 12 s. nd. per head, and for those in private dwellings ^18 13^. id.
per head. The total expenditure by Parish Councils for the year for
the maintenance of their pauper lunatics was ^445,967. The
Government grant is allocated pro rata on the other expenditure of the
Parish Councils, and as it is a fixed sum, while the number of patients
claiming on it is increasing, the average contribution per head is steadily
falling from year to year. Last year it was equal to a contribution of
2 s. 10 \d. weekly per patient.

Sixty-fourth Report of the Inspectors of Lunatics (Ireland) for the Year
ending December 3 1st, 1914.

The total increase in the number of insane under care in Ireland in
1914 was 171, being practically identical with that of the previous year
(170), and 50 less than the average increase for the preceding ten years,
which was 221.

In the table on page xi, which states the proportion of insane under
care per 100,000 of estimated population, the figures are given for the
seven five-year periods from 1880 to 1914, the last quinquennium
having been completed by the year under review. From it we learn
that the ratio has risen from 268 in the first period to 566 in the last,
an increase of 111 per cent ., or more than double. But if, as in last
year’s review, we analyse the respective increments for the several
periods, we find that during the last four the ratio of increase has
reduced considerably, notably so in the two latest. The percentage
increases for each successive quinquennium over the one preceding
workout as follows, commencing with the second: 16*4, 17'3, i 8'3,
15 2, 8 4, and 4’6. There is, therefore, in the most recent statistics
nothing to weaken the inference arrived at when dealing with those of
the previous year, viz., that the increase of insanity in Ireland, which
has been for so many years persistently progressive, is now at last on
the decline.

The number of admissions also is corroborative of this conclusion.
These reached their maximum in the quinquennium 1900-1904, when
they were 86 per r00,000 of population. In the last quinquennium
this ratio has fallen to8r. That of first admissions during the same
period has fallen from 68 to 64. Table II, on page 4, enables us to
take a more comprehensive view of the downward trend in the number
of admissions within recent years. In this table the figures for the
three decades from 1881 to 1910 inclusive are given. The average
annual number of admissions in the first decade was 2,792 ; in the
second, 3,302; and in the third, 3,720; the high-water mark having
been reached in 1908, when the total admissions to district asylums
were 3,798. From that on, down to the end of 1914, there has been
on the whole, with one slight fluctuation, a steady and continuous fall.
So that, if we take the first four years of the present decade, 1911-1914,
we find that the average number of admissions has dropped to 3,545,
the decrease being more than double in the case of males than in

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females. These figures certainly encourage the hope that the increase
of insanity in Ireland has reached its acme, and that our expectations
of a further reduction in the volume of lunacy will not be falsified in
years to come.

The total number of insane in establishments at the close of the year
1914 was 25,180, those in district asylums having increased by 213, in
private asylums by 19, and in Dundrum Criminal Asylum by 2, while
there was a decrease of 54 in the number of workhouse patients, and
of 9 in that of single patients in unlicensed houses. Only 10 per cent.
of the insane under care are now resident in workhouses; in 1880,
27 per cent, were located in these institutions. The transference of
insane from workhouse to asylum has been one important factor in the
apparent “ increase of insanity ” in Ireland for the past twenty-five or
thirty years. It is a source which is in gradual process of drying up,
and one which we hope will eventually altogether disappear.

The recovery-rate, 40 9 per cent, on admissions, is the highest recorded
during the past twenty-two years—all those that are scheduled in Table
VII—while the death-rate, 69 per cent, on the daily average, was the
lowest with two exceptions only (6 - 8 and 6 7) during the same period.
If, however, the ratio per cent, of recoveries be calculated on the daily
average instead of on the admissions, it shows a continuous decline.
For each of the four quinquennia comprised within the years 1893 and
1912 the respective ratios were g‘5, 81, 7^4, and 6 8, and for the last
two years 6‘5. If, therefore, any decrease in insanity, such as we hope
for, is in store for the country, it will probably be dependent on a
reduction in the number of admissions, to which there is a decided
tendency of late, rather than on any increase in the death- or recovery-
rates.

The recovery-rates in the various district asylums vary, as usual, to
an amazing extent from a minimum of 22^5 in Sligo to a maximum of
597 in Monaghan, a phenomenon to which we feel inclined to apply
the once famous Dundreary catchword, and must be content to let it
remain as one of those inscrutable mysteries which are occasionally
encountered. We may, however, hazard the opinion that the problem
is one into the solution of which the personal equation might be
expected largely to enter.

The death-rate also varies considerably, from a minimum of 4’i per
cent, (on daily average) in Kilkenny to a maximum of 8 6 per cent, in
Londonderry. Although Kilkenny has the lowest death-rate generally,
it shows the highest mortality from phthisis, viz., 42^8 per cent, of the
total deaths, while Carlow has only 3'i per cent, to record and Armagh4'5.
The enormous difference in the phthisical death-rate in different asylums
has been made the subject of comment at some length in previous
reviews, and it is unnecessary to deal with the subject at any greater
length in the present one. As regards the phthisical death-rate in
general, we welcome the addition in the table on p. xxii giving the five-
year averages for a series of years commencing with the year 1890,
which also includes the average death-rate from general paralysis and
epilepsy during the same period. From it we learn that the relative
mortality from phthisis during the last five quinquennia has fallen from
27'2 per cent, in the first to 215 in the last, a decrease of over 20 per

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cent. The mortality from epilepsy has fallen from 57 to 4'o per cent.,
while that from general paralysis has risen from 2^5 to 4'4 per cent.
This last may, however, be regarded as almost stationary, as for the last
four quinquennia the ratios are 4‘o, 3 - 6, 4'2, and 4 - 4. This brings us
to the subject which receives special attention in this report—venereal
disease as a cause of insanity.

In Table XII, App. B, it is recorded that in 68 cases admitted in
1914 a history of antecedent syphilis was ascertained, a percentage of
1‘93 of the total admissions, and in 55 of these it was assigned as a
principal cause, or i'46 per cent. This is a very small proportion, and
is under the average, 176, for the last five years. The Inspectors,
however, consider that these figures may almost certainly be taken as an
under-estimate, and that a truer estimate of the prevalence of syphilis
amongst the asylum population will be arrived at if the incidence of
general paralysis of the insane be adopted as a criterion. The writers,
after mentioning the fact that the average percentage death-rate from
this disease during the past five years was 4^4, add, “ It is evident that
the prevalence of the disease is gradually increasing, the death-rate
having doubled since 1890.” We can hardly accept this as a strictly
accurate view, as the “ doubling ” mainly occurred during the second
of five quinquennia, and, as shown in the preceding paragraph, the
relative mortality from general paralysis has been practically stationary
for the past twenty years.

This low mortality from general paralysis is in marked contrast to
what prevails in England arrd Scotland, where the deaths from this
disease amongst asylum patients average from 15 to 20 per cent, of the
total mortality. From the facts, as revealed by statistics, the Inspectors
draw the perfectly warrantable conclusion that “ venereal disease plays
a comparatively trifling part in the causation of mental abnormality in
this country as a whole.”

Many years ago, in a paper read at the annual meeting of the Asso¬
ciation in Dublin in 1894, it was shown that the apparently higher
proportion of insane in Ireland, as compared with the sister countries,
was altogether due to the much lower death-rate, and, consequently,
increased amount of accumulation in the former; and, further, that the
higher death-rate in England and Scotland was mainly, if not wholly,
dependent on the far higher mortality in those countries from general
paralysis. As is well known, this disease prevails to a far greater extent
in urban than in rural populations ; and, Ireland being principally
populated by rural communities, and possessing only comparatively few
large towns, cases of general paralysis are almost limited in their occur¬
rence to these latter, and are only rarely to be found in the majority of
the country asylums ; so that while Belfast and Dublin have a relative
percentage mortality of i7‘io and ii‘26 respectively, in twelve of the
district asylums the ratio is under 1 per cent., and in four others under
2 per cent. In Limerick asylum not a single death was due to this
cause. There are, therefore, reasonable grounds for the more general
inference advanced by the Inspectors that “ the greater part of Ireland
is practically free from venereal disease.”

The number of cases admitted in 1914 in which mental stress was
assigned as a factor was in much the same proportion as for the two

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years immediately preceding, the ratios for the three years being 1670,
16 83, and 16 72. From this the Inspectors conclude that there is no
evidence that the war has so far directly produced any increase in
insanity. We will be in a better position, however, to judge of this
next year, when the figures for the current year will have been com¬
piled, as only five months of the war had elapsed at the end of the year
i9 J 4-

On the other hand, the Inspectors regard as an indirect effect of the
war the increase in the number of cases in which alcohol was assigned
as the principal cause. The percentage of such cases in 1913 was 8 - 62,
while in 1914 it was iroi, showing a rise of nearly 2 1 per cent. This
surmise is probably correct. The increase—this is not stated in the
report—was confined to the male admissions, there being a reduction in
the number of female cases due to this cause.

Pathological work in Irish asylums is unfortunately heavily handi¬
capped, owing to circumstances peculiar to the country, which have
been adverted to in previous reviews, and it is to be feared that there is
not much likelihood of any improvement in this respect, as the prejudices
of the Irish population, especially against post-mortem examinations,
seem just as pronounced as ever they were. The number of autopsies
held last year was only 177, a percentage of exactly 12 on the number
of deaths, and compare very unfavourably with England and Scotland,
where not infrequently autopsies are made in over 90 per cent, of the
cases of deaths in asylums. The number is also lower by 41 than
that of the year preceding, which does not augur well for the future.
In five asylums not a single post-mortem was made, in two others only
1, and in tw r o only 2 were held—not a very satisfactory record.

It is regrettable that in five asylums no classes for instruction of the
attendants are held. In one no attendant holds the ceitificate of the
Medico-Psychological Association.

The reports on the condition of the insane in a large number of work-
houses are depressing reading. The sanitary (?) arrangements in many
are a disgrace to the twentieth century, and a few sentences culled from
these reports will indicate what it is to be feared is a state of things
which, with a few exceptions, may be said to prevail generally : “ The
sanitary accommodation consists of buckets in the wards, and latrines
or privies out of doors. The former have no water laid on for flushing,
and both the floor and the yard outside were in a filthy state.” This is
the condition in quite a number of these institutions. The patients
“occupy a gloomy, poorly-kept ward both by day and night.” “The
sheets were found infested with vermin.” “They sleep on old straw
ticks on the floor, bedsteads not being provided.” “ Antiquated privies,
which were in a filthy condition.” “The dinner on five days in the
week consists merely of bread and potatoes with a sort of thick gruel,
which latter, it was stated, is mostly given to the pigs, as few of the
inmates will touch it.” Patients “ found in a most unsatisfactory con¬
dition, being dirty, untidy, and badly kept; some had no socks.” “ The
beds and bedding were found in a neglected and unsatisfactory state,
with soiled and wet sheets and fleas plentiful.” “Beds of the old
wooden box type, with straw merely put into them, not even in ticks.”
“No day-rooms.” “No bath-rooms.” “One of the male wards is
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shared by inmates suffering from scabies,” which is characterised as
“an extraordinary arrangement,” a rather mild criticism ; “execrable”
would seem to us a more appropriate adjective. “ Total absence of all
proper bathing arrangements,” so that “ the inmates never get a com¬
plete bath except on first arrival.” We rub our eyes and ask: “Can
such things be ? ” in this age of progress. We ask further, what are
the masters and matrons in these institutions doing ? Uo the medical
officers of workhouses shut their eyes when passing through the “ idiot
wards,” if, indeed, they are visited at all? And, chiefly, do the guardians
of 'the poor really persuade themselves that they are conscientiously
discharging their duties and responsibilities in tolerating, if not approving
of, such treatment of a very helpless class ? Lastly, these reports pre¬
sumably come before the Local Government Board. Are they
merely consigned to the waste-paper basket ? This state of things has
existed in some, not all, w'orkhouses for an indefinite number of years.
These institutions are regularly visited and reported on both by Poor-
law and Lunacy Inspectors. Why is not pressure of some kind brought
to bear on the local bodies by the central controlling body to induce,
and, if necessary, compel them to abolish such an anomalous condition
of things, which, to say the least of it, is inhumane, and which in any
civilised country is nothing but a disgrace to those who are responsible
for it ? We need only repeat what has often been urged in previous
reviews in the Journal, that workhouses are the last places to which the
insane should be consigned, and the sooner every patient is removed
from such dreary and unsavoury surroundings the better it will be for
themselves and for the credit of humanity.

The Individual Delinquent. By William Healy, A.B., M.D. Illus¬
trated. Pp. 830. 8vo. Price 21s. net. London: Heinemann,
I 9 I 5-

The work of Dr. Healy, Director of the Psychopathic Institute
attached to the Chicago Juvenile Court, is widely known, and this sub¬
stantial volume raises high expectations. It may be said at once that
these expectations are amply fulfilled. Dr. Healy has here probably
produced the best book on criminals yet written in English. It is
certainly the most comprehensive account of actual work achieved, and
the most satisfactory statement of results. This end is not attained by
any attempt to compete w'ith the work of either Italian or German
criminologists. Dr. Healy represents the American spirit at its best,
and that spirit is simply a bolder and more thorough form of what we
usually consider the English spirit, the tendency, that is to say, to put
practice before science, and to prefer facts to theories. The book is
aimed throughout at practice, and intended for the guidance of judges,
lawyers, and institutional authorities, of physicians, psychologists,
religious leaders, teachers, and parents. The author admits that he
began the study of criminality in the neurological clinic, and his first
teachers were Lombroso, Ferri, and Talbot. But, while still fully
recognising the great part played by Lombroso and the Italian posi-

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tive school, he quickly found “ the facts too much for the theories.”
The intricacies of causation appeared manifold. He abandoned not only
theories but classifications, though practically he has not here been able
to avoid classification. Throughout he insists on the individual study,
and the individual treatment of the criminal. This doctrine of indi¬
vidualisation is by no means new, but Dr. Healy has been able to carry
it out more thoroughly and extensively than previous workers. No
doubt he has not always escaped theory so completely as he desires.
The actual result of avoiding discussion of theories is an unconscious
acceptance of theories. Dr. Healy has “not the slightest inclination
to place delinquents as such in the list of abnormal individuals.” But
the theory here suggested that criminality is normal may lead to deduc¬
tions which Dr. Healy is certainly not likely to accept. He is also
anxious, with excellent therapeutic intentions, not to admit the existence
of “ born criminals,” and quotes with approval the statement that
criminals are born and made just as policemen aie born and made.
But this method of regarding social activities as co-ordinate with anti¬
social activities again plunges us into dubious theories and classifications.
Dr. Healy thinks that we must reject utterly the conception of the
“ born criminal ” in favour of the “ born defective who is secondarily
criminal.” But it is by no means clear that those who accept the first
and more concise term would feel themselves separated by a great gulf
from those who prefer the other. Such minor points, however, need
not be pressed, for Dr. Healy seeks to avoid theories and classifications,
and in so far as he succeeds it is usually possible to accompany him
with hearty agreement and warm appreciation.

The volume is based on the study of youthful recidivists (the term
“delinquent” being used in no narrow or special sense), 1,000 in
number, though only 823 have been used for comparative investigation
of causative factors. They came from the Juvenile Court and other
sources, and nearly all were seen with other psychologists who co¬
operated in the investigation. The average age was between fifteen
and sixteen, some younger children and some adults being included.
They were brought from many sources, and there were numerous
troublesome “ problem cases.” Nearly all were seen in company
with relatives, and the information thus obtained was often full and
precise. The author is w r ell situated for the disposal of his cases, and
was thus greatly aided in their successful treatment. He appears to be
able to look down with lofty contempt on the ordinary legal criteria of
responsibility. They are, as he well points out, antiquated, meta¬
physical, intricate, and uncertain. Fortunately, he adds, when we are
dealing with criminals practically we find that the old idea of responsi¬
bility is unnecessary, and he appears to have been able to dispense with
it. “ We should not be stampeded in the least,” he says, “ by what vre
are asked for on the witness stand,” for the law cherishes “ its own
artificial standard,” which is not based on facts, or on a knowledge of
the interactive causative factors of delinquency in the individual
offender. “ Many a psychiatrist has met his Waterloo in attempting a
definition merely of insanity.”

Three chapters, extending to nearly a hundred pages, are devoted to
“Working Methods.” These, it may be scarcely necessary to observe

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in the case of so distinguished a worker, are admirable for their com¬
prehensiveness, their practicality, and the combination of the best
modern scientific conceptions with avoidance of unnecessary detail and
tedious over-refinement. Much flexibility is admitted, a special method
of approach to every case, for Dr. Healy, it may be repeated, is inspired
throughout by the idea that “ the dynamic centre of the whole problem
of delinquency and crime will ever be the individual offender.” The
purely objective method of psychological or medical approach is useless.
The investigator’s attitude must be shrewd but sympathetic, the attitude
of the family physician, with “no special nose for the pathological,”
but willing to survey the whole of the facts. The author places con¬
siderable, but discriminating, reliance on the Binet test, in combination,
however, with many other tests. On the basis of these tests, the sub¬
jects dealt with were classified in regard to mentality in thirteen layers,
of which the four lowest are denominated subnormal, moron, imbecile,
psychoses ; above the subnormal are three main divisions, variously sub¬
divided : the supernormal, the ordinary or fair, and the poor in ability.
The way in which psycho-analysis is included among the working
methods is characteristic. Dr. Healy takes no interest in any theories,
Freudian or other. He is only concerned with psycho-analysis because
of “ the commonsense explanations and therapeutic results it has given
us ”; these have been in some cases “ nothing short of brilliant.”
There has been no attempt to follow a strictly Freudian technique, and
no acceptance of the doctrine of exclusively sexual origin, but it has
been found that the mental and environmental experiences of early life
are very important for understanding later behaviour, and that hidden
mental conflicts have arranged the destinies of many a chronic offender.
The chapter on “ Mental Conflicts and Repressions ” is one of the most
original and valuable in the book.

A chapter is devoted to statistics of the cases. The method of
accumulating isolated facts is rejected. The factors in the history of
each case have been enumerated in rough chronological order, as they
apparently produced the offender’s career, and then estimated as far as
possible on their relative importance. It is on this basis that the
statistics are built up, and no characteristics are included but those that
are believed to have had some causative significance. Thus the
physical over-development of girl offenders, frequently found in these
subjects, is only taken into account when it appeared to be a causal
antecedent in the particular case. Again, as regards poverty, which is
found to be rare, in accordance with the general high level of well-being
in Chicago, even when it exists it is not to be regarded as a factor if
other members of the same poor family live honestly. Defective heredity
and defective early developmental conditions are also, on the other
hand, regarded as only minor factors, the major factors being the
qualities of mind and body which they leave in their train. It was
found that 67^4 of the whole number of cases were without doubt
mentally sound, and 10 per cent, were without doubt feeble-minded, the
figure being below the mark, as some of the others will fail to develop
with age. The criminal tendency itself is regarded as not inheritable,
only its basis, and it was found that in 61 per cent, of cases there were
distinct defects in the family inheritance. Among the parents and

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grandparents there were 82 cases of insanity, 12 of suicide, and 79 of
criminality.

In the chapter on “Treatment,” Dr. Healy shows no wish to elimi¬
nate “ punishment as such.” With full appreciation of the offender’s
family background, and with due attempt at all needed therapy, he
states, there may well go hand in hand the deliberate idea of building
up inhibitory powers by maintaining the conception of possible future
penalty. But, he adds, the punishment must not injure the offender,
as there are many possibilities of breeding evil by punishment. These
dangers begin at the moment of arrest, and are increased by the folly of
fixed short-term punishments without constructive treatment. An
extension of the excellent methods of the American Juvenile Courts up
to the age of twenty or twenty-one is advocated. Dr. Healy is not very
enthusiastic about institutions of reformatory type, and here, as ever,
emphasises the need for individualisation of cases. Good results can
only be obtained by understanding cases, and by following them up.
In a large proportion of the cases dealt with by the sagacious methods
here set forth the results have evidently been highly satisfactory.

It is not easy in a short review to give an adequate idea of the
variegated interest of Dr. Healy’s work, and the great variety of abnormal
mental states which are described and illustrated by appropriate cases.
Enough has perhaps been said to indicate the value of this splendid
record of a finely equipped and fortunately situated pioneer in a difficult
and important field. Havelock Ellis.

The Neiv Psychiatry. By W. H. B. Stoddart, M.D., F.R.C.P,
London : Bailliere, Tindall, & Cox, 1915. Pp. 67, 8vo.

Dr. Stoddart’s Morison Lectures furnish interesting evidence of the
extent to which Freudianism—for the “New Psychiatry” has no exist¬
ence outside the Freudian sphere—is spreading its influence among us.
It is perhaps unfortunate that this little book could not have appeared
ten years earlier, for the literature of psycho-analysis is now so extensive,
even in English, that a new attempt to cover the old ground is likely to
be viewed with more critical austerity than would formerly have been
the case. There is no doubt still ample room either for a full and
explanatory discussion of the various psycho analytic conceptions, or
for an attempt to transform and adapt those conceptions to our accepted
traditions. It cannot be said, however, that Dr. Stoddart has attempted
either of these tasks, and his suggestion that Hughlings Jackson was a
fore-runner of psycho-analysis scarcely seems convincing. As an exposi¬
tion, his little book is bald and doctrinal, so concise that it is not always
easily able to follow the logic of the Freudian mechanisms described,
and so uncompromising that it seems unlikely to conciliate opponents,
or win over adherents who are not already converted. When we read
Freud’s own writings we are so impressed by the magnetism of his genius
and the charm of his style, we are so carried away by the privilege of
this high adventurer in ever new and uncharted seas, we are so stimu¬
lated by the salt spray in our faces, that we overlook the fact that we are
not so sure as would be desirable concerning our precise latitude and

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longitude. But in the calm and sedate atmosphere of Dr. Stoddart’s
lectures we realise more keenly the uses of sextant and chronometer,
we become more critical. It is probable that many readers will prove
rebellious to such brief and rigidly dogmatic statements as “ The incest-
complex exists in the unconscious of every individual, normal or
abnormal”; or “ Paranoia is a psychosis erected on the invariable basis
of repressed homosexuality.” Dr. Stoddart has scarcely guarded
adequately against that mood of irreverence which still overcomes so
many in the presence of psycho-analysis, especially in its more dog¬
matically narrow and sectarian aspects. The smoker may be mildly
shocked to hear that “ smoking is frequently a sexual sublimation ”;
but will speedily be reassured by the statement that “ sublimation
always means diversion to useful, social aims.” It is not, indeed, made
quite clear why the puffing of smoke represents a more useful social
aim than the procreation of children, and the “race suicide” fanatic
may here take offence. Others may be surprised to hear that all our
knowledge of sexual development is due to Freud, and that even the old
term “erogenous zone ” must be ascribed to him.

Regarded as an exposition, Dr. Stoddart’s book will probably be
found most useful by those who are already persuaded, and therefore
not disposed to be critical. They will find here a reasonably straight¬
forward and faithful summary of the main Freudian ideas and practices,
together with some reference to those of Jung, the more obscure and
unpractical parts of the doctrine, as well as its discrepancies and modifi¬
cations in various hands, being judiciously passed over. (It is never
made clear that psycho-analysts are now split up into many groups, and
that even Jung is no longer within the Freudian fold.) Such readers
will find in Dr. Stoddart a sagacious guide in taking up for themselves
the practice of psycho-analysis. In this respect the book might have
been still more useful if it had been furnished with an appendix on the
copious literature of the subject.

Many readers, however, would probably sacrifice the expositional
portions of these lectures altogether in return for a more detailed
account of Dr. Stoddart’s own experiences and results with psycho¬
analysis. Within the narrow limits of these lectures he is only able to
summarise his own adventures in the unconscious as baldly as he
expounds Freud. He agrees that hysteria and neurasthenia, the field
in which Freud himself first applied it, is the most favourable region for
psycho-analysis. In maniacal depressive insanity it should only be
attempted between the attacks, and should not be pushed far. The
analysis of dementia praecox should not be attempted by the beginner;
the katatonic form is the most favourable for psycho-analytic treatment;
the paranoid form should be severely left alone, as there is some risk
that both experiment and experimenter may be brought to an untimely
end. The same unfortunate sequel might, obviously, also occur in
dealing with paranoiacs. Nor is Dr. Stoddart in favour of psycho¬
analysis being attempted in institutions by busy medical officers. At
the same time he is enthusiastic as to the results under suitable con¬
ditions, and considers that psycho-analysis has a bearing on 70 per cent.
of asylum patients. Dr. Stoddart emphasises the evil results of that
repression of the instincts which civilisation involves, and certainly with

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justice, but it may be added that on this point Kraepelin, who is
opposed to Freud, is here at one with him. There can be no reasonable
doubt also that mental and emotional conflicts, in which sexual factors
must often be blended, frequently prove disastrous. No one has
demonstrated this so thoroughly as Freud ; but it has been known
obscurely from of old; the Catholic Church has acted on that know¬
ledge for many centuries, and to-day Dr. Healy, for instance, finds it
possible to obtain brilliant results in solving the repressed conflicts to
which Freud has called attention, while yet remaining indifferent to
Freudian mechanisms and Freudian theories. To many readers
to whom the subject is new, Dr. Stoddart’s statement of the orthodox
Freudian formulas of the Unconscious may open the way to fresh
lines of thought and treatment, even though to other readers it may
suggest the reflexion that the Unconscious is a vast rubbish-heap in
which, by diligent search, you may find almost anything.

Havelock Ellis.

An Introduction to General Psychology. By Robert Morris Ogden.

New York, 1914. Pp. 270 -f xviii. 5^. net.

This book is designed to serve as an elementary text-book for
beginners, and particularly for those wishing to acquire some general
knowledge of psychology with a view to passing on to further work in
philosophy, education, sociology, and biology. It possesses two dis¬
tinctive features. The first is the abbreviation of the portion devoted
to sensation and physiological psychology, and the omission of any study
of the nervous system, with the object of devoting a proportionately
increased space to “ mind as a whole, and to the important topics of
personality and character.” The second arises from the author’s con¬
viction that “it is no longer possible to teach the old psychology, in
which sensation and association are the chief foundations,” and that
“the time has come when we must modify some of our psychological
principles and conceptions, with reference to the more recent investiga¬
tions of the thought-processes.” In pursuance of this aim stress is laid
upon purposive direction as a fundamental factor in mental processes,
and the modern conception of imageless contents is introduced. The
influence of Kiilpe and the Wurzburg school is shown here very
markedly.

The author has endeavoured to compress his work into the limits of
a one-term course, and although he has thereby managed to concentrate
in a small volume a general survey of a very wide field, this procedure
has inevitably brought with it many disadvantages. The brevity of the
treatment frequently makes adequate appreciation of the subject very
difficult, and this difficulty is further increased by the conspicuous lack
of examples and illustrations. No doubt the deficiency can be supplied
to a large extent by the co-operation of the teacher, and the author
explicitly states that this is his intention.

An interesting chapter on insanity is included, and some space is
also devoted to the phenomena of hypnosis, double personality, and
other abnormal mental conditions.

Bernard Hart.

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[Jan.,

An Introduction to Experimental Psychology. By C. W. Valentine.

London: University Tutorial Press. Pp. 190 + vii.

This little book is chiefly concerned with the application of experi¬
mental psychology to educational problems, and to the work of the
teacher in the school. Hence it is of only indirect value to psychiatrists.
The clinician will, however, find in it many hints which can be turned
to account in the examination of his patients, and it will enable him to
devise tests and methods of great assistance in his investigations.

The book is divided into two parts. The first contains detailed
instructions for carrying out the various experiments, while the second
deals with their theoretical and practical significance. All the experi¬
ments are capable of being carried out without apparatus, or, at most,
with apparatus that can be constructed in a few moments with pen and
paper. Bernard Hart.

Occultism—A Review.

Where do we stand to-day in our attitude towards occult matters —
no better generic term being available ? What knowledge have we of
the existence of communications between ourselves and discarnate
beings ? What actual knowledge—apart from faith—have we of the
continuity of human existence ? What knowledge have we of
the psychic powers inherent in ourselves ? Since the middle of
the nineteenth century, a large and increasing amount of investigatory
work has been done towards the elucidation of these problems, and it
is at all events a hopeful sign of our mental progress, that the proportion
of those who regard all serious inquiry in this direction as utterly futile
and indescribably absurd, is a daily decreasing one, and the storm of
peevish derision that was aroused by the publication in the Quarterly
Journal of Science in the early seventies of the results achieved by Sir
William Crookes, looks to us remarkably ignorant in the light of the
calm approbation with which the extraordinary results attained recently
by certain savants, notably Professor Ochorowicz, have been generally
received. There are so many people who are genuinely anxious to
know what is really the present stage to which knowledge has advanced,
that it seems a short survey of the conclusions at which investigators
have arrived would not be amiss, especially as we in this country are a
little behind in these studies, and just as the curative possibilities of hypno¬
tism are only now beginning to be used practically here, while in France
they are almost a commonplace, so in this country the majority of people
are either sceptics or convinced spiritualists. The former are merely
ignorant, and of their ignorance nothing further can be said, except that
it is necessarily ignorance of a dense form, in view of the ample sources
for its alleviation at their disposal; but for the spiritualists there is much
to be said, seeing how most of the phenomena of occultism have every
appearance of the intervention of outside intelligences to anyone who
does not know of the strange developments of which subcon¬
sciousness is capable under certain conditions, commencing with
hypnotism.

Through all the stages of the world’s history there have been people

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who have been blessed or cursed—according to the popular view
obtaining at the time—with supernatural powers, using the expression
to mean something more than our every-day conception of what is
natural. The experiences of the saints are redolent with psychic
faculties, and they were then mostly ascribed to Divine intervention.
Later, similar experiences were regarded as satanic, and the unfortunate
subjects were correspondingly punished : nowadays, they are con¬
sidered to be either “mediums,” /.<?., convenient vehicles used by
discarnate beings who desire to communicate (mostly with beneficent
intent) with us, or “ subjects ” for the profitable investigation of
scientific men. (Among the sceptics they are, of course, known as
“ frauds.”) And perhaps all three designations are true of different
individuals always, or of the same individual at different times.

There can be no doubt in any reasonable, well-read man’s mind that
strange things do undoubtedly happen, either to certain people, or in
their presence, and these strange things are divided into two broad
classes: those which are subjective , or manifest themselves to the
subject’s own consciousness, and leave no physical trace of having
taken, or of taking place, and those which are objective , or are accom¬
panied by some physical disturbance, or leave some physical trace.
In the former category may be included visions (clairvoyance), sounds
(clairaudience), feelings of different kinds, trance, premonitions, tele¬
pathy, and psychometry ; in the latter—apparitions, sounds perceivable
to others, movement of objects without contact, and all the host of
happenings which are known as physical phenomena. Obviously, the
latter are susceptible of proof, and the former may be so, but with
greater difficulty. Both categories have been proved to exist, and the
only thing that remains to be ascertained is whence they arise. Now
in England, speaking very broadly, they are generally taken to be
sufficient proof of the intervention of discarnate beings—hence the
belief of spiritualists, and to anyone who comes fresh to the subject
that would be the logical and only possible explanation of quite a large
majority of instances. But, commencing with the study of hypnotism,
we find that in certain conditions, such as hypnosis, a deeper stratum
of the human mind seems to be disclosed, in which it acquires powers
far beyond those of its normal condition : it can (only with certain
individuals and under certain conditions) report what is passing at a
distance, read writing which is sealed to the eye, measure time, assume
a totally different character, and, most important of all, obey commands
made, even to the extent of obeying them after awaking. So strong is
the obedience that, by this means, the beating of the heart can be
retarded or accelerated, and a finger laid on the arm of a hypnotised
subject, and stated to be a red-hot iron, will raise a blister.

This deeper stratum of the mind is called the subconscious mind,
and the important point, upon which all serious modern inquiry is
based, is that it can be reached by other means than by hypnotism. It
would appear that we all have this deeper layer of mind, but that we
differ in the extent to which our normal mind can communicate with it,
or to which it can surge up in our normal consciousness. In some the
communication is only established during trance, which can be brought
about by many causes in addition to the hypnotist’s command of

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“ sleep ! ” His is merely a very strong suggestion; and auto-suggestion,
the suggestion of circumstances, or any other form of suggestion may
produce the same effect, and, to those who are not aware of the efficacy
of these more hidden forms of suggestion, their result appears to be
clearly the work of unseen entities, and the communication given appears
naturally to come from them. The proof that in most cases it is not so
is difficult to state in a few words. It is a cumulative proof, and starts
from the curious likeness between the messages thus received and those
given by a hypnotised subject, the general triviality of the subject matter,
and the absence of any knowledge that is not shared (known or unknown)
by any individual present.

If, however, there are communications from the discarnate beyond
the rare instances of appearances of the dying and dead and other
unsought phenomena, it is evident that, as they are not received through
the normal channels of our every day senses, they must come through
some of these super-normal states of consciousness, t.e., through some
of the conditions of so-called mediumship, and these conditions exist
when the subconsciousness has been opened up either intentionally or
automatically. The phenomena which then manifest themselves may
thus have their origin merely in the subconsciousness itself, or might
be due to some other intelligence acting upon the subconsciousness.
In order to ascertain the real source of any such phenomenon each
individual instance must be specially studied by itself, and it is extremely
difficult to preclude the possibility of a purely subconscious origin. This
is what has to be done, however. It is no longer interesting to obtain
phenomena, except perhaps once or twice, in order to have an oppor¬
tunity of witnessing the strange things about which one reads ; as one
can now hardly doubt that they do happen, there is no particular
satisfaction in making them happen again, or in proving that this or
that particular medium is a genuine one. The truly interesting work is
to endeavour to obtain instances which cannot possibly be accounted
for by the action of the subconscious mind. A disheartening point
about this is the logical assumption that, inasmuch as phenomena which
a little time ago would have been, and actually were, taken as absolute
proof of discarnate intervention, have now been proved to be well within
the possibilities of the subconscious mind alone, similarly, anything
which we may now obtain in the nature of proof may a little later be
shown to be still within the subconscious domain. Well attested and
strictly supervised cases of the movement of object without contact
were, for instance, formerly regarded as conclusive evidence that
discarnate beings were at work, but Dr. Ochorowicz has now found,
photographed, and proved to the satisfaction of a committee of
naturalists, the existence of psychic rays, which he calls “ rigid rays,”
between the hands of a young medium, Mile. Tomczyk, which have the
power of moving objects.

The two popular points of view are admirably illustrated by the fact that
an Ecclesiastical Commission was recently appointed to inquire into the
conduct of a certain Anglican clergyman, whose sermons on spiritualism
attracted attention. Here we have the convinced spiritualist, who
obviously could not preach general spiritualism if he realised even a
part of the result of modern research, and the anti-occultist, who must

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either be ignorant not only of such results, but also of the very existence
of occult phenomena, or else realise their existence, and ascribe them to
a superstitious source.

Those who are drawn to further investigation should take no practical
steps until they have read the following works in the order stated : The
Law of Psychic Phenomena (Hudson), The Survival of Human Personality
(Myers), and Metaphysical Phenomena (Maxwell). Varieties of Religious
Experience (James) can be added with advantage.

L. Halliday.

Part III.—Epitome of Current Literature.

1. Physiological Psychology.

7 'he Integrative Functions of the Nervous System applied to some Reactions
in Human Behaviour and their attending Psychic Functions. ( Trans¬
actions of the American Medico-Psychological Association , 1914.)
Edward f. Kempf M.D.

The object of this paper is to harmonise certain psychic functions
with physiological and integrative functions of the nervous system.

When emotions are intensely generated they always cause more or
less derangement of the habitually used modes of psychomotor expres¬
sion. When nervous energy caused by the emotional state cannot
find its characteristic outlet through the voluntary motor system, it
overflows into the involuntary muscular system. The following example
is given : “A physician was fishing one morning just after eating his
breakfast. He hooked a goodly sized bass. After a pretty fight he
succeeded in drawing it up to the side of the boat, but as he tried to
land the fish it unfortunately escaped. A minute or two later he was
rather surprised by the unexpected regurgitation of his breakfast.”

Whatever view is held regarding the physiological mechanics of
emotion the following factors are constantly present:

(1) The emotional state is aroused by some kind of cerebral stimulus.
(2) It is a type of reflex action. (3) It involves essentially the cerebral
adjustment towards essential changes in the viscera, glands, and vaso¬
motor system. Viewing emotion in the light of a reflex there are two
great groups of effector (Sherrington) cells. Those connected respec¬
tively with the voluntary and the involuntary muscular systems—for
example, in anger, if the discharge is inhibited from the voluntary
system the viscera and vasomotor systems receive the surplus of the
discharge, and may cause disturbances of a severe and lasting nature.

The work of the analyst must be devoted to readjusting the ideas
which cause the repression of the affect from the voluntary system. The
paper then goes on to show that the symptoms of the psychoneurosis
are due to repressed complexes, and can be explained in the psychic
field in a manner similar to the work of Sherrington ( Integrative Action

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EPITOME.

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of the Nervous System) in the physiological field. A case of hysterical
lameness in which analysis effected a cure is given as an example.

He concludes by saying : The present day opposition of many
students of behaviour and mental diseases to a psychogenetic inter¬
pretation and formulation of the causes of abnormal behaviour is
not excused by the failure of the older organic or metabolic concep¬
tions. The new methods are in perfect harmony with critical studies
of the functions of the nervous system and the mind. Merely des¬
criptive studies of behaviour can never be sufficient or helpful for
therapy or understanding of processes. We need dynamic conceptions,
formulations, and methods which yield a practical psychological and
physiological analysis and applicability. R. H. Steen.

A Criticism of Psychanalysis. (Transactions of the American Medico-
Psychological Association , 1914.) Charles IV. Burr , M.D ., and
F. X. Dercum , M.D ., etc.

Dr. Burr confesses that his attitude, after study and investigation, is
not sympathetic towards Freudian psychanalysis. He gives a brief
resume of Freud’s teaching, and quotes cases from Brill and other
writers. Dr. Burr takes exception to the theory of “ complexes and
conflicts, and a censor which controls them,” and “ cannot understand
how a mental thing of which we are by definition unconscious can
influence conscious life.” Dr. Burr finds his greatest objection to
psychanalytic treatment in the stress laid on sexual matters. He points
out how the danger is greatly increased by the fact that the treatment is
no longer to be confined to physicians, “and only recently a German
has published a book the avowed purpose of which is to instruct
teachers and clergymen how to practise the ait. Need one ask if such
a thing is wise? We have seen in recent years the injury that has come
from amateur treatment of mental diseases by religious systems.”

He concludes as follows : “ I remember an old and distinguished
professor of medicine in Germany who, when some years ago I told
him I had aspirations to become a neurologist and alienist, looked at me
kindly and a little quizzically, and then said, ‘ Be careful, my young
friend; alienists are all a little queer.’ The old gentleman had some
justification then, but what would he think now could he be told what
we are often told, that psychanalysis is one of the greatest contributions
to therapeutic art ? ”

In the discussion which followed the reading of this paper Dr. Dercum,
wholly agreeing with Dr. Burr, presented a very able case against the
theories of Freud and his disciples. His contribution, which is difficult
to summarise adequately, is well worth reading in its entirety. He
pointed out how much more important in the aetiology of the psychoses
are intrinsic causes as compared with psychic traumata. He said “the
interpretation of the amnesias, of the dreams, of the association test,
depends upon the imagination, the auto-suggestion of the analyst, upon
the figments and fancies of his own brain.”

He closed by saying “that it should be a matter of keen humiliation
and chagrin that at an epoch when psychiatry is beginning to unfold a
practically limitless field for actual scientific research, men should be

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found willing to devote themselves to a cult, to an ism, which, like a
salted mine, returns to the investigator that which he himself puts
into it.”

Drs. W. A. White and Hoch spoke briefly and temperately on the
other side. They said that they saw certain facts which required
interpretation. If there were better interpretations available than
those they offered they would willingly accept them.

R. H. Steen.

On the Formation of the Erotic Complex in the Emotion of Lore [Sur
la formation du complexus eroiique dans le sentiment amoureux].
{Revue Philosophique, February, 1915.) Kostyleff.

The author discusses this question in connection with the studies of
Freud and his pupils regarding the psycho-sexual attitude of four
celebrated men as revealed in their love affairs and in their creative
work— viz., Leonardo da Vinci, Lenau the pessimist poet, Giovanni
Sebantini the painter, and Wagner. In each of these artists the psycho¬
analysts have discovered to their own satisfaction that the dominant
emotional influence throughout their lives has been the famous “ incest
complex.” Kostyleff fully accepts the view that in these cases and,
indeed, in general, impressions dating from early childhood and per¬
sisting subconsciously contribute to the formation of an erotic complex
in relation with the sexual instinct, but he disputes the further assumption
of the Freudians that this complex necessarily or ordinarily involves an
individual image, or even a group of individual traits. He maintains,
on the contrary, that a careful consideration of the facts shows that,
though the maternal caresses may awaken the first organic reflex, there
is not normally at that stage any true psychic accompaniment, and that
when in later development there is a psychic association with the reflex,
the link may be through some simple and more or less accidental
element without any persistence of the image of the mother. In the
case of Lenau, for instance, who was slavishly adored by his mother,
the various women with whom he had amorous relations had no physical
or mental resemblance to her or to one another, but they were all women
who worshipped him and were dominated by him; this emotional atti¬
tude was the common trait which constituted the association between
the first erotic reflex and the fully developed sentiment of adult love.
Similarly with Stendhal: his autobiography gives unmistakable evidence
of the awakening of definite sexual feeling in relation to his mother, but
in his numerous love affairs there is no trace of a feminine ideal formed
on her type; his several mistresses were quite unlike one another in all
respects, except in their power to arouse in him the feeling of intense
admiration which had accompanied his early and vivid impressions of
his mother. The author’s conclusion is, therefore, that the erotic com¬
plex need not be, and perhaps is not, ordinarily attached to an ideal
image of an individual of either sex : the “ incest complex ” has not
accordingly the importance and extension that the doctrine of Freud
would give it. W. C. Sullivan.

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EPITOME.

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2. Psychology and Psychopathology.

Infantile Sexuality and the Neuroses. (Revue de Psychothirapie,
February , 1915 ) Dr. J. Launionicr.

Freud and his school assign to. sexuality the most important and
almost exclusive role in the production of the neuroses and psycho¬
neuroses. To infantile sexuality he attributes the origin of hysteria and
obsessions. In his early period (1894-6) he divided the psycho¬
neuroses due to sexuality into two groups: (1) Neurasthenia and the
neurosis of anxiety, due to existing sexual troubles, and (2) hysteria and
the obsessions due to sexual traumata of early childhood, i.e., prior to
the age of eight years. The later Freud (1905) admits that he has
given too high a value to these infantile impressions, and that many of
the histories told by his hysterical patients are imaginary. He now
blames the “ sexual constitution ” of the infant. Here the word
“ libido ” comes on the scene. Freud’s definition of this term is that it
corresponds in the sexual sphere with the word “ hunger ” in that of
nutrition. It does not necessarily involve the idea of genital satisfac¬
tion, and may exist without the subject’s knowledge of its import. The
sexuality of the child consists in many fragmentary instincts, each
evoked by the excitation of some special zone (the “erogenous zones”).
In these Freud includes not only the genital zone, but the anus, belly,
chest, neck, ear, thumb, and foot ! Certain external causes may bring
into prominence one or more of these extra-genital zones, to the detri¬
ment of the proper subordination of all to the genital zone in the
normal sexuality. Thus, in Freud’s view, the child has in him the
germs of all the forms of perversion met with in the adult, and in spite of
his “ angel mien ” is really a “polymorph-pervert ” !

Normally at puberty the genital zone takes predominance, and the
auto-erotic child transfers his sexual objective to one of the opposite
sex. But there are three other courses open to him :

(1) The infantile tendencies may persist, and be recognised by the
subject, who then is a sexual invert or pervert.

(2) The infantile tendencies, normal or otherwise, may be energeti¬
cally repressed and hidden by the subject, but crop up after puberty as
the neuroses and psycho-neuroses.

(3) The sexual tendencies may be directed towards a purely psychic
end, in art, science, or mysticism—and this process is termed “ subli¬
mation.”

It is interesting that this conception of Freud should seem to support
the old idea of the purely sexual origin of hysteria. Examined closely,
however, its acceptance is full of difficulties. Doubtless there are
children vicious from a very early age, and some develop the habit of
masturbation untaught. But Freud invests certain acts of the infant
with a sexual significance, and then from these acts postulates the
existence of an infantile sexuality. Yet it is notoriously difficult to
penetrate the child’s psychology; even so simple a problem as whether
the infant of a year old can distinguish colours has not yet been solved.
How much more difficult to say whether the satisfaction which an infant

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seems to derive from sucking its thumb is of a sexual nature or not!
There is an inevitable tendency to attribute our own mentality to the
child, and to interpret its actions in terms of our own—a simple
method, no doubt, but one leading to quite false results, for, as a
thousand disconcerting occurrences daily demonstrate, the child-mind
is almost an unknown country to us.

The traces of infantile sexuality found in the adult are largely arte¬
facts, due to the suggestibility of the subject, and to the suggestions of
the psycho-analyst.

Other objections to Freud’s theory are based on anatomical grounds.
No doubt the infant has sex, but it is latent only, and the anatomical
provisions which exist even before birth have only a potential signifi¬
cance. Sex, though present, has no part in the vital mechanism ; there
is an absolute lacuna of function, in spite of the presence of organs
destined for future use. In the development of the embryo the appear¬
ance of the genital organs of ejaculation and copulation is independent
of that of the genital glands, and we may find the efferent organs of one
sex associated with glands of the other. Also, it is noteworthy that the
interstitial tissue filling the spaces between the follicles of the seminife¬
rous tubes, to which of late is attributed an important r 6 le in the
development of the sexual appetite, is of somatic and not genital origin.
It has in itself no sexual significance, but acquires one as soon as the
associated germinal tissue takes on its special activity, i.e., at puberty.
Only then do the sexual glands begin to throw into the circulation their
hormones, which on the one hand produce the secondary sexual
characteristics, determining the excitation of the certain zones, and on
the other by their action on certain groups of cortical cells give rise to
psycho-sexuality.

Before puberty, then, there should not exist tendencies and manifes¬
tations truly sexual, since these are connected with the exercise of a
function as yet in abeyance. When such seem to be present, the cause
may lie in faulty interpretation on our part, crediting the child with the
impressions and intentions of the adult, or they may result from a
precocious education in vice.

According to Freud the age of eight years is the limit beyond which
the manifestations of infantile sexuality are incapable of causing the
neuroses of maturity. The author believes the exact opposite to be the
case, and that it is only after puberty, or in the years immediately pre¬
ceding it, that sexual variations liable to give rise to future trouble
betray themselves. W. Starkey.

A Contribution to the Doctrine of Psycho-sexual Infantilism [Zur Lehre
vom psycho-sexuellen Infantilismus]. ( Zt. f. Sexualwiss , August,
1914.) fuliusburger , O.

From the alienist’s standpoint, the author seeks to emphasise the
importance of psycho-sexual infantilism. We are far too free, he states,
with our diagnosis of neurasthenia, sexual neurasthenia, hysteria, and
psychopathic inferiority, etc., without investigating the ontogenetic and
phylogenetic build of the individual. Not only from the theoretical
standpoint, but for therapeutic and forensic reasons, it is necessary to
give much more attention to infantilism.

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Juliusburger is chiefly concerned with the psychic aspects of infantilism,
but he points out that developmental arrest—a physical hypoplasia—is
never to be missed. The naive childish expression is also plain and
characteristic, together with a lack of differentiation in expressional
movements. The outspoken and decided expression belonging to each
sex is absent, and traits of the opposite sex are often present.

There is commonly no gross defect in intelligence. But on nearer
view we find a lack of strength and depth, inability to reason abstractly,
and a failure of causal connection between series of ideas, although
superficially there may be a quick and lively flow of speech and
thought.

In the emotional sphere there are manifold disturbances. Hypo¬
chondriacal feelings of every kind may be found, with excess and defect
of sensibility, and organically conditioned disturbances of function due
to failure of harmonious development. There is marked instability of
mood, the emotional waves quickly rising but very soon falling. Egoism
is prominent, and accompanied by a poverty of sentiments, which
approaches so-called moral insanity. With these emotional disturb¬
ances the tendency to terror and anxiety, with their related phobias, is
closely connected. Day-dreams, and the conscious or unconscious
tendency to falsehood, openly bear the infantile stamp.

The nature of the impulsive life is very characteristic of infantilism.
The inclination to seek sexual satisfaction in psychic or psycho-somatic
association with youthful individuals of the same sex is a fixation of
infantile activity. The complementary attitude of attraction to older
persons is equally a fixation of the infantile attachment to parents and
others. This attachment need not be sexual; it may be throughout a
purely psychic, but abnormal, dependence of the child on its parents.
Such persons remain helpless and timid, in life-long need of guidance,
unfitted to take an independent place in life. The opposite condition
of childish resistance and obstinacy, persisting into adult life, may also
be found. Juliusburger agrees with Eulenburg and Bloch that persistent
sexual frigidity and impotence are to be regarded as infantile manifesta¬
tions, as also masturbation when unaccompanied by normal adult
imaginative images. Very frequent, again, in the infantile character
are homosexual components. Regressive infantile traits have also their
part in various psychoses.

Surveying all the phenomena, the author concludes that the essential
character in all these cases is a persistent infantilism. There is an
inability to develop (we are dealing with defective persons) in spite of
any superficial brilliance in arts and science. Sublimation, the powerful
process by which lower psychic energies are transferred to higher psychic
energies, is lacking in these persons, who are dysharmonic and approach
the schizophrenic type.

The therapy must take into account the whole psycho-somatic
personality. We must not expect too much when we remember the
organic foundation of the symptoms, but Juliusburger views organo¬
therapy with much hope, and refers to the experiments of Steinach and
the investigations of Abderhalden.

Havelock Ellis.

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Observations on Dementia Prcecox. (New York State Hospital Bulletin ,
February, 1915.) Treadway , IV. L.

It is generally recognised that individuals of shut-in personality are
essentially the type to break down with this disorder. But the original
descriptions of this make-up largely left out of account the abnor¬
malities of the sexual life. It is now possible to say more about this.
In women there is often an unnatural attitude towards the opposite sex,
engagements, marriages, and childbirth being important precipitatory
factors. In men there is often a marked inability to attain adjustment
to the other sex, and especially a shrinking from marriage and an
inability to fall in love, often combined with free intercourse with prosti¬
tutes. This defect of sexual adaptation is part of a native congenital
defect by which the individual, being unable to attain adult sexuality,
remains fixed in infantile tendencies, the psychic pubertal changes
being incompletely effected, with the result of a warped love life. This
shows itself in various ways. There may be persistent and total
impotence. Or there may be homosexual tendencies. Or there is an
inability to combine the sexual feelings with the finer feelings, and to
bestow them both in combination on one woman; there may be sexual
gratification without tenderness and regard, and tenderness and
regard without sexual gratification, but the two sets of feeling cannot be
fused into one. It is admitted that these maladaptations are not con¬
fined to dementia prsecox, though they help to explain why some preci¬
pitatory causes induce it.

These views, which are obviously in large measure Freudian, are
illustrated by several cases. In all the cases it is shown that there has
been, notwithstanding sometimes an attraction to prostitutes, a lack of
adaptation to adult sexual love, sometimes a terror of marriage, fre¬
quently a homosexual tendency, showing itself in indirect or delusional
forms ; there always seems to be some infantile attempts to escape from
the true love destiny—that is to say, marriage.

Havelock Ellis.

The Newer Work upon Homosexuality. (New York State Hospital
Bulletin , November , 1914.) Pierce Clark.

The author considers that the modem direction of advance in the
study of the neuroses and psychoses renders absolutely necessary for
the alienist a deeper and clearer knowledge of the development of the
psychosexual life. Retarded condition of sexuality, fixation of the child
to an early phase of sexual evolution, undue emotional elaboration at
some special period of psychosexual development, may explain much
in the neurotic and psychotic. In the near future also it will be neces¬
sary to investigate the extent to which the irregularities are inherited.
The study of homosexuality has been especially neglected, nor has due
care been taken to distinguish among the homosexual those who may
be termed “ compulsion neurotics,” and are susceptible of cure or at
least improvement. It is necessary to take a new inventory of homo¬
sexuals, and Pierce Clark here makes a careful critical digest of
various recent studies, beginning with a summary of the chief con¬
clusions of Hirschfeld’s recent and highly important work, Die
Homosexualitat. He then passes on to Freud and the Freudian

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EPITOME.

[Jan,

psycho-analysts, especially Sadger and Ferenczi, discussing narcissism
(self-love), and the CEdipus complex (attachment to the mother with
hatred for the father) as phases in the development of homosexuality.
He also deals with the distinction between the “subject homosexual”
and the “ object homosexual.” The former, who is by some also
considered the true invert, feels like a woman and is attracted to
mature, powerful men ; the latter feels more like a man and is attracted
to boys and feminine men ; he is a neurotic, and the victim of com¬
pulsion neurosis. (This distinction is, however, by no means so often
or so clearly seen in actual practice as Pierce Clark seems to believe,
and the “ subject-homosexual ” is frequently much more neurotic than
the “ object homosexual.”) He briefly touches also on the place of homo¬
sexuality in the mechanism of paranoid states, and the transformation
of homosexual attraction into ideas of hate and persecution.

Homosexuality in both men and women, Pierce Clark concludes,
needs to be studied in still more detail by neurologists and psychiatrists,
for it touches a new phase of the utmost clinical importance in their
own future researches. It is really a part of the still larger problem of
psychosexual development, normal and abnormal, which lies at the
foundation of human conduct. Havelock Ellis.

The Father's Significance for the Daughter's Destiny \Die Bedeutung des

Voters filr das Schicksal der Tochter ]. {Arch. f. Frauenkunde u.

Eugcnik, October , 1914.) Sadger, J.

In this characteristically Freudian study Sadger brings forward an
able statement of a leading psycho-analytic thesis, with numerous illus¬
trations from practice. The significance of parental psychic influence
(apart from heredity) on the fate of the children is regarded as one of
the most important results of psycho-analysis. Sadger has dealt more
specifically with the direct influence of the father, the indirect influence
of his image, and the reactions of both on the conduct and mental con¬
dition of the daughter.

In most cases, just as the mother is specially drawn to her son, so is
the father to his daughter, and to this attraction she usually responds.
Psycho-analytic experience, the Freudian holds, shows that this attrac¬
tion rests regularly—in those who remain healthy, as well as in those
who become psycho-neurotically disordered—on a basis which is, in
the vague and wide sense, unconsciously sexual.

This attraction is, indeed (provided that sensuously exciting elements
have been escaped), absolutely essential for the child’s healthy growth
to the adult stage. As the boy learns to love from his mother, so the
girl learns from her father, and what the child receives in this first
period of life it gives out in the adult relationships of later life. More¬
over, the first love of early life largely helps to constitute the image
which determines the love-choice of later life. That explains some riddles
of love. The resemblance at the outset between husband and wife in
marriages of inclination has sometimes been considered puzzling; it
ceases to be so, in Sadger’s opinion, if we consider that the youth un¬
consciously seeks a bride in the image of his mother whom he naturally
resembles, while the girl seeks a husband resembling her father. A

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little girl will often speak of marrying her father or someone like him,
and in adult life a resemblance of this kind will actually evoke love.

It is a result of this typical wish of the child that if the little girl is
too tenderly treated by her father, the normal transference of affection
after puberty is rendered difficult. The daughter may, for instance, find
it impossible to decide on marriage. In every wooer she finds some
defect, the chief defect being really that he is not her father. The latter
may induce her to marry, but in such a case the husband is merely the
representative of the father, and while carefully, even too carefully, ful¬
filling her duties, she is never her husband’s sweetheart. Sadger has
found in these cases that after the father’s death divorce may take place.
In other cases not only does the father not press his daughter to marry,
but insists that she shall devote all her love to him, while her youth
slowly fades away. He is jealous of every wooer, not one is good
enough for her; selfishly blind to the wrong he is doing, he declares
that there is time enough for her to marry when he is gone.

Apart from the “typical bride-neurosis,” which results from sexual
needs which are constantly stimulated and constantly repressed, there
is another form of neurosis which may not be removed even when
marriage has been decided on. The approaching wedding-day is a
source of terrible anxiety, and the road to the altar seems the road to
the scaffold. Some young women break off several engagements in
succession in consequence of the depression thus caused. The author
_ states that in these cases psycho-analytic investigation reveals the
influence of the father, or sometimes, in the second line, that of the
brother. In yet other cases there is no marriage-phobia ; the woman
peacefully enters the marriage state and finds her husband sympathetic ;
yet no sexual satisfaction follows; these women present one of the
types of sexual anaesthesia. (Sadger is careful to add that it is not the
only type, and that women are often frigid because unable in marriage
to satisfy some abnormal component in their sexual nature, for instance,
a sadistic element.) In these cases, also, psycho-analysis shows fixation
of love on the father or else the brother.

In good middle-class circles, the author remarks, a husband is
anxious that he should have no predecessor in his wife’s love. But
this ideal can never be attained, or at most only on the physical side.
The husband is never the first lover; that place belongs to the father
or his representative. Marriage, in Freud’s words, is always a bad
business for the husband; he always occupies at best a second place.
This is clearly seen when a rift occurs in a seemingly happy marriage.
The wife’s love undergoes an infantile regression ; the father-imago of
her childhood re-emerges as an ideal figure.

The attributes of the father even become identical, in early life, with
those of God. Many children see a resemblance to their own fathers
in Biblical pictures of God the Father. The religious scepticism of
youth in adolescence is often associated with rebellion against paternal
authority. The youth becomes an ardent revolutionary in the class¬
room, as his professor (a representative of the father) knows to his cost.
The girl, on the other hand, seldom shares in these rebellious out¬
bursts ; for her the professor is the benevolent and attractive represen¬
tative of the father; for the same reason, also, she more rarely passes

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[Jan.,

through the atheistic phase, but, on the contrary, when in trouble
always finds refuge with God.

We cannot, Sadger concludes, over-rate the significance of the father
for his daughter’s future life. Front the eugenic standpoint, also, the
highest development of paternity seems necessary and beneficial for the
daughter, and so ultimately, for humanity. Havelock Ellis.

Experimental Psychology and Psycho-Pathology [.Psicometria e Psicopaio-
logia\. (Psiche, July-September, 1915.) M'orsc Hi, E.

The methods of experimental psychology inaugurated by Wundt
and his school are no longer viewed with so much enthusiasm as
formerly. The veteran Italian psychiatrist here discusses how far such
neglect is justified. It is certainly true, he remarks, that such
methods cannot reveal to us the intimate nature of consciousness. But
could we expect it ? The results reached in the determination of simple
and complex reaction times, and the measurement of perception,
attention, association, etc., are still of real value. The method of
measurement remains the method of science, the method not only of
physics but of physiology, and if psychology is not to renounce its
scientific character it is bound to cherish the positive and experimental
discipline of the other sciences. In this connection Morselli defends
psychology against the attacks of Bergson and the metaphysicians who
discredit scientific investigation of consciousness as merely “ spatial.”
Psycho-pathology, however, shows us that there cannot be order in
consciousness without quantitative relation and proportion. Anaes¬
thesia and hyperaesthesia, aboulia and hyperboulia, are psychic dis¬
orders of quantity ; the same may be said of intensity of pleasure and
pain as the regulators of life. It is, however, possible to go further in
defence of the Wundtian principle of measurement. Such measure¬
ment deals with time and intensity, and though we cannot measure
emotions and feelings arithmetically and geometrically, we can obtain
data which indirectly enable us to appreciate approximately the inten¬
sity of an emotional phenomenon when it transfers its inhibitory or
dynamogenic action to a measurable intellectual process. In this way
the technical methods of Buccola, Kraepelin, Sommer, Obici, and
others have rendered it possible to measure the velocity of handwriting
or reading in various emotional conditions, or under the influence of
various drugs, and thus to obtain knowledge which cannot be regarded
as unimportant. So also as regards Jung’s association method, to
which Morselli assigns a relative degree of value in hysteria, psychas-
thenia, and even dementia prascox. We must disregard, Morselli con¬
cludes, the charges of those who accuse experimental psychologists of
trying to find the ‘‘essence ” of consciousness in mechanism. Neither
Wundt, Mosso, Lehmann, nor any other born investigator has been
engaged in an absurd search of this kind, any more than the physicist or
the chemist are seeking to define the “ essence ” of the physical world.
Yet the results and the indications of Fechner, Wundt, Mosso, Binet,
Lange, and the more recent school of Wurzburg constitute a mass of
determinations which have at least served to demonstrate an irrefutable
relationship between thought and extension. Havelock Ellis.

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Violent Temper and its Inheritance. (Journ. Ncrv. and Merit. Dis.
vol. xlii , No. 9, 1915.) Davenport, C. B.

This is the first of a series of investigations into feeble inhibition, and
is issued from the Eugenics Record Office, of Cold Spring Harbour,
New York. The study is based on 165 family histories of wayward
girls in State institutions. The problem is : How far does heredity play
a part in these traits, usually of a highly “ emotional ” sort—in the
present case violent temper—that lie at the basis of criminal behaviour ?
The general method employed was that of research by a “ field worker ”
into the history of the families concerned, visits being paid to the homes
of the patients, and as many as possible of the family examined as to
their emotional traits. Further inquiries, if necessary, were made by a
special investigator.

In 79 of the families, or about 48 per cent., bad temper of some sort
is ascribed as a leading characteristic of at least one individual, and in
49, or about two-thirds of them, it marked more than one individual in
the family. As the inquirers were not specially searching for violent
temper, it would only be noted when very marked. The present study
is concerned with those families only which contained more than one
case of violent temper. The fraternities in question fell into three
groups : (a) with at least one epileptic person in the pedigree ; (l>) with
insane, but not epileptic, close relatives ; ( c ) with neither epileptic nor
insane relatives. In this last group the violent temper is regarded
as mainly of hysterical type.

Davenport concludes that the tendency to outburst of temper is not
inherited as a positive (dominant) trait, does not typically skip a
generation, and tends ordinarily to reappear, on the average, in half of
the children of an affected parent. It would seem probable that
epilepsy, insanity, and hysteria are not in these cases the causes of the
accompanying violent temper, which cannot, therefore, be regarded as
clearly their “ equivalent.” The violent outbursts are, rather, due to
an underlying factor that causes periodic disturbance (? paralysis of the
inhibitory mechanism), and this factor has greatest effect when acting
on a nervous system specially liable to show the other psychoses.

Havelock Ellis.

3. Clinical Psychiatry.

Crises in Dementia Frcecox \Les “ Crises ” des Dementes Precoces\ (Revue
de Fsychiatrie, April, 1914.) Halbersladt and Legrand.

Four distinct types of “ attacks ” have been described in dementia
praecox: syncopal, hysterical, epileptiform, and apoplectiform. The
authors describe a case in which convulsive attacks were for some time
an isolated and prominent feature. From the age of 16 until 32 the
patient suffered for some months every year, but was able to continue
her work and showed no other morbid symptoms. Then suddenly
delusions of persecution, anxiety, and ideas of poisoning and negation
made their appearance, followed by signs of mental enfeeblement and
a tendency for the delusions to become stereotyped. The clinical
features precluded the diagnosis of hysteria or epilepsy, and the con-

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elusion is drawn that such convulsive attacks must be definitely included
among the clinical signs of dementia prsecox. They usually appear at
the commencement of the psychosis, sometimes precede the mental
symptoms by several years, and tend to diminish in the later phases.

H. Devine.

The Binet-Simon Method and the Intelligence of Adult Prisoners.

(The Lancet, July 1 ~jth, 1915.) Smith, H. Hamblin.

What Tests in Childhood are best calculated to throw Light upon the
Capacities of Mental Defectives for Future Work ? (The Lancet,
July 17 th, 1915.) Potts, W. A.

In the first paper the writer describes the results obtained from the
employment of the Binet-Simon tests on 160 adult prisoners. He
comments upon the relative value of the individual tests, and suggests
certain alternative or supplementary ones. The result of his observa¬
tions are tabulated and can scarcely be epitomised, but the conclusions
drawn are summarised as follows: (1) The Binet-Simon method is an
excellent means of estimating the standard of intelligence of any parti¬
cular subject; (2) the method having been primarily devised for
school-children, would be rendered more useful for adults if certain
modifications were made in its details; (3) that defect of intelligence, as
estimated by this method, affords strong confirmation of a diagnosis of
feeble-mindedness made upon other considerations ; (4) that failure to
reach any given standard of intelligence is not of itself sufficient reason
for regarding a subject as feeble-minded.

The writer points out that a complete clinical study of all the factors
is necessary to justify the diagnosis of feeble-minded, and that a marked
deficiency of intelligence, as revealed by these tests, is not sufficient in
itself to justify a decision, still less to recommend detention as a mental
defective.

The second paper consists of a general review of the various tests for
the estimation of the capacity of defectives, with a critical survey of
their value.

The writer points out that there are no simple tests by which it can
be decided as to whether a defective child will develop into a wage-
earner, that the subject is complex and difficult, and that the subject of
mental tests is only in its infancy.

The most satisfactory decision would be attained by taking a large
group who were submitted to tests ten years ago and inquiring what
tests those now supporting themselves passed, and in what directions
the unsuccessful failed. As this information is not forthcoming other
methods must be adopted, and the following are suggested :

(1) A consideration of the causes of failure in normal individuals and
then, if these will operate in the case of defectives, devising a set of lists
to determine them. Under this heading four principal qualities are
enumerated upon which success in life depends, viz., ability, strength cf
character and will power, good health, and pluck, and it is shown
that it is frequently the absence of these qualities which determines
the failure of defectives.

(2) A determination of the good qualities common to a group of
employed defectives, and a comparison of these qualities with those of

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a group of unemployed defectives. Under this heading an investiga¬
tion was made to determine how far success in later life would be fore¬
told by the school records. A group of sixty-eight defectives over 18
years of age were investigated from this point of view, fifty of whom
had situations, while eighteen were not working. The results obtained
show that ability at manual work is the essential, and that if a defective
at school has a capacity in this direction, with no special moral or
physical defects, he is almost certain to earn a living afterwards.

An important index as to success after school is afforded by evidence
of a defective’s continual improvement in a special school. This is
best determined by the Binet tests. Progress at school usually indicates
slow, steady progress afterwards.

(3) An investigation of all known tests to decide which will be of
service.

In concluding the paper, the author points out how fallacious any
rule-of-thumb method must be, and that a diagnosis can only be made
from a record of the school attainments, the rate of advance during the
last two or three years, and a knowledge of the social and medical
record of the family. H. Devine.

Dementia Prcecox , Paraphrenia and Paranoia. (.American Journal of
Insanity , October , 1914.) Ruby, G. H.

This paper consists of a general review of Kraepelin’s present concep¬
tion of dementia prsecox and other psychoses contained in the title.
Dementia pnecoxand paraphrenia are placed under the general heading
of “ Endogenous Deteriorations,” in so far as they both have the
common peculiarity of developing independently of any perceptible
external influence.

Dementia praecox is now divided into no less than eight sub-types:
(1) Dementia simplex; (2) hebephrenia or silly dementia; (3) simple
depressive or stuporose forms; (4) depression with delusional forma¬
tion ; (5) excited forms—circular, agitated and periodic types; (6)
katatonic forms ; (7) paranoid forms; (8) forms with marked speech
confusion.

The writer inclines to the view that these artificial subdivisions are
desirable, since many cases did not fit into any of the old subforms,
and such divisions tend to emphasise clinical differences. Kraepelin
regards the disorder as an entity, a definite disease in the same sense
as general paralysis, and he regards the deterioration which occurs as
due to a progressive destructive process. The primary cause is auto¬
intoxication arising probably from a disturbance in metabolism, and
leading to a widespread and severe disease of the cerebral cortex.

Paraphrenia is differentiated from dementia prrecox by the fact that
the disturbance is in the intellectual sphere rather than in the will and
emotions, chronic delusional states without odd behaviour, deterioration
in conduct or emotional indifference. The disorder is sub-divided into
the following groups: (1) Paraphrenia systematica; (2) P. expansiva;
(3) P. confabulans ; (4) fantastica.

Paranoia, which is reduced to a very small group of cases, is regarded
as the reaction of an abnormally constituted personality to the struggle

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of life, the outgrowth of personal difficulties in adaptation to the
environment. It is thus founded on a particular form of faulty make¬
up, and is brought into the group of psychogenic disorders.

H. Devine.

The Role of the Psychiatric Dispensary. A Review of the First Year's
Work of the Dispensary of the Phipps Psychiatric Clinic. ( Trans¬
actions of the American Medico-Psychological Association, 1914.)
C. Macfie Camp hi ll, M.D.

The author of this paper first deals with the differences between out¬
patient and in-patient work. Among out-patients, where time is limited,
detailed studies are almost impossible, the history is frequently poor, a
comparatively quick examination, and quick working diagnosis have to
be made. Still, with all the difficulties, very much good can be effected,
and in the direction of treatment much use is made of the social service
worker who is able to bring about changes in the home life with
considerable benefit to the patient.

One of the surprises of this clinic is in the number of children
treated. The total number of patients for one year was 708, and
included in this number were 236 under sixteen years of age. Taking
the adults in order of frequency, first come the psychoneuroses (no
cases), then cases of depression (68 cases), dementia praecox(63 cases),
and organic brain disease (58 cases). Adult defectives, epileptics,
paranoiacs, alcoholics, unclassified cases, and manic depressives com¬
plete the list. The manic depressives gave a total of 16 cases,
included in which was 1 case of excitement. An apology is offered for
the loose classification involved in including 68 cases under the heading
of “ depression.” Doubtless some of these were cases of manic-
depressive insanity; others were cases of involution melancholia, yet
there were many others which required more prolonged study than was
possible under dispensary conditions. By means of the Social Service
Department suitable advice to the relatives, the treatment of physical
ill-health, and the correction of faulty mental outlook, good results were
forthcoming.

To return to the psychoneuroses. Many of the readers of this
Journal, who are concerned more with definite insanity than with these
borderland cases, have no doubt often wondered whether the number
of such cases would justify the extensive literature which deals with
them. It is therefore interesting to find that they comprise 1 percent,
of the total.

It is worth while to quote the figures :

Psychoneuroses (including ill-defined cases of nervous

invalidism). Total.no

Anxiety-neurosis.21

Hysteria with attacks or purely physical symptoms 23

Hysteria with morbid fears . . . . 19

Obsessive thoughts and actions .... 14

Hypochondriacal and neurasthenic states . . 13

Nervous invalidism of less well-defined type (fre¬
quently inadequate data).20

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Dr. Campbell thinks that these cases will always be an important
factor in dispensary work, because, owing to the less severe nature of
their symptoms, the patients frequently are disinclined to come into a
hospital, and because their treatment is, as a rule, too prolonged for
continuous hospital residence. The difficulties in the treatment, and
the limitations imposed by lack of time are dwelt upon, but the author
is optimistic, and says that even with a few interviews the results are
sometimes striking, and that though results rapidly attained may
possibly be only transitory (sufficient time has not elapsed to speak
with certainty), the general impression left by dispensary work is that
“dispensary conditions are not unfavourable for the treatment of this
class of patients.”

With regard to the children, who formed exactly one third of the
total number of patients, 148 showed definite intellectual defect, some
without other symptoms, and others with, in addition, speech, sense, or
moral defects, or epilepsy, chorea, or hysteria. Twenty five children
were practically normal, and the remainder, numbering 63, presented
a great variety of clinical problems. Several interesting cases are
given in detail, and the author is hopeful that from the study of such
cases light will be thrown on the development of the psychoneuroses.
Finally the author gave a short account of the cases of organic brain
disease, general paralysis, and dementia pnecox.

One cannot help feeling that when the present upheaval subsides
with the end of the war attempts should be made by the members of
our Association to establish out-patient mental departments in connec¬
tion with every general hospital in the kingdom. The work of the
Phipps Clinic forms a guide as to the kind of case which may be
expected to attend.

The general review is worth quoting in extenso :

“ In reviewing the work of the dispensary during the past year one is
impressed with the valuable nature of the material which is there
offered for study. It is in the dispensary that one will find perhaps the
best material for the study of many nervous and mental disorders
in children, and of the incipient stage of many of the disorders of
the adult. In connection with the dispensary one will be able to reach
some conclusion as to the course which such disorders run if, at an
early stage, they are taken seriously and an earnest endeavour made to
modify these factors which seem largely responsible for the disordered
adjustment. After some years one will have material which may be
useful in demonstrating that many disorders, which we are accustomed
to look upon in a rather fatalistic spirit, can be very much modified by
serious treatment, not only of the individual patient, but of the environ¬
ment in which he is living. The dispensary material emphasises very
strongly how much is gained by considering the individual in relation to
his environment, not merely as a unit by himself.”

R. H. Steen.

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4. Pathology of Insanity.

On the Degeneration of the Cerebral Commissures and the Hemispheres
in Chronic Alcoholism [Sulla degenerazione delle commissure encepha-
liche e degli emisferi nail' alcoolistno cronico], (Rivista Sperimentale
di Freniatria , vol. xli , fasc. 1, March , 1915.) Bignatni and
A T azari.

In 1911, in Ziehen’s Monatschrift fur Psychiatric und Neurologie
(vol. xxix) Bignami published, with Marchiafava, observations of twelve
cases of degeneration of the cerebral commissures in patients who had
suffered from chronic alcoholic intoxication, and since that date four
other similar cases have been reported in Italian medical journals. In
the present paper the results of this earlier communication are recapitu¬
lated, and 19 fresh cases are reported which have come under the
authors’ notice within the last four years. In explanation of the
relative rarily of confirmatory records by other observers, the authors
point out that the morbid condition in question, which is visible to
the naked eye in frontal vertical sections of the hemispheres, is readily
overlooked w r hen the brain is divided on other lines.

The characteristic lesion found in all the cases is a degeneration
affecting the fibres of the corpus callosum and extending antero-pos-
terioi ly from the genu to the splenium, and laterally to a variable distance
into the corona radiata. It is most distinct in the anterior part of the
corpus callosum. In frontal vertical sections the degenerated area is
always, even in advanced cases, limited dorsally and ventrally by two
complete layers of white matter of normal appearance. Histological
examination shows the morbid process to be a primary degeneration of
the nerve-fibres; secondary proliferation of the neuroglia elements is
ordinarily very slight in degree, and the vascular walls are little
affected. In some of the cases pathological changes similar to
those described were also found in the anterior commissure, the middle
cerebellar peduncle, and in the centrum ovale. In the series of obser¬
vations recorded in the present paper special note is made of the fre¬
quency of these latter sub-cortical alterations. The regular limitation
of the morbid changes to certain parts of the commissural tracts gives
a systematic character to the degeneration, and suggests an interesting
analogy with the degeneration, also axial in position, which the same
toxic agent produces in the optic nerve.

In all the cases in which this condition was found post mortem , and in
which the patients had been under observation during life, a charac¬
teristic symptom complex was recorded, distinguished from the ordinary
clinical picture of chronic alcoholism by the frequency of apoplectiform
and epileptiform attacks, and by the rapid decadence, with remissions
and exacerbations, to a state of marasmus. The authors state that this
commissural degeneration is never found in the absence of chronic alco¬
holism. The paper is illustrated by a plate showing the naked-eye
appearances in transverse vertical sections of the brain.

W. C. Sullivan.

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5. Treatment of Insanity.

The Modern Treatment of Inebriety (Transactions of the American
Medico-Psychological Association). Neff, Invin H.

The State of Massachusetts has for many years been amongst the
foremost of civilised communities in its efforts to combat and control
the evil of habitual drunkenness by practical measures, and in his paper
on “The Modern Treatment of Inebriety ” Dr. Neff gives a sketch of
the most recent methods adopted by that State for the attainment of
this end.

Special treatment for male inebriates has been provided by Massa¬
chusetts at the Foxborough State Hospital for twenty-two years. The
mode of admission up till recently was by committal from a court—
municipal, district, or police court—upon certification of two physicians
that the man is “subject to dipsomania or inebriety either in public or
in private, or . . . is so addicted to the intemperate use of narcotics
or stimulants as to have lost the power of self-control,” and “is not of
bad repute or of bad character apart from (his) habits of intemperance.”

Since 1907 provision has been made for the admission of voluntary
patients, either directly or from the criminal courts, with the result that
during the year ending November 30th, 1913, the number of committal
cases was 171, and of voluntary cases 577. This fact alone shows the
popularity which the system has attained, and to what an extent it has
won the confidence of the inebriate class.

The curative measures employed are chiefly directed, in the first
instance, to bringing about improvement in physical health. “ Special
individual treatment to build up the body, mind, and character of each
patient. . . . Good physical health is the foundation upon which

cure of habitual drunkenness must be built.” This is supplemented by
a systematic arrangement of work and rest, not merely for the benefit
which this directly confers on the patient, but also for its indirect effect
in developing and, if possible, permanently establishing habits of
regularity, in which every inebriate is notoriously deficient. Needless
to say', a thorough examination of the patient as to his bodily and
mental condition precedes the adoption of the curative means employed
in each individual case, and the cause or causes of the malady are
investigated as exhaustively as possible. The work assigned to each
patient is selected with the greatest care, as that which is best suited to
his interests and capacities, and even the employment of his leisure
hours is catered for with equal assiduity, so as to provide what is most
congenial to individual tastes and temperaments.

In addition to these ground principles of treatment—so we may call
them—great stress is laid on the important influence of suggestion.
Not suggestion in the technical (hypnotic) meaning of the term, but in
the sense of moral suasion. This is practised repeatedly, continuously,
by the physician, who unceasingly endeavours to make his patient
vividly realise (1) the danger to himself and others certain to accrue
from his drinking habits, (2) the necessity for complete abstention
from alcohol in any shape, and (3) the prospect of his achieving success
through perseverance in steady work and regular habits. “No two

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cases are precisely alike, nor can they be successfully treated by any
stereotyped plan. Diagnosis by a physician of specialised training in
nervous and mental diseases, and continuous suggestive treatment under
his direction, adapted at every point to the physical and mental needs of
the patient, are essential to cure.”

But the care of the patient does not cease with the cessation of
hospital treatment. Since 1909 a new and most important provision
has been adopted. Prior to that date a patient when discharged had
to run all the risks of a return to his old and unfavourable surroundings,
of renewed association with old boon companions, possibly of a more
or less comfortless home, without any counteracting influence, a con¬
dition of things not unlikely, sooner or later, to bring about a relapse.
To meet this difficulty, and help the patient at probably the most
critical period of his recovery, a special out-patient physician has been
appointed in connection with the hospital, who makes himself familiar
with each case while in the hospital, and also with the patient’s family.
“ Before the discharge the family is shown how they can co-operate in
perfecting the cure. Work is found for the patient before his release.
He is associated with local persons, or local clubs, or religious organisa¬
tions that will look after him, and provide temperate friends and whole¬
some amusement. By frequent visits to the hospital, and visits from
the out-physician, the suggestion made at the hospital is reiterated, until
years of abstinence prove that further oversight is no longer needed.”

This after-care of inebriates is conducted almost precisely on the
same lines as in the case of a number of institutions which have been
founded in Germany within recent years for the treatment of patients
suffering from various forms of nervous disease, exclusive of insanity, an
account of which, by Dr. Bresler, appeared in the Journal for April,
1914.

But Massachusetts has not contented itself with this organised
system of hospital treatment and after-care, however admirable it may
be. For the past six years it has been taking further steps with a view
to grappling more effectually with the problem of drunkenness. During
this period two special commissions were appointed, and on their
recommendations valuable legislative measures have been based, the
outcome of which has been the establishment of a colony system for
the treatment of inebriates. Penal institutions for drunkards, and
punitive measures of any kind, such as we persistently cling to in
these countries, are wholly condemned. They have been weighed in
the balances and found wanting. As far as remedying the evil of
drunkenness, they are practically worthless. But the necessity for a
uniform plan, with centralised control—State non-punitive control—is
insisted on.

For the typical inebriate institution a large tract of land, not less
than one thousand acres, should be available, so as to afford liberal
provision for both employment and recreation. Over this are distri¬
buted a large number of cottages, the cottage being the unit of the
system, varying in size according to requirements, the maximum
accommodation in any one being twenty-five. The cottages are arranged
in groups, each group forming a colony, each colony being adapted
for the treatment of one particular class of patient. There are, thus,

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four kinds of colonies: (i) For incipient, hopeful cases; (2) for more
advanced male cases, such as may need custodial care ; (3) for refrac¬
tory male cases, who may require more or less restraint; and (4) a
colony for inebriate women. In Massachusetts the system has been
initiated, and is now already in active operation, a number of cottages
having been built, which are occupied by patients. A group of
buildings has also been erected, to serve the purpose of administration,
and for the reception of patients.

Connected with the institution is an out-patient department, with its
office in a metropolitan area, not too remote. Its functions are: ( a )
Preliminary examination of the patient for the purpose of differentia¬
tion ; ( b) visits to patients while at the hospital; (<r) visits to the
homes of patients before their discharge from the hospital; (d) visits
to patients after discharge. This department is in charge of a physician,
and is conducted by the State as a permanent central office.

Lastly, detention hospitals are provided as adjunct institutions to the
central hospital, situated in the various cities and towns, and fitted for
the care and treatment of cases of acute alcoholism, although not
necessarily erected for that purpose. These fulfil certain definite
objects, viz. :

(a) The treatment of delirium tremens.

( b ) To serve as an observation and receiving ward for the parent
hospital.

(c) To provide a clinic for incipient cases of inebriety.

(d) To serve as sub-offices for the out-patient department.

(«>) To provide medical officers to visit prisons to examine cases
arrested for drunkenness, and to determine their fitness for treatment at
the hospital.

The system, therefore, comprises three essential and mutually depen¬
dent parts:

(1) A State hospital, developed on the colony plan.

(2) An out-patient department, with broad and well-defined duties.

(3) Detention hospitals.

The whole scheme of treatment appears to have been well thought
out and elaborated. Thoroughness, individualisation, and after-cure
supervision are the cardinal principles essential to success, and the
organisation in all its details seems well-nigh perfect. It contrasts
favourably with the half-hearted and ineffective measures in vogue in these
countries for dealing with the habitual drunkard, where an inordinate
veneration for that fetich (in this connection), the “liberty of the
subject,” has been always a bar to the adoption of resolute legislative
action which might prove a real check to the prevalence of inebriety,
and ultimately bring about inestimable results to the nation at large.
Future legislation might well follow on the lines so admirably devised
by the State of Massachusetts. T. Drapes.

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EPITOME.

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6 . Sociology.

Prostitution and Mental Deficiency. (Social Hygiene , June , 1915 )

Clarke , Walter.

The author, who is a “ Field Secretary ” to the American Social
Hygiene Association, here brings together and discusses various recent
American investigations into the mental condition of prostitutes, with
special reference to the hereditary factor of amentia in the causation of
prostitution. As regards the general prevalence of amentia, it may be
mentioned that a recent commission on the extent of feeble-mindedness
reported that in the State of New York there are 21,000 aments who
are not in any institution for the care of the mentally deficient, and
3,000 of them are between the ages of sixteen and forty-five.

The Virginia State Board of Charities states that of 120 prostitutes
examined 42 (35 per cent.) were imbeciles, and 58 (48 3 per cent.) were
morons. Thus 83 3 per cent, were mentally defective. The physician
of the Chicago Morals Court in her first report (1913) concludes that
of 639 prostitutes whom she examined, over 400 were mentally deficient
and 68 little more than imbeciles, that is, approximately, 62 per cent.
were aments. Dr. Hickson, of the Chicago Psychopathic laboratory,
examining 126 women brought before the Morals Court, and using
modifications of the Binet-Simon and other tests, found that 85‘6 per
cent, (excluding the insane, alcoholics, and drug -habituies) were dis¬
tinctly feeble-minded. At the Training School of Geneva, Illinois, of
104 girls committed for sexual delinquency, 97 per cent, were found by
Dr. Olga Bridgeman feeble-minded by the Binet tests, and were “ help¬
less victims, who under close supervision may had useful, contented
lives.” In Massachusetts a careful and scientific investigation was
carried out by Dr. Fernald in 1914. He selected 300 prostitutes at
random (100 each from a prison, a detention home, and an industrial
school) and found that, when all doubtful cases were recorded as
normal, 51 per cent, were feeble-minded in so pronounced a degree as
to warrant legal commitment. As measured by the Binet tests only
22 of the 154 women had a mentality of over the age of ten, and not
more than 6 of the entire number seemed to have really good-class
minds. At the Massachusetts Reformatory for Women at South
Framingham in 1914, Dr. Edith Spalding, using the Binet-Simon tests
in doubtful cases, found that among 243 inmates 49 per cent, prostitutes
were mentally subnormal or aments ; there were also many borderland
cases. At the New York State Reformatory for Women in 1914 Dr.
Jean Weidensall, the resident psychologist, examined 200 women as
they came in sequence from the courts by the Binet test, revised by
Goddard, and found that only o‘5 per cent, could pass the twelve-year-
old test; Dr. Katharine Davis at the same institution found that of
116 women 37^9 per cent, could be definitely declared mentally
defective.

Clarke concludes that the correlation between prostitution and
amentia is sufficiently striking to demand more careful mental examina¬
tion of all pre-adolescents, and more elaborate provisions for the
discovery, training, and protection of children whose minds are not

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normally developed. But he points out that all these groups of prosti¬
tutes are inmates of institutions, and therefore already a selected class,
which cannot represent the average prostitute, for we may safely assume
that only the dullest and least efficient mentally are likely to fall into
the hands of the authorities. He also comments that norms have not
yet been established for women of the same social standing, employ¬
ment, education, and age as those to which most prostitutes have
belonged before entering on their irregular life. Tests have not been
made on a large scale of ordinary char-women, factory girls, and domestic
servants. We cannot, therefore, positively say, at present, that prosti¬
tutes are more or less intelligent than the groups of women they spring
from. There is also some question as to the applicability of the Binet-
Simon tests; Dr. Weidensall gave the Binet tests to a number of
Chicago Normal School girls, with the result that a large number failed
to scale up to normal, though, as a matter of fact, there could be no
question regarding their normality. Yerkes believes the Binet tests to
be unsuited for post-adolescents, and Frederick Ellis states that at the
New York Neurological Institute experience shows that the Binet-
Simon scale has a higher value for group study than for the interpreta¬
tion of individual cases. The mental tests should also be accompanied
by careful physical tests. The wider range in the results (from 97 per
cent, to 29 per cent.) must also be observed. On the whole, it must be
said that the precise correlation between prostitution and amentia is
not yet determined, but that the most accurate and consecutive studies
thus far indicate that about one half of the prostitutes in institutions
are mentally defective. Havelock Ellis.

Psychoses among Negroes : a Comparative Study. {Journal of Nervous
and Mental Diseases, vol. x/i, No. 11, November , 1914.) E. M.
Green.

The asylum of which Dr. Green is director receives all the cases of
insanity from the State of Georgia, and therefore affords exceptionally
good opportunities for a comparative study from the statistical point
of view of the characteristics of mental disease in negroes and whites
living under fairly similar conditions of environment. The paper is
based on the records of the patients, 5,410 in number, admitted to the
asylum during the five years 1909-13. Of this number, 3,291 (1,855
males and 1,436 females) were of the white, and 2,119 (1,096 males and
1,023 females) of the coloured race. The point which the author
specially considers is the incidence of the several forms of mental
disease in the two races, as shown on comparing the percentage ratio
of each form to the total number of admissions in the racial group.
The results obtained by this method of comparison are summarised thus:

(1) Psychoses occurring with equal frequency in both races: Brain
tumour, traumatic psychoses, infective-exhaustive psychoses and allied
states, psychoses accompanying pellagra, and epileptic psychoses.

(2) Psychoses occurring more frequently in the white race : Psychoses
accompanying nervous or brain disease other than tumour and general
paralysis, alcoholic psychoses, drug psychoses, involution melancholia,
undifferentiated depressions, symptomatic depressions, paranoiac con¬
ditions, psychoneuroses, constitutional inferiority, idiocy, and imbecility.

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(3) Psychoses occurring more frequently in the negro race : Senile
psychosis, general paralysis, dementia praecox, and manic-depressive
insanity.

It is interesting to note that alcoholic insanity is much more preva¬
lent in the white population, accounting for 41 per cent, of the admis¬
sions as against 1’4 percent, amongst the negro patients; and in the
drug psychoses the predominance of whites is even more marked—only
six cases occurring amongst coloured patients as compared with 142
(4-3 per cent, of the total admissions) amongst the whites. The author
would explain the rather surprising rarity of these psychoses in the
coloured population as due to the lower economic status of the negro,
which prevents him from indulging freely in the extravagance of drug
taking. General paralysis was found to be far more prevalent amongst
the negro patients, the percentage of the disease calculated on the
admissions during the five-year period being: White males, 45 ; white
females, I'a; negro males, 10 2 ; negro females, 4 2. This is ascribed
by the author to the wide diffusion of syphilis in the negro population,
and to the difficulty of inducing infected subjects to submit to regular
treatment. A simple dementia is the most common clinical form of
general paralysis in negroes. In the affective psychoses in coloured
patients there is a marked predominance of gay and expansive moods due
apparently to racial temperament. W. C. Sullivan.

Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly General Meeting of the Association was held at the Medical
Society’s Rooms, No. u,Chandos Street, Cavendish Square, London, on Tuesday,
November 23rd, 1915, Lieut.-Colonel David G. Thomson, M.D., President, in the
chair.

There were present : Drs. H. M. Baker, C. H. Bond, D. Bower, P. E. Campbell,
J. Chambers, R. H. Cole, E. M. Cooke, T. Drapes, J. H. Earls, C. H. G. Gostwyck,
A. H. Griffith, B. Hart, H. E. Haynes, H. A. Kidd, N. Lavers, W. H, C.
Macartney, A. Miller, A. W. Neill, W. F. Nelis, H. J. Norman, J. G. Porter
Phillips, Bedford Pierce, J. N. Sergeant, Sir G. H. Savage, G. E. Shuttleworth,
R. P. Smith, J. G. Soutar, T. E. K. Stansfield, H. Stewart, R. C. Stewart, T. S.
Tuke, W. R. Watson, H. Wolseley-Lewis and R. H. Steen (Acting Hon. Gen.
Sec.).

Visitor: Dr. Edith R. Spaulding.

Present at Council Meeting : Lieut.-Col. David G. Thomson (President) in the
chair. Drs. James Chambers, R. H. Cole, Thomas Drapes, Norman Lavers, H.
Wolseley-Lewis, A. Miller, Hubert J. Norman, J. G. Soutar, T. E. K. Stansfield,
T. Seymour Tuke, and R. H. Steen.

Apologies for absence were received from: Drs. G. Douglas McRae, R. B.
Campbell, G. S. Pope, Donald Ross, W. R. Watson, H. H. Newington, T. S.
Adair, and J. W. Geddes.

Minutes.

The President said the minutes of the May meeting required confirmation.
They had already appeared in the Journal, and perhaps members would agree to
accept them as correct.

This was agreed to.

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Obituary.

The President said he regretted that there were one or two matters to which
he must allude before the general business of the meeting was commenced. Since the
Association’s last meeting two very important men in the specialty had passed
over to the majority. The first of these was Sir James Moody, his own late Chief.
Sir James Moody, as members knew, was the doyen of the London county asylum
superintendents ; he was a man whom members all knew officially, and some knew
privately, a man for whom he, Dr. Thomson, who worked under him for three and
a half years, had the greatest respect and admiration, and to whom he owed,
personally, any administrative capacity he possessed. He died not long ago, in
full harness, keen and enthusiastic in his work to the last. He proposed that a
vote of condolence be sent from the Association to his widow, Lady Moody.

He had other proposals of a similar kind, and he would ask members to take
them together. The next member whose loss was deplored was Dr. A. R. Douglas,
also a very well known man, and a great authority on all matters connected not
only with administration, but with the medical aspects of the feeble-minded. He
was Medical Superintendent of the Royal Albert Institution.

The Association has also to regret the dtath of Dr. W. H. Macfarlane, not so
well known to London alienists, as he had been for some years in the Colonies.
He was Medical Superintendent of the Hospital for the Insane, New Norfolk,
Tasmania.

Coming to the war victims, since the last meeting, Captain Arthur Kellas, of the
R.A.M.C. (T.F.), had been killed at the Dardanelles. He was Senior Assistant
Physician at the Royal Asylum, Aberdeen. Lieut. Edgar Faulks had been killed
in France. He was Senior Assistant Medical Officer at Bexley Asylum.

Another member of the specialty, though not of the Association, Dr. Francis
Wisely, had died at Alexandria of wounds received at the Dardanelles. He was
Assistant Medical Officer at Worcester County Asylum, Powick.

The sympathy of the Association should also be extended to Dr. John Carswell,
a very prominent and well-known member of the Association, and Commissioner
of the Central Board of Control, Scotland, who had lost his youngest son, killed
in France.

To the relatives of all the gentlemen who had passed away, he asked members
to pass a resolution of condolence.

The resolution was passed by members rising in their places.

Election of Candidate for Membership.

The President nominated Dr. Tuke and Dr. Soutar as scrutineers for the
ballot in regard to—

Gray, Cyril, L.R.C.P., L.R.C.S., etc., Edin., Assistant Medical Officer, Gates¬
head Borough Asylum, Stannington, Newcastlc-on-Tyne.

Proposed by Drs. J. B. Tighe, T. Stewart Adair, and Richard Kelly.

The scrutineers reported that Dr. Gray had been unanimously elected.

The President said members would remember that some time ago it was
esolved to send the name of any member of the Association to the Secretary who
was known to be absent on national service. He feared that direction had not
been very fully attended to; hence he wished to remind members of it.

The President’s Address,

" A Descriptive Record of the Conversion of a County Asylum into a War
Hospital for 1,050 Sick and Wounded Soldiers in the Year 1915 ” (see p. 109).

Dr. Marriott Cooke remarked that he had listened with pleasure to the very
interesting, full, and accurate account given by Lieut.-Colonel Thomson. He
thought it would have have been difficult, if not impossible, to give a better resume
of the great movement than the President had done. The members might perhaps
be interested to know what had been its practical effect hitherto, and so Dr. Bond
and he had brought statistics as to the number of patients who had been admitted
into their hospitals, and what had happened to them. They were fortunate in

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having, from all the twelve hospitals, monthly returns. By the first of the
present month these twelve hospitals had admitted no less than 23,996 sick and
wounded soldiers. Of that number, 14,776 had been discharged or transferred,
101 had died, and there remained under treatment at that date 9,120, leaving, at
the same time, vacant beds for 4,108. That was a record of which he thought the
specialty might well be proud. Those who had organised these hospitals with so
much ability and with so much patience had, perhaps, the greatest reason to feel
proud ; but he ventured to think that all the other asylums in the country had
also cause for the same feeling, because if it had not been for the way in which
they had assisted in this movement, and come forward to help by receiving patients,
thereby putting themselves to a great inconvenience, this movement could never
have been successfully brought into being. The President had dealt in his address
with every matter in such a thorough, exhaustive, and well-balanced way, that he
thought it would be almost invidious of him, the speaker, to follow to any extent
in his footsteps. There were, however, several points which one might emphasise.
One was the remarkably successful way in which patients were transferred from
vacating asylums owing to the admirable manner in which the arrangements were
made. People outside were astonished when he told them that the asylums had
moved 10,000 lunatics, some of them as far as 150 miles. They asked, “ Have
you not had a great many accidents ? ” and they have been surprised when assured
that there had been practically no untoward event. What Colonel Thomson
said about the staff was particularly true and interesting. Many of the asylum
nurses had had a very arduous time, and it only shows how satisfactorily they
have been trained that they had acquitted themselves so well. The War Office
matrons were already fully alive to their worth. The administrator of one hospital
<a permanent officer in the R.A.M C.) said that if it had not been for the asylum
attendants, he did not know what they would have done, as they were the backbone
of his orderlies.

Lieut.-Colonel H. A. Kidd (Graylingwell War Hospital, Chichester) said
he would like to associate himself with the tribute which had been paid by Dr.
Cooke to the most excellent paper which the President had read. It was extremely
interesting to him, as a fellow worker in the same line as Dr. Thomson, to hear
what he had to say, and the way in which he had stated the details of the hospital
organisation. He wished to express his extreme indebtedness to the superintendents
of the receiving asylums in the country for the very great assistance he had received
in the transferring of his patients ; they had helped the movement in every possible
way. He also wished to associate himself with what the President said con¬
cerning the Board of Control. In the early days of the movement they very much
appreciated the ability with which this scheme was brought into being. One
felt very thankful that there was a Board of Control to save one from the
grave errors which otherwise would have been committed. It would be useless
for him to say anything with regard to the organisation and construction of one’s
own building, therefore he would supplement what the President said by referring to
the work of these hospitals. Dr. Cooke had given a general summary, but it might
interest the meeting to know what a particular hospital had to do. His hospital
had 1,000 beds, and affiliated with it was the West Sussex with 50 beds, and
seven auxiliary hospitals with 300 beds. The hospital had been open six
months. During this month they had taken in 313 cases and discharged 380.
There had been 3 deaths. During the whole period in which the building had
been open they had admitted 3,767 patients and discharged 2,938. There had
been 22 deaths. There were 864 on the books and 350 vacant beds. With
regard to the character -of the cases, they had had all kinds. The first day's
experience was to receive 490 cases in thirty hours, mostly from the Dardanelles,
though there were also some from Flanders. There were wounds of all sorts, and a
large number of medical cases, especially latterly, from the Dardanelles. In
peaceful times at ordinary hospitals, if they took in ten patients in one day it was
considered a hard day. The rate at which patients were admitted was interesting.
Notice was received of a convoy coming to the station, numbering 200, and they
were admitted to the wards, cleaned, and had their Bovril, etc., inside a couple of
hours. A word might also be said as to the nature of the cases which had been
received lately. He received a telegram announcing the coming of a convoy from the
Dardanelles, consisting of 200, 170 of which were enteric, and the remainder cases

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of dysentery. He mentioned this because in the usual way a large proportion of the
cases received were surgical, only a few medical, and preparations had been made
accordingly. Yet in a quarter of an hour the whole arrangements had to be
altered. The last convoy of cases of supposed dysentery, though a number were
paratyphoids a and paratyphoids b, largely b, were to a considerable extent con¬
valescent. Of the dysentery cases, very few had been of the acute form. Being
between Southampton and Dover, a bad lot of cases were sent to his hospital, some
so seriously ill on arrival that they die within a day or so of admission. In the past
he had been interested in the subject of dysentery in asylums. The method of treat¬
ment consists in giving drachm doses of sulphate of soda, also by injections of
eusol. Sometimes appendicostomy is done, and the cases do remarkably well. It
is astonishing to see how these cases improve and go out again. Another point he
would like to refer to was, how extremely easy it is to deal with wounded soldiers in
the matter of discipline. They give practically no trouble at all. He was very glad
to hear what the President said about the nursing staff. Asylum officers were
proud of their old nursing staffs. The War Office had supplied him with an
anresthetist, and he was indebted to Dr. Bond for sending him a lady doctor lately.
Apart from that he had to get his own medical and nursing staff in a short time,
and had been very glad to find how extremely well they had been doing, and
the way in which they had adapted themselves to the changed conditions. The
President had put it very well when he said they were nurses possessing a
nursing certificate, who had had some years' training, and some had had charge
of wards, and they now suddenly had to give up such charge, and serve under
others, doing work of lesser degree. That work they had done well and uncom¬
plainingly, and he was glad to say they had been much approved by the general
nursing staff, so much so that several of his mental nurses had been, at its instance
promoted, and were acting staff nurses. The X-ray work at the hospital was,
of course, heavy, and it was good. All surgical cases were radiographed, and
he had brought a selection of radiograms, which he would be pleased to show to
anybody interested.

Lieut.-Col. Vincent (Wadsley War Hospital) sent a communication, entitled
“ Use of Asylums as Military Hospitals” (see p. 174), which was taken as read by
the meeting.

Dr. G. M. Robertson (Edinburgh) said he wished to add his praise of the most
excellent account which the President had given of the conversion of a mental
hospital into a war hospital for the treatment of sick and wounded soldiers.
Another interesting account might also be given of those asylums upon which
extra pressure had fallen in order to receive the patients which formerly went to
the vacated mental hospitals. He had an asylum which had undergone that
experience. He had had to receive all the admissions of mental cases from the
City of Edinburgh, in addition to those which he had previously been receiving, so
that he was now taking in more than double his former admissions, and yet he had
a much smaller staff with which to cope with them, both medical and nursing. He
would not say any more about that, but he thought the experience which the
President and others had had in the conversion of a mental hospital into a military
hospital would result in our obtaining a great deal of valuable knowledge. Dr.
Thomson had pointed out one or two instances in which a change had to be made
in his asylum in order to convert it into a hospital, and one of the first he mentioned
was the placing of handles on the doors. Handles, he (the speaker) contended,
should be placed on all asylum doors ; for many years his patients had complained
of the unpleasantness of having to occupy rooms the doors of which had no
handles. The rooms in asylums should be exactly like those in hospitals. Refer¬
ence was also made to opening the windows, and that was another lesson which
should be taken to heart. The profession had been talking a great deal about the
importance of open-air treatment, yet one of the first things which had to be done
in converting one of the most modern asylums into a hospital was to open the
windows. It was anomalous that asylums should not have adopted a system of
opening windows which supplied more fresh air than was provided for in the past.
He had little doubt that the reason there was so much phthisis among insane
people was in great measure this lack of a plentiful supply of fresh air. The
arrangement in the past was that the windows should open not more than five
inches. He considered that a good asylum window had not yet been invented,

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and that was a thing which should be done by asylum architects, so that, while there
was abundant fresh air, patients who wished to run away and injure themselves
should not be able to do so. Another point he would refer to was the question of
the relationship of ordinary hospital nurses to mental nurses. The President
had given his experiences of the unpleasantnesses, and the same obtained at other
institutions. He supposed he, the speaker, had had more experiences of hospital
nurses in contact with asylum nurses than any other person in Great Britain, there¬
fore he might be allowed to make a few observations on the matter. The reason
there had been trouble was that the classes of nurses did not understand
each other. When he first introduced hospital nurses into the wards of an asylum,
which he did at Perth District Asylum about twenty years ago, he found it impos¬
sible to get nurses to come into the wards of an asylum. The reason he introduced
them was, that Dr. Elkins, who had been appointed medical superintendent of an
asylum, wished to have, as his matron, an official who had been trained in both
asylum and hospital work. He advertised, and there was only one person in Great
Britain who was eligible for the post, and she was already an asylum matron. He,
Dr. Robertson, thought that if he could create nurses in asylums it would be a
splendid opening for hospital nurses. He went to the principal hospitals in
Scotland, and induced matrons to send hospital nurses to be trained. He was told
it was absolutely useless to think of it, because no hospital nurse would enter the
wards of an asylum—they looked down upon it. It took him from six to twelve
months to induce anybody to come, and then it was owing to a series of accidents.
They were with him two years, and they were all appointed matrons of asylums.
After that he got hospital nurses to come to him. He found that hospital nurses,
did not understand the system of nursing in asylums, and at that time asylum
nurses did not understand about hospitals, and there was no sympathy between
them. What he had recommended was that they should know more of one
another, and once they did that they would come to appreciate the good qualities
in each. In Scotland there were now a large number of nurses working in asylums,
and he had sent more hospital nurses into the military hospitals than all the asylums
in England put together. He spoke also of the ordinary hospital system requiring
any complaint of nursing to be made to the matron. At his own asylum the
system was the same as that of hospitals, and he still made the nurses understand
that they were to regard themselves as solely under the matron. The matron of
an asylum was under the superintendent, and the latter could order the matron to
do whatever he pleased. In that way the authority of the superintendent was
maintained. When he found anything wrong in his asylum he never spoke to a
subordinate about it, but went to the head, and got the regulation carried out
through the senior authority. Hospital nurses were not now of the same standard
as they were fifteen or twenty years ago. Since then there had been a large
number of hospitals, especially w’orkhouse infirmaries, which had produced trained
hospital nurses on the three years' system, and the class of nurse in those work-
house infirmaries had not been the same as used to exist in the hospitals of large
towns. Those large hospitals had twenty applicants on the list for every nurse
they took on, hence they had a very fine class of nurse. But those nurses had now
been swamped by the large number of nurses from workhouse infirmaries, who
were of no better social position or education than the nurses in asylums. He felt
certain that the experience of this war conversion would be of very great value to
the asylum services, and after the war he hoped Colonel Thomson and others
would again give their experiences, so that with them as a basis there might be a
remodelling of asylums.

Sir George Savage said he had not intended to take part in this discussion,
for two reasons : first, that he had no practical knowledge of it, and secondly that
his imperfect hearing prevented his grasping all that had been said. But a point
which seemed not to have been raised was that of employing asylum staffs for the
treatment of wounded soldiers. Even in Parliament, remarks were made about
the iniquity of sending poor wounded soldiers into institutions intended for the
insane. He had thought that sort of thing had died out. But only two days ago
he received a series of cuttings and a long letter from a “ Miss,” requesting him to
take the chair at a meeting in the provinces at which the whole of that question
would be considered. His reply, of course, was that his personal experience was.
such that the very best was being done by the asylum staffs. And what had now

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been heard from the President only convinced him of the enormous benefit which
had been conferred upon the wounded men, and how necessary it was to suppress
the aggressive League he had hinted at.

The President, in reply, said he very much appreciated the kindly and patient
way in which members had listened to what, after all, was a rather dry record of a
sequence of official and other events towards establishing these hospitals. He saw
that it would overload his paper if he were to give matters of more purely medical
interest; he was therefore very glad indeed to hear Dr. Cooke’s appreciative
remarks, which, coming from him, he, Dr. Thomson, valued extremely. Dr. Kidd
had given very interesting particulars of his results. He, the speaker, visited
Dr. Kidd’s hospital, and learned a good deal there, and that was the highest
praise one could give of anything. Dr. Robertson had referred to some of the
Association’s old controversial subjects ; and it was true that while there were,
as always, arguments on both sides, there would be a good deal to learn, to be
assimilated and applied by the asylum administration from what one saw in
hospital work now. Late though it had come in his career, his present ex¬
perience would be a very valuable lesson to him and his colleagues. One had
learned that some things were not as necessary as they had been thought to be.
But perhaps such controversial matters would form suitable material for dis¬
cussion at a later period. In answer to Sir George Savage, he was glad to hear
that Sir George, as well as asylum officers, heard the adverse criticism that
asylums were still receiving wounded soldiers. It was a superstition which died
hard. However, they kept on working and hoping. He thanked members very
much indeed.

NORTHERN AND MIDLAND DIVISION.

The Autumn Meeting of the Northern and Midland Division was held at
the kind invitation of Dr. T. W. McDowall, at the Northumberland County
Asylum, Morpeth, on Thursday, October 7, 1915. Dr. McDowall presided.

The following ten members were present: Drs. J. W. Geddes, J. R. Gilmour,
C. McDowall, T. W. McDowall, H. J. Mackenzie, J. Middlemass, B. Pierce, E. S.
Simpson, J. B. Tighe, T. S. Adair, and one visitor, Dr. Mary S. Gordon.

Previous to the minutes being read, Dr. McDowall made suitable reference to
the sudden and unexpected death of Dr. A. R. Douglas, of the Royal Albert
Institution, Lancaster, a member of this Division of the Association, and one of its
representatives on the Council. A vote of condolence with Mrs. Douglas was
passed, and the Secretary was instructed to write and convey to her the sympathies
of the meeting.

(1) The minutes of the last meeting were read and confirmed.

(2) Dr. J. W. Geddes was unanimously elected to fill the vacancy on the Council
caused by the death of Dr. Douglas.

(3) Drs. McDowall, Pierce, and Street were unanimously re-elected to form the
Divisional Committee for the next twelve months.

(4) Dr. Colin McDowall then read an interesting paper on “ Nucleinate of
Soda : its use in acute mental states.” After describing the method of application
of the drug, he gave a short account of a number of cases, of excitement and of
depression, in which he had tried it. He found that in “ excited, noisy cases of
acute mental disturbance ’’ it was useful in " allaying excitement and encouraging
rest,” but in cases suffering from depression it was of no service, and tended to be
harmful.

Drs. T. W. McDowall, Gii.mour, Pierce, and others discussed the subject,
and gave the results of their experience.

(5) Dr. T. W. McDowall read a paper on “A Case of Epileptic Idiocy with
Adiposity and Premature Sexual Development.” The paper was one of marked
interest, and was further elucidated by the exhibition of the patient, and also of a
number of photographs and radiographs.

A very enjoyable meeting was brought to a close by a hearty vote of thanks to
Dr. McDowall for his kind invitation and hospitality.

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SOUTH-EASTERN DIVISION.

The Autumn Meeting of the South-Eastern Division was held at it, Chandos
Street, on October 6th, 1915.

Among those present were Drs. F. Beach, A. H. A. Boyle, H. E. Haynes, G. H.
Johnston, E. S. Pasmore, G. E. Shuttleworth, J. G. Soutar, J. Stewart, T. S. Tuke,
and J. N. Sergeant (Hon. Divisional Secretary).

Expressions of regret at inability to be present were received from several
members.

The meeting of the Divisional Committee was held at two o’clock.

The General Meeting was held at 2.30 p.m.. Dr. Fletcher Beach in the chair.

The minutes of the last meeting, having been printed in the Journal, were taken
as read and confirmed.

It was decided to arrange for the Spring Meeting to be held at it, Chandos
Street, on Friday, April 28th, 1916.

SOUTH-WESTERN DIVISION.

The Autumn Meeting of the above division was held, by kind permission of
Dr. MacBryan, at 17, Belmont, Bath, on Friday, October 22nd, 1915.

The following members were present: Drs. Bartlett, Norman Lavers, Nelis,
MacBryan, Macdonald, Rutherford, Soutar, and Aveline, who acted as Hon. Div.
Secretary.

Dr. Macdonald was voted to the Chair.

Dr. Blachford having intimated that it was quite impossible for him to undertake
any outside work until after the war, and that he would be very glad to be relieved
of his duties as Hon. Div. Secretary, Dr. Bartlett, Medical Superintendent of the
Exeter City Asylum, was nominated in his place.

Drs. Norman Lavers and G. S. Pope were nominated as Representative Members
of Council.

The following candidate was elected a member df the Association : Dr. Hamilton
Marie Grigsby, L.R.C.P.S.E., etc., 79, Victoria Road, Southsea. (Proposed by
Drs. Devine, Steen, and Patterson.)

It was left to the Acting Hon. Div. Secretary to fix a place for the Spring Meet¬
ing to be held on Friday, April 21st, 1916.

The question of granting medical certificates to asylum patients coming under
the provisions of the National Insurance Act was then discussed by the meeting,
and the suggestion that a certificate of disability on admission, and a certificate of
ability, if required, on discharge (if recovered), should be all that is necessary, was
approved, and it was resolved to forward to the secretary of the Parliamentary Com¬
mittee a draft certificate, embodying these recommendations.

The Hon. Secretary was requested to convey to Dr. Morrison the sympathies of
the members present, and to express their hope of his speedy recovery from his
illness.

SCOTTISH DIVISION.

A Meeting of the Scottish Division of the Medico-Psychological Association
was held in the Royal College of Physicians, Queen Street, Edinburgh, on
November 19th, 1915.

Present: Lieut.-Col. Keay, Drs. Dods Brown, Cruickshank, Easterbrook, Kerr,
McKenzie, G. M. Robertson, Ford Robertson, Watson, and R. B. Campbell
(Divisional Secretary).

Lieut.-Col. Keay occupied the Chair.

Before taking up the ordinary business of the meeting, the Chairman referred in
appropriate terms to the great loss which the Association and the Specialty of
Psychiatry had sustained since last meeting through the death of Sir Thomas
Clouston, a distinguished physician, an authority on mental diseases, and a former
President of the Association. Dr. G. M. Robertson, in endorsing the Chairman’s
remarks, paid a further tribute to the late Sir Thomas Clouston, and referred to
the active and kindly interest which he had always taken in the affairs of the
Division. It was unanimously resolved that it be recorded in the minutes that the

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members of the Scottish Division of the Medico-Psychological Association desire
to express their deep sense of the loss sustained through the death of Si^Thomas
Clouston, and their sympathy with the members of his family in their bereavement.
The Secretary was instructed to transmit an excerpt of the minute to Lady
Clouston.

The minutes of the last Divisional Meeting were read and approved, and the
Chairman was authorised to sign them.

Apologies were intimated from Drs. John Fraser, Carlyle Johnstone, Turnbull,
Oswald, Hotchkis, Alexander, McRae, Shaw, Ross, and Crichlow.

The Business Committee was appointed, consisting of Drs. Carlyle Johnstone,
G. M. Robertson, Kerr, Orr, and the Divisional Secretary.

Drs. J. H. Orr and C. C. Easterbrook were nominated by the Division for the
position of Representative Members of Council, and Dr. R. M. Campbell was
nominated for the position of Divisional Secretary.

The following two candidates after ballot were admitted to membership of the
Association :

(1) David Kennedy Henderson, M.D.Edin., Senior Assistant Physician, Royal
Asylum, Gartnavel, Glasgow. (Proposed by Drs. Oswald, G. M. Robertson, and
Campbell.)

(2) Charles James Lodge Patch, L.R.C.P. and S.Edin., Assistant Medical Officer,
Renlrew District Asylum, Dykebar, Paisley. (Proposed by Drs. Hotchkis,
Campbell, and Gostwyck.)

Dr. Ford Robertson read an instructive and interesting paper on '* Some
Examples of Neurotoxic Bacterial Actions.” He maintained that the part played
by bacteria in the causation of disease was much more extensive than was
generally' believed, and that the infective agents that produced the most prevalent
forms of disease were those that were more or less generally distributed, such as,
for example, the pneumococcus, Bacillus coli communis, and Streptococcus
pyogenes. As a means of determining the relation of common bacteria to morbid
conditions in the human subject, animal experiment was of little value ; the method
of focal reaction and therapeutic immunisation had, on the other hand, proved
capable of determining many of the questions at issue. Evidence had been
collected that served to show that very many forms of mental disease were
dependent upon bacterial action ; the infective conditions were, for the most part,
those that were commonly found in other patients; the mental disturbances were
the expression of an individual reaction, consequent upon an inherent tendency
to fix toxines in the cortical nerve cells. Some bacterial toxines were specially
prone to exercise a neurotoxic action. Cases were cited illustrating the neurotoxic
action sometimes manifested by various species of streptococcus, the bacillus of
influenza, diphtheroid bacilli, and bacilli of the coli-typhoid group. In cases of
mental disease the infected conditions were often complex; this fact rendered
their bacteriological investigation difficult, but it did not necessarily prevent the
successful application of therapeutic immunisation.

Drs. G. M Robertson and Cruickshank afterwards discussed the paper.

Dr. Cruickshank also read an interesting paper on “The Cholesterol Content
of the Serum in Mental Diseases” (see p. 168).

A vote of thanks to the Chairman for presiding concluded the business of the
meeting.

No dinner was held after the meeting.

IRISH DIVISION.

The Autumn Meeting of the Irish Division was held on Thursday, November
4th, at the Royal College of Physicians, Kildare Street, Dublin.

Present: Drs. Drapes, J. A. Greene, Redington, Dawson, Lawless, Rainsford,
Eustace, and Dr. Leeper (Hon. Secretary).

Dr. Drapes having been moved to the chair, the minutes of the previous
meeting were read and signed.

A letter of apology for unavoidable absence was read from Dr. Oakshott, of
Waterford.

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NOTES AND NEWS.

[Jan.,

A telephone message having been received from Dr. J. O'C. Donelan that he
was unavoidably prevented from attending the meeting, Dr. Dawson kindly
consented to introduce the discussion upon “ Alcoholism and Insanity,” which was
the principal item of the agenda. He cited extracts from a former paper upon the
subject, read by him before the Academy of Medicine, a valuable contribution to
the literature of the subject, which were most opportune, more especially as little
light had recently been thrown upon the particularly interesting and difficult
questions which must inevitably arise during any debate upon the subject. The
matters discussed in Dr. Dawson’s paper were of a wide and far-reaching
significance, and dealt with the scientific and eugenistic problems inseparable from
the consideration of the effects of alcohol upon the human subject, together with the
statistics of alcoholically produced insanity in asylums, and were of much interest.

After some remarks by the Chairman, who expressed himself as very gratified
by the kindly act of Dr. Dawson in so ably introducing the discussion in the
absence of Dr. J. O'C. Donelan,

Dr. Rainsford said that alcoholism as a cause of insanity was much over¬
estimated. In Bristol Asylum, where he had had considerable experience, the
admissions directly due to alcohol were not more than 5 per cent . As regards the
effects of alcoholism, in the parents as a cause of imbecility in the offspring, he had
decided opinions. He believed alcoholism was a cause of imbecility, and more
especially of imbecility associated with epilepsy as a marked condition. As regards
the causation of insanity, he regarded alcoholism as playing a small rdle , and
being responsible for not more than from 3 to 5 Per cent , of the admissions to
asylums.

*Dr. Redington drew attention to the curious fact of the small number of
alcoholic patients who suffer from cirrhosis of the liver. He had had only one such
case in a number of years at Portranc Asylum, and only two cirrhosed livers
in alcoholic patients had been found in the Richmond Asylum during a number of
years.

Dr. J. Adrian Greene gave the members the benefit of his large experience
of inebriates in the Ennis Inebriate Institution. Many of the cases were feeble¬
minded on admission, and he considered that a lengthened period of detention
was necessary if any good result was to be achieved. He humorously referred
to the fact mentioned by some American wiseacres that a condition of teetotalism
was a more frequent forerunner of insanity than alcoholism.

Dr. Eustace dealt with the treatment of acute cases of alcoholic mania. He
usually treated these cases by immediate deprivation of alcohol and saline enemata,
together with atropine injections in suitable cases, and with in his hands excellent
results, some of the patients so treated having remained well for years.

Dr. Leeper drew the attention of the members to the fact that so many alco¬
holics came under treatment suffering from delusions of persecution. These
distressing delusions often deterred the relatives of such patients from placing
them under control until they had done much injury to their families. Legislation
was urgently needed to deal with both the entrance and exit of alcoholic patients
into and out of asylums or other institutions where alone alcoholics could hope for
any amelioration of their condition, or where any curative treatment was possible.

The Chairman commented on the fact that statistics as regards the role of
alcohol in the causation of insanity were contradictory and misleading. Dr.
Rainsford’s estimate of 3 to 5 per cent , as the ratio of cases due to alcoholism he
considered far below the mark ; and he believed that most authorities regarded
15 to 20 per cent , as about the true proportion. One fruitful source of error and
ambiguity in determining this question was the fact that for many years in the
official statistical returns from asylums only one cause of insanity was allowed to
be given, whereas in probably every case the causes are multiple. Where, then,
alcohol and some other cause or causes were combined, as where alcoholism and
heredity coexisted—a very common occurrence—the medical man making the
return had to take his choice as to which cause he would enter, and his decision
was absolutely dependent on the personal equation. In recent years both principal
and contributory causes are entered in the return, and it was probable that many
years would have to elapse before reliable deductions could be drawn from these
amended and more accurate returns. He next drew attention to the modern
methods of treatment of alcoholics in America, and especially to the colony

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system which, combined with watchful after-care and supervision by medical men
specially appointed for the purpose, seemed to give more excellent results.

An expression of thanks to the President and Fellows of the College of
Physicians for the use of the college rooms for the purpose of the meeting
terminated the proceedings.

EXAMINATION FOR NURSING CERTIFICATE.

List of Successful Candidates.

Final, November, 1915.

Fort Beaufort, S. Africa. —Letitia Brandt, Janet Olive Wallace.

Brentwood , Essex. —Annie Josephine O'Donovan, Sarah Collins.

Barming Heath, Kent. —Dora Louisa Henwood, Florence List.

L.C.C., Bexley. —Beatrice Brawn, Eva Thornton, Ethel Hallam.

I- Vest Sussex. —Elsie Rose Cording.

Cheddleton, Stafford. —Ada Godber (distinction), Nellie May Bright, Matilda
Sharpe Givin.

Menston, West Riding. —Amy Longstaff, Hilda Mary Marsh, Maggie Nolan.

Wakefield, West Riding. —Nellie Clayton, Alice F. Cottam, Cissie Harriet Millns.

Winson Green, Birmingham. —Edith Emma Lowe.

Cardiff City. —Lilian Emily Downes.

Hull City. —Ethel Kirkby.

Bethlem Hospital. —Elizabeth Ellen Maddick, Etta Trevethan, Ernest Charles
Kind.

Coton Hill Hospital. —Amelia Lawton Cooke.

Fountains Temporary Asylum. —Priscilla Elizabeth Knott.

Camberwell House. —Mary Smith, Hilda Kemp, Olive Florence Crook, Eva May
Fauk, Mary Ellen Jackson Watt.

Virginia Water, Holloway Sanatorium. —Ethel May King.

Redland, Tonbridge. —Colin Roots.

The Retreat, York. —Lily Evans, Elizabeth Alison Gracie (distinction), Dorothy
Hughes, Constance Evelyn Kent.

Norfolk County. —Lilian A. Lyon, Ethel Maud Fiddaman.

Aberdeen Royal. —Mary Jane Aitken, Elizabeth Stevenson Watt, Margaret
Hutchison, Margaret Milne.

Aberdeen District. —Margaret Henry Kennedy.

Craig House. —Mary A. Goodsir, Flora Macrae, Elizabeth Paton, Margaret D.
Mclnnes, Lillie Fry, Maggie Stuart.

Murray, Perth. —Elsie A. Simpson.

Edinburgh, Royal. —Janet Macphail, Elizabeth Milne Finingham, Caroline Green
Robinson, Laura Augusta Stuart Forsyth, Jessie Carmichael McArthur, Charlotte
Margaret Ross, Mary May Ross, Margaret Nicol Birrell Reith.

Gartloch, Glasgow. —Jane Lyall Milne (distinction), Jane Annie Oselton,
Isabella Newlands (distinction), Catherine McNiven Wynd, Jessie Sinclair, Mabel
Beatrice Parfitt.

Woodilee, Glasgow. —Sarah Annie Streetley, Mary Downie, Agnes Doig Howie.

Haddington District. — Isabella Macdonald Chisholm.

Montrose Royal. — Mary Helen Matthew Coull.

Larbert, Stirling. — Alice Jane Duff, Jessie Finlay Robertson.

Edinburgh District. —Janet Adams, Alison Wright Ferguson, Susan Theresa
McGarvey.

Portrane, Dublin. — Ellie McCormack.

Preliminary, November, 1915.

Fort Beaufort, S.A.—Maggie Grant, Elvin Leslie Yorke.

Grahamstown, S.A .—Ivy Muriel Boardman, Annie Catherine Dew Rand,
Katherine Philippina Terblanche, Stephanus Johannes Bosch, Frank Norman
Emslie, William Davidson.

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Robbin Island, S.A.—Arthur Harold Celliers Sasser, Edward Patrick Smithwick,
Birdie Catherin Cocker.

Federated Malay States. —Muttu Kanapathipillai, Hilda May Joseph.

Pietermaritaburg, S.A. —Irene Ryan, Eleanor Maxwell Richardson.

Denbigh, North Wales. —Margaret Jane Jones, Annie Griffiths, Frances Myfanwy
Owen, Margaret Edwards.

Kent, Barming Heath. —Eleanor Wood Griffiths, Edith Dorothy Hall, Ethel
Gould, Eva Caroline Browning, Annie Mabel Franklin, Ethel Jackson Griggs,
Ella Beatrice Watson, Ada Florence Wratten, Annie Mary Jones.

Fountains Temporary Asylum. —Mabel Marlow, Ethel Jakes, Dorothy Mary
Cook, Jessie Macdiarmid.

Stafford. — Margaret Budd, Frances Mary Walters, Elizabeth Bill, Gertrude
Jane Davis, Jessie Bradbury, Emily Spencer, Bessie Parry.

Cheddleton. —Maggie Ellen Derry, Irene Ethel Godber, Sophie Louise Gray.

Mcnston. —Ruth Elizabeth Marsh, Annie Baguley, Kathleen Gould, Margaret
Scanlan, Susan Emily Buttler, Ethel Bailey, Isabella Young, Ethel Acton.

Wakefield. —Gertrude Wheatcroft, Charlotte Jones, Ada Roulston.

Camberwell House. —Eva W. Walter.

Claybury. —Nellie Williams.

Cardiff. —Elsie Muriel Prowse, Mary Lewis, Evelyn Valerie Joels.

Coton Hill. —Florence Louisa Wilson, Millicent Burgess, Winifred Keeling.

Derby Borough. —Lucy Griffin, Charles Henry Hester, Hannah Hill, Florence
May Hutchings, Norah May Murrell, Hypatia Lilian Musty, Mabel Ida Pitt, Mary
Addielade Stacey, Sarah Ellen Martha Smith, Winifred Lilian Stevenson.

Hull City. —Mary Imdda Carlin, Edward McCormick, Hilda Burgess, John
Douglas Mood}'.

Middlesboro'. —James Cass.

Norwich City. —Mabel Elizabeth Barnes, Elizabeth Ann Holliday, Jessie Annie
Holmes, Caroline Elizabeth Smith, Dorothy Lucy Waters.

St. Luke's. —Maude Florence Nicholls, Annie Flanagan, Noah Stroud, Josephine
Flanagan.

Retreat, York. —Miriam Grace Brock Thompson, Aileet. Dora Hume, Lucy
Dorling, Dorothy Bumby.

Aberdeen, Royal. —Adam Harcus, Jean Finnie, Euphemia Glashan, Jessie Craig,
Elsie Helen Cowie, Mary Dickson Taylor, Caroline Margaret Lorimer, Jane
Young, Annie Hay, Isabella A. M. Shand, Flora Pirie.

Aberdeen, District. —Sarah Coull, Amy Robertson, Jane Ann Buchan, Maggie
Mary Duff, Charlotte Brown Sherriff, Mary Ann Robertson, Helen Johnstone,
Jeannie Agnes Rennie, Helen Ann Watt, Jane Ann Gould Connon, John Smith.

Edinburgh District. —Annie Maria Butler, Annie S. Little, Annie Redmond,
Catherine Horsburgh Spiers, Marion Terris Tennant.

Craig House. — Isabella Maud Cromarty, Ruby Swanson.

Edinburgh Royal. —James Bonnyman, Herbert Smith, Gideon Ramsay, Agnes
Rutherford Mawer, Mary Stalkin Farmer, William J. Fraser, Annie Fraser, Mary
Ann Duncan.

Gar/loch. —John Barron, William Lewis Sands, Dan Kelly, William John Ross,
Christina Forbes Neill, Mary Johnston, Janet Lindsay Mitchell, Mary Scott
Charlton, Annie Milne, Agness Baird Cross.

Woodilee. —Jessie Burnett Findlay, Mary Malcolm Brown Gordon, Janet P.
Gordon, John Livingstone, Elizabeth Marshall, Julia Guthrie Turnbull, George
Chaplin.

Inverness.— Isabella Campbell, Beatrice Elsie Montgomery, Kathleen Connolly.

Montrose Royal. —Jessie Paton, Isabella Leighton Urquhart, Mary Buick,
Christina Johnson.

Murray, Perth. —Mary Jane Meldrum, Margaret Henderson.

Perth District. —William Hamilton.

Larbert, Stirling. —George Reid, Hugh McBride, Mary Kate Hart, Catherine
Lavin, Isabella Black, Jean Whitelaw Philp, Mary Clark, Evyleen Cloonan.

Larbert Institution. —Jessie Murray, Maggie F. Taylor, Isobel Taylor.

St. Patrick’s, Dublin. —Muriel Elizabeth McKenna, Margaret C. Nugent.

Warwick County. —Edith Annie Smith, Rose Goodall, Phyllis M. Radnor, Annie
L. Mason, Agnes R. Jenkins, Amelia Patrick.

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Examination for Nursing Certificate, November, 1915.

Final Examination.

List of Questions.

1. Describe by what means the various foods after digestion are absorbed into
the system. What do you understand by assimilation ?

2. How would you classify poisons ? Give an example of each class. What
would you do if a patient under your care were suspected of having taken poison ?

3. Describe the mental symptoms of a case of confirmed epileptic insanity.

4. In what classes of patients are b'edsores most likely to occur, and what steps
would you take to prevent their formation ?

5. Describe the mental symptoms which may be present in a case of General
Paralysis of the insane.

6. Mention some of the causes which may lead a patient to attempt suicide.
What precaution would you take with a patient who was known to have suicidal
tendencies ?

7. A patient receives a deep punctured wound in the palm of his hand ; what
arterial vessels might be divided, and state any difficulties that might arise in
stopping the flow of blood in this situation.

8. Describe the conditions likely to be present in a patient suffering from severe
varicose veins: how would you treat the case ?

Preliminary Examination, November, 1915.

List of Questions.

r. Where and by what means are the following foods digested ? (1) Bread and

butter. (2) Lean meat. (3) Potato. (4) Cheese.

2. A patient has tried to hang himself with a rope; what will you do if you find
him hanging and apparently unconscious ?

3. State the dangers and the first aid treatment when a patient (a) drinks floor
polish composed of turpentine and wax, and ( b ) receives a sting in the mouth from
a wasp.

4. Give a description of the structure of the skin and state its functions.

5. Why are (1) Regular bathing, and (2) Exercise, necessary for good health ?

6. Mention the methods of artificial respiration and describe the one most
commonly employed.

7. Describe the varieties of fractures and the principles in treatment.

8. What varieties of unconsciousness simulate drunkenness, and how are they
distinguished ?

Resolutions re Nursing Examinations.

“(1) That no candidate be excused the Nursing Examination or any part of it,
on any ground whatever.”

“ (2) That those male or female nurses who have served during the present war
in either the Navy or Army be excused all the items of training mentioned in para¬
graph (8) of the training regulations except (a) requiring twelve months' attendance
on the insane.”

“ (3) That, in the case of any male or female nurse who by reason of war service
has been prevented from sitting for the Preliminary Examination, the statutory
interval between the two examinations be not insisted upon, provided the three
years’ service in an Asylum be not shortened.”

The above resolutions were confirmed at the February meeting of the Association.

December, 1915. Alfred Miller, Registrar.

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NOTES AND NEWS.

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OBITUARY.

Dr. Edward Daniel O’Neill.

By the death on January 12th of Dr. Edward Daniel O’Neill the Asylum Service
of Ireland has lost one of its most capable administrators. His symptoms did not
appear to be of serious import until a comparatively short time before his demise.
His health, however, had been a good deal impaired for some time past, and he
suffered more or less from chronic insomnia and gouty attacks. He was sixty-three
years of age, and had been for twenty-six years in charge of the Limerick District
Asylum, in which capacity he had won the confidence and esteem of his Committee
of Management, of the Inspectors, and of the public generally. His medical
education he obtained in the Carmichael School of Medicine in Dublin, where he
took the diplomas of L.R.C.S. (1872), L.R.C.P. (1878), and M.R.C.P.I. (1884).
He was for five years (1881-18S6) Assistant Medical Officer at the Richmond
Asylum, Dublin, and from there was promoted to be Medical Superintendent of
Castlebar Asylum, where he remained for four years, and in 1890 he succeeded in
obtaining the similar but more important post in Limerick Asylum. Dr. O’Neill
took a warm interest in the welfare of his patients, whom he treated with invariable
kindness and consideration. His courtesy towards all with whom he had to do
will be a grateful reminiscence in the minds of many. He was a representative
member of the Council of the Association, and attended the Quarterly Meeting in
London in November last. His too early removal has occasioned the deepest
regret to his colleagues in Ireland, and indeed to everyone who had the pleasure of
knowing and appreciating his genial personality.

Lieutenant Edgar Faulks, R.A.M.C.

The speciality has sustained a loss by the death of Lieutenant Edgar Faulks,
R.A.M.C., late Senior Assistant Medical Officer of the London County Asylum,
Bexley, which took place on September 26th last whilst he was dressing a wounded
man in the fighting line near Loos in France.

Dr. Faulks, who was the son of Mr. and Mrs. Arthur Faulks, of Loughborough,
Leicestershire, was 38 years of age, and received his medical education at Guy’s
Hospital, where he held a number of resident appointments, and during which time
he was President of the Residents’ Club. He was appointed Junior Assistant Medical
Officer at Bexley, and during eleven years’ service there he steadily rose, and was
for the latter five years Senior Assistant Medical Officer. He was a very
keen student, and took a deep interest in all new developments in the treat¬
ment, care, and housing of the insane. He was a very able clinician, and his
opinion, owing to his well-balanced judgment, was always much sought by his
colleagues. He had a very delightful personality, and entered very fully into the
life of the Institution.

A special Memorial Service was held in the Asylum Church on the Sunday
following the news of his death. Beloved alike by his colleagues and by the
patients and staff, the death of Dr. Edward Faulks has left to all who knew him a
deep sense of personal bereavement.

CORRESPONDENCE.

To the President and the Members of the " Medico-Psychological Association .”

Gentlemen, — I take the liberty of soliciting your kind support in the interests
of juvenile defectives in Belgium, and more especially in the Province of Brabant.
This question was in a fair way of being solved at the time of the outbreak of the
war, and the provincial authorities of Brabant had decided to erect an institution
for the "feeble-minded” at Waterloo. The construction of this establishment
had begun when the war broke out, and all the operations were stopped.

It is to be feared, and news from Belgium confirm this apprehension, that the
heavy expenses that our country will ultimately have to meet will be a pretext for

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abandoning a number of works and reforms which up till the eve of the war were
thought to be absolutely indispensable. It is evident that we shall have urgent
duties to discharge towards our compatriots who are victims of the war, and
especially as regards our orphans and cripples. But, are we on that account to
give up the sick and infirm, the old, the insane, and abnormal. To put the ques¬
tion is to solve it. We could not consent to such a retrograde course of action,
resigning ourselves to a barbarism almost as horrible as that which our unscrupulous
enemies have inaugurated during this war. Philanthropists and savants who have
interested themselves in “ abnormal childhood ” in all civilised countries will lend
an ear to the appeal which I am making now in favour of the abnormals in
Belgium, and after reading these few lines will promise help and advice to the
Belgians who have taken an especial interest in this subject, and will direct their
thoughts in particular to the very interesting work in the Province of Brabant.

I hope to interest such persons by rapidly enumerating the efforts which have
been made in Belgium to help "deficient children.” It was about the year 1898
that the movement in favour of defectives started. At that time a regular medico-
educational campaign in primary instruction began in the town of Brussels, in
favour of the separation of deficient from normal pupils. Later on classes, and a
school of special instruction were instituted. Soon afterwards the town of Antwerp
followed suit. And since then these schools and classes have proved a very fruitful
field of work for doctors and teachers. A few years later the town of Gand started
a wonderful school of instruction for the weak-minded, and towards 1912 and 1913
the town of Lifege, in its turn, took up the study of this question. Thanks to these
special schools and classes some new educational methods have been discovered,
which, in their turn, proved of value even in the case of normal children. Since
1906 doctors and teachers in Brussels applied themselves to estimating the mental
capacity of the scholars with the help of the tests methods of De Sanctis and
Binet. During this time the Society for the Protection of Abnormal Childhood
in Belgium continued its unwearied propagandist efforts. It addressed itself to
the communal, provincial, and governmental authorities without being discouraged
by the numerous rebuffs to which it had to submit, due to ignorance of the import¬
ance of the subject. But, thanks to its repeated efforts, the said Society succeeded
in giving effect to its views. In the new law dealing with juvenile crime the
existence of abnormal children was noted, and the attention of judges was especially
called thereto.

In 1901, the Society for the Protection of Abnormal Childhood presented a plan
of a “ farm-school ” to the Society of Martyr Children. But it was not till 1909 that
this project was restarted, and this time submitted to the provincial authorities
of Brabant. The latter agreed to establish a " farm-school ” at Waterloo. The
plans were completed in 1913, and the erection of an institution for 240 defectives
was commenced in 1914. The war stopped all work. The institution, when com¬
pleted, was to comprise four pavilions on separate floors, a farm, a laundry, a
kitchen, offices of administration, workshops, a gymnasium, a lazaretto, and an
infirmary ; and land to the extent of 15 hectares (about 2j acres) was reserved for
cultivation. During this time the Province of Brabant instituted a temporary
course for the instructors desirous of specialising in the subject. The courses were
inaugurated in January, 1914, and came to an end some weeks before the war.
The examinations were to have taken place in October, 1914.

The Province of Brabant, moreover, provided a special subsidy to be given to
each communal or free school for the maintenance of classes for giving instruction
to backward or deficient children. And the complete and harmonious development
of a system of aid for children mentally afflicted was anticipated.

For the sake of those dour souls who repeatedly tell us that more is done for the
abnormal than for the normal, we must add that the Province of Brabant encourages
professional teaching, and that it has instituted schools for teachers in baking and
carpentry, in agriculture and horticulture, normal schools for teachers, etc.
That is to say, the resources of the leading province of Belgium were devoted to
works which were the most useful to the nation and to humanity.

All these excellent plans are upset. The Belgian provinces and communes are
systematically ruined by an unscrupulous enemy, who has levied taxes as exorbi¬
tant as they are illegal (500 million francs), and who at the same time has requi¬
sitioned, without paying for them, a quantity of things, stores, machinery, and

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NOTES AND NEWS.

[Jan.,

alimentary substance^. Belgium will then be without any resources whatever after
the war. Assuredly, the enemy who has pillaged and stolen will have to make
restitution. But even if he wanted to, he would be incapable of doing so, seeing
that he will have consumed an enormous proportion of what he has taken.

Our hope of “Justice,” however, so slow in coming, still remains unshaken.
Justice must be done, and completely, too. But in the presence of the material
ruin of our splendid Flemish and Walloon cities we must not forget our social
ruin. Are we going to allow the hygienic, educational, and social works of the
finest of our Belgian provinces to perish—Hainault, Brabant, and Li^ge ? Are we
going to leave in jeopardy the works of our great cities ? This is impossible, for
after the war they will be more useful than ever. The splendid school for cripples
at Charleroi and the one at Brabant, will they not need to be indefinitely extended
in consequence of the war ? Will it not be the same with respect to the insane and
the feeble-minded ?

Besides, is it not the duty of all savants and philanthropists to think about
these objects ? The favoured ones of fortune whom the war has not only spared,
but who have even, thanks to it, found their means increasing, do these not think
it their duty to humanity to spend a portion of their revenues on these social
schemes in Belgium ? Wherever they may be, may their consciences tell these
privileged persons, the rich ones, that they cannot enjoy their wealth without
remorse, if they have not helped and if they do not continne to give unflagging
help to a nation which has been the victim of its own loyalty! Wherever they
may be, let learned men also give voice to their conscience and their heart, and
claim it as an honour to support these Belgian scientific and social objects both
by word and writing. May psychologists, interested in deficient children, be
willing to reply to my appeal, and give their support to the efforts being made
in the interests of the mentally deficient, and more especially those in connection
with the “ Farm School " of Waterloo.

1 beg to thank, as much in the name of the Society for the Protection of
Feeble-minded Children in Belgium as in my own name, the “ Medico-Psycho¬
logical Association of Great Britain ” if they will accord a favourable reception to
this appeal.

M. F. Boulenger, M.D.Brussels,

Member of the Office of the Society for the Protection of
Abnormal Childhood in Belgium.

Darenth Industrial Colony,

Dartford, Kent,

England.

NOTICES BY THE REGISTRAR.

Nursing Examinations.

Preliminary.Monday, May ist.

Final ...... Monday, May 8th.

Professional Examination Certificate in Psychological Medicine and Gaskell
Prize, first week in July.

Essays for Bronze Medal must be sent to Registrar on or before June 14th.

NOTICES OF MEETINGS.

The next General Meeting will be held at 11, Chandos Street, Cavendish Square,
W., on Thursday, February 17th, when a paper will be read by George M. Robert¬
son, M.D., F.R.C.P.Edin., on “The Employment of Female Nurses in the Male
Wards of Mental Hospitals.”

Quarterly Meetings: February 17th, 1916; May 16th, 1916.

The Divisional Meetings are proposed as follows :

South-Eastern Division .—April 28th, 1916.

South-Western Division .—April 21st, 1916.

Northern and Midland Division .—April 27th, 1916.

Scottish Division .—March 17th, 1916.

Irish Division .—April 6th, 1916; July 6th, 1916.

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APPOINTMENTS.

Drummond, W. B., M.B., C.M.Edin., Medical Superintendent of Baldovan
Certified Institution for the Treatment and Education of the Feeble-minded,
Dundee.

Peachell, George Ernest, M.D., C.M., M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent of the Dorset County Asylum, Dorchester.

A'.S.—The Editors will be glad to receive contributions of interest, clinical
records, etc., from any members who can find time to write (whether these have
been read at meetings or not), for publication in the April number of the
Journal. They will also feel obliged if contributors will send in their papers in
good time, if possible.

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THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.']

No. 257 [To":/."] APRIL, 1916. VOL. LX 11 .

Part I.—Original Articles.

ON CAUSATION

WITH A CHAPTER ON BELIEF

BY

CHARLES A. MERCIER, M.D., F.R.C.P., F.R.C.S.

(1 Continued from p. 108.)

III. Similarity.

Unquestionably the most usual and frequent ground for
assuming a causal relation which is not immediately apparent
is the similarity of the case in hand to other cases in which the
causation has been ascertained. As it is the most frequent, so
it is the most direct application of the fundamental Axiom of
Causation, that Like causes in like conditions produce like effects,
from which we obtain, by a logical process that is unknown to
logicians, the immediate inference that Like effects in like con¬
ditions are due to like causes. It is by the application of this
method not only that causation is most often established, but
also that some of the most important discoveries of causes in
the various sciences have been made. It is in perpetual use,
both in the most recondite problems of science, and in the
commonest affairs of daily life.

It is asserted in nearly every book on Logic that the planet

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ON CAUSATION,

[April,

Neptune was discovered by Mill’s Method of Residues. The
planet Neptune was not discovered by the Method of Residues.
The very descriptions of the discovery that are given to show
that it was discovered by the Method of Residues show that it
was not discovered by the Method of Residues, and the same is
true of every other instance in which the books assert that
a cause has been discovered by this method. No cause of
anything has ever yet been discovered by the Method of
Residues, and it is extremely unlikely that any cause of any¬
thing ever will be discovered by it. What was discovered by
the Method of Residues was that there were certain move¬
ments of the planet Uranus that were not accounted for by
known causes. The Method of Residues did not discover the
cause, nor point to the cause. All it discovered, and all it
pointed to, was that there was something for which an addi¬
tional cause was required. The additional cause was discovered
by the Method of Similarity. It was found by applying the
Axiom Like effects in like conditions are due to like causes. After
all the perturbations of Uranus that are due to the attraction
of known planets had been reckoned, it was found that there
was a residue of perturbation unaccounted for; and this led
astronomers to guess that there must be some other cause of
perturbation, yet unknown, and to look for it. The astronomer
said ‘This residual effect must be due to some extra cause that
I have not reckoned on. But though it is a new effect, it is
not a new kind of effect. I am familiar with perturbations of
planets, and I know how they are produced. They are produced
by the attraction of other planets. Now, Like effects in like
conditions are produced by like causes ; therefore this perturbation
must be due to the attraction of some undiscovered planet,
and I must proceed to discover it. In order to produce this
effect, the causal agent must have been in a certain place at a
certain time.’ Then he investigates, and finds that at that
time Neptune was in that place.

Precisely the same method is employed by the cook when
she finds herself short of a pot of jam. This also is a residual
phenomenon. After accounting by known causes for the
absence of most of her jam, she finds there is a residue of loss
that cannot be so accounted for. This is all she can learn from
the Method of Residues. She learns from it that there is
something for which a cause is required. She then sets to work
to discover the cause. She says ‘ This loss must be produced

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by some cause that I have not reckoned on ; but though it is a
new effect, it is not a new kind of effect. I am familiar with
the abstraction of pots of jam from my cupboard, and I know
how it is produced. It is produced by the action of human
hands. Now, Like effects in like conditions are produced by like
causes ; therefore the abstraction of this pot must be due to the
hands of some undiscovered person. In order to produce this
effect, the causal agent must have been in a certain place at a
certain time.’ Then she investigates, and finds that at that
time the page-boy was in that place.

It is the same with every other application of the Method of
Residues. What is found by it is not the cause of anything,
but something unaccounted for, something requiring explana¬
tion, something for which a cause must be found ; but in finding
the cause the Method of Residues is never employed, and
would be useless if it were employed. The cause is found by
one of the methods here described, and very often by the
Method of Similarity.

When physicians desired to know the cause of yellow fever,
did they proceed by the Method of Agreement, or the Method
of Difference, or the Joint Method of Agreement and Difference,
or the Method of Concomitant Variation, or the Method of
Residues? They did not. They were not so foolish. The
way they went to work was to assume that the cause of this
disease is like the cause of a similar disease occurring in similar
conditions. There is no disease exactly like yellow fever:
such a disease would be yellow fever itself; but there is a
disease, ague, which is like enough to yellow fever for the
purpose of the argument; and the cause of ague is known.
Ague is caused by the injection, by the bite of a mosquito, of a
parasite into the blood ; therefore, it was argued, on the ground
of the Axiom of Causation, that yellow fever also is caused by
the bite of a mosquito ; and suitable investigations being made,
the conclusion was verified in this case and in that. But it
was not verified in every case, and it cannot be verified in every
case. In the cases that now come under care, we do not and
cannot satisfy ourselves by observation or experiment that they
have been caused by the bites of mosquitoes; but for all that
we do not doubt for a moment that they have been so caused.
What, then, gives us our assurance ? The same variant of the
Axiom of Causation, that Like effects in like conditions are due to
like causes.

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ON CAUSATION,

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When a chemist wishes to determine whether lead is present
in certain water, he applies certain reagents ; and if he obtains
certain results, he concludes at once that lead is present; and
so sure is he, that he is prepared to go into a court of law and
swear to it. By what method has he ascertained that the
cause of the reactions that he obtained was the action of lead
in the water? By the same method that leads the cook to
conclude that the disappearance of her jam was due to the
action of the page. The chemist knows that on every previous
occasion on which he or anyone else has ever tried it, lead has
had this effect, and nothing else has ; and he assumes at once
that since the effect and the conditions are similar, the cause is
similar.

When the photographer finds that directly he pours his
developer on the plate, the image flashes up, he knows that the
plate has been grossly over-exposed; and he discovers the
cause of this effect by the Method of Similarity. The effect is
like the effect that has in like conditions been produced by
a certain cause; therefore, he concludes, the cause in this
instance is like the cause in that. Is his plate fogged ? Then
he concludes that diffused light has fallen on it, and his reason
is the same. Is his result brilliant ? Then he determines that
on future occasions he will repeat the conditions as closely as
possible; and is confident that the more closely he can get
them like the conditions in this case, the more closely similar
will be the result.

When the horticulturist finds his tomatoes suffering from
disease displaying certain symptoms, does he apply any of
Mill’s Canons? Not if he knows his business. He looks
round for similar diseases in similar plants, confident that if
he finds such a disease, and the cause of it is known, he may
assume a similar cause for the disease of his tomatoes. He
has not far to look. On his potatoes, plants belonging to the
same natural order as the tomato, he finds a very similar
disease; and he knows that this potato disease is due to a
fungus of a certain kind. He concludes at once that the
disease of his tomatoes is due to a fungus, and to a similar
fungus; and more, he concludes that whatever treatment
effectually cures the disease of his potatoes is likely to relieve
the disease of his tomatoes. He does not look for two or more
instances which have nothing in common but the occurrence
of the phenomenon, and two or more instances which have

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nothing in common but the absence or the phenomenon : he
looks for a single instance as like as possible ; and having found
an instance that is like enough for the purpose of the argument,
he looks no further, for he knows that Like effects in like con¬
ditions are due to like causes.

A remarkable instance of the application of this method has
recently divided with the war itself the interest of this country.
Four women in four different parts of the country were found
drowned in baths under conditions that were closely similar;
and the similar conditions were not only closely similar, but
were numerous. In each case the woman was recently
married ; in each case she either possessed money or her life
had been recently insured ; in each case she had made a will in
favour of her husband ; in each case the husband reported the
death on his return from going out to buy food; in each case
the woman had been said by the husband to have fits, though
she was not otherwise known to have them ; in each case
the funeral was hurried, and was carried out as cheaply as
possible. Such closely similar effects in such numerous closely
similar conditions pointed conclusively to closely similar causes
and closely similar agents. When it was discovered that in all
the cases the husband was the same man, the similarity became
merged in identity. This one circumstance was antecedent in
every case, and was the only common antecedent; and it was
impossible to doubt that he was the agent that had produced all
the effects. But the Method of Similarity, though by itself it was
sufficient, was not the only method employed in discovering
the agent. The sixth method also, the Method of Common
Rarity, was employed. It is, in fact, not usual for the discovery
of a cause or of an agent to be made by the employment of one
method only; and here we may give an anticipatory instance
of the Method of Common Rarity. Death in a bath is rare.
Death in a bath of a newly married woman, under all the
conditions enumerated, is extraordinarily rare. The rarity of
the effect pointed in each case to a cause equally rare; the
common rarity of all the effects pointed not merely to rarity,
but to actual uniqueness of the cause and of the agent. In all
the cases there was but one common factor that alone could
possibly be the agent, and this was the husband; who was
accordingly charged with murder, tried, convicted, and
executed.

Instances of the application of the Method of Similarity

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might be multiplied indefinitely. It is the ordinary common
method of discovering those causes that are not forced upon
our attention by the Method of Instant Sequence; it is used
by everyone many times every day, and is more frequently
employed in scientific investigations than any other method;
but logicians, though in common with other people they are
constantly using it, have never described it, and never dis¬
covered it.

IV. Association.

The mere association between an action upon a thing and a
following change or accompanying unchange in that thing
points to a causal connection between the action and the effect,
and is often taken to establish the causal connection. It does
not necessarily establish the connection, but in certain circum¬
stances it may do so, and our task is to discover and state these
circumstances.

This is the method so clumsily expressed, and so erroneously
expressed, by the first three of Mill’s Canons, which we may
now examine. The first thing that strikes us upon reading
them is the extraordinary cumbrousness, the elephantine pon¬
derosity, of their expression. A statement is not necessarily
erroneous because it is badly expressed ; but cumbrous and
awkward expression is a sign of confusion of thought; and
when we find such portentous circumlocution as these Canons
display, we may be quite sure that the writer is trying to
convey some thought that he has not thoroughly worked out;
that it is certainly no more than an approximation to the
truth ; and that it is very likely to be erroneous. Elegance of
expression is no guarantee of accuracy, but it is an indication
of care ; and clumsiness of expression is an almost certain sign
of confusion and want of thoroughness in thought.

The first of the Canons runs : ‘If two or more instances of
the phenomenon under investigation have only one circum¬
stance in common, the circumstance in which alone all the
instances agree [why not ‘this circumstance’?] is the cause
(or the effect) of the phenomenon/

Apply this to a concrete case, and let the ‘ phenomenon
under investigation 1 be green colour. Two or more instances
of green colour (a bucket, an armchair, and a pool ball) have
only one circumstance (that they are green) in common; this
circumstance is the cause (or the effect) of the green colour.

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So obvious is this booby-trap that some of Mill's followers
have noticed it, and have modified the Canon so that it reads
‘ have only one other circumstance in common.’ Let us see
how the amendment works out in practice, and let the ‘ phe¬
nomenon ’ still be green colour.

If two or more instances (a bucket, an armchair, and a pool
ball) of the phenomenon under investigation (green colour)
have only one other circumstance (that they are in the same
house) in common, this circumstance (being in the same house)
is the cause (or the effect) of the green colour.

Of course, according to my nomenclature, the green colour
of these objects, since it is neither a change nor an unchange,
is not an effect but a result; but it is certainly a phenomenon,
and according to Mill’s nomenclature it is an effect; and out of
his own mouth must he be judged. If he had recognised that
an effect means a change or an unchange, and that a cause
means an action, and had expressed his Canon accordingly, it
would have at least been true, though even then it would not
have been much use. It would then have run as follows :—

If two or more instances of an effect are preceded or accom¬
panied by only one mode of action on the thing changed or
unchanged, that mode of action is the cause of the effect in
each case.

This of course would be true, but when was there ever such
an effect? Events in this world are not thus isolated, and we
have no experience, and are never likely to have any experience,
of an effect that is preceded or accompanied by one action and
no more on the thing in which the effect is produced.

Mill’s second Canon runs thus :—‘ If an instance in which
the phenomenon under investigation occurs, and an instance
in which it does not occur, have every circumstance in common
save one, that one occurring only in the former; the circum¬
stance in which alone the two instances differ, is the effect, or
the cause, or an indispensable part of the cause, of the pheno¬
menon.’

Again let us clothe these dry bones in flesh and skin, and let
the phenomenon still be green colour. If an instance (a pool
ball) in which the phenomenon under investigation (green
colour) occurs, and an instance (another pool ball) in which it
does not occur, have every circumstance in common save one
(touching the cushion) that one occurring only in the former;
the circumstance (touching the cushion) in which alone the

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two instances difter, is the cause, or the effect, or an indis¬
pensable part of the cause of the phenomenon (the green
colour).

In terms of action and effect, this Canon would run as
follows:—‘ If an action and an effect in the thing acted on are
associated both in presence and in absence, everything else
being the same, the action is the cause of the effect.’ This of
course is true, but in practice the Canon, even in this form, is
of no value, for everything else never is the same. In order to
give it any value the Canon should run:—‘ every other material
circumstance remaining the same.’ In this form the Canon is
true, and is valuable, but it is a very different Canon from
Mill’s.

Mill calls his third Canon the Joint Method of Agreement
and Difference, and puts it thus:—

‘ If two or more instances in which the phenomenon occurs
have only one circumstance in common, while two or more
instances in which it does not occur have nothing in common
save the absence of that circumstance; the circumstance in
which alone the two sets of instances differ is the effect, or the
cause, or an indispensable part of the cause, of the pheno¬
menon.’

In a concrete instance, If two or more instances (say a blade
of grass, a garden seat, and a park gate) in which the pheno¬
menon (green colour) occurs have only one circumstance (that
they are out of doors) in common, while two or more instances
(say a reel of cotton and a frying-pan) in which it does not
occur have nothing in common save the absence of this
circumstance (being out of doors) the circumstance (being out
of doors) in which alone the two sets of instances differ is the
cause, or the effect, or an indispensable part of the cause, of the
phenomenon.

The qualifications of this Canon are grotesque. When were
there ever two instances of any * phenomenon ’ that had only
one circumstance in common ? It is impossible to find such
instances, and impossible to imagine such instances. The
supposition is outrageous. If the ‘ phenomenon ’ is a material
thing, or a change in a material thing, the instances must have
at least the common circumstance that they are all subject to
the action of gravity. If the ‘phenomenon ’ is a mental state
or a mental change, the instances must have at least in common
the circumstance that they are in some mind or other. And

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how is it possible to find two other instances that have nothing
in common but the absence of the ‘ phenomenon ’ ? Instances
of what? Of the ‘phenomenon’? No, for that is to be
absent. Of the ‘circumstance’, then? No, for that also is
to be absent. And these instances of nothing are to have
nothing in common but the absence of the * circumstance ’, yet
they are to have also in common the absence of the * pheno¬
menon ’! Was there ever such a farrago or nonsense ? And
yet this precious Canon was not only gravely stated by Mill,
but has been gravely accepted by every writer of his school
ever since, and in seventy years not one of them has discovered
its tomfoolery ; nor has even any one of his critics, and they are
numerous enough, discovered its tomfoolery. Had its author
been anyone else, I should have suspected him of perpetrating
a huge joke, and laying an elaborate trap for his worshippers ;
but Mill was as destitute of humour as Herbert Spencer him¬
self, so that hypothesis will not stand. No. The only expla¬
nation is that Mill, and everyone else who has accepted or
criticised the Canons, have had their minds so bemused and
bemuddled by the study of Traditional Logic, that they are no
longer capable of distinguishing sense from nonsense.

As with the previous Canons, I have tried to make sense of
this by translating the terms ‘ circumstance ’ and ‘ pheno¬
menon ’ into action and effect, but no such amendment, and
no amendment of any kind, can make sense of it. Its inepti¬
tude is hopeless and incurable, enormous and incredible ; and
no tinkering or patching can amend it.

Preposterous as these Canons are, both in sense and in
expression, they are nevertheless blind gropings after a meaning
that is both true and valuable; that is to say, that there are
circumstances in which the association of an action on a thing
and an effect in that thing indicate a causal connection between
the action and the effect, and that these circumstances may
be formulated. We have already seen that this is true in one
set of cases—in those cases in which the effect is associated in
instant sequence with the action—and have now to show
what other cases there are. It must first be insisted that the
mere association of an action on a thing with an effect in that
thing does not necessarily imply causation. The sun may
shine on a house when it falls down; or on a river when it
overflows; the birds may be singing in the hearing of two
pugilists ; the train may be late when the rain is falling on it;

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the wind may be blowing on the corn when it is falling in
swathes; all these actions may be associated in time with
effects in the things acted on, and yet the association does not
justify us in concluding that the action is the cause of the effect.
Nor can we draw this conclusion from an association in space.
Grooming the horse is not the cause of its casting its shoe;
painting the gate is not the cause of its being out of plumb :
putting the kettle on the fire is not the cause of the fire burning
up, or of the kettle being full; crossing the swing bridge is not
the cause of its opening.

Yet there are cases in which we may properly argue from
association to causation, and it is important to distinguish the
cases in which we are warranted in so arguing from those in
which we are not. There are four such cases, that is to say—

Causal connection between an action on a thing and an
effect in that thing may safely be argued from their associa¬
tion

A. When other material action can be excluded;

B. When the association is of proved constancy ;

C. When, though inconstant, the association is more frequent

than casual concurrence will account for ;

D. When, though itself inconstant, the associated effect has

constant peculiarities.

A. If a certain action on a thing is associated with a certain
effect in that thing, and all other material action can be
excluded, then that action is the cause of that effect.

This is indubitable. It needs no proof. It is axiomatic;
and the method is unassailably valid whenever it can be
employed; but the occasions on which it can be employed are
restricted. Of course, if it were necessary to exclude all other
action, the method could never be employed at all, since such
exclusion is impossible. In material things, for instance, it
would often be impossible to exclude the pressure of the air,
and always impossible to exclude the action of gravity. But
there are few cases in which causation needs to be investigated
and in which these actions are material. A greater difficulty is
to know what actions are material to the effect and what are
not: and even if we do know this, it may be difficult to exclude
all the material actions but one; and often there may be a
material action at work of which we know nothing. If we
suspect an action of being the cause, and can isolate it, the
method is easy, and the result, positive or negative, is certain ;

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but in many cases in which we have to depend on the method
of association the inquiry is a fishing one. There may be no
single action that can be plausibly suspected, and the number
of actions that may, for aught we know, be material, may be
indefinitely great. Take the case, for instance, of a disease.
It occurs among men and women whose course of life brings
upon them the action of innumerable agents, some of which we
know ; some of which, without knowing, we suspect; and
many others of which we are altogether ignorant, and of whose
very existence we entertain no suspicion. Yet any of these
may, for aught we know, be material. In such a case it is in¬
evitable that the method of association, employed loosely and
without rigour, as it always is at first, should lead us astray.
In such cases we are apt to choose, pretty much at random, an
action or an agent that may or may not exist, and assign to
this action or agent, real or imaginary, a causal influence. We
assign the causation of disease, or of a disease, to the planets;
to the air; to some food, or ingredient in food, such as purin;
to some drink, or ingredient in drink, such as port wine; to
anything in the heavens above, or in the earth beneath, or in
the waters under the earth. These are mere random specula¬
tions ; it is not until we submit our speculation to the test of
one of the twelve methods here described that any reasonable
assignment of cause begins; and the method that first
suggests itself is usually the method of association. The first
step towards accuracy is made when we establish an association
in time or space between the agent or action that we have
tentatively fixed upon and the effect or result whose cause we
are seeking.

It is not enough, however, to establish an association in
time or space between them, for, in such an effect as disease,
innumerable actions on the body of the patient are associated
with the disease. It is necessary to pick out one particular
action, and prove that it is associated with the disease in one
of the four ways that have been enumerated above; and the
most obviously conclusive association is that now under con¬
sideration, viz., association in isolation; that is to say:—

If, in given conditions, other material things remaining the
same, the addition alone of an action is attended by an effect,
or the withdrawal alone of an action is attended by the dis¬
appearance of an effect, that action is the cause of that effect in
those conditions. The obverse also is true :—

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If, in certain conditions, other material things remaining the
same, the addition of an action is not attended by an effect,
or the withdrawal of an action is not attended by the dis¬
appearance of an effect, that action is not the cause of that
effect in those conditions. Both these maxims are easily
derivable from the Axiom of Causation.

Unlike Mill’s so-called Experimental Methods, these methods
are almost of necessity experimental. The isolated addition or
withdrawal of an action does not often take place unless it is
artificially produced. If, however, the action can be isolated,
and added or withdrawn without disturbing other material
actions or conditions, then a single instance is all that is
necessary to establish causation, not only for that instance,
but generally for all cases that are similar in material respects.

Is the pressure of the air the cause of the maintenance of
the mercury in a Torricellian barometer ? If we place the
barometer in a chamber, and exhaust the air from that chamber,
we can determine the question with certainty, for by so doing
we withdraw the single action of the air-pressure, and leave all
other material actions and conditions unaltered.

What is the cause of the baby’s crying ? Is a pin pricking
it ? The nurse undresses the baby and finds a pin in such a
position that it may perhaps have pricked the baby. She
removes the pin, and the crying ceases. Was the pricking of
the pin the cause of the crying ? We cannot be sure. We
are not sure that there was any such action on the baby as we
supposed, and therefore cannot be sure that any such action
was withdrawn. Nor can we be sure that other material things
have remained the same. In undressing the baby some other
source of pain or discomfort may have been removed.

What is the cause of this cutting in my greenhouse wilting ?
Is it drought ? I water it, and after the lapse of an hour I can
discern no difference: the cause is not drought, therefore. Is
it the scorching of the sun ? I move it into the shade, and in
due time it recovers. There is little doubt the cause was
scorching; but in moving it, I may have altered other condi¬
tions. If, however, instead of moving it, I screen it from the
sun, and find that it recovers, I can have no doubt that scorching
was the cause.

A certain milk or water supply is suspected of being the
cause of an epidemic of disease. If, upon cutting off that
supply, the epidemic ceases to extend, the suspicion is con-

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firmed. If the spread of the epidemic is unaffected, the
suspicion is removed. In this case the conditions are complex,
and it is difficult to be sure that all other material circumstances
remain the same. Even if the suspected supply is the cause of
the disease, the epidemic may still spread after the supply is
cut off, for persons who were infected before the supply ceased
may not exhibit the disease until a week or a fortnight after¬
wards. Again, suspicion of the supply may lead many people
not to use it, or to boil the milk or the water before using it,
and in such a case other material circumstances will not be
the same, and again the effect will be obscured. If, however,
the conditions of the test can be observed, and are observed,
then the test is infallible.

Is the fogging of the photographic plates due to leakage of
light into the camera? Expose the next plates in another
camera, and observe the result. If they are not fogged, the
fault is probably in the camera, but it is not certainly so unless
we can be sure that all the other operations were carried out
in the same conditions. If the plates are still fogged, the fault
is probably not in the camera, but this is not certain, for the
second camera also may not be light tight. The method
requires care and strictness in its application, but, properly
applied, it is thoroughly trustworthy.

Is the discontent in the regiment due to the incompetence or
lack of judgement in the colonel ? Remove the colonel, and
see if it subsides. In this case, again, there are sources of
fallacy. A regiment that has once got out of hand cannot be
restored to discipline in a day, or a week. The evil that men
do lives after them ; and it may be that no ordinary man, and
no ordinary measures, will cure the regimental defect. Even
in so simple a matter as altering the pendulum of a clock we
may be deceived, unless we take precautions to observe that all
other things remain the same. It may be that the very day
we lengthen the pendulum a severe frost sets in and counteracts
our action by shortening it. In short, the sources of error in
the application of this method are numerous, and are often
difficult to guard against; but none the less is the method
perfectly efficient if we can and do eliminate errors in its
application.

By these instances we may see that the method requires
great care in its application; that it is often difficult, and often
even impossible to isolate the action, and to be sure that in

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adding or withdrawing it, no other material action has been
added or withdrawn; nevertheless these instances also show
that when the method can be employed, and when it is employed
with care, it yields results which are perfectly trustworthy.

B. When the association of an action with an effect, though
not isolable, is yet of proved constancy, causal connection
between the action and the effect may be presumed. By proved
constancy is meant constancy without exception in cases that
are numerous and diverse.

Constant association between an action and an effect may
be association in presence, that is to say, that if one is present
the other also is present; or it may be association in absence,
that is to say, that if one is absent the other also is absent.
In practice these amount to the same thing.

Constant association in presence may mean that whenever in
given conditions the action occurs, the effect occurs ; which is
the same thing as saying that whenever the effect is absent the
action is absent. In this case, the more numerous and diverse
the instances in which the association is observed, the more
surely we may presume that the action is a cause of the effect ;
but we have no reason to assume that it is the sole cause.

Or it may mean that whenever in given conditions the effect
is present, the action is present; which is the same as saying
that whenever the action is absent the effect is absent. In this
case, the more numerous and diverse the instances, the more
surely we may presume that the action is the sole cause of the
effect.

The removal of a queen bee from the hive is always followed
by the rearing of a new queen by the bees ; and this associa¬
tion has been so frequently observed without any exception,
that we may now confidently presume that the removal of the
queen is a cause of a new queen being reared. We may not,
however, presume on the ground of this association, constant
though it is, that the removal of the queen is the sole cause of
a new queen being reared; and in fact bees at a certain time
of year will always rear new queens, even if the old queen
remains. A severe frost when fruit trees are in flower is always
followed by failure of the crop, and the association is so constant
that we may conclusively presume that the frost is a cause
of the failure. We may not, however, presume from this mode
of constant association that frost is the only cause of failure of

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the crop, and in fact it is well known that it may fail from
other causes. The warrant for the presumption, and the
justice of it, are so manifest that no further illustrations are
needed.

If the effect never occurs unless the action occurs, this mode
of constancy in association warrants us in concluding, and if
the cases are numerous and diverse compels us to conclude, not
merely that the action is a cause of the effect, but that it is the
sole cause. A watch never goes unless it is wound: we are
compelled to conclude that the winding is the sole cause of the
going. Eggs never hatch unless they are incubated: we are
compelled to conclude that incubation is the cause, and the
sole cause, of the hatching. This man is never quarrelsome
unless he is drunk: we are justified in concluding, and com¬
pelled to conclude, that his drinking is the sole cause of his
quarrelsomeness. Certain flowers are never fertilised unless
they are visited by insects: we are justified in concluding, and
compelled to conclude, that the visits of insects are the sole
cause of fertilisation. Cancer of a certain kind is never found
except among chimney-sweeps; chimney sweeping is the sole
cause of that kind of cancer. Instances could be added in
indefinite numbers. It is important to appreciate that the
constancy of association is quite a sufficient warrant for con¬
cluding causation, even though we may not know, and may not
be able to surmise, how the effect is brought about by the
action, or what intermediate steps there may be between the
action and the effect. Though we may not know anything of
the mechanism of a watch, how the action of winding affects
the mainspring, or even that it has a mainspring, yet the
constant association, both in presence and in absence, of winding
and going compels us to conclude that there is a causal con¬
nection between them. It is not material to the conclusion,
and does not affect the validity of the conclusion, whether or
not we know how the removal of the queen bee influences the
bees to rear another queen; how the frost causes failure of the
crop of fruit; how incubation promotes the chick in the egg;
how insects contrive to fertilise flowers; how chimney-sweeping
causes cancer; and so forth. These are, no doubt, useful and
valuable things to know, and until we know them our know¬
ledge of the chain of causation is not complete: we know a
cause, but not the immediate cause. Nevertheless, we do
gain from observing association a very valuable knowledge of

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causation, and a knowledge that, though it may not be complete,
is none the less certain as far as it goes.

The method of establishing constant association is the
method that Mill had confusedly in his mind when he formu¬
lated his ridiculous Canons of Agreement and of Difference.

C. If the association is inconstant, it may be that the action
is sometimes attended by the effect and sometimes not, or it
may be that the effect is sometimes attended by the action and
sometimes not. For the sake of brevity we will consider those
effects only that are changes.

If, on the action occurring, the effect sometimes follows and
sometimes does not, the action may be a cause of the effect,
but can be so in certain conditions only.

If the effect is sometimes preceded by the action and some¬
times not, the action may be a cause of the effect, but cannot
be the sole cause.

If, however, the association of the action with the effect,
although inconstant, is yet more frequent than casual concur¬
rence will account for, the action must be the cause in some
cases.

No housekeeper has any doubt, or need have any doubt, that
thunder is causally connected with the beer turning sour. The
association is not constant. Beer does not always turn sour in
thundery weather, and sometimes turns sour when the weather
is not thundery; but still, considering how relatively rare
thundery weather is, and how relatively rare it is for the beer
to turn sour, the relative frequency of the conjunction is much
greater than mere casual concurrence will account for on the
Doctrine of Probability. The excess of cases of the association
over the number that casual concurrence will account for
justifies the presumption, in that excessive number of cases, of
a causal connection.

The presumption that fog is a cause of bronchitis is entirely
justifiable, and is justified by the same principle. Not everyone
who is exposed to fog has bronchitis; not everyone who has
bronchitis has been exposed to fog. Clearly, therefore, fog is
not a necessary cause of bronchitis : it can be a cause, if at all,
in certain conditions only; and clearly, fog cannot be the only
cause of bronchitis. Nevertheless we may safely presume that
in certain conditions fog is a cause of bronchitis, because,
though the association is not constant, it is much more

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frequent than mere casual concurrence will account for. In
this instance the method of association grades off and merges
into the method of concurrent and proportional variation, for
not only is the number of cases of bronchitis increased whenever
there is a fog, which exemplifies the first method, but also the
number of cases of occurring bronchitis has a direct relation to
the severity and duration of the fog, so that there is to some
extent concurrent and proportional variation. The proportion
is, however, but very vague, for on the one hand, though we can
measure the duration of a fog, we cannot, or do not, measure its
severity; and on the other, though we register the number of
deaths from bronchitis, we do not register the number of cases
that occur; and this vagueness in the proportion prevents us
from applying Method V (Concurrent and Proportional Varia¬
tion) with any strictness; and in fact our presumption, our
valid and justifiable presumption, that fog is one cause of
bronchitis rests in the main upon the observation that they
occur in association much more often than a casual concurrence
would account for.

Many of the assigned causes of disease, and most of the
assigned causes of insanity, are assigned upon this principle
when they are assigned on any principle at all. No alienist
has any doubt that childbirth is a cause of insanity, nor need
he have any doubt, although by far the greater number of
childbirths are not followed by insanity, and by far the greater
number of attacks of insanity are not preceded by childbirth:
in fact, many cases of insanity occur in males, and could not
own this cause. The reasons which justify us in presuming
that childbirth is a cause of insanity are first, the rapidity with
which the insanity follows the childbirth, which goes some way
to bring the case under the first Method of ascertaining causes,
the Method of Instant Sequence; and second, and mainly, the
fact that insanity and childbirth are associated together more
frequently than can be accounted for by casual concurrence.
That they are more frequently associated is always taken for
granted, and though it has never been avowed, or even dis¬
covered, that it is this more frequent association that is the
warrant for our presumption of a causal connection, there is
not the slightest doubt that this is our warrant. Now that the
warrant is discovered, it will be easy to show how JaJriitTis
valid. The aggregate number of the femaie.rjjo^uhtionifof
child-bearing age in this country in any;>yieairMs.^ppratxHhartely
VOL. lxii. 17

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known. The number of child-births, and the number of women
of child-bearing age who become insane, are also known for any
one year. From these data it should be easy for any com¬
petent statistician to calculate the number of child-bearing
women who would become insane, on the Doctrine of Proba¬
bility, if child-bearing had no part in the causation of the
insanity. Any excess over this number of cases of insanity at
the puerperium must be due to child-bearing, provided, ot
course, the numbers in the calculation are large.

Most of the cases in which heredity is alleged as a cause of
disease rest, though the assertors do not know it, upon the
same principle. Gout, insanity, phthisis, leprosy, cancer, and
other diseases, are found sometimes to occur in those whose
one or more relatives have suffered from the same disease; and
when this is the case it is usually assumed without hesitation
that inheritance was the cause, or had a share in the causation,
of the disease. On the principle now under discussion there
is no warrant for such an assumption unless the number of
cases occurring in one family is greater than would be normal
on the Doctrine of Probability, and unless also causal influences
proper to the families, and common to the several members 01
the families, can be excluded.

While this principle, if applied strictly, and with caution to
ensure that the cases of association are actually more numerous
than they would be on the Doctrine of Chances, is sound, and
justifies the presumption that the association is causal in some
at least, though probably in some only, of the cases in which it
is found, yet, when this precaution is not taken, the method is
extremely likely to mislead, and is more often the ground of
false attribution of causes than perhaps any other method.
Nothing is more frequent than to find an action assigned as
the cause of an effect on no other ground than that of an asso¬
ciation, which may have been merely casual, which may not be
more frequent than casual concurrence will account for, and
which may have been observed in but few cases, or even in but
one. It is perhaps the most frequent source of the fallacy of
arguing post hoc, ergo propter hoc.

D. Again, we may assume causal connection from association,
even though the association of the action with the effect is not
constant, if the associated effect has a constant peculiarity : if,
that is to say, whenever that action has preceded, the effect

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has a certain quality, which is absent when the effect is not
preceded by that action.

Insanity often occurs in persons who have not drunk to
excess, or have even been total abstainers; and often does not
occur in those who have drunk to great excess for many years.
The association between drinking to excess and insanity is
very inconstant. But when insanity does occur in those who
have long drunk to excess, it has certain features which are
peculiar—which are alike in all such cases, and are never seen
in the insanity of those who have not drunk to excess. This
constant quality in the effect warrants a confident presumption
that the cause in all such cases is similar; and as the only
constant preceding action is excessive drinking, we assign this
as the cause.

Similarly, there is no constant association between total
abstinence from alcohol and self-righteousness. There are
many total abstainers who are not self-righteous, and many
self-righteous persons who are not abstainers; but when a
total abstainer is self-righteous, there is a smugness in his self-
righteousness that is so constant that it warrants us in attri¬
buting the self-righteousness to the total abstinence, or at least
in presuming a causal connection between them.

The handling of primula obconica, humea elegans, wliitlavia
grandijlora, and certain other plants, is apt to be followed by
the appearance of nettle-rash on those who handle them. The
association is not constant: nettle-rash does not always follow
the handling of these plants, and often occurs in people who
have never been near any of them; but when nettle-rash does
follow the handling of the plants, it has certain characters that
are the same in each case, and do not appear in other cases
of nettle-rash. Hence we may presume, from this constant
character, a causal connection between the nettle-rash and the
handling of the plants.

Rain often falls without the accompaniment of a thunder¬
storm : thunderstorms sometimes occur without the accom¬
paniment of rainfall; but when rain does accompany a thunder¬
storm, it has, in the large size of the drops, a peculiar character
by which it may be recognised, and which justifies us in pre¬
suming a causal connection between the thunderstorm and the
rain.

This is as appropriate a place as any in which to examine
Mill’s fourth Canon, which runs as follows:—‘ Subduct from any

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phenomenon such part as is known by previous inductions to
be the effect of certain antecedents, and the residue of the
phenomenon is the effect of the remaining antecedents.’

Why Mill should have invented the word ‘ subduct ’ when he
had already to his hand the familiar words subtract and deduct,
it is not easy to say. Used by a latter-day philosopher, one
would surmise that it had been employed to conceal poverty of
thought, to strike awe into the mind of the reader, and impress
him with an expectation of the profundity of the wisdom and
penetration of what follows; but Mill was too honest to have
recourse to such a stratagem unless he had first deceived him¬
self, and this was probably the case. Passing this, we may
next notice that the method has no claim whatever to the title
of Experimental. The instance given, not by Mill, but by every
other authority, is the discovery of the planet Neptune, and
Mill, though he does not give this particular illustration, gives
others from the science of astronomy. But no experiment was
employed in the discovery of Neptune, nor is it possible to
experiment with the positions of the planets or the stars. This
Experimental Method for the discovery of causes is therefore
neither experimental, nor is it employed in the discovery of
causes. We have already seen that it was not the method by
which Neptune was discovered, and if we analyse the instances
that are adduced by Mill and other writers, we shall find that
in not one case has the cause of anything ever been discovered
by the Method of Residues. I do not say that it is impossible
to discover a cause by this method, though I think it very
unlikely that it can be done; but it has certainly not been done
yet. All that has ever been discovered by the method is that
there is something new to be accounted for, something of which
the cause is not yet known, and then the cause of this new
‘ phenomenon ’ is discovered by one of the methods set forth
in this Chapter, but not by the Method of Residues.

V. Concurrent Variation.

Causal connection may be established by the discovery of
concurrent and proportional variation of action and effect; and
is the more warrantable the closer the concurrence and the

jr^exact the proportion.

ment ' *° m vei T ^ ar ' reac ^* n ff method, and though its employ-
is se dor^ j n com p ar i son w ith some of the other methods,

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it gives results when their employment is impracticable. In
some cases, as will be seen in the examples adduced hereunder,
it is impossible to trace any action upon the thing changed, but
the concurrent and proportional variation of the action and the
change impels us irresistibly to conclude a causal connection
between them.

The method, as stated above, replaces Mill’s Method of Con¬
comitant Variations, which, as he states it, is manifestly false.
His fourth Canon runs:

* Whatever phenomenon varies in any manner whatever
whenever another phenomenon varies in some particular
manner, is either a cause or an effect of the phenomenon, or is
connected with it through some fact of causation.’

This Canon is, if possible, more ludicrously inept than the
others, but it has nevertheless been endorsed by every writer
of the school of Mill since he first stated it. According to this
Canon, if the weather varies in any manner whatever whenever
a child is growing, then the weather is either a cause, or an
effect of the child’s growth, or is connected with the child’s
growth through some fact of causation. Similarly, if the tide
varies in height when the corn is ripening; if the fashion in
women’s dress * varies in any manner whatever ’ whenever
icebergs are unusually numerous in the Atlantic ; if slugs
become very numerous when Halley’s comet reappears; then
these * phenomena ’ are connected through some fact of causa¬
tion. Manifestly, it is not enough that the one ‘ phenomenon ’
should vary in any manner whatever; such a stipulation is of
no value, as any child can see. The one phenomenon must
vary proportionally with the other. The proportion need not
be exact, but some proportion there must be between the two
occurrences or changes to enable us to presume a causal con¬
nection ; and the more exactly the proportion is maintained,
and the closer in time the one change to the other, the more
confidently we may presume the connection.

The most familiar instance is the concurrent and propor¬
tional variation between the turning of a tap and the flow of
water or the size of the gas flame. As the tap is turned more
and more towards the straight position, so, concurrently and
proportionally, does the flow of water increase in volume or
the flame increase in size. As the tap is turned more and
more towards the cross position, so, concurrently and propor¬
tionally, does the flow of water or the size of the flame

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diminish. The variation is not exactly proportional through¬
out the whole range. When the tap is near the straight posi¬
tion, the additional effect produced by additional alteration is
less than when it is near the cross position ; and when it is
straight, or nearly straight, slight alterations of position have
no answering alterations in the flame or the stream of water;
but still, on the whole, the variation in the size of the flame or
the stream are so closely concurrent with the variations in the
position of the tap, and generally observe so strict a proportion,
that a bystander who had never before seen a tap or a gas
flame would be compelled to presume the causal connection,
and would feel his conclusion the more inescapable, the more
often he saw the experiment repeated. Still more assured would
his certainty become when he found that the more rapid or the
slower the action, the more rapid or the slower was the effect, and
that any interruption of the one was attended by interruption
of the other. Concurrence so close, and generally so closely
proportional, would carry to his mind the irresistible conviction
of causal connection. It is true that in this case our conclusion
is partly derived by the Method of Instant Sequence, but, as
will be more fully shown hereafter, we usually employ more
than one method.

The great importance of the method of concurrent and pro¬
portional variation is that it can be applied when no other
method of ascertaining causation is applicable, when experi¬
mentation is impossible, and even when the means by which
the effect is produced are beyond our knowledge and beyond
conjecture. It is by this method that a causal connection has
been established beyond all doubt between spots in the sun
and magnetic storms on the earth, a causal connection that
could not possibly have been established in any other way. It
is by this method that a causal connection has been established
beyond all doubt between the tendency of mankind to suicide
and the length of the day. The number of suicides in Europe,
and the proportion of suicides to the population, have been
found to be subject year after year to seasonal variations. The
number of suicides is lowest in December, when the days are
shortest, and highest in June, when the days are longest. The
proportional variation is not exact: if plotted on a curve, the
curve would be irregular, and would vary from year to year and
from country to country : but still, taken over many years and
in many countries, the number of suicides increases with an

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approach to regularity, month by month from the winter
solstice, until, when the summer solstice is reached, the number
is doubled, and it then declines again irregularly through the
summer and autumn months to its minimum in November and
December. Since the proportion is not exactly maintained,
it is clear that other influences are at work; but since the
proportion obtains generally year by year in every European
country, we are compelled to presume a causal connection
between the number of suicides and the length of the day, even
though we are utterly unable to conjecture the manner in which
the causal influence is exerted. It is clear that the number of
suicides cannot affect the length of the day; and we cannot
suppose that longer hours of daylight affect the mind of the
potential suicide so as to confirm his purpose. Through what
devious channels the causal influence travels we cannot conjec¬
ture ; but that the length of the day is in some way causally
connected with the number of suicides we cannot doubt.

In such a case as has just been examined, the facts are
beyond doubt, and admit of no uncertainty; but the method
requires care in its application, and is open to more oppor¬
tunities for error than any other method, for this reason among
others, that it is employed usually in cases that are complex
and intricate; in cases in which many causes, some perhaps
unsuspected, may be contributing to a result; in cases in which
other methods cannot be employed to check and control our
conclusions; and also because it usually depends on the collec¬
tion of statistics, with all the numerous and inevitable errors to
which the collection of statistics is liable. The manipulation
of numbers is perhaps the most accurate process of which the
human intellect is capable. Given a set of numbers to start
with, every step in calculation can be checked with the most
rigid exactness, so that it is scarcely possible for two competent
calculators to arrive at different results; but the applicability
of these results, and the correctness of the inferences to be
drawn from them, depend entirely on the correctness of the
original figures from which the start was made, and this is
usually sadly to seek. It is easy, for instance, to establish a
concurrent and proportional variation in the amount of drunken¬
ness in a community and the number of crimes committed in
that community, and hence to establish a causal connection
between drunkenness and crime; but consider the methods in
which the statistics of crime and of drunkenness are collected.

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The statistics of crime are taken from the records of the police,
but different chief constables have very different views of what
should constitute an offence * known to the police and their
statistics will vary accordingly. When loss of property is
reported to one chief constable, he enters it at once as a theft.
If it is subsequently discovered to have been an accidental loss,
it is taken out of the class of thefts; but if the manner of the
loss is never discovered, the loss remains recorded as a theft.
Another chief constable will not enter a loss as a theft unless
there is good reason to believe that the property has been
stolen ; and a third will not enter anything as a theft unless
the thief has been caught and prosecuted, and a conviction
obtained in a court of justice. It is clear that to compare with
one another the statistics of theft in these three districts would
be absurd. Again, in a district in which the Watch Committee
contains a large proportion of teetotalers, and the magistrates
take a stern view of drunkenness, the number of drunkards
apprehended, or summoned, and convicted will be at a maximum.
In an adjoining district, in which the amount of drunkennesss is
not less, or may even be greater, but in which the police have
instructions to look leniently on slight departures from sobriety,
and rather to see a man home or to put him in care of a friend
than to arrest him, and in which the magistrates are prone to
give offenders the benefit of any doubts they may entertain, the
statistics of drunkenness may be less by a third, or even a half.
Again, ‘ serious ’ offences are those which are tried at assizes
or quarter sessions : ‘ trivial’ offences are those disposed of in
courts of summary jurisdiction ; but in many cases the offender
has an option whether he will have his case disposed of by the
magistrate, or whether he will elect to go for trial; and in
exercising this option he will be influenced by the reputation of
the magistrate for leniency or severity; and in this case again
the statistics of ‘ serious ’ crime in the jurisdiction of one
magistrate are not comparable with those of such crime in the
jurisdiction of another. Differences such as these are seldom
allowed for by the statistician. In his eagerness to have a set
of figures to manipulate, and to produce a result that shall be
* mathematically accurate ’, he is too often blind to the initial
errors of the figures that form the basis of his calculations.

In most cases, variation, when concurrent and proportional,
is so within certain limits only, and unless these limits are
observed the causal connection will be stated too absolutely, as

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in fact it usually is. Within certain limits, the rate at which a
plant grows is concurrent and proportional to the temperature;
but there is a certain lower limit of temperature at which the
plant will not grow at all, and however much this limit may be
exceeded, the growth of the plant exhibits no proportional varia¬
tion ; and there is a certain higher limit at which the plant
suffers damage, and will not grow, and however much this limit
may be exceeded, the growth of the plant exhibits no pro¬
portional variation. Within certain limits, the consumption of
a commodity varies in inverse proportion to the price; but
there is a certain lower limit of price at which the consumption
is at a maximum, and however much the price may be lowered
beyond this limit, the consumption will not increase; and there
is with many commodities a certain price at which the con¬
sumption of that commodity is at a minimum, and however
much beyond this the price may be increased, the consumption
of the commodity will not diminish. Within certain limits,
the amount of work that a man can do varies concurrently and
proportionally with the amount of food he eats; but there is in
the quantity of that food a certain lower limit at which he can
do no work, and no diminution of the food below this limit can
diminish his work ; and there is in the quantity of this food a
certain upper limit at which he can do the maximum of work,
and any increase beyond this does not increase, but diminishes,
the quantity of his work. This limitation of the application of
the method of concurrent and proportional variation, obvious
as the limitation is, has never been noticed by any writer on
the subject; but then no one but logicians have written on the
subject, and, as I have said elsewhere, logicians are blind to the
obvious, naturally blind; but they must have taken great pains
not to see many of the things they neglect. Such an excess
of unobservation is not in nature.

VI. Common Rarity.

If an unusual effect is associated with an unusual action, we
are apt to assume a causal connection between them, and the
assumption has the more justification the more unusual both
the action and the effect are.

In the early ’ 8 o’s of the last century there was a terrific
volcanic eruption at Krakatoa, in Java, a great part of the
mountain being blown up and dissipated. An eruption of such

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violence had not occurred in historic times. Weeks afterwards
there occurred in this country, and indeed almost the world
over, a prolonged series of most wonderfully coloured sunsets,
such as no one living had ever witnessed before. This extremely
unusual effect was connected by its very rarity with the
extremely unusual volcanic action, far away as that action was ;
and it was argued, and the argument was generally accepted,
that the gorgeous sunsets were due to the presence in the air of
an unusual quantity of impalpably fine dust, which had been
projected into the upper regions of the air by the explosion of
the volcano, and had floated to distant parts of the earth. It
was the common rarity of the action and the effect which
suggested a causal connection between them.

In the great frost of 1686 many great trees suddenly split
from top to bottom with a loud report like that of a cannon.
Our ancestors did not know how the frost could produce this
effect; but it is a very rare occurrence, and so intense a frost
was a very rare occurrence ; and the common rarity of the two
events led to the assumption that they were causally con¬
nected, and that the frost was the cause of the splitting of the
trees.

In sparsely populated countries the advent of a visitor is a
rare occurrence. If, after such an occurrence an object is found
to be missing, and this also is a rare occurrence, causal con¬
nection between the occurrences will be presumed on the
ground of their common rarity.

In the very exceptionally severe winter of 1895, seagulls
appeared for the first time as far inland as London Bridge.
The common rarity of the two events pointed inevitably to a
causal connection between them.

VII. Corresponding Qualities.

Any peculiar quality in an effect points to a corresponding
quality in the agent that produces the effect.

This principle is very frequently employed in practice, so
frequently that it is puzzling that writers on causation have
overlooked it. Like several of the other methods here described,
it jumps up and hits in the face anyone who gives a moment’s
consideration to the subject; and like others of the methods, it
has been familiar to us from our earliest years. The leading
case is that of Robinson Crusoe and the footprint. When he

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saw the footprint in the sand, did Crusoe wait until he had seen
two or more instances of the phenomenon having only one
circumstance in common, and two or more instances in which
the phenomenon was absent having nothing in common but
the absence of that circumstance ? Not being a logician or a
lunatic, he did nothing of the kind. He said at once * A man
has trodden here.’ What was his justification for this conclu¬
sion ? It was that he saw in the print certain peculiar qualities
which pointed irresistibly to corresponding qualities in the
agent that produced the print. These peculiar qualities in the
print corresponded with peculiar qualities of the human
foot. No other agent possesses them. The inference was
inescapable that the human foot was the agent that produced
the print.

This method is particularly valuable when it is desired to
identify, not so much the cause, as the agent that has produced
a certain effect. It is therefore especially used by the police in
criminal investigations, in which the cause, human agency, is
already known, and what is desired is to identify the agent.
The modern method of criminal investigation, devised by Major
Atcherley, the Chief Constable of the West Riding, is avowedly
founded on this principle. He takes it as an accepted fact that
no two men are exactly alike, and that the differences, small but
easily distinguishable, that enable us to identify the face and
figure of every man, and to distinguish him from his fellows, are
paralleled by differences that, if small, may be distinguished by
skilled and trained observation, between their modes of action.
Thus it is found that each criminal has his own special depart¬
ment of crime, to which he confines himself wholly or mainly.
One is a burglar, another a pickpocket, another a long firm
swindler, another an area sneak, another a perpetrator of the
confidence trick, and so on. More than this, each pickpocket,
each burglar, each long firm swindler, and so on, has his own
minor peculiarities of action, which leave their peculiar impress
on the effects that he produces; so that, given all the details
of the effects produced by a crime, it is usually possible to con¬
clude which particular criminal known to the police has
committed it.

In order to secure a conviction, however, it is not enough
that the police should know what criminal has committed the
crime; it is necessary in addition that they should have
evidence to lay before the jury connecting the criminal, as

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agent, with the crime as effect or result. This can only be done
by proving some peculiar quality in the crime, or in some
accompaniment, part, or condition of the crime, that corre¬
sponds with a peculiar quality, either in the agent himself, or in
some instrument peculiar to him.

Thus, if a wound has such qualities as show that it was inflicted
by the left hand, and the accused is left-handed, the conjunc¬
tion is evidence against the accused; but since left-handedness,
though unusual, is not peculiar to the accused, he should not
be convicted on this evidence alone. If, however, the print of
a bloody hand shows that the criminal had lost half the second
finger and the whole of the third, and if the accused has lost
these parts, then he must be convicted, for such qualities are
peculiar to him. It is on this principle that the evidence of
finger marks is conclusive of the presence of the person with
whose fingers they correspond ; for the finger markings of each
individual person are peculiar to him alone.

If a jemmy found in the possession of the accused exactly
fits marks on a door that has been prized open, the jemmy is
evidence against the accused ; but it is not proof, for many
jemmies may be made of the same bar of steel, and many bars of
steel by the same rollers, and therefore the quality of the jemmy
would not be peculiar or proper to that jemmy; but if the edge
of the jemmy is chipped and shows a notch, and if the mark on
the door fits the edge of the jemmy, notch and all, then the
identification of the jemmy, as the agent that produced the
effect, is beyond doubt, for now the corresponding qualities of
the effect and the agent are peculiar.

When Crippen was accused of the murder of his wife, certain
human remains were found in his cellar wrapped in pyjamas.
So far this was no evidence against Crippen; but it was
subsequently proved that he had bought those very pyjamas;
and thus an instrument of the crime was shown, by the
possession of peculiar qualities, to have been in his ownership.

An anonymous letter, typewritten throughout, is received.
The script is that of a common make of typewriter, and is not
peculiar; but every impression of one of the letters exhibits a
certain defect. If a typewriter can be found having that
peculiar defect in that letter, then there is no doubt that this
typewriter was the agent employed, and that the person who
wrote the anonymous letter had access to that typewriter.

A gardener finds his seedlings gone, and on the soil on which

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they grew he finds a shining track of dried slime. He concludes
at once that the agent that has taken his seedlings is a slug,
for the quality of the shining track is peculiar, and corresponds
with the peculiar quality of slugs of leaving such a trail behind
them. He knows, moreover, that slugs have an appetite for
seedlings, having often lost seedlings by slugs before. Thus by
a combination of the Method of Corresponding Qualities with
the Method of Similarity he concludes that the criminal that
stole his seedlings was a slug.

It is usual in English parks to see all the trees, however
irregular the rest of their outline may be, present a flat surface
towards the ground, at the same distance from the ground in
every tree. The common effect points to a common cause : the
peculiar quality of the effect points to a peculiar quality in the
agent: the agent must be one that can reach to just the height
from the ground at which the foliage terminates ; and the only
such agents that have access to the trees are the cattle or deer
that are pastured in the park.

VIII. Coincidence in Area.

If an action has taken place on a certain area of a thing, and
if subsequently a certain effect is found to be precisely limited
to that area, then we may confidently presume that that action
was the cause of that effect. It is more frequent, however, to
infer from coincidence of area the influence of a condition
than that of a cause, and in many cases the distinction is
practically unimportant.

When a picture that has long been hanging on a wall is
taken down, it is usual to find the area of wall paper that was
behind the picture deeper in colour than that of the surround¬
ing wall paper, and the area of the deeper colour coincides with
the area of the picture. In such a case we are driven to the
conclusion that the prolonged presence of the picture in that
place was a condition of the retention of its colour by the
paper behind.

If in summer a drain is laid across a lawn, and the ground
is filled in, and the turf relaid, it may be found in the
following winter that hoar frost is thick upon the ground over
all the rest of the lawn, but that the line over the drain is free
from frost. The coincidence in space compels us to presume
that the altered state of the ground brought about by laying the

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drain is a condition of the non-appearance of the frost, and that
the action of laying the drain was an indirect cause of this
unchange.

It sometimes happens that a rash appears on a person’s legs
exactly up to the level of the top of his stockings, and there
ceases abruptly. Such coincidence in area compels us to pre¬
sume that the wearing of the stockings is a condition of the
effect, the putting of them on an indirect cause of the
effect, and the action of something in the stockings the direct
immediate cause of the effect.

In experimental agriculture it is a frequent practice to sow
an area of soil uniformly with a certain kind of seed, after
different portions of the area have been treated with different
manures, and one portion of the area with none. Any difference
in the crop which is uniform over one portion so treated, and
coincides with the area treated, is presumed to be due to the
presence of the manure in that area, which was a condition, as
the manuring was an indirect cause, of the result.

It has been found that the vegetation of a meadow is different
in two narrow parallel lines a few inches wide, extending from
one gate across the meadow to another. When it was remem¬
bered that a cart was driven across the meadow from one gate
to the other, and that the lines of different vegetation coincide
with the cart track, it could not be doubted that the traverse
of the cart was the cause of the difference in the vegetation.

The area over which the action extends, and to which the
effect is limited, need not be continuous.

Every gall that grows on trees or plants is found to contain,
or to have contained, the larva of an insect. It is therefore
presumed that the presence of the larva in the gall is causally
connected with the formation of the gall. From other sources
of information we know that in each case the larva grows
from an egg that has been inserted by the mother insect into
the tissues of the plant. As galls do not grow on any part of
a plant into which an egg has not been inserted by an insect,
the coincidence in area, of the attachments of the galls with the
places into which eggs have been inserted, compels us to presume
that it is the operation of inserting the egg, or something
accompanying that operation, which is the cause of the galls.

The same principle is constantly employed in the physio¬
logical and pathological laboratory. To find the physiological
action of a food or a drug, two animals as nearly as possible

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alike are taken, and placed under similar conditions. The food
or drug is then administered to one, and not to the other; and
any physiological change that is limited to the one to which the
food or drug has been administered is presumed to be due to
the administration.

Similarly, in experimenting on or with bacteria, two or more
test-tubes or surfaces are taken, and are treated similarly in
every respect but one. Whatever difference ultimately appears
between them is held to be due to the one respect in which
they were differently treated.

IX. Coincidence in Time.

As the method of Instant Sequence is limited in application
to the discovery of those effects, or of the causes of those effects,
that are changes, so the method of Coincidence in Time is
limited to the discovery of the causation of those effects that
are unchanges; with this exception, that by the latter method
we may sometimes identify the agent that produces repeated
instances of change. This we do by ascertaining the presence
during the whole time these effects are being produced, of a
certain agent, or of similar agents.

If, upon making a manure heap near a house, that house
becomes infested by a plague of flies, and if, upon the removal
of the manure heap, the plague is stayed, then we should
presume a causal connection between the manure heap and the
flies, even if we did not know that flies breed in manure.

How do we gain the belief that sea-sickness is due to the
motion of the boat ? The sole foundation for the belief is in
the coincidence in time of the motion with the unpleasantness.

How do we know that the din of a factory is due to the
motion of the machinery ? Partly, no doubt, by Subsumption
of the case under the law that all noise is due to motion ;
partly by the method of Concurrent and Proportional Varia¬
tion, since the nearer we approach to the apartment in which
the machinery is, the louder the noise becomes, and vice versa ;
but mainly by the knowledge that when the machinery starts
the noise begins; that the noise continues as long as the
machinery is going; and subsides into silence the instant the
machinery stops.

How do I know that the draught that is blowing my papers
about comes from the open window? By observing that it

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began the moment the window was opened, continued as long
as the window remained open, and ceased as soon as the
window was shut.

It is necessary, I suppose, to adduce an instance from
‘ science,’ and therefore I may here point out that the
causation of magnetic storms by sunspots, which is ascertained
partly, as already shown, by the method of Concurrent and
Proportional Variation, receives corroboration from the method
now under consideration, of Coincidence in Time.

If a number of thefts take place in a house, and if, upon one
of the servants leaving the house, the pilferings cease, and
especially if it is then remembered that the pilferings did not
begin until after that servant entered the house, the presumption
is very strong that that servant is the pilferer. In this case the
coincidence in time is not between a cause and an effect, but
between the presence of an agent and a series of effects.

If it is found that explosions in coal mines coincide in time
with depression of the barometer, the presumption is raised that
the lowness of the pressure of air has a causal influence on the
explosions. It is evident that, while from one aspect this may
be regarded as a case of Coincidence in Time, from another
aspect it may be regarded as a case of Association.

These, then, are the nine or twelve circumstances that warrant
us in presuming a causal connection between an action, an
agent, or a condition, and an effect or result. Any one of them,
if fully established, justifies the presumption of causation or of
causal connection, but in practice we rarely limit ourselves to
one method, and in practice, moreover, they are not as distinct
as they are here made to appear by systematic description and
somewhat artificial separation. When we seek to discover a
cause, or a condition, or an agent, we use what means we can ;
and it is only after our reasonings are complete that we are
able to analyse them, and to extricate from the various con¬
siderations that influenced us the separate elements that are
here disentangled and separately displayed. In practice they
are no more pursued in isolation from one another than deduc¬
tion and induction, fundamentally different as they are, are
employed in isolation from each other. Few of the methods
of ascertaining causation can be employed quite separately, for
as most of them have a common origin in the Axiom of
Causation, they are not wholly different, but merge and blend

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into one another; what separation they have being largely
artificial, so that a given instance may often be ranked under
one or another method according to the way in which we
contemplate it, and according to the feature to which we give
prominence. The only methods that are not derived from the
Axiom of Causation are the Method of Instant Sequence, the
Method of Coincidence in Time, and the first application of
the Method of Association. It will be interesting to inquire
what grounds we have for inferring causation by the use of
these methods.

What warrant we have for concluding that a change in a
thing that instantly follows upon an action on that thing is the
effect of the action, is not immediately apparent. Few con¬
victions are more firmly and deeply rooted in our minds, and
at a very early age too, as we see when the baby in arms blows
upon a watch. Having seen the change follow once, the child
concludes that it is the effect, and that it does draw this
conclusion is proved by the child repeating the action with the
evident intention of seeing the change repeated. If the
sequence, of a change in a thing occurring instantly upon an
action on that thing, were constant in experience, the empirical
ground of the conviction would be manifest and would be sure;
but there is no such constancy in experience. We frequently
witness actions that are not instantly followed by perceptible
changes in the thing acted on, and we frequently witness
changes in things that are not instantly preceded by perceptible
action on the thing changed. The experience of instant
sequence is no doubt frequent; but it is by no means constant
in experience. The real ground of the inference is, I believe,
in our experience of our own acts—in the changes in our own
bodies that instantly follow the exertion of our wills, and in the
changes instantly produced both in things around us and in
ourselves by our own acts. The first sequence is strictly
constant in experience. Our own movements instantly follow
the action of our wills, and never in health take place except
in instant sequence to volition. It is often objected that this
cannot be the origin of our notion of causation, because we do
not know how the mental operation of the will can produce a
bodily movement; but this is beside the question. Such
knowledge is quite unnecessary for the origin of the notion.
It is enough for us that the exertion of the will is to us an
action. It is an exertion of the activity of the self, and is not

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only to us an action, but is, I believe, the ultimate source of
our notion of action. And it is, to us, an action on our bodies
and limbs. Whether the will does or can act upon the body,
and if so by what means, is beside the question. It is indis¬
putable that it seems to us to do so, and that, until our minds
are sophisticated by the teaching of philosophers, it is to us as
unquestionable a certainty as the existence of an external world,
or as our own existence. The second sequence also, that of
the instant changes that follow our own acts on things around
us, is constant in experience. It is true that some of our
actions on things around us are not instantly followed by
perceptible changes in them, as when we hit a brick wall with
the fist, but there is always an instant change either in them,
or in ourselves, or in both. Even when we hit a brick wall
with the fist, the action is instantly followed by the sound of
the blow and by the pain of the blow. I think, therefore, that
the ground of our belief in the causation of a change that
instantly follows an action is empirical, and is based, as so many
of our most certain convictions are based, upon the enumeratio
simplex.

That we should argue causation from Isolated Action is more
easily explained. We come to the instance with the conviction
in our minds that a change in a thing must be due to an
action on that thing; and if the change is preceded by one
action only, or by but one material action, that action must be
the cause of the change.

The method of Coincidence in Time rests upon the manifest
connection that this coincidence establishes. A cause is an
action connected with a change or unchange in the thing acted
on. If we can establish a coincidence in time between the
unchange and an action, we have gone far to identify the cause;
for, as already shown, the action that causes an unchange is
necessarily contemporaneous with the unchange, and begins,
continues, and ends with the unchange.

All the other methods derive their validity from the funda¬
mental Axiom of Causation, that like causes in like conditions
produce like effects. The Method of Assimilation is the direct
application of the principle. Subsumption under a general
law is a direct, but a wider application of it, to cases funda¬
mentally similar though superficially different. It is effected
by establishing similarity in material features between the
case in hand and the cases assembled under the law. Constant

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Association of the action with the effect means the constant
association of similar action with similar effects, so that if
one pair is causally connected, the other pairs are causally
connected.

Constant Association of an action with some quality in the
effect comes under the same rule. An association that is
more frequent than casual concurrence will account for again
implies the comparison and assimilation of cases, and assumes
that in similar conditions similar effects are produced by
similar causes. The Method of Concurrent and Proportional
Variation rests upon the assumption that not only do like
causes in like conditions produce like effects, but also like
differences in causes produce like differences in effects; and
similarly, the other Methods manifestly obtain their validity
from the same fundamental axiom, or from some derivative
of it.

It follows that the methods, being founded upon the same
principle, and being but different applications of the same
principle, are not only fundamentally similar, but merge and
blend into one another, so that not only may we employ
more than one concurrently, but also the method that we
employ in any individual case may often be relegated to one
or another of the twelve methods, according as we choose to
regard it, or according as we lay stress on this or that feature
in our method. The Method of Coincident Areas, for instance,
may be regarded as a case of the Method of Association. It
may be called a case in which the addition alone of an action
is followed by an effect, or the withdrawal alone of an action
is followed by the disappearance of an effect. In this way of
stating the matter, however, the time element is brought into
prominence; but in applying the Method of Coincident Areas
we drop the time element out of consideration, and found our
conclusion directly upon the coincidence in space which is a
guide or indication to the presence or absence of the action.
The Method of Common Rarity is, in one aspect of it, another
instance of the first Method of Association. Seeing that Like
effects in like conditions are always owing to like causes, it
follows that a rare effect must be due to a rare cause or to
rare conditions; and when it is preceded by a rare action we
are justified in associating the rare action with the rare effect,
because common actions can be excluded if the conditions are
common. It is possible, therefore, to diminish the number of

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methods, but only at the cost of exercising a certain amount
of ingenuity in bringing some under others; and it would be
possible to increase the number, but only by making dis¬
tinctions scarcely worth making, and at the cost of increasing
the burden on the memory. As they are stated, they present
a useful and practical compromise.

Summary.

The methods of ascertaining causation used by scientific
men in scientific matters are precisely the same as those used
by everyone else in the common affairs of daily life, and are
nine in number, one of them including four distinct methods,
so that there are twelve in all, as follows—

I. Instant Sequence.

II. Subsumption under a general law.

III. Assimilation.

IV. Association.

A. When sole, or isolable.

B. When constant.

C. When too frequent to be casual.

D. When attended by a constant peculiarity

in the effect.

V. Concurrent and Proportional Variation.

VI. Common Rarity.

VII. Corresponding Qualities.

VIII. Coincidence of Area.

IX. Coincidence in Time.

These are here substituted for Mill’s four Methods of
Experimental Enquiry, which are not four, but five; some
of which cannot be, and none need be, experimental, and none
of which ever has been used or ever could be used. Mill’s
methods are examined and found to be all absurd, and one
of them unintelligible.

Each of the methods above enumerated is examined, and
shown by illustrative examples to be in use for the discovery
of causes, both in scientific and in other matters. In practice it
is usual for more than one method to be employed without
discrimination in the same case; and as all but three of them
are founded on the Axiom of Causation, separate discrimination
of any but these three is to some extent artificial.

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CHAPTER VII.

ERRORS IN ATTRIBUTING CAUSATION.

Causation has been defined as the connection between
action on a thing and the sequent change or accompanying
unchange in the thing acted on. It follows that in order to
prove causation we must prove

(1) Action on the thing changed or maintained unchanged.

(2) Sequence of the change on the action, or contemporaneous
action and unchange.

(3) Connection between the action and the change or
unchange.

It follows also that the following blunders in attributing
causation are possible, and in fact they are often committed.

(1) An agent may be taken for a cause.

(2) The agent may not exist.

(3) The action may not exist.

(4) The action may not be on the thing in which the effect is
produced.

(5) The action on the thing changed may not be connected
with the change.

(6) The action may not precede the change or accompany
the unchange.

(7) A condition may be taken for a cause.

(1) A cause is an action, and an action implies an agent.
It would seem, therefore, that the first step in discovering a
cause is to discover the agent; but this is not necessary. A
cause is an action, and when we have identified the action that
causes the effect, we know the cause, and need not go behind
it to discover the agent. Before the discovery of gravitation,
the action of the earth, in attracting bodies on its surface
towards the centre, was as well known as it is now, but
that action was attributed, not to the earth, which contributes
immeasurably the greater part of the action, but to the heavy

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body, which contributes but an infinitesimal part. When we
have discovered that a man’s death is due to the action upon
him that we call typhoid fever, we know the cause of his
death; and this cause was known long before the agent, the
micro-organism, was discovered. When we find a window
starred, we have no doubt that the starring is due to the impact
of a hard body, though we may be quite unable to discover
the body, the agent whose action was the cause of the
damage.

An action is sometimes mistaken for an agent. Natural
Selection, which is the action upon living organisms of
destructive agents, is often spoken of as an agent, and taken
to be an agent. Few expressions are more frequent in the
writings of biologists than ‘ the action of Natural Selection ’,
an expression that is quite correct if it means * the action that
is called Natural Selection ’, but that is mistaken if it means, as
it often does, ‘ the action that is produced by Natural Selec¬
tion.’ Passing this error, which is something more than an
error in nomenclature, we come to the first of the errors
enumerated in our list, the taking of an agent for a cause.
This is a very common error in popular speech. ‘ Thou art
the cause of this anguish, my mother.’ ‘ You are the cause
of this disaster.’ Mill even considered the earth to be the
cause of the fall of a stone. It is, of course, the action of the
mother, and of the other person accused, and of the earth, that
were the causes. The persons were the agents, and not being
actions, could not be causes. I think every one with a nice
sense of the use of language, and of the meanings of words, will
admit that to speak of a person, or indeed of any other agent,
as a cause, is a perversion of language.

(2) In the search for causes we are not obliged to go back as
far as the agent. The cause is already discovered when we
have discovered the action connected with the change or
unchange in the thing acted on; but it is often extremely
useful to identify the agent, and some of our investigations
into causation, such as those into the causation of crimes, have
no other purpose. Still, as we have seen, the action and the
agent are often identified, and very often indeed no sufficient
distinction is drawn between them, and search is made for an
agent instead of for an action. Nay, the fancied necessity for
finding an agent is so urgent, that not only may that be taken

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for an agent which exerts no action on the thing changed or
unchanged, but also an agent that is purely imaginary may be
invented ad hoc, and the cause may be identified, not only
with an agent that is no agent for the purpose in view, but
even with an agent that does not exist.

The attribution of causation to agents that have no existence
except in the imagination of the searchers after cause appears
a priori unlikely, but in experience it is frequent enough.
Gardeners attribute canker in fruit trees to the action of
sourness in the subsoil on the roots of the trees, but there is
neither proof nor evidence that the subsoil is sour. I have
myself tested the soil three feet below a badly cankered fruit
tree, and found no acid reaction; but this is, I am pretty
sure, the only attempt that has ever been made to test the
subsoil for sourness. The spiritualistic medium accounts for
the table rapping out a wrong answer, by the existence of a
lying spirit in the table; but there is no proof and no evidence
that the spirit of the medium has entered into the table. The
Mendelian accounts for feeble-mindedness in other people by
the transmission of a unit-character from the parents of the
feeble-minded; but there is no proof and no evidence of the
existence of a unit-character in either parents or child. Perhaps
the most remarkable and the least justifiable of these imaginary
agents is that of the psycho-analyst. He assumes that the
cause of your forgetting a word is some unpleasant association
of the word in your mind. In fact, in most cases there is
no evidence of any such unpleasant association; but the psycho¬
analyst, like the spirit rapper, is equal to the occasion. He
says the very fact, that you cannot remember any unpleasant
experience connected with the word, is itself proof that you
have had such an experience; for, being unpleasant, you have
thrust it out of your mind. The less you remember it, in
fact, the more certain it is that you are wilfully putting it out
of your mind, and the more you wilfully put it out of your mind,
the more certain it is that the remembrance is unpleasant. In
short, the less evidence there is that you have had such an
experience, the more certain it is that you must have had it.
Deny that you have wilfully put out of your mind either the
word you have forgotten or its unpleasant association, and still
the psycho-analyst is ready for you. Your will was exercised
unconsciously. Manifestly, by such means as this one could
prove anything. What cannot be accounted for by uncon-

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scious volition is accounted for by repressed sexual passion, the
existence of which is assumed with a similar disregard of the
necessity of evidence. It is another imaginary agent. It would
be tedious to enumerate but a tithe of the imaginary agents that
have been invoked as causes of phenomena. They range from
the sour subsoil of the gardener, through the repressed com¬
plexes of the psycho-analyst, the Social Contract of Rousseau,
and the archasus of Paracelsus, to the hypostatised Ideas of
Plato.

The imaginary agent invoked as a cause was the causa non
vera of the Scholastic writers.

(3) Next in gravity of error to imagining an agent that is
imaginary is to take for a cause an action that is imaginary.
Though not quite so grave or so gratuitous a blunder as the
last, this is bad enough, and it is extremely frequent. It is
the error that underlies judicial astrology, and the greater part
of the bewildering lore of amulets, mascots, omens, talismans,
phylacteries, and lucky and unlucky things of all descriptions.
Astrologists declared, yes, and still declare, for there are still
survivors of this queer class of believers, that the position of the
planets at the moment of a man’s birth determines the whole
course of the subsequent life of the ‘ native.’ The planets do
really exist. They are not mere phantoms of the imagination,
like the lying spirit of the table or the unconscious pain of the
psycho-analyst; and having a real existence, they are agents
in some respects and towards some things. They act, for
instance, on their satellites, and on one another. But there is
not a smidgeon of evidence that they act upon the course of
human lives in the way the astrologers imagine. Similarly,
charms and amulets, and the whole apparatus of popular
superstitions, do exist as material objects; and having a real
existence, they are capable of action of some sort, if only by
their weight; but there is no evidence that they exert the
action that is attributed to them by popular fancy.

It is common to find that people who go to warmer,
damper, and more low-lying places sleep more and are less
energetic than they were when at home ; and it is common
to find that people who go to colder, higher, and drier places
appear to gain energy and to be capable of more exertion.
These effects are always attributed to the action of the air in
such places, which is said to be * relaxing ’ in the one case,

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and ‘bracing’ in the other. There is no evidence that the
air has any such action, or that there is any difference in the
air of the one place and the air of the other. Not seldom
places of the two different qualities are near together, and the
wind frequently blows from the relaxing place to the bracing
place, and vice versd. It is most improbable therefore that the
air in the one place is appreciably different from the air in the
other; and if a difference were found, it would still remain to
be proved, by one of the twelve methods set forth in the last
chapter, that this difference has or can have such an action
on the human body as is attributed to it;

Many temporary and obscure ailments are attributed, not
only by the laity, but by some medical practitioners, to ‘ a
sluggish action of the liver,’ or to ‘ a chill on the liver.’ The
actions of the liver are many, and are imperfectly known, but
in the cases in question there is not a shadow of evidence that
any one of them is being performed less actively than usual,
nor is there any evidence that the liver has been chilled. The
liver is deeply seated, and is covered by thick layers of muscle,
bone, skin, and other structures, and could not possibly be
chilled unless the temperature of the whole body were reduced ;
and if it were, there is no evidence whatever that such lowering
of the temperature of the liver could produce the effects that
are attributed to it. Many drugs are advertised and taken for
the purpose of purifying or cooling the blood; but apart from
the want of evidence that the blood of the person taking them
is impure, or is unduly hot, there is no evidence whatever that
these drugs exert any purifying or cooling action upon it.

Gardeners and rustics commonly attribute changes in the
weather to changes in the moon, which are really changes in
the relative positions of moon, earth, and sun; but that these
relative positions have any influence upon the weather there is
no evidence to show.

At a certain spiritualistic seance at which Dr. (now Sir James)
Crichton Browne was present, ‘ manifestations ’ occurred until
he so plugged the eyes and ears of the medium that the medium
could neither see nor hear; then the manifestations ceased.
At the end of the sitting, a believer who was present attributed
the cessation of the manifestations to ‘ the offensive incredulity
of Dr. Crichton Browne.’ There was no evidence, however,
that this mental attitude of the sceptic exerted any action upon
the medium, or upon the spooks who were supposed to be in

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relation with the medium; while there was another action of
Sir James’ upon the medium to which the effect might well
have been attributed.

When the Hawke rammed the Olympic in the Solent, those
on board the Olympic attributed the change in the course of
the Hawke to the action of starboarding her helm ; but it was
proved at the trial that this action was imaginary: the Hawke
had not starboarded her helm.

The mistake of attributing as a cause an action that is entirely
imaginary is as old as humanity, and shows little sign of be¬
coming less frequent, although the most impressive exposure of
it that has ever been made is three thousand years old. It is to be
found in the Wisdom of Solomon, xm, n, and runs as follows:—

‘Now a carpenter that felleth timber, after he hath sawn
down a tree meet for the purpose, and taken off all the bark
skilfully round about, and hath wrought it handsomely, and
made a vessel thereof fit for the service of man’s life;

* And after spending the refuse of his work to dress his meat;
hath filled himself;

‘ And taking the very refuse among those which served to no
use, being a crooked piece of wood, and full of knots, and hath
carved it diligently when he had nothing else to do, and formed
it by the skill of his understanding, and fashioned it to the image
of a man;

‘Or made it like some vile beast, laying it over with ver¬
milion, and with paint colouring it red, and covering every spot
therein ;

‘ And when he had made a convenient room for it, set it in a
wall, and made it fast with iron;

‘For he provided for it that it might not fall, knowing that
it was unable to help itself; for it is an image, and hath need
of help;

* Then maketh he prayer for his goods, for his wife and chil¬
dren, and is not ashamed to speak to that which hath no life.

‘ For health he calleth upon that which is weak; for life he
prayeth to that which is dead ; for aid humbly beseecheth that
which hath least means to help; and for a good journey prayeth
of that which cannot set a foot forward ;

* And for gaining and getting, and for good success of his
hands, asketh ability to do of him that is most unable to do
anything.

‘Again, one preparing himself to sail, and about to pass

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through the raging waves, calleth upon a piece of wood more
rotten than the vessel that carrieth him.’

No doubt it will startle the ecclesiastically minded ladies who
throw some of the spilt salt over their shoulders to avoid
disaster, to know that their attitude of mind is the same as that
of the idolater.

(4) The action attributed as a cause may not be on the thing
in which the effect is produced.

This is the fundamental error of witchcraft, of spells and
charms, and many other superstitions. Witches undoubtedly
existed: the agent was not imaginary. Nor was the action
imaginary, for the witches did undoubtedly exercise their craft.
They did cast spells and execute incantations, they did say the
Lord’s prayer backwards, they did make wax figures, and stick
pins in them, and exercise in other ways the craft of the witch ;
and these things they did in order to influence the weather, to
produce illness and misfortunes to their neighbours, to make
their cattle slip their calves, their children have fits, and to
cause other effects. But the gap in the chain of causation was
that the action they exercised was not upon the thing they
desired to change. Whatever incantations they uttered exer¬
cised no action on the weather. The pins which would have
produced pain and injury if they had been stuck into the persons
of the witches’ enemies, were not stuck into their persons; they
were stuck into images of them. The action was not on the
thing in which the effect was to be produced. The spells that
they cast upon the cattle or the children did not act upon the
cattle or the children; and if any effects on the various objects
followed the witchcraft, they could not have been due to the
witchcraft, which did not act on the things in which the effects
were produced.

It is currently believed that if you cut your nails on a Friday,
or bring a peacock’s feather into the house, or cross the knives,
or spill the salt, or view the new moon through glass, or do
any of a hundred other harmless acts, the action will bring
misfortune upon you. In each of these cases there is an action;
but in none of them is the action upon the thing in which any
unfortunate effect that may follow is produced. You cut your
nails on Friday, and on Sunday you put a sovereign instead
of a shilling into the offertory. The misfortune happens right
enough, but the action was on the nails, not on the sovereign

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You bring a peacock’s feather into the house, and in the follow¬
ing week your child at school is attacked by measles; but your
action was on the feather, not on the child. You spill the salt,
and next day your horse casts a shoe, or your motor tyre bursts
at an inconvenient moment; but your action was on the salt
and the tablecloth, not on the horseshoe or the tyre.

A certain Irish tenant tried to diminish what he considered
his landlord’s rapacity by shooting the landlord’s agent; but
the action, strenuous though it was, was not directed at the
thing, the landlord, that the tenant desired to alter, and was
therefore ineffectual; and so the landlord explained. ‘ If you
think ’ said he * that you can intimidate me by shooting my
agent, you are very much mistaken.’

An old woman who had the reputation of a witch acquired a
large practice by uttering a certain spell, to which immense
efficacy was attributed by her neighbours, who willingly paid
her for it the fee that she demanded, which consisted of a loaf
and a penny. At length her practices reached the ears of the
authorities, who seized her and threatened to tie her thumbs
and great toes together, and to duck her in the horse-pond,
secundum artem, unless she revealed the spell by which the
wonders were worked. I trust I do them no injustice if I
surmise that the authorities would not have been unwilling to
have in their own hands an instrument of such power. Under
this duress the poor woman consented to reveal the text of her
spell, which ran, so she said, as follows:—

Thy loaf in my lap,

Thy penny in my purse;

Thou art never the better,

And I am never the worse.

It seems unlikely that the action of uttering this could have
had the causal influence with which it was credited, and the
same may be said of all spells and incantations, whether of
witches or of psycho-analysts.

(5) The action on the thing changed may have no connection
with the change.

To attribute an effect to an action with which it has no con¬
nection is a blunder, and a very frequent blunder, but it is a
much more pardonable blunder than any that we have con¬
sidered hitherto. As we have seen in the seasonal variations in

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the frequency of suicide, it may be impossible to trace the nature
of the connection, even when the facts render a connection of
some kind certain ; and experience of such cases might well
lead us to suppose a connection when the nature of the con¬
nection is obscure. But the error we are now examining does
not rest on experience of such cases, and does not consist in
inferring a connection that is obscure: it consists in inferring
a connection without sufficient evidence. The seasonal varia¬
tion of suicides, the concurrent variations of sunspots and
magnetic storms, and many other instances, show that to
establish a connection it is by no means necessary to discover
the nature of the connection ; but it is necessary to establish,
by one of the twelve methods described in the previous
Chapter, that there is a connection, or causation cannot properly
be inferred.

It is evident that the fallacy in all the previous cases that
have been examined lies in the absence of any connection
between an action and the change or unchange in the thing
acted on. Such a connection is necessarily absent when the
supposed action is that of an imaginary agent, such as acid in
the subsoil, or unconscious pain, or a Social Contract; or is
itself imaginary, such as the supposed action of the planets on
human life, or that of a chill on the liver; nor can there be a
connection between an action and an effect if the action is on
something other than that in which the effect is produced, as
when witches stick pins into the effigy of a person they desire
to bewitch, or a tenant shoots the agent in order to affect the
landlord ; in all these the connection is wanting, but is not the
only thing that is wanting. There remain still other cases in
which an agent that actually does exist, exerts a real action
upon the thing on which the effect is produced, and yet we are
not justified in regarding it as a case of causation, for want of
evidence, such as is required by the Methods described in the
last Chapter, of connection between the action on the thing
and the effect produced in that thing. In these cases, since so
many more of the conditions of causation are satisfied, and the
last link only is wanting, the error is less enormous, and may
easily be committed by those who have sense enough to avoid
the greater errors; while, on the other hand, those whose
mental equipment is insufficient to save them from the greater
blunders are scarcely likely to avoid the less.

The opportunities for committing the error now under con-

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sideration are perhaps greater in medical practice than in any
other range of observation. When a drug is administered to
a person who is ill, and thereafter the symptoms change for
better or for worse, it is difficult not to assume that the admini¬
stration of the drug was the cause of the change, especially
if the change is in the direction of improvement. In such a
case all the gross errors are eliminated. The agent, the drug,
does exist; it does exert action ; its action is upon the thing,
the body of the patient, that changes ; and moreover the action
definitely precedes the change. All these conditions are satis¬
fied, but we are still in doubt, or ought to be in doubt, whether
the action of the drug was the cause of the change in the
symptoms; for connection between the action and the change
is not established.

There is a widespread notion, dating from the battle of
Waterloo, that the firing of heavy guns is a cause of rain.
The firing of heavy guns does produce an action, and a powerful
action of its kind, upon the thing, the atmosphere, in which
a change occurs when it begins to rain ; but no connection
has been shown between the cause and the effect. At the
battle ofWaterloo, and no doubt many times before and since
that battle, there was an association between the cause and the
effect: but in the first place, the alleged cause did not precede
the effect, for it had rained heavily for several days before;
and in the second place it has never been shown, A, that the
action was isolated—that it was the only action upon the
atmosphere at that time— ; nor, B, that the association is con¬
stant—that the firing of heavy guns is always followed by rain—;
nor, C, that it is followed by rain more frequently than casual
association would account for; nor, D, that there is any pecu¬
liarity in the rain that falls after the firing of heavy guns,
that is constantly present in such rain, and absent from other
rain. We may therefore confidently assert that the firing of
heavy guns has not been proved to be a cause of rain.

The fallacy of arguing post hoc, ergo propter hoc is so frequent
and so well recognised that further illustrations are not needed,
but what is needful is to point out, what never has been pointed
out, viz.: why it is a fallacy when it is fallacious. For it is not
always fallacious. Quite the contrary. In every case in which
a cause acts and produces a change, the effect follows the
cause, and is both post hoc and propter hoc ; and in those cases
in which the effect immediately follows the cause we argue

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propter hoc because of the immediacy post hoc, and on no other
ground. It is only when an interval of time elapses between
the action and the effect that there is opportunity for fallacy
to enter into the reasoning; and whenever the interval is short,
the fallacy is extremely alluring and extremely frequent. Never¬
theless, it has been recognised as a fallacy for two thousand
years, and yet, in the face of this common knowledge, Hume
and Mill, and all their followers down to the present hour, have
taught that causation is nothing but sequence—invariable
sequence it is true, but still, invariable sequence and no more.

What constitutes the argument post hoc, ergo propter hoc a
fallacy when it is fallacious, is, of course, the absence of any
proof of connection between the action that is ante and the
effect that is post. This is the element that must be added
to mere sequence in order to transform it into causal sequence;
and this is the element that Hume perversely denied, and that
Mill and all his followers have failed to appreciate, although
in every case of causation that they witnessed throughout life
it must have jumped at them and hit them in the face. When
the sequence is instant and immediate, we argue connection
from sequence alone: in other cases it must be proved by one
of the methods set forth in the last Chapter, on the Methods
of Ascertaining Causes, for each of these methods is a method
of establishing connection between action and effect. Until a
connection is established, that which is post can never safely be
assumed to be propter: as soon as the connection is estab¬
lished, causation is proved. Of course, if causation were mere
sequence, or invariable sequence, or unconditional sequence,
whatever that may mean, the argument post hoc, ergo propter
hoc would not be fallacious; but the very same writers who
declare that causation is nothing but sequence insist in another
chapter that to argue from post hoc to propter hoc is a notorious
fallacy.

(6) The action may not precede the effect if it is a change,
or be contemporaneous with it if it is an unchange.

Of all the errors in attributing causation this is the most
difficult to avoid, and the most pardonable when it is incurred.
In some cases it is so difficult to determine precedence that
the only justifiable course is to suspend our judgement; but
this course, always difficult, seems to be most difficult in
attributing causation. In many cases the action, which is

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the cause, arises so gradually that it is difficult to fix its
position in time; and the change also that it effects may
be spread over a considerable duration, so that the cause and
the effect are for part of their duration contemporaneous, even
when the effect is a change. When the effect is an unchange,
contemporaneousness may be difficult to establish; and when
the effect as well as the cause is’an action, as it sometimes is
in the case of an unchange, cause and effect are reciprocal, and
which is to be called cause, and which is to be called effect,
depend on the way in which they are contemplated.

Was his excessive drinking the cause of his insanity ?
Granted that the proper association is established, so that
we may be sure there is a causal connection between the
drinking and the insanity, then the answer to this question
depends on which came first. If the drinking preceded the
insanity by months or years, that settles the question ; but
supposing that he did drink heavily for a short time before
the insanity was recognised, is it certain that the insanity was
recognised as soon as it existed ? One of the earliest symptoms
of insanity is defect of self-control, and defect of self-control
is a condition that favours excessive drinking. Insanity in
the early stage is often difficult to detect, and to be sure of.
Is it not possible then, that the excessive drinking was rather
an early symptom than a cause of the insanity ?

A certain game becomes popular, and about the same time
a book upon it is published. It is said that the publication
of the book is the cause of the game becoming popular, but
may it not be the other way about ? A book is not often
published unless there is a public to which it appeals, and
the existence of such a public is just the thing to stimulate
an enterprising publisher. In such a case we must ask which
came first, but this cannot be determined with certainty. The
date of publication of the book can, indeed, be determined
with accuracy, but how are we to determine when the game
became popular? Attaining popularity is a gradual process,
and may spread over months or years. In such a case we
must suspend our judgement pending further information, and
it may be that the matter cannot be determined.

Increase of population has been said to be a cause of taking
inferior and hitherto uncultivated land into cultivation; and
reversely, the taking of such land into cultivation has been
said to be the cause of increase in the population. Which is

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correct? It seems that the only way to determine is to
discover which was first; but by the nature of the case this
cannot be discovered, for both are slow and gradual processes,
having no definite time of beginning.

Is the failure in the flow of the sap the cause of the death
of the leaves in autumn ? or is the death of the leaves the
cause of the failure of the sap to rise ? or are they not common
effects of some other cause ? In this case again, the causal
connection is established ; but again it is quite impossible to
say whether the slackening of the sap-flow precedes the begin¬
ning of the death of the leaves first to die, or whether the
gradual death of the leaves precedes the gradual failure of the
sap-flow. But in this case we can call experiment to our aid.
We can ring the tree, and so stop the flow of sap ; and then
we find that the leaves do in fact die, but they die in a very
different manner, and the tree dies too. Or we may strip
the tree of leaves and see if the sap ceases to flow ; and when
the experiment is tried, we find that the sap does not cease to
flow, for the naked branches bud again. In this case, there¬
fore, we may confidently assert that the death of the leaves
and the failure of the sap-flow are common effects of some
other cause.

Is the formation of the heavy rain-drops of a thunderstorm
the cause or the effect of the electrical disturbance ? If we
could tell which change preceded the other we should have no
doubt; but this we cannot tell.

Syphilis is said to have been introduced into Europe in
April, 1494, by Pedro Boyle and Pedro de Margarit, the first
a Benedictine monk and the second a Calabrian gentleman,
both of whom accompanied Bartholomew Columbus, the
brother of Christopher, in his voyage to and from New His¬
paniola. On the other hand it is alleged that the disease had
long existed in Europe, and even that Egyptian mummies
have been found with the signs of the disease upon them.
If the latter assertion is true, the former is a false attribution
of causation.

It appears from the foregoing considerations that even when
we employ our nine or twelve canons for ascertaining causation,
we cannot always be successful; and when we can successfully
establish a causal connection between two events, we cannot
always determine which is cause and which is effect, or whether
both may not be effects of some third action.

vol. lxii. 19

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(7) The last error in attributing causation is that a condition
may be mistaken for a cause.

This is a blunder that is very commonly made : it is perhaps
the most frequent of all the blunders that are made in assigning
causes; and fortunately it is the least important. If we discover
that a certain percentage of potash in the soil is necessary to
obtaining the maximum crop of potatoes, it does not greatly
matter, from one point of view, whether we speak of the
application to the soil of so much potash as the cause of a
bumper crop, or of the presence in the soil of the potash as
the cause; though of course the latter, as a passive state, is
a condition, not a cause, of the crop being a bumper crop.
On the other hand, to call a man’s sex, or age, or the locality
or climate in which he lives, a cause of his disease, is clearly
a misnomer, and shows a confusion of mind : and it can never
be as important, with reference to the causation of his disease,
to discover his age or sex as to discover that which acted
on him.

Though a condition is not a cause, and though the difference
between condition and cause is often conspicuous and important,
yet there are many cases in which the distinction is not impor¬
tant, and many in which it is quite as important to discover
the conditions of an effect as to discover its causes. The
external causes of the growth of plants are few, and are
ascertained. They are the action of warmth and light upon
the plant; but the conditions under which a given plant will
thrive are often extremely difficult to ascertain. There are
certain plants that seem to be animated by feminine caprice.
Side by side in the same garden, in the same soil, in the same
aspect, subject, as far as we can discover, to the same con¬
ditions in every ascertainable respect, one plant of troptzolum
speciosum will thrive luxuriantly, and another will dwindle and
perish. The sciences of agriculture and horticulture consist
almost wholly in the study of conditions. Obviously, a passive
state is by its very nature less conspicuous than an action, and
therefore the discovery of a condition is almost necessarily
more difficult than the discovery of a cause.

It is often as important to discover a condition as to discover
a cause, and for this among other reasons, that the discovery
of a condition often points to a cause, or enables us to eliminate
an action or an agent that we have thought of as causally con¬
cerned. The researches of Wells into the cause of dew con-

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sisted in identifying one after another the conditions under
which dew is deposited, and those which interfere to prevent
its deposition; and when these were ascertained they pointed
straight to the causal action, namely refrigeration of the stratum
of moist air in contact with the bedewed surface, the only
action common to all the conditions. One of the conditions
of the occurrence of a strong wind is a low pressure of air,
as indicated by a low barometer; and this points straight
to the cause—the action of the pressure of the air in a neigh¬
bouring region of higher pressure. A motor-car runs better
after it has been running for some time, and again the con¬
dition points to the cause; for the only action that has taken
place in the interval has been the action of the engine and
moving parts on themselves and each other, and this action,
whatever other effect it may have had, must have had the
effect of warming up the engine and other moving parts ; and
it can be shown a priori that warming them up is likely to
improve the running of the car.

On the other hand, the discovery of a condition may assist
us in eliminating an action or an agent that we have thought
of as possibly having a causal connection with the effect.
A man is suspected of having committed a certain burglary,
but it is found that one of the conditions of the burglary, the
window through which the burglar is known to have entered,
is incompatible with this man’s action, for it is too small for
him to get through. It is surmised that sourness in the subsoil
is the agent that causes canker in fruit trees; but one of the
conditions in which the tree grows is the presence of chalk
in the subsoil, and chalk is incompatible with sourness. It is
suspected that the ship was lost in obedience to the orders of
the owners, that they might claim the insurance money; but
it is discovered that the ship was under insured.

Again it is often important to discover a condition for its own
sake. The cause may be well known, but the conditions under
which it acts may be obscure, and in that case it is important
to discover the governing conditions; and these are the cases
in which it is usual to call the enabling condition the cause.
No harm is done in practice by the confusion of nomenclature,
but still, the confusion is there, and accurate thought expressed
in accurate language would clear it up. It is, however, as
prevalent in books on logic as among plumber’s labourers.
We speak of the absence of a damp-proof course in the walls

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of a room as the cause of the room being damp. Strictly
speaking the effect is not the room being damp, but the room
becoming damp; and the cause of this is the action of the
moisture from the soil, creeping, by capillary attraction and
other forces, up the walls. One condition of this penetration
of moisture into the wall is the absence of a damp-proof course;
and so we speak of the absence of this course as a cause of the
room being damp. It is not a cause. The absence of a thing
cannot possibly be a cause. It is a condition. If there were
a damp-proof course in the wall, the moisture could not pene¬
trate that course, and could not rise above it; and the wall not
becoming damp, the room would not become damp. Still, for
practical purposes we call the absence of the course the cause,
because we'know now what prevention to apply, and where to
apply it. What is the cause of the oven not getting hot ?
The cook will tell you it is the door or the window being open ;
but these are passive states, and therefore conditions, and not
causes. The cause is the action of the draught of cold air ;
and this is not caused, but permitted, by the door or the window
being open. If she said that the opening of the door or of the
window was the cause of the oven being refractory, she would
be punctually correct, for this, though not the proximate cause,
was the cause of the proximate cause, and therefore a cause of
the effect. A cause is an action, and an effect is a change or
unchange. But when the result of an action upon a thing is
to produce a change, the changed state or result may be a
condition of further change in that or other things. In the
instances just given, the confusion of cause with condition is
not important for the purpose of the cook, or of the builder who
is called in to remedy the dampness of the room, but it is
important for the logician who is discussing the nature and
relations of cause and effect, and the rules for discovering them.
The importance of the distinction appears very plainly in the
indescribable muddle that, for lack of it, appears in the books
that discuss these subjects, omnes libros canentes eandem
cantilenam, as Van Helmont says.

Summary.

In order to prove causation it is necessary to prove

(1) Action on the thing on which the effect is produced.

(2) Precedence of the action on the change, or accompaniment
of the action with the unchange.

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(3) Connection between the action and the effect.

In thus endeavouring to prove causation, the following
blunders are committed:—

(1) An agent may be taken for an action.

(2) The agent may be imaginary.

(3) The action may be imaginary.

(4) The action may be real, but not on the thing changed or
unchanged.

(5) The action may be on the thing, but unconnected with the
effect.

(6) The action may not precede the change or accompany
the unchange.

(7) A condition may be taken for a cause.

The first blunder is frequent, but not often very important.
The second is the worst of all, and is not made except by the
most muddleheaded. The next is nearly as bad, and the rest
decrease in importance in succession until the last is often
practically unimportant, though it is one which a clear thinker
would never make.

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CHAPTER VIII.

CAUSES OF DEATH. CAUSES OF INSANITY.

How great is the need of clear and correct concepts of cause
and effect, and how great, too, the need of a knowledge of the
proper methods of ascertaining and assigning them, is well
shown by the official publications on the causes of death and
of insanity. The Registrar General and the Board of Control
annually publish elaborate Tables, from which it is evident that
neither of these authorities has any clear notion of what is
meant by a cause, or of the means that should be adopted to
verify causation. Both authorities publish as causes what are
not causes, and both authorities have altered from time to time
the construction of their Tables without improving materially
their illogical character. The Board of Control, the successor
of the Lunacy Commission, has followed its dignified prede¬
cessor in frankly abandoning the attempt to distinguish causes
of insanity, not only from its conditions, but even from its
accompaniments. This seems to me a deplorable admission of
incompetence. The old Table, that did at least purport and
pretend to be a Table of Causes, is now superseded and
replaced by a Table of /Etiological Factors and Associated
Conditions. ‘^Etiological Factors ’ would not be a bad term if
it were intended to embrace causes, direct and indirect, imme¬
diate and remote, as well as conditions. It is a sound, logical,
comprehensive term, which might properly be employed to
include all these things; but I am sure that I do no injustice
to the Committee of the Medico-Psychological Association
which drew up the Table and gave to it its title, when I say they
had no such meaning and no such intention. There is not
the least doubt that their reason for giving to the Table this
new title was to seek in vagueness a refuge from uncertainty.
They did not know what constitutes a cause, nor did they know
the rules or methods by which causes should be assigned; and
small blame to them, for philosophers could not tell them, and
if they knew, which is improbable, of the various definitions of

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cause given in the books, they had the good sense to disregard
them. They collected a hotch-potch, whose constituents they
were unable to discriminate from one another, and they selected
a title that is a dignified name for a hotch-potch. If it is
objected, as it well may be, that many of the items in the
Table are not Causes nor .Etiological Factors, they can reply
that at any rate they are Associated Conditions, and thus
silence that criticism. It is true that they lay themselves open
to the much more damaging criticism that such a hotch-potch
is of no conceivable use to any human being ; but this, perhaps,
they did not foresee.

I. Causes of Death.

The Registrar General divides causes of death into Primary
causes and Secondary causes; and it is significant of the
validity of the distinction that at different times he has defined
them in different ways. Originally, in 1845, the instruction of
the Registrar General was : ‘ Write the causes of death in the
order of their appearance, and not in the presumed order of
their importance.’ As he did not mean primary and secondary,
that is to say, first and second in order of importance, it is a
pity that he used these terms ; and as he meant first and
second in the order of time, it is a pity that he did not use
terms, like first and second, or earlier and later, which would
have expressed accurately what he did mean. However, some
of the medical practitioners to whom the forms were issued
persisted in assuming that the Registrar General meant what
he said, and accordingly returned as primary cause of death
that which they considered more important, and as secondary
that which they considered less important. As this practice
grew and increased, the statistics naturally lost in value, and
became much confused, so that it might have been supposed
that the Registrar General, who recognised and deplored the
confusion, would have revised either his formula or his instruc¬
tions. In fact he did neither. He allowed the terms to remain,
and withdrew his instructions altogether, leaving the certifiers
to interpret his terms as they pleased. This happened in 1902,
and for the next nine years medical men who certified causes
of death were left to their own discretion, to interpret primary
and secondary as they pleased. The result, which is creditable
to the doctors, was that most of them interpreted the terms

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in their proper sense, as first and second in the order ox
importance.

In 1893, a Select Committee reported on the subject, and
advised that if the terms primary and secondary were retained,
they should be defined ‘ as meaning the order of the develop¬
ment of the diseases as they occurred,’ that is to say that the
Registrar General should revert to the former vicious practice of
defining the terms in a sense that is false, and that they cannot
properly bear. The Registrar General did not take this advice.
As I have said, he withdrew the instructions, and left the doctors
to do as they pleased; and then, after a decent interval of nine
years, he directed that the primary cause of death was to be con¬
sidered ‘ that cause of death which was of greatest importance
and upon which any other related causes were dependent.’

It is unfortunate that the Registrar General, following the
example of Mill, whose teaching has so long been dominant in
the matter of causation, is not able to make up his mind about
the meaning of his terms, and gives several definitions, which
are not only unsatisfactory, but are inconsistent with each other,
and even with themselves. In his Suggestions to Medical
Practitioners, he defines primary cause of death (in the case of
deaths from disease) as ‘ the disease, present at the time of
death, which initiated the train of events leading thereto, and
not a mere secondary, contributory, or immediate cause, or a
terminal condition or mode of death.’ In a footnote he adds :

‘ Acute specific diseases, if of recent occurrence, are to be con¬
sidered the primary cause of death, even though the actual
disease, as tested by the power of infection, be no longer
present at the time of death.’ Thus he warns us that his
cardinal test of what is primary may be no test at all. He
takes back with one hand what he has just given with the other,
and leaves us in confusion. If we turn to the remainder of the
definition for guidance we are no better off, for it does not help
us much to understand what is meant by a primary cause of
death to be told that it is not a mere secondary cause. But
even in this he is not consistent, for though this contradictory
footnote appears in his Suggestions, it is not embodied in the
instructions to medical practitioners that appear on the face of
the certificate of death. ‘ Secondary cause ’ he does not attempt
to define, though he warns us that a terminal condition or
mode of death should not be entered as a secondary (or con-

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tributary) cause; but as he does not tell us what he means by
a terminal condition or mode of death, this does not give us
much assistance; and if he did, it would only tell us what a
secondary cause is not : it would not tell us what it is.

In most ordinary cases of causation a cause is a cause; that
is to say, it is one of a train of causes, and if it is omitted, if
the train is broken at any point, the effect will not be produced.
If the cat does not begin to eat the rat, or if the rat does not
begin to gnaw the rope, or if the rope does not begin to hang
the butcher, the rest of the effects will not be produced, and the
old woman will never get home. The case of death, however,
is peculiar. The death of every human being is inevitable, and
the utmost that any cause of death can do is to hasten or
precipitate a result that must take place some day. For
practical purposes, however, we look upon the duration of life
as indefinite, and call that a cause of death which is the cause
that death, which otherwise would have been postponed, occurs
at a particular time. In other words, the cause of death is that
which hastens or precipitates an event that would in any case
have occurred sooner or later. Now it is evident that the
extent or degree to which life is shortened by any cause
materially affects our estimation of the cause. If a man is
already so ill that his life is despaired of, and he may die any
hour, we scarcely regard as a serious or important ‘cause of
death ’ the dose of morphia that not only relieves his pain,
but overpowers his enfeebled respiratory centre, and accelerates
his death by a few hours at most. We should not in such a
case enter poisoning by morphia as a cause of death. On the
other hand, if a young man in robust health, whose expectation
of life is thirty or forty years, were to die with symptoms of
narcosis after a large dose of morphia, we should unhesitatingly
enter, as the cause of his death, poisoning by morphia.

We may look upon the living animal as a clock, wound up
at conception to go for a certain maximum time. When death
occurs, the clock stops; but, apart from disease and accident,
the clock will not stop until it runs down—until the spring has
unwound itself and its resilience is exhausted. When this
happens, the clock must stop. For the first years of life the
spring has double work to do. It has not only to keep the clock
going, but also to build it up in bulk and complexity. When
this task slackens and ceases, the whole energy of the spring is

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devoted to keeping life going, and therefore early adulthood is
the time of greatest vigour, and the time when the attacks of
disease are most easily repelled. As the tension of the un¬
winding spring diminishes, less and less serious interference
suffices to stop the clock. When it is fully wound, the power
of the spring will drive the clock even though the pivots are
lubricated with cart-grease ; when it is nearly run down, a slight
thickening of the oil on a frosty night will arrest the action.
So it is with human life. In early adulthood, the motive power
is abundant, and it takes much interference to stop the clock of
life; but as age advances, the power of living weakens and
fails, until at length in extreme old age, which is to be
measured not by years only, but rather by the amount remain¬
ing of the initial store of energy, a very trifling obstruction, an
obstruction so trifling that we cannot identify it, is enough to
be a ‘ cause of death.’ It may be in some cases, such as that
of the first Duke of Wellington, that the clock merely runs
down, and there is no more to be said. The Registrar General
deprecates the return of old age as a cause of death, but in
such a case as that of the Iron Duke it is difficult to see what
more accurate return could be made.

Properly considered, life is what I have called an unchange.
It is the maintenance of a continuous state in spite of opposing
forces which tend to terminate it. A cause of death is an
action that removes one or more of the conditions maintaining
the unchange, and allows it to be brought to an end. Life is
maintained with effort and with striving, and subject to certain
conditions. Any interference with any of these conditions
increases the difficulty of maintaining life ; interference with a
second condition, or further interference with the same con¬
dition, further increases the difficulty; and the concurrence of
two or more interferences may increase the difficulty to the
point of impossibility. In this way there may be several
causes simultaneously tending to bring life to an end, and it
may be very difficult in a given case to say how much of the
effect is due to one cause, and how much to another. The effect
is death, and it is incongruous to speak of part of death being
produced by one cause and part by another; nor is it much
less incongruous to speak of death as being partly due to one
cause and partly to another. In such a case it is the combina¬
tion of causes that produced death, and if this is so, and if

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neither of the causes acting singly would have produced it as
and when it happened, can we rightly say that one was a more
important cause than the other ? Which is the more important
cause of the discharge of a gun—the loading of it, or the pulling
of the trigger? This case is scarcely on all fours, however,
with the case of death. If one cause would have produced
death sooner or later, and the cooperation of a second caused
the death to take place sooner, then I think the former may be
considered the more important, the less the anticipation pro¬
duced by the latter.

The cause of death is always a function of two variables—
the power acting to maintain the unchange that we call life,
and the action or actions that increase the work that the
power has to do. To recur to the simile of the clock, the time
of death depends on the amount of resilience left in the spring
and the amount of friction in the works that must be over¬
come. If this friction is materially increased at more than one
place in the train, then each increase is a separate cause of the
stopping of the clock. The less the power or means of living,
the less interference with the processes of life necessary to
bring life to an end ; the greater the life-worthiness, the more
powerful must be the interference necessary to cause death.

Again, the living body may be likened, and the likeness is
more than a mere simile, to a besieged fortress. It is con¬
stantly subject to the assaults of microscopic enemies, who are
trying to obtain a footing, but are repelled as long as the
garrison is strong enough. If the fortress is attacked by a
single foe strong enough to break down its defences and
capture it, then the action of that foe singly is the cause of the
fall of the fortress. But it may be that while engaged in
repelling one invader, which is not strong enough alone to
capture it, the fortress is attacked by another, and the com¬
bined assault succeeds. In such a case the cause of the
capture is the combination of assaults. Or it may be that
the garrison is completely successful in repelling one assailant,
but at such a cost that it falls a prey to a second, of perhaps
inferior power, which succeeds in consequence of the exhaustion
of the defenders. In such a case the second attack was the
cause of the capitulation, but the exhaustion left by the first
was a necessary condition.

If we use the term Cause, with a capital, to include both

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cause and condition, and cause, with lower case, to mean a true
cause or action as distinguished from a condition, then I think
the Causes that may combine to produce the death of any
individual man may be combined in any of the four following
ways :—

Case I. The first Cause is a cause of the second ; or, other¬
wise put, death is due to some particular manifestation of a
disease, which, without that manifestation, might or might not
have been fatal. A man suffers from typhoid fever, from
which he might recover, but that the fever causes a perforation
of the bowel, which kills him. He might recover from his
rheumatism, but for endocarditis which is a manifestation of
the rheumatism. He might recover from his endocarditis, but
for an embolism which is caused by the endocarditis. He
suffers from phthisis, which might endure for years but for an
haemoptysis, which is rapidly fatal. He suffers from diabetes,
and the diabetes causes coma, which ends in death. He suffers
from general paralysis, and dies in status epilepticus , which is a
manifestation of the general paralysis.

The fatal manifestation of a disease is, I surmise, what the
Registrar General means by a terminal condition or mode of
death ; but as he gives no indication whatever as to what he
does mean, this can be no more than a surmise. In such cases
the disease may appropriately be called the Principal cause of
death, and the manifestation the Precipitating or Subordinate
cause of death.

Case II. The first Cause is not the cause, but is a necessary
condition of the second. It is necessary in the sense that
without it the cause could not have come into operation. A
person suffers from a compound fracture, which becomes
complicated with pyaemia, of which he dies. The fracture
is not the cause of the pyaemia. The cause of this is infection
with the appropriate coccus ; nevertheless, this infection would
never have taken place but for the existence of the compound
fracture, regarded as a continuing passive state—as a condition.
It is not the occurrence or action of the fracture that produces
the infection, and therefore the fracture is not the cause of the
infection ; but without the existence of the fracture the
infection could not have occurred. The fracture is a necessary
condition of the pyaemia which is the cause of death. Or a
man suffers a chill, which so diminishes his powers of resist-

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ance that the pneumococci, that before were harmlessly present
in his body, are now able to make an effectual attack, to invade
his lungs, and to cause pneumonia, of which he dies. Regarded
as an action on the body, and it is quite legitimate so to regard
it, the chill is a cause of death ; but it is not the cause of the
pneumonia. The cause of the pneumonia is the invasion of
the pneumococcus, and of this invasion the chill was a necessary
condition. But when we regard the chill as a condition, we
do not regard it as an action ; we regard it as a passive state ;
and as a passive state it is a necessary condition of the attack
of pneumonia, for without the existence of the chilled state of
the body the infection of the pneumococcus would not have
taken place. The chill by itself was not the cause of death.
Death would not have occurred from the chill without the aid
of the coccus. The pneumonia was the cause of death, but
without the chill there would have been no pneumonia.

In such cases we may call the necessary condition the
Preparatory cause of death, and the subsequent cause the
Consummating cause of death.

Case III. The first Cause is a favouring, but not a necessary
condition of the second. Persons who are already suffering
from measles or typhoid fever are more obnoxious to the
attack of broncho-pneumonia than those not so suffering ; and
broncho-pneumonia is more likely to be fatal to those who are
already suffering from measles or typhoid fever than to those
who are not. Yet measles and typhoid are neither of them a
necessary condition of the pneumonia. They are not necessary
either in the sense that pneumonia necessarily follows them, or
in the sense that one of them must necessarily precede pneu¬
monia in general. Nevertheless, it may be that in any
particular case the precession is necessary, and that without it
the pneumonia would not have occurred, or would not have
been fatal. Still, since it is impossible to say that broncho¬
pneumonia cannot occur unless it is preceded by measles or
typhoid, we cannot say that the specific fever is a necessary
condition of the broncho-pneumonia. Persons suffering from
diabetes are specially liable to be attacked by phthisis.
Diabetes is no necessary condition of phthisis, either in the
sense that diabetes is necessarily followed by phthisis, or
that phthisis is necessarily preceded by diabetes ; but the
frequency with which diabetics are attacked by phthisis

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indicates that the existence of diabetes favours the occurrence
of phthisis.

In this case again the condition may be called a Preparatory
cause, and the subsequent disease the Consummating cause of
death.

Case IV. The last case is that in which two causes, neither
of which is in any way dependent on the other, combine to
bring about a death that neither of them singly might have
been able to produce. A man is suffering from heart disease,
which does not menace his life as long as the heart is not
subjected to extraordinary strain. He is attacked by bron¬
chitis, which would not be fatal if his heart were sound ; but
the effect of the bronchitis is to put a strain upon the heart
that, in its damaged condition, the heart is unable to overcome;
and the combination of diseases is fatal. Or he suffers from
ague, which by itself might leave him years of life, but that
he is attacked by dysentery, which alone would not be fatal, and
the combination of the two diseases carries him off.

In such cases one of the two diseases may be found to play
a preponderant part in bringing about the fatal issue. In the
first of the two instances given above, the heart disease may be
regarded as preponderating, and in the second the dysentery.
Thus viewed the causes may be called Preponderant and
Adjuvant; but it is not easy in any case, and in many cases
it is not possible, to assign to either of the diseases a prepon¬
derant part; and if it is not practicable, then we can only fall
back upon the order in time, and speak of the causes as Earlier
and Later.

There are here three pairs of terms that may be used to
characterise, in appropriate cases, the several causes of death.
They may be characterised as

Principal and Precipitating or Subordinate,

Preparatory and Consummating,

Preponderant and Adjuvant, or Earlier and Later.

If I am right in my surmise that what I have called a
Precipitating or Subordinate cause of death is what the
Registrar General means by a terminal condition or mode of
death, then, as he advises the certifier not to insert the terminal
condition or mode of death into the certificate, this cause is
ruled out, and in cases in which the causes of death can be
distinguished as principal and subordinate, the principal cause

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only should appear in the certificate. I should have thought
that it would be of value to know the number and proportion
of cases in which the precipitating cause of death in typhoid
fever, for instance, is perforation, those in which it is haemor¬
rhage, those in which it is hyperpyrexia, those in which it is
exhaustion, and so forth ; but no doubt the Registrar General
knows best.

Excluding the pair just dealt with, in the very great majority
of deaths in which more than one cause can be assigned, the
causes are related in the way I have explained as Preparatory
and Consummating, or as condition and cause. Most people,
I think, would understand the term ‘ condition ’ in the sense
in which it is here used, as a pre-existing state, either
necessary or helpful to the occurrence of the fatal disease ; and
the term Preparatory cause would, I think, be allowed to be a
substitute for condition, accurate enough for ordinary use. The
term Consummating cause would perhaps scarcely be as readily
accepted, but once accepted and become familiar, it would not
give rise to difficulty. I do not think there is any other term
that expresses the nature of the cause, and its relation to the
preparatory cause or condition, with the same accuracy. Im¬
mediate cause is ambiguous, and might easily be misleading.
It would be very apt to be confused with what I have called
the Subordinate or Precipitating cause of death. The terms
Primary and Secondary have been found in the experience of
many years to be misleading and confusing, and I think they
would be better abandoned ; but if they are to be retained, then
I think it should be explained that in these classes of cases,
Primary means Preparatory, and Secondary means Consum¬
mating, in the senses here explained.

When the causes of death are two independent diseases,
the difficulty is greatest. If it were possible always, or even
frequently, to decide which of them took the greater share in
bringing about the death, it would undoubtedly be better to
distinguish them as Preponderant and Adjuvant; but this is
unfortunately not often possible. The alternative is to distin¬
guish them by the order in time of their occurrence, as Earlier
and Later ; but this distinction is ruled out by the instructions
of the Registrar General that are now in force. In a consider¬
able proportion of cases in which two diseases that appear to
be independent co-operate to bring about death, we may sus-

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pect that the earlier in time does in fact facilitate the attack of
the later, and therefore many cases that appear prirnA facie to
belong to Class IV may be removed into Class III without
doing violence to the facts ; but when the case unmistakeably
belongs to Class IV, and it is not possible to apportion the
degrees of importance among the causes, I do not see how the
terms Primary and Secondary can be made applicable except
by taking them to mean first and second, which would not only
be contrary to the instructions of the Registrar General, but
would introduce inexcusable ambiguity and confusion into the
meaning of the terms. It seems that there is no single sense
in which the terms Primary and Secondary can be used that
will cover all the cases of the relation between two causes of
death when more than one cause has been in operation ; nor is
there any other pair of terms that can be used for the same
purpose, for the relation is not the same in all cases.

In the tabulation of causes of death, one cause only is
entered, and the Registrar selects for this purpose that cause
which is ‘ most important ’ out of the two or more that are
submitted to him by the certifier. Now, it seems from the
language used by the Registrar General, and from the whole
trend of his remarks, that he looks upon the ‘ importance ’ of a
cause of death as in the first place an ascertainable quality,
and in the second place a fixed quality, a quality that is
present or absent, and if present at all, present in some fixed
degree which does not vary. This, however, is not so. The
importance of anything varies with the point of view from
which we regard it. Regarded from the point of view of the
hostess of a garden party, or of the farmer whose hay is cut
but not carted, the state of the weather is of great importance ;
regarded from the point of view of the cook, who spends her
life in the basement, or the prisoner, who spends his life
under cover, the state of the weather is of no importance at
all. The cause of death which is important to the doctor who
has an hypothesis to test may be of no importance at all to
the police ; and the cause of death which is important to the
police may not have any importance at all to the company in
which the life of the deceased was insured. Before we can say
that a cause of death is important or unimportant, or estimate
the degree of its importance, we must settle the point of view
from which the importance is to be regarded. It is more im-

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portant, says the Registrar General, that this death, which was
caused by the combination of measles and bronchitis, should
be registered as death from measles than as death from bron¬
chitis ; but why ? From the point of view of the doctor who
has views about bronchitis it may be very much more impor¬
tant that bronchitis was a cause of death than that measles
was a cause of death. If the Registrar General considers that
measles is a more important cause than bronchitis, it can only
be because for some purpose it seems more important
to ascertain the number of deaths in which measles had a share
than to ascertain the number in which bronchitis had a share.
It is impossible, therefore, to estimate the relative importance
of the different causes of death in any given case for the purpose
of registration, until we know what this purpose is ; and as to
the purpose of compiling tables of the causes of death, the
Registrar General does not enlighten us. I do not know for
certain what this purpose is. I do not even know whether
the Registrar General has any one purpose distinctly and
prominently before his mind, and I strongly suspect that he
has more than one purpose, but does not distinctly formulate
to himself what his purposes are. It is clear, I think, that
it is impossible to estimate with any approach to accuracy the
relative importance of different causes of death until we know
for what purpose the information is required, and in what
respect importance is to be estimated ; and if more than one
purpose is to be served by the estimation, it must often happen
that more than one estimate of the relative importance must be
made. It is clear that no single set of Tables could be com¬
piled from both points of view; and if more than one purpose
is to be served by compiling these Tables, the purposes should
be clearly before the mind of the compiler, and each purpose
should have a separate set of Tables to itself. The suggestion
may be a counsel of perfection, and very likely the Registrar
General would say that it is impracticable; and with the funds
and the staff at his disposal it may be so; but what I have
said is true for all that. Relative importance cannot be gauged
until purpose is settled ; and/ causes, rightly selected for their
importance for one purpose, will be wrongly selected if used for
another purpose; and whatever the purpose of the Registrar
General in selecting this or that cause of death, he should have
it clearly before his mind, and he should stick to it.

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[April,

II. Causes of Insanity.

Among the Tables of Statistics issued by the Board of Control
is a Table of the ./Etiological Factors and Associated Condi¬
tions of Insanity. The former Table, now superseded, spoke
frankly of Causes of insanity, but this term is now replaced by
./Etiological Factors, which is more vague and more cautious.
The table is as follows :

Heredity.

Insane

Epileptic

Neurotic

Eccentricity

Alcoholism

Mental Instability, as revealed by
Moral Deficiency
Congenital Mental Deficiency
not amounting to insanity
Eccentricity

Deprivation of Special Sense
Smell and Taste
Hearing
Sight

Critical Periods
Puberty and Adolescence
Climacteric
Senility

Child-bearing

Pregnancy

Puerperal State (non septic)
Lactation

Mental Stress
Sudden
Prolonged

Physiological Defects and Errors
Malnutrition in early life
Privation and Starvation
Over-exertion, physical
Masturbation
Sexual Excess

Toxic
Alcohol
Drug habit

Lead and other such poisons
Tuberculosis
Influenza
Puerperal sepsis
Other Specific Fevers
Syphilis, acquired
Syphilis, congenital
Other toxins
Traumatic
Injuries
Operations
Sunstroke

Diseases of the Nervous System
Lesions of Brain
„ „ Spinal Cord

Epilepsy

Other Definite Neuroses (limited
to Hysteria, Neurasthenia,
Spasmodic Asthma, Chorea).
Other Neuroses which occurred
in infancy (limited to convul¬
sions and night terrors).

Other Bodily Affections
Hsemopoietic System
Cardio-vascular Degeneration
Valvular Heart Disease
Respiratory System and Tuber¬
culosis

Gastro intestinal System
Renal and Vesical System
Generative System, excluding
Syphilis

Other general affections not
above included

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The Committee that drew up this Table was cautious, but it
was not clear. The Table previously in force was headed and
called a Table of the Causes of Insanity; and a queer hotch¬
potch it was, in which overwork appeared in one place, and
over-exertion in another, and a previous attack was entered as
a cause of the existing attack of insanity. I had pointed
out that several of the ‘ causes’ enumerated in that Table were
not causes, and could not be causes of anything, and it may
have been my protest which induced the Committee to sub¬
stitute for the term Causes the term ^Etiological Factors. The
old legal maxim says that fraud lurks in generalities, and to the
uncritical it often seems that safety lies in generalities. Certain
it is that refuge in generalities is a great saving of thought,
and appears a great safeguard against criticism. Any criticism
of any item in the Table, based on the ground that it is not a
cause, may be met by the defence that it is an ^Etiological
Factor, or at any rate an Associated Condition ; and of course
it would be difficult to show, if it existed at all, that it was
not one or the other. The manoeuvre, adroit as it is, has the
defect, frequent in such manoeuvres, of being too clever by half.
It is true that it eludes criticism of the items in the Table, but
at the cost of transferring the criticism to the Table as a whole.
What is the use of a Table which includes both ^Etiological
Factors and Associated Conditions, and, it may be added, other
things as well, and does not distinguish the one class from the
other ?

Some of the items in the Table are neither ^Etiological
Factors nor Associated Conditions. Mental Instability, for
instance, may be sufficiently great to amount to insanity, but
then it is the insanity, at least it is so in the eyes of the com¬
pilers of the Table, to whom insanity means disorder of mind.
Mental Instability can no more be an ^Etiological Factor of
insanity, or an Associated Condition of insanity, than a move¬
ment of the air can be an ^Etiological Factor of wind, or an
Associated Condition of wind ; or than sunshine can be an
^Etiological Factor of light, or an Associated Condition of
light. The movement of the air is the same thing as wind :
the sunshine is the same thing as light: and the Mental
Instability is, at any rate in the eyes of the compilers, the same
thing as insanity. It is in truth a part of insanity.

Again, there are many items in the Table that are not of the

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slightest value there, and that make one wonder what on earth
they were included for. I conjecture that the Committee was
nervous lest anything should be omitted, and therefore put in
everything its members could think of. Defect of smell and
taste are, no doubt, conditions that may be associated with
insanity, and so are baldness and tight boots, a Roman nose
and a fondness for pickles ; and it is about as useful to know
that any one of these is associated with insanity as any of the
others. The last two clauses include, or may include, every
disease to which humanity is subject, and I can conceive that
it may in certain connections be useful to know whether any
particular disease is particularly frequent or infrequent among
mad people; but I cannot conceive that a disease that may
affect a person years before or years after he becomes mad, can
have any rightful place in a Table of .Etiological Factors of
insanity. To mix up with Etiological Factors of insanity con¬
ditions that are manifestly only accidentally associated with it
seems to me to go out of the way and undertake a laborious
task in order to introduce confusion, and destroy what useful¬
ness the Table might otherwise have had.

The influence of Heredity in the causation of Insanity seems
to me misconceived, or rather perhaps unconceived, in spite of
the explanation that I gave a quarter of a century ago, an
explanation which has never been even examined or criticised
by any subsequent writer, although it carries a fundamental
revolution in the concept of the causation of insanity. Insanity
is the breakdown of the human machinery; and when a
machine becomes unable to do its work, the reasons cannot be
anything but the original construction of the machine and the
strains or stresses that it has had to bear. The strains or
stresses that it has to bear are actions upon the thing, the
human machine or organism, in which the change or effect of
insanity is produced ; and are therefore rightly called causes ;
but the constitution of the machine, the way in which it is put
together, the stability of its construction, is not an action. It
is a passive state; and at the utmost cannot be more than a
condition. Indeed it almost requires a stretch of language to
call it a condition. The man is the thing on which the action
takes place and on which the effect is produced ; and the man
is the result of his heredity, that is to say of the mixture of
the qualities of his ancestors. This mixture is, therefore, at the

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utmost the cause of a condition, which means an indirect cause.
By the study of the patient’s heredity, that is to say of the
qualities of his parents and ancestors, we can make a very
rough guess at the nature of the thing, the man, upon which a
cause acts so as to produce the result insanity, and that is the
utmost that a study of heredity can give us.

The causes of insanity, properly so called, are the actions
brought to bear upon the man which produce in him the
change from sanity to insanity, and the result of insanity. For
the purpose of the argument, the man is summarised in his
brain ; and actions that produce insanity are actions on the
brain, which may most conveniently be divided into the direct
actions of physical agents, the indirect actions of physiological
processes, such as child-bearing, and the still more indirect
action of emotion-producing situations of the man in the world
around him. This is the natural grouping and classification
of the strains or stresses that produce insanity ; but for some
reasons known only to themselves, writers on insanity refuse to
adopt it. I do not know what their reasons are, but I surmise
that one reason is that the classification is a clear, useful, and
scientific classification, and the other is that it is proposed by me,
who am not a German. Had it been proposed by a German, it
would have been adopted with acclamation long ago, but no
German would be capable of discovering a classification so
clear and logical.

However, taking the list—it cannot be called a classifica¬
tion—proposed by the compilers of this table, it will be
interesting to inquire into the grounds for the supposition that
the alleged causes, or aetiological factors, are in fact causes.

Heredity has already been examined. The next group,
Mental Instability, includes no cause of insanity, and nothing
that by the utmost stretch of the meaning of words can be
called a cause of insanity, or of anything else ; for nothing in
the group is an action. The same may be said of the third
group. Deprivation, by which is evidently meant not depriva¬
tion, but absence, of a special sense, is not an action : it is a
passive state ; and I know of no evidence that, as a passive
state, the absence of a special sense is material to the result
of insanity ; and if not, then it cannot be even a condition.

The next group is composed of critical periods of life ; and
these come in the class of physiological strains or stresses that

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may be causes of insanity, because they undoubtedly are, or
may produce, actions on the brain. But what evidence is there
that these do in fact exert such action on the brain as may
disorder its mode of working, and so produce the change from
sanity to insanity ? Many people, the great majority of people,
who go through these physiological crises do not become insane.
Many people become insane at other times than at the times of
these crises. On what ground, then, are they regarded as causes
of insanity, and what is the justification for so regarding them ?
These are questions which no writer on insanity has ever
answered, or ever asked, or ever considered ; but they are
questions that demand an answer, for until they are satisfac¬
torily answered, the writers have no business to assume that
these crises are causes at all; and the same may be said of all
the other alleged causes of insanity. Does the belief that these
alleged causes are causes of insanity rest upon the application
of Mill’s Canons, or of any of them ? It certainly does not. No
one has ever yet discovered, or ever will discover, two or more
cases of insanity that have nothing in common but the circum¬
stance that the patient was going through one of these crises.
No one has ever discovered, or ever will discover, an instance
in which insanity occurs, and an instance in which it does
not occur, which have every circumstance in common except
adolescence or senility. No one has ever discovered, or ever
will discover, two or more instances of insanity having only
adolescence and senility in common, and two or more instances
of sanity that have nothing in common but the absence of
adolescence or senility ; and no one, as far as I know, has ever
wasted time in an unprofitable search after such impossible
instances. Yet there is a general consensus that these and
other physiological crises are causes, or at least occasions, of
insanity, a consensus not merely of opinion, but of deep-rooted
conviction. What is the justification for the belief? It is to
be found in those methods of assigning causes that I have
grouped together under the heading of Association. It is
found in experience that these physiological crises are asso¬
ciated as antecedents with insanity, not in isolation, not con¬
stantly, but either more frequently than casual concurrence
will account for, or, when associated, the insanity has some
peculiar feature which does not occur in other cases of insanity,
not so associated. In other words, the causal connection is

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ascertained by the Method IV. C., or IV. D.; and the same
methods are employed in almost every case in which causes
are assigned for the occurrence of insanity; but not in every
case.

In the insanity that is due to drunkenness, and in that which
follows immediately or rapidly upon the absorption of other
drugs, the first Method, that of Instant Sequence, which in
these cases becomes Rapid Sequence, is employed, together
with Method IV. A, Association in Isolation. The effect follows
rapidly after the action, and so raises a presumption that it is
due to the action. The action is isolated : it takes place in
circumstances which enable us to say with considerable confi¬
dence that no other material action has occurred; and this
confirms the presumption. Further, in many cases the associa¬
tion is, in the same person, constant; whenever he takes the
alcohol or other drug, the insanity of intoxication constantly
follows: when he does not take it, the insanity does not occur.
But suppose the association is not constant, or that no oppor¬
tunity of observing constancy has occurred ? Suppose that an
excess of alcohol has been taken only once, and that insanity
has occurred only once, and then following the drink ? Then
the Method of Common Rarity is applicable, and is applied.
In other cases it is found that a little drink is followed by but
slight indications of insanity, and that the more drink is taken
the more complete and profound the insanity becomes. In such
cases the Method of Concurrent and Proportional Variation
confirms our conviction. Commonly, too, the insanity that
follows drinking has peculiar qualities that are present in
other cases of such insanity, and are not present when insanity
is not preceded by drinking; and the Method of Association
D becomes applicable. In short, whenever causation is rightly
assigned, it is assigned by the application of one or more
of the twelve Methods here described ; and never by any of
the Methods prescribed in Mill’s Canons.

Summary.

Causes of Death.

The instructions of the Registrar General require us to
distinguish primary from secondary causes of death, but give

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us no clear guidance what is to be considered primary and
what secondary.

Death is inevitable, and its causes are inherent in human
nature. That which we call the cause of death in any
individual case is the cause of death happening at the particular
time and in the particular way it does. Life is an unchange,
and death the cessation of the unchange.

When more than one cause co-operate to produce death, the
causes may be combined in one of four ways.

I. The first cause may be a cause of the second.

II. The first cause may be a necessary condition of the
second.

III. The first cause may be a favouring condition of the
second.

IV. The several causes may be independent.

In the first case the causes may be called Principal and
Subordinate, or Principal and Precipitating; in the second
case, Preparatory and Consummating; in the third, Pre¬
ponderant and Adjuvant; and in the fourth, Earlier and
Later.

The first three pairs may all be included under Primary
and Secondary. The last pair cannot be so included.

The relative importance of different causes of the same
death must depend on the purpose the observer has in view.

Causes of Insanity.

The Table issued by the Board of Control rightly does not
pretend to be a Table of Causes exclusively ; but to mix up
causes, conditions, and associated states in the same Table
deprives the Table of any value whatever for any purpose ;
and some of the headings in the Table are neither causes,
conditions, nor associates of insanity.

By following the rules laid down in Chapter VI., it might
be possible to identify many causes of insanity, and to avoid
the useless confusion of the Table.

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CHAPTER IX.

ON BELIEF.

Every philosophical discussion, and most of other discus¬
sions, are discussions about the meaning of words, either of
single words, or of phrases, or of propositions; and most
philosophical discussions, and many others, are barren and
inconclusive because the different disputants, and often the
same disputant, attach different meanings to the same word,
phrase, or proposition, and often attach to it no clear meaning
at all. In order to use a word, or a phrase, or a proposition,
correctly and with propriety, it is by no means necessary that the
user should be able to formulate in other words what his
meaning is. The ability to feel and appreciate nice shades of
meaning, and to express them in appropriate words, long
precedes the ability either to define the distinctions or to
formulate the meaning. The difference between ‘ I shall ’ and
‘ I will ’ is felt by every Englishman, though by no Irishman
or Scot ; but not one in ten thousand of those who use these
expressions correctly, and never confuse them, could formulate
in words the difference of meaning. It is the same with the
great majority of words and expressions in common use. We
feel their meanings : we always use them correctly ; but if we
are asked to define them in other words, not one of us in ten
thousand could do so satisfactorily.

In common use, and on common occasions, the want of •
formal definitions of the words we employ does not matter
much, for we understand each other, and ourselves, sufficiently
well for common purposes ; but discussions, and especially
discussions upon matters that have puzzled mankind for ages,
are quite futile unless we fix beforehand, as accurately as we
can, the meaning of the words and phrases upon which the
discussion hinges. In common use, the words Belief and
Believe have many different meanings. As used in the
Catechism—* All this I steadfastly believe ’—and in the

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Creeds of the Christian Church, the phrase ‘ I believe ’ means
‘ I am convinced,’ ‘I accept that statement as an assertion of
fact.’ In current use, as when we say ‘ I believe he is gone
out,’ it means uncertainty. It means not ‘ I am convinced he
is gone out,’ or ‘ It is a fact that he is gone out,’ but ‘ I think
he is gone out, but I am not sure.’ Again, Belief may mean,
not only at one time, as in the first example, assured conviction,
and at another time, as in the second example, doubt inclining
to affirmation, but it may be used, as I have used it at the head
of this chapter, as a generic term, to mean at one and the same
time every degree and shade of belief, from axiomatic certainty,
through approximate certainty, and every degree of increasing
doubt, to utter disbelief and inconceivability. In this sense the
name Belief has many meanings, all, however, referring to
states of mind or attitudes of mind. Attitudes of mind towards
what ? Towards fact, most people would say, and the answer
would be approximately true, but fact is not the only thing to
which we attune our beliefs, and if it were, and as far as it is,
we must know precisely what we mean by fact.

Belief, Truth, Doubt, Certainty, Opinion, Possibility, Credi¬
bility, Probability, and many more, are all words germane to
this discussion, and if we scrutinise them with care, we shall
see that they fall naturally into three classes. Some of them
we can predicate of ourselves, but not of impersonal things. We
can say I doubt, I believe, I think, I am of opinion ; but we
cannot say It doubts, it believes, it thinks, or it is of opinion.
Others we can predicate of impersonal things, but not of
ourselves. We can say It is true, it is probable, it is credible,
or possible, or likely ; but we cannot say I am true, I am
probable, I am credible, or possible, or likely. A third set of
words, which are but few, we use indifferently either way. We
can say I am certain, and It is certain ; I am doubtful, and It
is doubtful. In these cases, however, we are conscious of a
certain impropriety in one of the uses. ‘ I am doubtful ’ means
no more and no less than ‘ I doubt,’ and the latter, as the shorter
and more direct expression, is the one that ought to be preferred.
‘ I am certain ’ means no more and no less than ‘ I know ’ ; and
might be discarded in favour of I know. Discarding the words
of this mixed and intermediate class, there remain those which
we predicate of ourselves, and which indicate states of our
minds, and those which we predicate not of ourselves, but of

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impersonal things. The question arises To what kind of things
do words of the second class refer ? What is in apposition to
the ‘ It ’ which is the subject of the proposition ?

About this there is no room for doubt: ‘ It ’ refers to a

statement. It is true that-, or probable that-, or credible

that-. In every case the predication refers to a statement;

but in every case an attitude of mind is implied, and in every
case the statement is a statement of fact: so that in every
case of the kind there are three things to consider and investi¬
gate : the fact, the statement about the fact, and the attitude
of mind towards this statement. These three factors may at
once be reduced to two. When we express the attitude of our
minds towards a statement of fact, we are adopting an indirect
method of expressing an attitude towards the fact itself. This
is clearly shown by those cases in which we use the same word
towards both. ‘ I am certain that hens lay eggs ’ indicates our
attitude of mind towards a fact. ‘ It is certain that hens lay
eggs ’ is an assertion directly about the statement that hens lay
eggs, indirectly about the fact that hens lay eggs. It seems
that it does not matter much which form we use, and in this
particular case it does not matter; but in many cases it is
more convenient to assert indirectly our mental attitude towards
a fact through a statement than to assert directly our mental
attitude towards a fact, and this for two reasons. In the first
place, a statement is a form of words that may embody fact,
or pseudo-fact or quasi-fact, or what is not fact ; and we can
express our attitude of mind towards such a statement without
inconsistency ; but we cannot without inconsistency, or at least
incongruity, express our attitude of mind towards what is not
a fact. We can say with propriety ‘ I believe hens lay eggs,’
but we cannot say without a sense of irksomeness and impro¬
priety ‘ I disbelieve hens lay chickens,’ or ‘ I disbelieve hens do
not lay eggs,’ for in these expressions we are virtually asserting
and denying the same fact in the same breath. The incon¬
gruity is at once removed by inserting the relative ‘ that,’ for
by so doing we transfer our opinion from the fact or quasi-fact
to a statement of it. There is no sense of impropriety or
incongruity in saying ‘ I disbelieve (the statement) that hens
lay chickens ’ or ‘ I disbelieve (the statement) that hens do not
lay eggs.’

The second reason that induces us often to prefer an asser-

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tion about a statement to an assertion about a fact is that by
using the former method of expression we have at our com¬
mand a larger choice of shades of meaning than is available by
the other mode : and with both at our command, the number
of shades of meaning that we can express is largely increased, as
we may see from the following examples.

‘ It is certain ’ means * I affirm that the statement is true ’;
and corresponds nearly with ‘ I know that the fact is so’, but
is rather more emphatic.

* It is true ’ means * I admit that the statement is true ’;
and corresponds nearly with one of the senses of* I believe that
the fact is so ’, but is perhaps more emphatic.

‘ It is probable’ means ‘ I incline to believe that the state¬
ment is true ’; and corresponds in some cases with ‘ I think ’,
in others with ‘ I suspect that the fact is so.’

‘ It is possible ’ means ‘ I do not deny that the statement
may be true ’ ; and corresponds with ' I dare say the fact is so ’
or * may be so.’

* It is doubtful ’ means ‘ I neither affirm nor deny that the
statement is true ’ ; and corresponds pretty accurately with * I
do not know whether the fact is so or not.’

In all these cases the last assertion expresses the attitude of
mind towards a fact ; the second expresses the attitude of mind
directly towards a statement, indirectly towards a fact; and the
first expresses explicitly an assertion about a statement, and
implicitly the attitude of the mind towards, first, the statement,
and second, the fact, or quasi-fact, expressed in the statement.

In the foregoing discussion the term ‘ fact ’ has been freely
used. It is time to define it, and to ascertain how it is
expressed. Of course, originally and strictly, a fact means a
thing done, but few words have been more abused, battered
and transmogrified ; and by many writers and speakers it is
used pretty much in any sense they please at the moment. I
discard all these meanings, and define it for the present purpose
as anything existing or happening, in the past, present, or
future. To us, however, a fact is always a relation, and we have
no means of expressing, or indeed of apprehending, a fact
except as a relation. Our expression of a fact is always in the
form ‘ A is related to B,’ and this empty form is filled out and
vitalised by substituting appropriate terms for A and B, and by
interposing between them a verb as a connecting link, as for

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instance, Hens lay eggs. This is an expression of a fact, and
the fact is expressed by asserting a relation of laying, which
means in this case origination or parentage, between the eggs
and the hens. It is manifest that there are as many relations
known to us as there are verbs to express them ; and more¬
over, we are constantly inventing new verbs to express relations
that we newly appreciate. I mention this because the teach¬
ing of every book on logic is that there is only one relation
between things, and that there is only one verb in any language,
namely, the verb ‘to be ’ ; or if there is any other verb, it
cannot be used to express a fact, or to argue or reason about
it. This is what logicians teach, although they use all the verbs
in the dictionary as freely as anyone else, and cannot, any
more than other people, conduct their arguments without
these verbs. The doctrine is a curious superstition, and well
worthy the attention of students of irrational beliefs, but it
need not detain us now.

Things exist or do not exist, happen or do not happen.
Our business, if we think about them at all, is to bring our
attitude of mind into conformity with fact, so that if a thing
has, does, or will exist or happen, we should so believe; and
if it has not, does not, or will not exist or happen, we should
attune our minds accordingly, and disbelieve. Now, it is a
common-place of philosophy that we have no experience of
things themselves, but only of their appearance; and with
respect to many things that we rightly believe, such as the
landing of Caesar in Britain, and the great earthquake at
Lisbon, we have no experience even of appearance to go upon.
How, then, are we to bring our beliefs into accordance with
facts, our disbeliefs into accordance with the absence of facts ?
In this way : Between facts, or the existence and happening of
things, and our minds, which should be moulded into con¬
formity with the facts, there is an intermediary, which we term
evidence. The facts give rise to evidence, and it is the evidence
and not the fact that impresses our minds. We can never have
any direct knowledge of things or facts external to our minds :
all that we can ever know is the evidence for or against them,
and it is notorious that evidence may mislead. Still, though
it may mislead, it is the only means we have of attaining a
knowledge of fact, and therefore it is of the utmost importance
that we should discover what is evidence and what is not; what

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evidence is trustworthy and what is not; what are the sources
of error in interpreting evidence, and how they may be avoided ;
what kinds of evidence there are ; and, generally, ascertain how
to bring our beliefs into accordance with the best evidence we
can get.

For, as belief should rest upon evidence, so it should be in
accordance with the evidence. Of some things, as of the size
and position of a possible crater on the other side of the moon,
we have no evidence at all, and therefore ought not to have
any opinion at all. Of many other things, such as the exist¬
ence of an enormous sea-serpent, the evidence is imperfect and
inconclusive, and towards these the attitude of our minds should
be one of doubt or scepticism. We have no right either to
believe or disbelieve. Of yet other things, such as the exist¬
ence of the moon, and the recurrence of the tides, the evidence
is conclusive and unassailable, and towards these our attitude
of mind should be one of belief.

It is customary to speak of a * knowledge of the fact,’ as if
such knowledge were practicable, and indeed frequent; and no
doubt when the evidence is quite conclusive it would be
pedantic and ridiculous to object to the expression. In such
cases we may, for the common purposes- of life, leap over the
evidence, and conclude that the knowledge and belief conform
to the fact; but the habit of leaping over the evidence has its
dangers. It leads very often to accepting a knowledge of
evidence as a knowledge of fact; and to a disregard of flaws
in evidence which should make us hesitate. The attitude of
hesitation is, however, irksome, inconvenient, and painful; and
few will maintain it until they have trained their minds to
submit to it.

Evidence.

Evidence of fact is of three kinds, and is derived from three
sources : evidence of sense, evidence of reason, and evidence of
hearsay; and any one of these may be conclusive or incon¬
clusive, convincing or worthless.

Evidence of Sense .—The evidence that facts themselves
afford directly to the senses of hearing, sight, touch, and so
forth, is commonly regarded as conclusive and irrefragable.
* Seeing is believing ’ is an aphorism that everyone accepts.

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That which is palpable cannot be gainsaid. These statements
are in one sense the truest of truths, but in another they may
be very misleading. When we have an impression on a sense,
when we see a light, hear a sound, or feel a touch, these are
facts of ultimate certainty ; and it is not open to us to doubt
that we do experience the sensation ; but a sensation no more
remains a bare sensation when it is received by the mind than
a fly remains a bare fly when it is received into a spider’s web.
In the one case as in the other, the intruder is instantly
enveloped in a web of new material furnished by the owner of
its new surroundings, which distorts and transforms it, and
makes of it a very different thing. The mind is rarely content
to receive a sensation and let it remain a bare sensation. It
instantly begins to work upon it, to interpret it, and to infer
from it to some external fact which corresponds with it and
gives rise to it. This is seen by the character of the response
that is instantly made by the mind to any sudden and un¬
expected sensation. When we receive a sudden and unexpected
flash of light, or sound, or touch, the instant and unfailing
response is 1 What’s that ? ’ The question does not refer to the
sensation. We know perfectly well what the sensation is. It
is a flash of light, it is a loud crack or boom, it is a touch, light
or heavy; and no investigation can give us any further know¬
ledge of the sensation itself. What the question refers to is
not the sensation, but the source or origin of the sensation :
not the feeling, but the fact that gives rise to the feeling. We
say or think ‘ What’s that ? ’, but if we were to express our
meaning with pedantic accuracy we should say 1 What has
happened ? ’ ‘ What fact has occurred to give rise to this

sensation ? ’ The sensation is evidence ; the knowledge of the
external fact that gives rise to the sensation is arrived at by
interpreting the evidence; and the knowledge will be true or
false according as the interpretation is correct or incorrect;
and so will be the belief. I hear a booming rumbling noise,
and this noise is evidence to me that something has happened
in the world outside of me; but what it is that has happened,
the noise does not tell me. What conclusion I come to about
the origin of the noise must be arrived at by interpretation;
that is to say, by the activity of the mind working upon the
materials it possesses. I interpret the sound as thunder. I
may be right: I may be wrong. It may be thunder, or it

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may be heavy guns. The sensation itself does not tell me.
It is from the interpretation of the sensation that I derive my
belief; and although sensation cannot err, the interpretation of
sensation may be very erroneous ; and the moment interpreta¬
tion steps upon the scene, the chances of error begin. At how
early a stage interpretation begins, and how irresistibly it may
lead us to false conclusions, are shown by the many examples of
what is called sensory illusion. If we touch a marble with two
adjoining fingers, we have two sensations of touch which we
interpret as due to one object; but if we cross the fingers and
again touch the marble simultaneously with both, we cannot
help interpreting the sensation as due to two objects. The
familiar experiences afforded by the conjurer and the ventrilo¬
quist give us examples of illusion of the senses of sight and
hearing, illusions which are in every case due to misinterpreta¬
tion of what we see and hear ; but it would be quite a mistake
to suppose that misinterpretation is limited to the cases in
which others lay elaborate schemes to deceive us. When sight
or hearing is impaired, misinterpretation of these sensations
becomes frequent, and it is occasional with all of us, as the
many cases of mistaken identity testify. For a long time it
was in doubt, and for aught I know it may still be in doubt,
whether there are or are not rectilinear markings on the surface
of the planet Mars; and the interpretation of the markings, if
they exist, is still a matter of dispute.

Interpretation of a sensation consists in likening it to some
previous sensation that we have had, the source of which we
have ascertained. Thus, when I hear that deep booming
sound, I mark its resemblance to such sounds that I have
heard in the past, and say ‘ That must be thunder,’ or ‘ That
must be guns.’ Which source I choose must depend upon my
recollection of the sounds of thunder and of guns ; and upon
which of these the sound that I now hear most resembles.
When I identify a man as one that I have seen before, my
interpretation of the visual sensation depends on the faithful¬
ness of my memory of what I have seen before, and on the
degree of likeness that I can trace between the present sensa¬
tion and the memory of the past sensation. Accuracy of
interpretation depends partly on faithfulness of memory, and
partly on the ability to discern likeness and difference.

A powerful aid to interpretation, in cases in which it can be

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employed, is the checking of the evidence of one sense by the
evidence of another. If a thing looks as if it were hard or soft,
we can test that interpretation by the sense of resistance. If it
looks as if it were at a certain distance, we can traverse that
distance, and note whether we reach it. The corroboration of
one sense by another usually removes the possibility of doubt;
but we find that seeing is not always believing, or if it is,
the belief may be erroneous; and although the evidence of
sense may usually be trusted, and in almost every case must be
trusted, yet possibilities of error lurk in the interpretation of
this evidence, and there are cases in which these possibilities
ought to be borne in mind, and judgement, even of the evidence
of sense, suspended.

Evidence of Reason .— As we have just seen, the whole
cogency of the evidence of the senses lies in the way we inter¬
pret it; and we interpret it by the activity of the mind working
on the material with which the senses furnish it. Interpreta¬
tions of sensations, or perception, is, in short, an example and
a method of reasoning ; very elementary reasoning it is true,
but still reasoning of a kind, and of a kind that is the model of
a very large part of our reasoning. The only difference is that
in the rest of this kind of reasoning the material is not the
direct evidence of the senses, but other evidence—evidence that
has been gradually accumulated in our minds by experience
and hearsay, and which the mind can work upon and interpret
in the same way as it works upon and interprets the evidence
of sense ; that is to say, by remembering, and by tracing likeness
and difference between the things remembered. The general
rule is that the more completely the evidence harmonises and
accords with what we know to be true, the more readily we may
accept that evidence as evidence of truth; and vice versa, the more
incongruous and discrepant the evidence with what we know
to be true, the more cautious we should be in admitting it.

This raises the crucial question, What do we know to be
true ? and this question has, curiously enough, two answers,
one derived from reason and one from experience.

As we have already found, a statement is not bound to
conform to truth. We can form the statements ‘ Paris is in
London,’ ‘ The Thames is run dry ’; but we cannot assert
either of these statements, for assertion means that we intend

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what is asserted to be received as true. Now there are certain
statements that are not merely false, like the instances just
given, but that the mind refuses to entertain. A statement
consists, as we have already found, of two terms predicated to
hold towards each other a certain relation. It is possible to
take any two terms we please, and to couple them in a state¬
ment by any verbs we please, and the resulting statement then
comes before the mind for acceptance, or rejection, or any other
operation the mind can perform upon it. With this wide liberty
of concocting statements it is evident that we can, if we please,
form some that are nonsensical, and that convey no idea to the
mind, as for instance ‘ Two o’clock is solid,’ ‘ Limestone reasons
downward,’ ‘ Hens shine pocket-books.’ Such statements the
mind has nothing to do with. It neither accepts nor rejects,
but disregards them. It is impossible even to consider whether
they are true or not. There is a second kind of statement
which is not nonsensical, which can be entertained by the mind,
but which the mind instantly rejects, because it cannot conceive
the terms to stand in the relation which the statement purports
to assert. Such are the statements * The hen laid an egg larger
than itself,’ ‘ The space was enclosed by two straight lines,’

‘ The solid body is liquid,’ ‘ The pain was unconsciously felt.’
In these cases the relation expressed in the proposition is in¬
conceivable. The mind cannot put the terms together in the
relation that is predicated. It is intuitively perceived that the
statement is false, and that its contradictory is true. Thus, by
the light of reason alone, by the very nature of the terms, it is
seen that they cannot exist in the relation predicated, and that
the contradictory of that relation must be true. The realisation
of this truth does not rest upon experience. It is independent
of experience, and apart from it; and it is the highest and
most assuredly certain truth that the mind can entertain. We
need no experience to assure us that the hen did not lay an
egg larger than itself, that the space was not enclosed by two
straight lines, that the solid body is not liquid, or that the pain
was consciously felt. Such truths, which are the contradictory
of what is inconceivable, are called Axioms ; and as already
said, axiomatic truth, or axiomatic certainty, is the uttermost
certainty of belief that the human mind can entertain. The
terms are bound up indissolubly in the relation, and no effort
of mind can tear them asunder.

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Axiomatic truth is the contradictory of what is inconceivable.
Herbert Spencer arrived at the conclusion that the test of
truth is the inconceivability of the opposite, and this doctrine
was strenuously opposed by Mill ; who declared that it is no
test, since many things, such as the antipodes, the rotation of
the earth, and gravitation, were inconceivable to our forefathers,
but are become commonplaces to us. The contradictory of
these beliefs was accepted by our forefathers as true, and is
known by us to be false. The contradictory of what is incon¬
ceivable is therefore, in Mill’s opinion, not necessarily true. It
may be as mistaken and false as any other belief. Spencer felt
that he was right, and he was right; but he had great difficulty
in meeting Mill’s objection, and never met it satisfactorily. He
maintained that in the cases adduced by Mill, the relations that
had been thought to be inconceivable were not really incon¬
ceivable, but had been thought to be so because they were not
clearly represented or pictured in the mind. When, however,
we do clearly represent a relation in the mind and find it indis¬
soluble, it must, so Spencer said, be true, and we cannot help
admitting that it is true. Spencer rested his defence upon a
wrong ground, and it is easy to demolish. There is no difficulty
in clearly representing or picturing in the mind the antipodes
and the rotation of the earth ; and both their existence and its
contradictory are easily conceivable, and have in fact been
conceived. The true defence is that Spencer, when he said that
the contradictory of the inconceivable must be true, was refer¬
ring to axiomatic truth ; Mill, when he denied it, was referring
to empirical truth ; and thus both were right and both were
wrong. That the earth rotates, or does not rotate, is a relation
whose terms do not refuse to exist in either relation. The
mind can put them together in either relation, and does not
intuitively perceive that either is true or false. Which is true
and which is false is for evidence drawn from experience to
decide. But to perceive the truth of an axiom we need no
evidence. We need no evidence to enable us to decide whether
a hen can lay an egg larger than itself, or whether two straight
lines can enclose a space, or whether a pain can exist without
being felt, or whether a solid thing is liquid. As soon as we
have experience enough to comprehend the relation that is
asserted, we see that it must be false. The mind refuses to
entertain it, and asserts at once that the contradictory must be

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true. Mill’s instances are not of this nature. Whether they
are true or false is matter for discussion : it is for experience to
decide : their truth or falsity is not intuitively perceived the
moment they are stated and the mind grasps their meaning.
In short, they are not axiomatic truths or certainties, they are
empirical beliefs.

Rightly apprehended, an axiomatic truth cannot be doubted.
Of course we may frame a statement which purports to deny
an axiom, but it is beyond human capacity to doubt an axiom,
and anyone who pretends to do so is either deliberately lying,
or is so muddle-headed as not to know the meaning of what
he says.

Empirical certainty is a degree less assured than axiomatic
certainty. Empirical truth, once established, must be believed ;
but it is always open to us to conceive the contradictory,
though we may not be able to believe it. Empirical truth is,
as its name implies, founded upon experience, and our warrant
for it is experience alone. Conceivably the fact might be
otherwise. In experience it never is and never has been other¬
wise. Consequently, as long and as far as our knowledge that
it never has been otherwise extends, we are precluded from
believing that it ever will be otherwise. It is to us an empiri¬
cal certainty. The basis of empirical certainty is constancy in
experience, by which is meant, in the first place, the accumula¬
tion of instances without exception. The greater the number
of experiences of a given fact that we can accumulate without
finding any exception, the firmer becomes our belief that the
fact is universally true, and that no exception will be experi¬
enced ; until at last conviction becomes unshakeably assured.

No one nowadays doubts that mankind are necessarily
mortal—that every man, woman, and child that now lives will
die, and that there is no one now living who was alive two
centuries ago. This is not an axiomatic truth. The contra¬
dictory of it is not only conceivable, but has by many people
been believed. There have been few primitive peoples who
have not believed in the immortality of some chief or promi¬
nent character who impressed himself powerfully on their
minds during his lifetime, and became the centre of legend
after his death. We have our King Arthur, our Merlin, our
Thomas of Ercildonne, the Germans their Frederick Barbarossa,
Denmark its Holger Danske, and other nations their analogous

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characters; but such beliefs have prevailed only among
primitive people, belonging to small communities without
authentic memorials of past times, and without any critical
faculty of interpreting evidence. As far as we know, there has
never been an instance, there is no evidence worth the name,
that of all the millions of millions of mankind who have lived
in past ages anyone has escaped the fate of dying.

This complete constancy in experience of the sequence of
death upon life in men is of itself sufficient to produce in us an
empirical certainty that the sequence never will be broken, and
that all children who are born into the world will die sooner or
later; but this constancy in experience is reinforced and cor¬
roborated by a constancy of far greater extent. Men are living
beings, and with respect to what they have in common with
other living beings we can argue from other living beings to
men ; and our constant experience of all living beings, animal
and vegetable alike, is that after a period of life they die. More
even than this, the slowly accumulating experience of mankind
through the centuries, and the insight that we have gained in
the last few generations into the processes of nature, all go to
show that destruction, dissolution, decay, or at least change, is
the universal law of all material things ; and man’s body is a
material thing. This vast concourse of experiences, to none of
which can any permanent exception be shown, breeds in us a
corresponding fixity of belief in the inherent mortality of man,
a belief that is not axiomatically certain, for it is not difficult
to conceive that a man should go on living for an indefinite
time, and indeed, many have conceived, and even in a sense
believed it; but the belief is empirically certain, for, with the
evidence now at our command, it is impossible to admit that
any man has lived much beyond a century, and this complete
constancy in our experience of an indefinitely great multitude
of cases of men and other living things, justifies and compels an
empirical certainty of belief.

A very similar empirical certainty is that heavy bodies, if
unsupported, fall to the ground. This, again, is not an axio¬
matic certainty. It is easy to imagine heavy bodies without
support remaining suspended above the ground ; and the case
of Laputa shows how easily it can be imagined, while the case
of Mahomet’s coffin shows that it can be not only imagined but
believed. We have, in fact, many experiences of heavy bodies

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without visible support which yet do not fall to the ground.
Every flying bird is such an instance, and we frequently see
leaves, straws, and other things tossed about by the wind with¬
out falling. In such cases we soon learn that the air, though
invisible, is a support, and that the rule is not really broken ;
and so at length, by the accumulation of innumerable experi¬
ences without any real exception, experiences constantly re¬
curring throughout every moment of our lives, we are driven and
compelled to adopt as quite certain the belief that heavy bodies,
if unsupported, will inevitably fall to the ground ; and although
we can imagine exceptions, we cannot believe that there ever
has been or ever will be a real exception, and the belief is
inescapable. It is an empirical certainty.

These, it will be seen, are cases of that enumeraiio simplex ,
ubi non reperitur instantia contradictoria which Bacon and sub¬
sequent logicians have scouted as utterly untrustworthy as a
ground of belief. It is unquestionable that it is, on the contrary,
the ground of the most certain and inescapable of all our
empirical beliefs.

It is true that it is not always a satisfactory ground of belief,
or at least that the evidence may be so interpreted as to give
rise to beliefs that are unwarranted. The ancients believed, on
somewhat similar grounds, that every swan is and will be white,
and that no such thing as a black swan is credible. Since their
day, black swans have been discovered, and they have been
shown to have been in a sense wrong ; but they were not wholly
wrong. Let us see what were the grounds of their belief.
They had had many experiences of swans, and in every case
without any exception the swans had been white. According
to rule, therefore, it seems that they were justified in entertain¬
ing the certain conviction that all swans thereafter discovered
would be white, and no swan of any other colour would ever
be found. It will be seen at once, however, that the number
of cases, in which swans had been seen and found without ex¬
ception to be white, were as nothing in comparison with the
number of cases in which unsupported things had fallen to the
ground, or with the number of cases in which men and other
living beings had proved their mortality by dying. A very
important element in confirming the certainty of an empirical
belief is the number of cases in which the conjunction or rela¬
tion has been witnessed and found to be constant. Constancy,

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however complete, that extends over but few cases ought never
to be accepted as ground for a certain belief; and the acceptance
of a few cases as proof of a general law is one of the most
fertile sources of erroneous belief. If, upon visiting a new
country, the first man we met was six foot four, or even the
first two or three men we met were more than six feet high, it
would be manifestly very unsafe to form the belief that all the
inhabitants of that country were exceptionally tall. Although
the relation would be constant in experience as far as experi¬
ence went, the experience would be far too limited to justify a
belief in the general prevalence of the relation. A similar error,
not so gross, but similar in kind, though less in degree, vitiated
the belief of the ancients in the universal whiteness of swans.
The instances were too few.

But there was another and more serious error. We have
seen how enormous a corroboration and justification for the
belief in the mortality of men is afforded by the constancy in
experience of the mortality of other living things, that is to
say, of things that, for the purpose of the argument, are like
men. It is manifest that if all birds, and still more if all
animals also, had been white, and no instance of a bird or an
animal of any other colour had ever been known, the certainty
of the belief that all swans are and will be white would have
received a tremendous corroboration. But this is not so. Not
only animals, but birds also, exhibit a great diversity of colour,
and even some birds that are, for the purpose of the argument,
not unlike swans, such as geese, exhibit some diversity of
colour. Therefore the belief that all swans are and will be
white was risky, and should have been held lightly, and subject
to further experience.

Nevertheless, as far as it went, and as they understood it, the
belief of the ancients that all swans are white was justified, and
was true. By ‘ swans ’ they meant the species and breed of
swans that they knew, and with respect to these ‘ swans ’ they
were right ; for no swan of that species has ever yet been of
any other colour, as far as we know, in the two thousand years
that have elapsed since their day; and with every generation
of these swans the appearance of an individual of any other
colour becomes less likely. The black breed of birds resembling
swans, that has since been discovered, we call by the name of
swans, but they are not the same kind of swans as were

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known to the ancients, and might very well have been called
by some other name. They may be swans, but they are swans
with a difference ; and as far as the swans which the ancients
believed to be always white are concerned, their assertion was
true.

It is clear, I think, that empirical beliefs in the general truth
of relations always depend upon the constancy in experience of
those relations, and are the more justifiable, the more confirmed,
and the more inescapable, the greater the number of instances
in which the experience has been constant.

Supposing, however, that the relation is not constant in
experience, but is liable to exceptions, in which its terms are
experienced dissevered from one another, what effect will this
inconstancy in experience have upon the attitude of mind ?
For instance, cancer is generally a fatal disease, but every now
and then there occurs a case in which a cancer, after having
advanced to a certain stage, shrinks up, dwindles away, and
disappears, or leaves a mere remnant, and the patient recovers
his former health. If we have had, directly or indirectly, that
is to say by ourselves or by others, experience of a very large
number of cases of cancer, every one of which has been fatal,
our belief in the fatality of cancer will be strong in proportion
to the number of cases in which a fatal issue has without
exception occurred. Now if a case occurs in our experience in
which recovery ensues, we have two alternatives of interpreta¬
tion. We may believe that we have been mistaken in sup¬
posing that the disease is cancer, and may adhere to our
original belief that cancer is always fatal ; or we may modify
our belief about the fatality of cancer, and admit that though
it is very generally fatal, yet it is not always so. There is no
doubt that in every case in which the experiences of constancy
have been very numerous, the safest course is the first. We
should assume that we have been mistaken in supposing that the
constancy has been broken, and should require the most strin¬
gent and unimpugnable evidence, first that the tumour really
was cancer, and second that it really did shrink up, dwindle
away, and allow the patient to recover. Unless and until
evidence on both these points is established beyond reasonable
doubt, we ought not to admit that cancer can ever recover.
But if these two matters are satisfactorily established, then we
can no longer doubt, but must modify our original belief, and

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admit that, although cancer is generally fatal, yet it is not
universally or necessarily so.

The number of cases in which cancer has been watched and has
been found to be fatal is many thousands, many tens of thousands,
perhaps many hundreds of thousands ; and the number in which
the result has not been fatal has been few, perhaps a few dozen,
perhaps a few score ; but in any case, constancy in experience,
even if complete, and even in hundreds of thousands of instances,
does not warrant the assured certainty that is derived from the
constancy in experience of the fall of unsupported bodies. Ot
this we have experiences by myriads, experiences daily and
hourly all our lives long, experiences that are common to our¬
selves, our companions, our predecessors, and as far as we know
to the whole human race. To such constancy in experience
no exception ought to be admitted on any ordinary evidence.
Any apparent instance to the contrary should be prima, facie
disbelieved, and no approach to belief should be admitted until
the instance has been examined, and tested, and re-examined,
and retested, in every possible aspect and by every possible
means. Mere eyewitness of such an instance is worthless, and
should not be admitted for an instant. If a person thinks he
sees a heavy object, such as a table or a man, rise from the
ground and remain suspended in the air without visible means
of support, he should assume as a matter of course that there
are means of support invisible to him ; and in the improbable
event of his investigating the matter closely and still discover¬
ing no means of support, his proper attitude of mind is to
assume that the means of support are so cleverly hidden that
he is not able to discover them. In face of the universal ex¬
perience of the human race that the relation is constant in
experience, he would be guilty of unjustifiable credulity if he
believed, on the evidence of a single instance, that an exception
could occur.

In many things experience exhibits little or no constancy.
In this country there is very little constancy in the sequences
of the weather. A fine day may be followed by a fine day, or
it may be followed by a wet day ; and as there is no constancy
in experience, so there can be no assured belief, and in any
individual case no assured expectation. We may, indeed, be
able on other grounds to forecast with some success what the
weather will be to-morrow, but we cannot do so on any con-

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stancy in experience of the succession of a wet day on a fine
one, or vice versa ; but though we cannot rightly form any
belief of the kind of weather that will occur on the day
following a wet day or a fine day, we are not altogether de¬
barred from belief. On the contrary, our experience has been
in some respects constant, and consequently in some respects
we have very definite and positive beliefs about the weather
generally. As far back as our records go, and as far as the
memory of the oldest inhabitant serves, the weather in these
islands has been generally inconstant, with occasional spells of
uninterrupted rain, and occasional spells of uninterrupted fine
weather. We are therefore justified in believing, and indeed
compelled to believe, that in future the weather here will con¬
tinue to exhibit these characters, and that we shall go on
indefinitely having spells of fine weather, spells of wet weather,
and spells of changeable weather. In short, in whatever
respect experience has been constant, even in inconstancy, in
that respect we are justified in believing, and compelled to
believe, that it will continue to be constant.

Empirical belief rests, therefore, upon two elements in expe¬
rience : first on the absolute number of the experiences of the
particular relation. If these experiences are sufficiently
numerous, and are all one way, we must believe that the
experience is necessary and will continue. The smaller the
number of experiences, even if they are all one way, the less
are we justified in arguing to other similar cases, and the more
cautious should we be to keep an open mind. When expe¬
riences are not constant, but are sometimes one way and
sometimes another, we are not warranted in believing that any
new experience of the kind will be either way ; but when
experiences of one way preponderate numerically over expe¬
riences of the other way, and the total of experiences of both
kinds is very large, we are justified in believing, and compelled
to believe, that a similar proportion will hold of such expe¬
riences in the future, and that the chances of a new experience
being one way rather than the other will be in the proportion
that the ways have borne to one another in the past.

Evidence of Hearsay .—Immense numbers of our beliefs
are based on this kind of evidence ; and as it is manifestly
open to more sources of error than either of the other kinds,

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it is incumbent on us to examine it with some care. It is
more open to sources of error than the other kinds because all
evidence, including that of hearsay, is ultimately derived from
experience or from reasoning, and hearsay evidence has
additional sources of error in the untrustworthiness of the
witness, either from bias, or from deliberate intention to
deceive, or from defect of memory, or from other causes.

With respect to every assertion, the first necessity is that it
shall be understood in the same sense by both the assertor and
the recipient, and this is often not the case. The ancients
asserted that all swans are white. A modern zoologist will
assert that all swans are not white—that in fact some swans
are black. Either assertion may be true or false, according as
it is understood. If by ‘swans’ we mean the familiar Euro¬
pean species, the ancients were right ; but if we include in the
term ‘ swans ’ birds that are sufficiently like the European species
to be included in the same genus, and extend the name so as
to cover this genus, then the moderns are right and the ancients
are wrong. Again, there is another sense in which both are
wrong. No swans are wholly white or wholly black. The
legs and beak of the white swan are not white, and the beak of
the black swan is not black. Still, it would be pedantic and
unnecessary to deny, on account of these exceptions, that the
one is white or the other black. Neither statement is strictly
accurate; but this does not matter, because both assertor and
recipient are quite aware of the exception, and both under¬
stand the assertion in the same sense. If I assert that all
gnats bite, the assertion is true in one sense and false in
another. It is true that gnats of every species bite, but the
males of some species do not bite ; and while it is true that the
females of every species bite if they get the chance, many
individual female gnats never do get the chance, and therefore
in this sense all female gnats do not bite. Still, though
exception may be taken to the mode of expression, the mode
of expression is of no importance as long as both parties
understand it in the same sense.

Having ascertained that we understand the assertion in the
sense in which it is meant, the next question we are to ask our¬
selves is Is it true ? It may be true or false, and if false, it
may be false with or without the knowledge of the assertor ; in
other words, it may be a lie or a mistake ; and if a mistake, it

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may be a sane or an insane mistake—it may be a sane
mistake or a delusion.

The first question to determine is whether the witness is a
witness of truth as far as he knows it—whether he is asserting
what he believes to be true, or what he knows to be false, or
recklessly, what he does not know to be either true or false. As
to this we must be guided mainly by two considerations :—by
the previous record of the witness, and by his responsibility.
The previous record of the witness for truthfulness and careful¬
ness must go far to determine our judgement whether he is
truthful and careful on this occasion. That is unavoidable, and
in accordance with the general principle of induction, by which
we infer that that which has been constant in experience will
continue, and infer it with a confidence proportioned to the
number of uncontradicted experiences. In the absence of any
such record, we ask, first, if he is responsible, and our opinion
of the bona fides of his assertion rests largely upon the degree
of his responsibility ; that is to say, upon how far he would
suffer in reputation by telling a lie. Hence we are always
ready to accept as truthful in intention the assertions of
prominent persons on important and public occasions, and
accept them the more readily the more prominent the position
of the assertor, and the more public and important the occasion
on which the assertion is made. It is true that our faith is
sometimes unwarranted, but the rule is a wholesome one, and is
usually justified.

A third consideration, which must influence us, rightly or
wrongly, is whether the assertor has a personal interest in
getting the assertion accepted.

Having determined that the witness is in intention a witness
of truth as far as he knows it, the next stage is to estimate how
far he does know the truth, and this is the matter that is most
often neglected. In order to estimate it we must consider,
first, what his opportunities of knowing are, and second, what
his bias is likely to be.

It is surprising how implicitly most people receive as true
the evidence of those who have no better means of knowledge
than the recipients themselves. ‘ They say ’ is an authority
that is accepted with unquestioning submission, without even a
query as to who are the ‘ They ’ who say it. The whole fabric
of popular superstition about what is lucky and what is unlucky

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rests entirely upon what ‘They say.’ Who ‘They’ are, or what
opportunities ‘ They ’ have of knowing, are questions that are
never asked, and that the superstitious people who entertain
these beliefs never think of asking. They would, I fancy,
regard it as presumptuous, and almost irreligious, to ask. But
it is not only with respect to beliefs like these, that are primci
facie irrational and absurd, that the omission is made. Many
prevalent beliefs on other subjects are equally without rational
foundation. There is a prevalent belief, for instance, that
cigarette smoking is more injurious to the smoker than the
smoking of pipes ; and this belief is widely and firmly held on
no better ground than the belief that it is unlucky to look at
the new moon through glass. Occasionally we may obtain the
assurance that ‘ doctors have said it,’ but it is usually found
that ‘ doctors ’ is but another expression equivalent to ‘ They.’
Supposing, however, that the dictum can be traced to a doctor,
I have never found, and I have often tried to run to earth the
origin of this strange belief,—I have never found that the
doctor has any better ground for his belief than the fact that
* They say.’ In discussing the matter with an intelligent person
who is not a doctor, I have been told that he felt bound to
accept the dictum of a doctor, because the doctor was in a
position to know. This is an instance of simple faith com¬
parable with the confident assurance that was reposed in the
middle ages on the assertions of an ecclesiastic. It is clear to
anyone who gives a moment’s thought to the matter, that to
determine whether cigarette-smoking is or is not more deleterious
to health than pipe-smoking would require a very long and
laborious course of experimentation, such as no one has ever
yet undertaken, or an accumulation of non-experimental
evidence, such as has certainly never been attained.

The belief that canker and other diseases of fruit trees are
due to sourness of the subsoil rests also upon what ‘ They say.’
Most people who are not gardeners accept it upon the evidence
of gardeners, and assume that gardeners ‘ must know.’ But
why must they know ? I am pretty sure that no gardener
except myself has ever tested the subsoil to discover whether it
is sour, nor is there any evidence to show that if the subsoil were
sour it would be any more favourable to the growth of canker
than an alkaline subsoil.

Many people believe in the occurrence of what has been

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called telepathy, and many believe in the genuineness of the
‘manifestations’ of ‘spiritualism.’ In some cases the belief is
founded upon the experiences of the believer, but there is now
besides these a large number of people who hold these beliefs
upon hearsay evidence. Certain persons profess their faith in
the existence of telepathy, or in the ‘ manifestations,’ and a
ruck of other persons hold the belief on the evidence of those
witnesses, without any critical enquiry into the worth of that
evidence. ‘ So and so,’ they say, ‘ that is, Sir Roland Illogic
and Sir William Hookes, say so, and they are scientific men ;
and what a scientific man says on a scientific subject is good
enough for me. I myself have no personal experience, but as
a sensible man I must accept the opinion of an expert. No, I
shall not suspend my judgement about it. You might as well
ask me to suspend my judgement about the revolution of the
earth. To me it seems that the sun goes round the earth, but
scientific men who are in a position to know tell me that it is
not so, and that the earth goes round the sun, and I accept
their evidence. How can I consistently accept the evidence
of scientific men in the one case, and reject it in the other ? ’
The reasoning seems plausible on the face of it, and is repre¬
sentative of such a large body of opinion on so many subjects
that it is worth examination. The assumption that underlies
it is that the evidence of a witness who is a witness of truth,
and is in a position to know the fact to which he testifies,
ought to be accepted. There is no question about these wit¬
nesses being witnesses for truth in intention, that is, of what
they believe to be truth ; but the assumption that they are in
a position to know the facts to which they testify is altogether
unwarranted. That we must trust the expert is a sound general
maxim ; but before we trust him we must make sure that he is
an expert. The greatest possible eminence of an expert in one
branch of science adds not a grain of weight to his opinion in
another branch of science. However profound may be a man’s
knowledge of chemistry, his opinion is not on that account
more to be trusted than that of a farmer or a fishmonger upon
a question of astronomy. But, it may be said, he is accustomed
to weigh evidence ? He may or may not be. Many scientific
men are very poor hands at weighing evidence ; and in any
case, no scientific man has any experience at all in weighing
the kind of evidence that is necessary to distinguish between

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genuineness and imposture in spiritualistic * manifestations.’
The ‘ manifestations ’ are the kind of occurrences that, if not
genuine, can only be produced by conjuring tricks, and the
only expert whose opinion of them is of any value is a conjurer.
The opinion of a professor of electricity or of spectrum analysis
is of no more value in such cases than the opinion of a ship’s-
captain or a carpenter. The evidence for the revolution of the
earth rests upon quite a different basis. The experts who
testify to this are experts in this very subject. The whole of
their science is founded upon this supposition ; and upon this
supposition is founded the compilation of the Nautical Almanack ,
by means of which innumerable ships find their way across the
pathless ocean with unerring certainty to their destinations. In
other words, conduct founded upon the supposition never leads
to experience inconsistent with the supposition; and this is the
conclusive test of truth.

‘ They say ’ was the foundation, and the only foundation, for
the belief in judicial astrology—the belief that the position of
the planets, and especially of the moon, influences and regu¬
lates the course of human lives, and the fortunes and misfor¬
tunes to which human beings are subject. In the long history
of judicial astrology, extending over six thousand years, it
scarcely ever occurred to any one to ask the crucial question,
‘ What opportunity have the assertors of knowing whether their
assertions are true? What is the evidence on which their belief
is founded ?’ Moreover, never did anyone test whether conduct
founded on the belief led to experiences inconsistent with the
belief; or if they did, these experiences were powerless against
the overwhelming efficacy of ‘ They say.’

Galen thought that the arteries carry the vital spirit from the
heart to all parts of the body; and if this is so, there must be
a hole in the septum of the heart to allow the spirit to pass
from the arteries of the lungs into the arteries of the rest of the
body. He taught, therefore, that there is such a hole, and for
fourteen hundred years anatomists believed him, and in spite of
the plain evidence of their senses, followed his teaching, and
believed that a hole is there, although they could not find it ;
so strong is the power of ‘ They say.’ He taught also that
the veins carry the blood from the heart, and so sure were
anatomists that he must be right, that when a valve was found
in the azygos vein, a valve which effectually prevents the blood

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in that vein from flowing away from the heart, they again
refused to believe the evidence of their senses, and declared that
the valve operates in the direction the reverse of that in which
they saw it operate.

It would be a great mistake to suppose that the efficacy of
what ‘ They say ’ is abolished in these latter days, or that it
influences the minds of the uncultured and the vulgar only.
Logicians were told by Aristotle that a universal is necessary
in every act of reasoning, and they believed him, and still
believe him as faithfully as ever an anatomist of the School of
Salerno believed Galen about the hole in the heart. In many
arguments, as for instance in the argument a fortiori , there is
no universal. Logicians have been trying for two thousand
years to find a universal in the argument a fortiori , and they
have failed, just as the anatomists failed to find Galen’s hole in
the heart; but does this failure modify their belief? Not a bit
of it. * They say ’ there must be a universal in that argument,
and a universal there must be. To doubt it would be to doubt
the omniscience and infallibility of Aristotle, and no logician
would dare to be guilty of such blasphemy. What are two
thousand years of failure ? Did not belief in judicial astrology,
founded on precisely the same kind of evidence, last three
times as long ? and may not the belief in the universal in
reasoning hope for similar longevity ? To doubt it would be to
doubt the efficacy of * They say.’

For nearly as long ‘ They ’ have said that insanity is disorder
of mind, and disorder of mind is insanity. In vain it is pointed
out that that there are many disorders of mind that are not
insane, and that there is much in insanity besides disorder of
mind. Reason, observation, experience, the plain evidence of
the senses, are powerless against the authority of ‘ They say.’
What they have said, that they continue to say, and that they
will continue to say to the end of time. In vain it is asserted,
in vain it is proved, that what a man says and does is alone
enough to prove his insanity, which also cannot be proved
without this evidence. ‘ They say ’ it is not, and what 1 They
say ’ must prevail, and does prevail.

The influence of bias upon opinion has been so thoroughly
considered by Herbert Spencer in his Chapters on the subject
in the Study of Sociology, that little need be said of it here.
There is one kind of bias, however, that Spencer does not

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mention, and as it is perhaps as frequent as any other, a word
may be said of it. We are strongly biassed against any asser¬
tion made by a person we dislike, and against opinions we
dislike. The former is too frequent to need illustration ; of
the latter the following instances will suffice. A certain pro¬
fessor of philosophy in Padua asked Galileo to explain to him
the meaning of the word parallax, so that he might refute the
doctrine it expressed, which was opposed, so he had heard, to
the teaching of Aristotle. Another admirer of the Stagyrite
refused to look through a telescope, lest he should be convinced
of the existence of Jupiter’s moons. It would be a great error
to suppose that this attitude of mind did not survive the six¬
teenth century. The greater part of the opposition to the Nexv
Logic , and to the doctrine that madness is disorder of conduct,
rests on precisely the same prejudice.

From the foregoing considerations it would appear that
hearsay evidence is open to so many sources of error that it
can never have any great value, and that it would be most
dangerous to base any firm belief on any important subject
upon hearsay alone, or even chiefly. Such an attitude would
be very erroneous, even if we could adopt it; and we cannot
adopt it. It is quite true that hearsay evidence should be
received with care and discrimination ; and it is true also that
all our most grossly and flagrantly erroneous beliefs are founded
upon hearsay ; but on the same evidence are founded some
beliefs that are but little inferior in justification to the
empirical certainties, such as that noise always proceeds from
movement, that yield only to axiomatic certainties in justifica¬
tion and inescapability. Besides the intrinsic credibility of
hearsay evidence that arises from our trust in the truthfulness
of the witness, and our estimate of his opportunity of knowing
the fact, there are extrinsic circumstances which may add such
weight to hearsay evidence as compels us to accept it as true,
or may demolish its cogency altogether, and leave us no alter¬
native but to reject it. These are, first, the congruity of the
hearsay evidence with already existing beliefs, and, second, the
concurrence of witnesses ; or we may put it corroboration by
experience, and corroboration by other witnesses.

In days when knowledge was less diffused than it is now, a
sailor on his return to his native village reported that he had
seen in his travels mountains of sugar, rivers of rum, and fishes

VOL. LXII. 2 2

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that flew like birds. The village gossips received the first two
items of information with acquiescence, ‘ for,’ they said, * we have
seen sugar and rum, and they must come from somewhere ; but
flying fishes are a traveller’s tale; you cannot deceive us with
such a cock and bull story as that.’ The judgement was
erroneous, but the principle on which it was founded was cor¬
rect. It was the comparison of the hearsay evidence with
knowledge already in possession, and the reception or rejection
of the evidence according to its congruity or incongruity with
what is already known. They were wrong in believing in the
alleged origin of sugar and rum, because the corroboration was
insufficient. The known existence of these commodities proved
that they must have some origin, but did not point to one
origin rather than another. But they were right in disbelieving
in the existence of flying fish, for such animals are so incon¬
gruous with all the experience that the audience had had of
fish, that they ought not to have believed it upon mere hearsay
from a single witness ; and they were none the less right in
spite of its happening to be true. Such a startling incon¬
gruity ought not to be accepted without strong corroboration.
Similarly, when the reported discovery of the X rays reached
this country, some scientific men disbelieved it, and many sus¬
pended their judgement, and refused to believe it until it was
corroborated. The latter were undoubtedly right, and the
former were not very far wrong. That any rays but those of
light could affect a photographic plate was so incongruous with
all our experience up to that time, that scepticism was not only
justifiable but proper. That radiant forces could penetrate
solid and opaque substances was, indeed, familiar in the cases
of gravitation and magnetism, but neither of these has the power
of precipitating silver from its combination in a colloid, and the
cases were not in point.

It is customary for the newspapers in the summer, when
Parliament is not sitting and news is scanty, to make jocose
remarks about the sea serpent ; and it is generally assumed
that no such animal exists. There is nothing, however, in the
evidence we have of the existence of a gigantic sea serpent
that is incongruous with zoological knowledge. Many fabulous
animals, such as the griffin, the cocatrice, the phoenix, the
centaur, the dragon, are zoologically impossible. They are
inconsistent with what we know of the necessary structure oi

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animals. The griffin, for instance, is represented with the body
of a quadruped, the claws and head of a bird, and the wings of
a bat, and with the ability to fly. Now it is quite beyond
question that the ability to fly with wings implies the existence
of very powerful muscles, and therefore of very large muscles,
such as constitute the breast of a flying bird ; and without
such muscles a pair of wings would be of no more use for fly¬
ing than if they were cut out of paper and stuck on with glue ;
but in the fabulous griffin there is no sign of any more muscles
than are needed for quadrupedal progression, and we may
therefore be sure that such an animal could have no wings.
There is no such incongruity in the structure of the sea
serpent. The only thing unusual in the reported appearance
of the animal is its size, and we know that very large animals
do inhabit the sea. There is therefore no reason on the ground
of incongruity why we should positively disbelieve in the exist¬
ence of such an animal as has been described as the sea
serpent. It may be wise to suspend our judgement, but that
is a very different attitude of mind, and is inconsistent with
disbelief.

As long as I can remember, and I am now growing old,
‘ They ’ have said that this or that prominent personage has
been addicted to drink ; and as long as I can remember the
question has been put to me, or to others in my presence, ‘ Do
you believe it ? ’ Rightly conceived, the question is an insult
to the intelligence of the person to whom it is put. It assumes
that he will form a belief, without any adequate grounds for
doing so, on the mere authority of what * They say.’ It is on
a par with asking if we believe that there is a crater fifty-
one and a half miles in diameter on the other side of the
moon. There may be, or there may not be; but as we have
no evidence either one way or the other, it would be a sign of
weak intellect to believe either way. It is true that the
interrogator does not really want an answer to his question.
What he wants is to obtain a momentary factitious importance
as the retailer of a spicy bit of gossip. The question is merely
an excuse for the gossip ; but it does not make the gossip
excusable. None the less is it an insult to the intelligence of
the person to whom the question is put ; and to meet such an
assertion of what ‘ They say ’ with an indignant denial, as a
worthy but ill-advised bishop did on one occasion in a sermon,

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is injudicious and disproportionate. The proper course for the
interrogatee is to resent the insult to his intelligence.

Suspension of judgement is an extremely important attitude
of mind, and one that it is frequently most important to adopt ;
but it is an attitude of mind that is not always easy to adopt,
even for cultivated persons, and one that many persons are
quite incapable of. They must either believe or disbelieve,
and no middle course is possible for them. There are, how¬
ever, so many cases in which suspension of judgement is the
right attitude to adopt, that it is the plain duty of everyone
to cultivate this attitude, and not to allow himself to be enticed
out of it by anything but evidence.

In this respect nothing is more important to remember, and
nothing is more often forgotten than this :—Whoso makes an
assertion , upon him lies the burden of proof. The time, labour,
paper, ink, and temper that are wasted every year by neglect
of this maxim are altogether incalculable ; and the waste is not
less, indeed I think it is more, in matters that are called scien¬
tific, and by men that are called scientific, than in any other
field of human endeavour. When we are confronted with an
assertion that appears to be false, or pernicious, or extravagant,
or baseless, our first and natural impulse is to deny and con¬
trovert it ; and hence arise most of the endless controversies of
scientific men on scientific subjects. The impulse is a natural
one, but it is injudicious, and the course adopted is injudicious
and unnecessary. When such an assertion is made, the proper
course is not to deny it, nor to attempt to controvert it, but
to call upon the asserter for proof. If, as sometimes happens,
he can bring forward no evidence in support of his assertion,
cadit quatstio. Except for fanatics and other irrational persons,
the matter is at an end. If he responds to the invitation, and
brings forward evidence, or what he thinks is evidence, of his
assertion, then our duty is to examine that evidence, and ascer¬
tain whether it does in fact bear out the assertion or not. In
many cases it will be found that what is adduced as evidence
has no bearing at all on the assertion ; and when it has, it
will usually be found that what is merely evidence is put
forward as proof.

For there is a vast difference between evidence and proof,
a difference that is not often recognised. I have found the
assertion of this difference has aroused astonishment and

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incredulity when I have made the assertion even to very
intelligent and highly educated men, accustomed to form
independent opinions. The difference is this :—

Anything germane to the issue and consistent with the
assertion is Evidence of the assertion.

Proof is evidence that is inconsistent with any alternative
assertion.

Thus, to take an illustration of Lord Bowen’s, if a man is
seen coming out of a public house and wiping his mouth, that
is evidence that he has been having a drink. It is germane to
the issue, and is consistent with the assertion. But it is not
proof that he has had a drink. It is consistent with several
alternatives. For instance, he may have gone in to the public
house to fetch a friend out, and that friend may have hit him
in the mouth for his pains. But if he has been seen to raise a
full pint pot to his mouth, and if when he lowered it the pot
was found empty, that is proof that he has had a drink, for it
is evidence that is inconsistent with any alternative.

If these three principles are faithfully observed :—to lay the
burden of proof upon the assertor, to examine the evidence, and to
accept nothing as proof but that which is inconsistent with any
alternative, we shall effectually safeguard ourselves from be¬
lieving any assertion that we ought not to believe. Unfor¬
tunately for the cause of truth, this is not the common practice.
Not only are assertions commonly received, accepted, and
believed without proof, but they are commonly believed without
the evidence for them being examined and tested, and even
without any evidence, worthy the name, at all. Many instances
have already been given in previous chapters in this book, and
many more must be known by experience to every thoughtful
person. The belief in witchcraft was supported by abundant
evidence, much of it of a very cogent character ; but in no case
was there proof, and it is now generally abandoned. I say the
evidence was cogent, and in fact it was a great deal more cogent
and satisfying than the evidence for many beliefs that are still
very generally held. Many persons confessed that they were
witches, that they used charms and spells and the other
armamentaria of witchcraft, that they had personal colloquies
with the devil, that they rode on broomsticks, and so forth ;
and they confessed these things well knowing that their
confessions would bring upon them a cruel and agonising

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death. Yet they confessed. As to part of these confessions,
there is little doubt that they were true. The witch believed
in the efficacy of spells and charms, and no doubt she did use
them. The effects for which she employed them did no doubt
in some cases follow. The objects of her malevolence did fall
ill ; their cows did slip their calves ; their milk did turn sour ;
their children did have fits ; and so forth. The evidence was
abundant ; and it was cogent ; but it was not proof. It was
not proof, but in an uncritical age it passed for proof, and the
wonder is, not that the belief prevailed so extensively, but that
it ever died out ; for we find other beliefs now held with equal
tenacity, beliefs that have not behind them any of the ancient
prescription that attached to witchcraft, and that have not in
their favour a twentieth part the tithe of the evidence that
witchcraft could show. We should no longer believe in the
efficacy of the spell that has been quoted on a previous page,
but we still believe in the efficacy of two tablespoonsful three
times a day ; and a sick man would consider himself defrauded
if he did not get them.

Such a belief, too, is that in the efficacy of what is called
psycho-analysis. The fundamental doctrine of this strange faith
is that every disorder of mind is caused by repressed sexual
passion. Of this doctrine there is not only no proof, but there
is positively no evidence that is worth the name of evidence.
In the first place, the universal repression of sexual passion is
a mere assertion, and no proof and no evidence is adduced of
any such general state of affairs. Secondly, granting the
universal repression of sexual passion, there is no evidence that
this repression can produce mental disorder. Not one of the
nine or twelve methods, that are set forth in Chapter VI for
ascertaining causes, has ever been applied to show that
repressed sexual passion has or can have any causal influence
in producing mental disorder. The assertion is exactly on a
par with the assertion that sour subsoil produces canker in fruit
trees. There is no evidence that the subsoil is sour, or if it
were that it could cause canker. It is much less rational
than the assertion that the positions of the planets govern the
fortunes of human beings, for there is plenty of evidence that
the planets do exist, but there is no evidence at all that
repressed sexual passion exists in most cases of mental
disorder.

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Another assertion of the psycho-analyst is that if you have
difficulty in recalling a word, the difficulty is caused by an
involuntary exertion of will (which is of course a contradiction
in terms) or an unconscious exertion of will (which also is a
contradiction in terms) by which the word is thrust out of the
memory. There is no evidence of any such exertion of the will,
and a contradiction in terms is an axiomatic impossibility. It
is inconceivable, and its contradictory is the strongest and most
assured certainty that the mind can entertain. This uncon¬
scious volition is exerted because of the association of the
forgotten word with some painful experience or painful idea :
that is the assertion of the psycho-analyst. Of course, in the
multitude of words that are forgotten there must be some that
have some unpleasant association ; but there are many that
have no such association. How do the psycho-analysts surmount
this difficulty ? With the utmost ease. They say ‘ You
cannot remember any such painful association, but it is there
nevertheless. The fact that it is painful causes you to drive it
out of your mind, and so to forget the association. The word
is painful to you, but you do not know that it is painful. The
pain is unconscious pain.’ Well, if it pleases them to juggle
with words in this manner, there is no reason why we should
interfere with such a childish occupation, until they proceed to
apply their doctrine with disastrous effects to the treatment of
cases of mental disease. Then I think it is time to protest.
Then I think every honest man should call upon them for
evidence. Not, indeed, for evidence of unconscious pain, for
we might as well ask for evidence of a solid liquid, or a round
square, or a protuberant hollow ; but for evidence, first that
every forgotten word has a painful association attached to it,
and second, that if it has, this painful association is the cause
of the forgetting. Of course there is and can be no such
evidence, let alone proof.

But although there is not and cannot be any such evidence,
the resources of the psycho-analyst are not exhausted. He
makes assertions that may be evidence, but that he pretends
are proof. Look, he says, at the cures that I effect by pro¬
ceeding on the hypothesis that my doctrine is true ! And he
relates case after case that can only be paralleled by So and So’s
Institute for the Treatment of the Deaf, or Thingamy’s Cure
for Consumption. It is no doubt quite true that some cases of

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mental disorder will recover even if treated by psycho-analysis,
though how much sooner they would have recovered without it
we do not know ; but it is also certain that many cases that
might, according to our experience of similar cases, be expected
to recover rapidly, remain ill for an indefinite time under
treatment by psycho-analysis. I am reminded of a case that
was related to me at the height of the craze for treatment by
sour milk, which preceded the craze for psycho-analysis. A
physician, who had had no experience of cases of mental disease,
told me that he had treated by the administration of sour milk
a gentleman who, from the physician’s account, was suffering
from a mild attack of melancholy, ‘ and ’ said the physician
triumphantly, ‘ in six months he was quite well ! ’ I did not
tell my friend that six months is the usual maximum duration
of that malady, and he departed rejoicing in his adoption of
such an efficacious mode of treatment. The recovery of the
patient was evidence of the efficacy of his treatment, but it was
not proof. It was not inconsistent with every other explana¬
tion. It was a good case of the fallacy post hoc , ergo propter hoc.
The effect did follow the alleged cause, but no connection
between them was traceable.

It is a little surprising that in these days, when the merits
and wonders of Science are so loudly acclaimed, that so few
people, even in a learned profession like that of medicine,
should have even a rudimentary notion of what constitutes
proof; of what constitutes evidence ; of the difference between
evidence and proof; and of the grounds upon which causation
may properly be assumed. It has been the part of Logic to
teach these things, but unfortunately logicians have even less
knowledge of them than physicians, and it is a safe assumption
that anything taught by logicians is false.

Assertion may be accepted, then, when it is borne out by
experience ; but there is another mode in which assertion may be
corroborated, and when this mode is fully and freely employed,
hearsay evidence may properly become the ground of belief as
assured and as certain as even the concurrence of innumerable
experiences. This method is the concurrent testimony of a
plurality of witnesses. Hearsay evidence becomes more trust¬
worthy the more numerous, the more unanimous, and the more
independent of one another the witnesses ; and when innumer-

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able independent witnesses concur unanimously in an assertion,
that assertion must be accepted, unless it violates our own
experience. If, however, the assertion violates our own experi¬
ence, experience which has been tested, considered, and proved,
which is plain and inescapable, then no concurrence of testi¬
mony, however numerous, independent, and unanimous the
witnesses, ought to shake our belief.

Whately argued, ironically, the non-existence of Napoleon
Buonaparte, by showing that each witness, or set of witnesses
for his existence, taken separately, might have had good reason
for lying. His argument was directed against the independence
of the witnesses, and is based upon the assumption, which is
sound as far as it goes, that the unanimity of different witnesses
goes for nothing if it can be shown that they had a common and
paramount interest in lying. The difficulty of establishing the
thesis increases, of course, with the number and variety of the
witnesses ; and if the number is small, and all are bound together
in a common interest and a common character, it may well be
established ; and thus do counsel often try to discredit the cor¬
roborative evidence of witnesses in courts of law. But when,
as in the case of Napoleon Buonaparte, the witnesses are in¬
numerable, and are of the most divergent interests—friends
and foes, admirers and contemners, rich and poor, natives and
foreigners, beneficiaries and sufferers,—the attempt to discredit
them all must be hopeless. No one familiar with the history of
the time can really doubt that Napoleon Buonaparte existed ;
and the belief is as assured and certain as any empirical belief
can be. We can no more doubt it than we can doubt that trees
grow upward, or that unsupported bodies fall downward.

Our belief, that is to say the belief of stay-at-homes, in the
existence of India, rests upon similar grounds, and is similarly
assured and unassailable. We have never been there : we have
never seen it: we have no experience of it; but we cannot
doubt it. We can no more doubt it than we can doubt the
existence of our own parish or our own home. The belief rests
upon no experience of our own : it rests entirely upon hearsay ;
but upon the hearsay of witnesses innumerable, independent,
and unanimous. It is the accumulated evidence of at least
five generations of men. The witnesses belong to many
countries, many classes, many occupations, and have many,
and often conflicting interests. They are thus completely

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In the last two cases, those of the logicians and the alienists,
it will be seen that although they are numerous and unanimous,
yet the third element is wanting—they are not independent, and
this it is that vitiates their testimony. The logicians are not in¬
dependent of one another, for they have all drunk of the same
fount; they have all been indoctrinated with the same belief
from the same ultimate source ; they have all learnt the same silly
system ; and none of them has had sufficient independence of
mind to trust to his own experience rather than to authority.
It is much the same with the alienists. They have all been
taught the same false doctrine with the same air of assurance
as if it were an axiomatic certainty, and none of them has
taken the trouble to compare the teaching with his own
experience. No doubt the retention of these beliefs in the
teeth of plain and frequent experience to the contrary is partly
due to intellectual inertia, or, to use a plainer term, laziness ;
partly to timidity of authority, or, to use a plainer term,
cowardice ; but it is also largely due to that influence of all
upon each which is one of the penalties we pay for the benefits
of social life. It is difficult to maintain a belief, or to reject a
belief, against the unanimous opinion of our fellows—of those
of our fellows with whom we are associated. It is the tyranny
of what * They say ’ that quells our opposition. These beliefs
of the logician and the alienist rest upon the same basis as the
belief that it is unlucky to spill the salt, or to cross the knives,
or to view the new moon through glass, and a hundred other
such absurdities. You can no more persuade a logician that
he is constantly constructing, and asserting, and denying propo¬
sitions with active verbs, or an alienist that he is constantly
witnessing disorders of mind that are not insane, than you can
persuade a seafaring man that it is not unlucky to go to sea on
a Friday, or a rustic that it is not unlucky for a hare to cross
his path. Superstitions are not assailable by reason, nor do
they depend upon evidence ; and counter-evidence has no effect
upon them.

Note on the Meaning of ‘Fact.’ —Strictly speaking,
a fact is a thing done, and means ‘ that which has happened ’;
and in this sense I have defined and used it in previous
writings. In this book I have somewhat extended the mean¬
ing of the word, and the extension needs justification. The

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extension to that which exists, or has existed, and also to that
which happens or is happening, needs but little justification,
and will, I think, be generally allowed. That which exists has
come to exist by way of some happening ; and though it is
not itself, strictly speaking, that which has happened, it is the
result of that which has happened ; and the same is true of
what has existed. There would be little or no impropriety in
speaking of the existence of the earth or of Julius Ciesar as a
fact. The real need of justification is for the extension to the
future. Can we justifiably speak of that which will certainly
happen as a fact ? Manifestly, in the strict meaning of the
term we cannot. But there is no other word that will cover
both what has happened and what is about to happen, and
a word to cover them both is wanted. I have therefore taken
this liberty with the word ‘ fact ’ in this essay, and for the
present purpose ; but in other connections I should still use it
in its strict sense.

Sir Clifford Allbutt takes me to task for speaking of the
1 fact ’ of gravitation. This, he says, is an illegitimate use of
the word, and an instance of the detestable misuse, which I
deprecate as much as he does, of the term ‘ fact ’ for the term
‘ theory.’ Gravitation, he would say, is not a fact, but a
theory to account for facts. The facts are that ponderable
bodies move towards each other, and we account for this move¬
ment, this fact, this actual happening, by the theory that they
attract each other. Manifestly he is right, and at first I was
inclined to confess aliquando dormito; but on retracing the
course of my thought, I find the use defensible. As explained
in the text, we have no direct knowledge of fact. All that we
have direct knowledge of is evidence ; but when the evidence
is conclusive, it is legitimate shorthand to speak of our know¬
ledge as if it were knowledge of fact. Now, if ponderable
bodies do attract each other, that is fact : that is what happens ;
and in any individual case of attraction, such as a heavy body
falling to the ground, the appearance of falling is evidence of
the fact of falling ; and the fact of falling is evidence of the
attraction that produced the fall. And in the latter case the
evidence we now have is as conclusive as in the former. The
fact-in-itself we do not know : we know only the evidence for
it; but the evidence that the body falls is conclusive, and
therefore we may speak of the fall as a fact ; and I submit

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349

that the evidence of gravitation is quite as conclusive, and that
we may, without undue straining of the meaning of the word,
speak of gravitation also as a fact. At any rate, we may so
speak of it in any individual case.

Summary.

The different meanings of ‘believe’ are defined, and the
meanings of various cognate expressions explained. An asser¬
tion of any degree of belief or disbelief expresses an attitude of
mind either directly towards a fact, or, while directly towards a
statement, indirectly towards the fact stated.

A fact means anything existing or happening, in the past,
present, or future.

Belief ought to conform to fact, but cannot be directly
related to fact, for we have no direct knowledge of fact.
Between belief and fact there is always the intermediary of
evidence. It is evidence and not fact that impresses our minds,
and when we have brought our belief, or the want of it, into
accordance with the evidence, we have done all we can, and can
do no more.

Evidence is of three kinds :—Evidence of sense, evidence of
reason, evidence of hearsay.

Evidence of sense is certain as to the sensation only ; but
sensation is of little value until it is interpreted, that is, until
its source or cause is arrived at by the elementary process of
reasoning called perception. This process may be faulty, and
the percept false, or erroneous.

Evidence of reason gives us two criteria of certainty. That
which cannot be conceived is certainly false, and its contra¬
dictory is certainly true, and constitutes an axiomatic truth or
certainty. It is necessary, in using this test, to be careful not
to confuse, as Mill and Spencer did, inconceivability with
incredibility.

Empirical certainty rests upon constancy in experience.
That relation which has been found constant (i.e. never con¬
tradicted) in experiences diverse and incalculably numerous, is
true for us, and cannot be believed to be false, although its
contradictory may be conceivable.

If the relation is not constant in experience, then the degree
of belief ought to correspond with the proportion that the

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positive instances in experience of the relation bear to the
negative instances, in which the terms of the relation occur apart.
The more nearly constant in experience the relation, the more
carefully should apparent exceptions be scrutinised.

Evidence of hearsay may be maximally trustworthy or may be
worthless. The following are the criteria to be depended on :—

(1) The statement must be understood in the same sense by
the receiver as by the assertor.

(2) The witness must be a witness of truth so far as he
knows the truth.

(3) The witness must have means of knowing the truth.

(4) The hearsay evidence must not be inconsistent, or even
incongruous, with experience.

Whoso makes an assertion, on him lies the burden of proof.
No attention should be paid to bare assertion unsupported by
evidence.

Evidence is anything germane to the issue, and consistent
with the assertion.

Proof is evidence inconsistent with any alternative to the
assertion.

The evidence of a single witness may be received in propor¬
tion to his previous record for truthfulness, and in proportion
to his responsibility, that is to say to the ill-consequences that
would accrue to him if he were found to have given false testi¬
mony ; also to his freedom from interest and bias in making
his assertion.

The evidence of a plurality of witnesses is valuable in pro¬
portion to their independence of one another. Evidence of
many independent witnesses goes to prove an assertion if they
have means of knowing the truth, and if the assertion is con¬
sistent with experience. Otherwise, the evidence of witnesses,
however many and however unanimous, has no value.

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FEMALE NURSES IN MALE WARDS.

351

The Employment of Female Nurses in the Male Wards
of Mental Hospitals in Scotland.^) By George M.
Robertson, M.D., F.R.C.P.Edin., Physician Superin¬
tendent of the Royal Edinburgh Asylum, Morningside,
and Lecturer on Mental Diseases in the University of
Edinburgh.

Ten years ago I was requested by the Secretary of the
Medico-Psychological Association to open a discussion at the
annual meeting of the Association on this subject. It was
then regarded by some asylum medical officers as “ the topic
of the hour,” largely because of certain views on administration
which I had expressed, and certain innovations in methods I
had made at the Stirling District Asylum.

This method of caring for the insane has again come into
prominence on account of the somewhat alarming position
that has been created by the shortage of male attendants in
asylums. No class of the community has done its duty by
voluntary enlistment for the war more loyally, and the diffi¬
culties caused by the departure of attendants, and the impossi¬
bility of getting suitable men to replace them, have been
relieved in many asylums by the introduction, for the first
time, of female nurses on the male side. In many other insti¬
tutions the advisability of taking this departure from estab¬
lished routine is being seriously considered. Great interest
has, therefore, revived in this method of care and nursing, and
I have had the unusual distinction conferred upon me of being
asked for the second time by the Secretary of the Association
to open a discussion on it. This is now a much easier task
for me than it was ten years ago, for during the interval the
principles and practices then advocated have been very widely
adopted in Scotland. It is not too much to say that they
now form a characteristic and firmly established feature of the
modern Scottish system for the care of the insane.

Many of us have now grown so accustomed to female
nursing, and value it so highly, that, on contemplating the
subject, the question that comes most readily to our minds is,
Why were women not always employed ? To others, who
only know the mental hospital as it now is, with its carefully
designed accommodation and its comfort, its good order and

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discipline, its skilful and intelligent nursing staff, its prevailing
atmosphere of consideration for the patients and their medical
care, the question also seems a very obvious one. But the
mental hospitals of to-day are not less remote from the mad¬
houses of 125 years ago than the period we live in from the
Bronze Age, though we inherit many archaic traditions and
practices from them. The madhouses at the end of the
eighteenth and the beginning of the nineteenth centuries were
not hospitals ; they were prisons for the safe custody of a
dangerous class. Little wonder, then, that the methods adopted
in them were those of the prison, that “ keepers ” alone were
employed on the male side, and that women were rigidly
excluded from it. The modern mental hospital can justly
claim to be classed with other medical institutions; but, if so, it
should fall into line with them by the discarding of an anachron¬
ism, and by making use of women’s mothering instincts, and
natural gifts for the nursing and care of male patients, as has
been done in other hospitals. There rests, it seems to me, a
heavy responsibility upon those who now fail to do so.

(1) Auxiliary Female Care.

The story of the introduction of women’s help on the male
side of asylums forms an instructive chapter in the history of
the care of the insane, but it is only possible here to refer to
the most important landmarks. Judging by the inertia shown
with regard to their employment that still exists in many
quarters—although in a neighbouring country its success is an
established fact—the man who first employed women in this way
must have been of a very independent and original spirit. He
was no less a person than Dr. Samuel Hitch, the founder of the
Medico-Psychological Association. He introduced this system
into the Gloucester General Lunatic Asylum in the very same
year that he founded the Medico-Psychological Association—
namely, 1841—and could he have survived till to-day to see
the development attained by the twin offspring of his mind,
he would have much reason to be proud of both of them.
Dr. Hitch employed the wives of his married charge atten¬
dants to help their husbands in the male wards, and I was
informed by his widow that it was because of the harsh
manner in which the male patients were then treated by the

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JOURNAL OF MENTAL SCIENCE, APRIL,

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Nurses on male side, Stirling District Asylum, 1902.
To illustrate paper by Dr. G. M. Robertson.

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353

attendants that he was induced to take this step. This state¬
ment is confirmed by the Minutes of the asylum, which I was
permitted to see, in which it is recorded that a husband and
wife had charge of the refractory ward. Dr. Hitch’s lead
was followed by many English asylums during the next forty
years.

Another step in advance was taken in 1883 by Dr, R. M.
Bucke, of the London Asylum in Canada, who employed
widows of good character in the male wards. Dr. Bucke was
one of the most striking personalities of the American
Medico-Psychological Association, and this experiment in his
hands was a complete success.

A third step was taken by Sir Thomas Clouston, who had
adopted Dr. Hitch’s system by placing a married couple in
charge of the male hospital at Morningside. The husband
then died, and in 1890 he appointed the widow in full charge,
with the male attendants under her authority. He permitted
her to engage the services of two ordinary asylum nurses to
assist her, and occasionally female patients would help as
well.

These three methods for the employment of women on the
male side—namely, Dr. Hitch’s, Dr. Bucke’s, and Dr. Clous-
ton’s—illustrate what I regard as the phase of Auxiliary
Female Care. Its defect lies in the fact that the nurses were
few in number, and only assisted the male attendants, and the
bulk of the nursing, even in those wards in which they were
employed, continued to be done by the male attendants. It
would appear that no danger was apprehended to these women
from the violence of the patients, but the selection of wives or
widows of good character indicates that the risk of misconduct
was recognised, and thus guarded against.

(2) Entire Female Nursing.

The first step towards the system by which a group of male
patients is entirely nursed by women was taken by Dr. Turnbull
in the Fife and Kinross Asylum in 1896. He placed a ward
containing thirty male hospital patients, by day only, entirely
under the charge of female nurses. Owing to the construction
of the hospital very efficient supervision was capable of being
VOL. lxii. 23

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exercised over these nurses by the matron and the charge-
nurse of the female hospital. The proximity to the other male
wards also enabled male help to be immediately summoned if
necessary. The Scottish Commissioners in Lunacy at once
realised that Dr. Turnbull’s innovation constituted an important
new departure, and a great advance on anything that had been
attempted before. Acting on the advice of Sir John Sibbald,
who thought very highly of it, a similar arrangement was soon
after introduced into the Glasgow (Gartloch), Lanark, and
Perth District Asylums. In the year 1900, at the Stirling
District Asylum, I placed a group of male patients, by night
as well as by day, under the charge of female nurses, thus for
the first time frankly handing over the entire care and nursing of
insane male patients to women alone during the whole twenty-
four hours.

These arrangements just described may very appropriately
be called the Scottish system of Entire Female Nursing , for its
special features were not only developed in the Scottish
asylums, but it has been very extensively adopted by them for
nearly a generation. It is a totally different thing in practice
from the system I have called that of Auxiliary Female Care , in
which a few women assisted the male attendants. All who have
had great experience of women nurses in male wards agree in
saying that they are infinitely more useful if placed in sole
charge of a group, and they much prefer it themselves. The
patients benefit more certainly from their ministrations, for it
provides a guarantee that they must be nursed by women.
Under the system of Auxiliary Female Care there is a division
of labour in the ward, and the nursing may be done by the
men, and the cleaning up and household duties by the women.
The danger of misconduct which has been already referred to
decreases as the number of nurses employed becomes greater,
and is least when the care of a whole ward is handed over
entirely to women. It must be remembered, too, that super¬
vision and discipline in the asylums of the early and mid-
Victorian period, when the system of Auxiliary Female Care
was employed, were not so perfect as they are now. What
with the advent of efficient supervision, and of the good class
of men and women now engaged in asylum work, difficulties
of this nature can be overcome, and need not be feared in a
modern asylum.

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355

(3) The Hospitalisation of the Asylum.

The employment of female nurses on the male side has not
stopped at this stage of evolution in Scotland. Their intro¬
duction was in very large part due to the desire to make use
in asylums of the very high standard of skill in nursing
possessed by those who had been trained in our general
hospitals. Three-quarters of a century ago, in Dr. Hitch’s
time, “ Sarah Gamp ” was in the flesh (Martin Chuzzlewit,
1843), and there cannot have been much inducement to
employ her, or others like her, on the male side for the sake of
their skill in nursing. Dr. Hitch’s first female nurse attended
to refractory patients ! If this highly skilled form of nursing
be desired, then women must be employed, for unfortunately
men do not receive this training in our general hospitals.
Large numbers of trained hospital nurses have thus been
appointed during the last twelve years in the Scottish asylums
to important positions for the sake of their technical skill and
training. Dr. Campbell Clark was the first to appoint a trained
hospital nurse (Miss Mary Macfarlane) to the post of matron,
at the Kirklands Asylum, Bothwell, in 1880. In the following
year he commenced the systematic teaching and training of
his asylum nurses and attendants, as was the practice in
general hospitals. The idea took root, and in 1885 the
Scottish Division published the Handbook for Attendants on
the Insane , the most enterprising action ever taken by a
Division of the Association. This handbook, as is well known,
has since been adopted by the Medico-Psychological Associa¬
tion, and has led to the granting of the Certificate for
Proficiency in Mental Nursing, and to the Registration of
Certificated Mental Nurses. The first hospital nurse to work
within the wards among insane patients and asylum nurses
was appointed by me at the Perth District Asylum in 1896.
This was an important step, not only on account of its direct
influence on ward work, but because it created a supply of
hospital nurses who were specially trained for the duties of
asylum matronship, which had not previously existed. The
demand for these became so great that over three dozen of my
own nurses have received such appointments in other institu¬
tions. As all hospital nurses are accustomed to attend to
male patients in the general hospitals, they think it the most
natural thing in the world to continue to take charge of male

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patients in asylums. They have gradually extended the sphere
of their usefulness far beyond the limits of the hospital wards
on the male side to which they were first appointed, and have
invaded other departments. They have introduced innu¬
merable reforms which have approximated the methods
employed in the asylums to those in the hospitals, and
amongst these the greater employment of women in the male
wards is only one. The trend of events in Scotland has been
such that this employment of female nurses in the male wards,
when seen in its proper perspective, is found to be only a part
of a much greater scheme or ideal that has flowed like a tide
over the land—that of the Hospitalisation of the Asylum. It
is fifteen years now since this ideal was organised into a
working system at the Stirling District Asylum, and a paper
describing the methods employed there, entitled “ Hospital
Ideals in the Care of the Insane,” was published by me in the
Journal of Mental Science in the year 1902. The details of
this system go, however, beyond the scope of the present paper,
and include the building of asylum hospitals, the bed treatment
of the insane, the study of the physical aspects of mental
disease, etc.

Time is not only a great healer, but a great judge, who
decides most appeals by very convincing logic, and fifteen
years is a liberal period in which to test the merits of a
system of asylum management. It was said thirteen years
ago by a distinguished member of our specialty that the
“ nursing of male insane patients by females ” was “ prepos¬
terous,” and that to run everything in asylums on hospital
lines was “a great fad.” It must be hinted in palliation that
this authority had not had any experience of the methods
which he criticised so freely. This method of nursing is now
as distinctive and as firmly established a feature of the Scottish
system of care of the insane as the well-known Boarding-out
System. It is employed in some measure or other in all
but two of the important asylums of the country, and in
these the Superintendents have so far failed to introduce it,
not because they are opposed to it on principle, but on
account of structural difficulties with regard to supervision,
housing, etc. This wonderful unanimity of opinion and
practice amongst Scotsmen, whose national proclivities do
not tend to concord, is remarkable testimony in its favour,

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and points to the manifest practicability and overwhelming
merits of the system. The Hospitalisation of the Asylum is
still on the whole an ideal to be aspired to, but it too is
steadily developing and gaining ground year after year. It
will perhaps come as a surprise to many to know that in
a fourth of the asylums in Scotland, and among them are
included some of the large ones, the matron is head of the
nursing staff on the male side as well as on the female. How
many hospital nurses are employed as sisters or assistant
matrons it is impossible to say, but it must be large, for
twenty-two were lately doing duty in the military hospitals.
A system such as this, which has survived the test of fifteen
years’ experience with enhanced reputation and has become
national in scope, must now have some other qualification
than “ preposterous,” some other appellation than “ a fad,”
applied to it by all fair-minded and reasonable men and
women. The man who sees no good in it, who thinks its
adoption impossible, must believe that the Scottish Board of
Control and the majority of the Medical Superintendents in
that country, in other respects with the reputation of being
shrewd and level-headed, are labouring under an obsession !

Having briefly described the history of the introduction of
female nursing in the male wards of asylums, I shall now
refer to certain objections and difficulties.

In the first place, it is said that this work is not a suitable
form of employment for women. In reply to this, it may be
pointed out that the work in question is actually being done
by women in all but two of the Scottish asylums, and the
consensus of opinion in Scotland, where experience of the
system is unsurpassed, not only does not support, but con¬
tradicts the objection. The personal offices that all nurses,
including hospital nurses, may be called upon to perform in
the nursing of adult males may be objected to, and have been
objected to. Between fifty and sixty years ago, before the
movement started by Florence Nightingale had been given
time to effect a reformation, I have been informed by my
teachers that no woman with any self-respect or regard for
her reputation nursed adult males in our general hospitals.
Women from every rank of society are prepared to do so
now, and are held in the highest esteem if they do. Is it
not then clear that it is not the work alone that matters, but

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that the spirit in which it is done, the methods that are
employed, and the character of the person who comes to the
work, are essential elements in any judgment upon it? If,
therefore, the status of hospital nursing can be so transformed
in the estimation in which it is held, may not a similar change,
by the adoption of similar methods, take place in connection
with asylum nursing? If approached in the proper spirit, if
performed by approved methods, and if undertaken by the
right persons, this form of employment has been found in
Scotland quite suitable for women.

In introducing female nurses into the male wards for the first
time, the most reliable women on the staff would naturally be
selected by anyone who wished the experiment to be a success.
They should be experienced, and they should not be young.
The working unit should not be less than four in number.
It is a great advantage to place a hospital nurse with asylum
experience in charge of them. The methods employed in
handling the patients and in the management of the ward
should be those which have been adopted in general hospitals,
on account of their regard for the decencies. It is naturally
found that these can be most readily adopted for those patients
who are confined to bed. When the patients are dressed and
going about it is advisable to employ auxiliary male care, in
the form of one or two trustworthy married attendants, to
bathe the patients and to assist in other ways if required.
I have never had the least difficulty in arranging for this
small amount of auxiliary male care, and I have always found
convalescent and working male patients willing to help the
nurses.

In the second place, it has been said that the male side
of an asylum is not a fit place for a woman to be in. The
presence of good women always has a refining influence on
male society, and whatever the conduct of male patients in
speech and in general behaviour may be, the advent of female
nurses among them, if managed with care, will effect a change
for the better. The capacity of the insane for education in
good habits, while not illimitable, is very extensive, and in
practice it is never exhausted in our large institutions. Were
we not so familiar with it, their good behaviour and self-
control, for example, during divine service, would astonish us
every week as it does those who see it for the first time. If,

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therefore, it can be alleged of any asylum that its male wards
are not a suitable place for women, then the sooner a reforma¬
tion be effected the better for the patients there, for it is not
a condition that need continue indefinitely.

It is then asked, Are women who object to nurse male
patients to be compelled to do this work ? The answer is, Of
course not. There are women who object to nurse male
patients, just as there are women who object to be nurses at
all, but of the hundreds who have been nurses in the asylums
of which I had charge those who have objected during twenty
years can be counted on the fingers of one hand. As a matter
of fact, the vast majority prefer to do so, and the reason is not
difficult to find. Male patients are always less troublesome
and excitable than female, and women find that they receive
more courtesy and readier obedience from men than from
members of their own sex. They do not require to receive
any extra salary to do this work, once it has been started, for
the women are engaged, as they are in general hospitals, simply
to nurse, and it is all in the day’s work whether they nurse
patients of the male sex or of the female. It is very doubtful
if there be any saving in expenses by the employment of
women instead of men, because, owing to the higher standard
of hospital care aspired to, there is usually found to be a larger
number of nurses required. In Scotland any saving there may
have been from this source has been more than expended on
an increased night staff, which is proportionally much larger
than that employed in English asylums, and on hospital nurses
for purposes of supervision, which is a practice that has now
been largely adopted.

Lastly, it has been pointed out that many male patients,
owing to their sexual proclivities, cannot be cared for by women.
This is undoubtedly true, but the remedy is a simple one. Do
not place them under women ; let them be cared for by men.
It is unthinkable that any experienced administrator would
allow a simple difficulty of this kind, with an obvious remedy,
to deter him from the introduction of women nurses. It may
give him a little more trouble, which at present he escapes,
but that is no excuse for avoiding a duty. Every day of the
year, in every asylum in the country, a much more difficult and
responsible task of an analogous nature is faithfully performed,
that of distinguishing the patients who are suicidal from those

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who are not, and of making special arrangements for their
care. To pick out patients whom it is undesirable to place
under the care of women is, compared with this, an exceedingly
simple matter.

Far from the employment of female nurses in the male wards
of asylums being unsuitable in form, out of place, and objec¬
tionable to them, in the high state of organisation and
development now attained by mental hospitals, whatever may
have been the case in the past, it is most appropriate, and a
beneficent duty to the insane male patients under our care.
They appear to be the last class of the helpless to benefit
from the superior aptitude and skill that women show for
the duties of nursing, and this privilege should no longer be
denied them, as it is overdue. The reason for this superiority
of female nursing rests on a solid foundation—the mothering
instinct in women. It is an instinct so strong that in many
cases it cannot be suppressed, and must manifest itself in one
form or another. There are, of course, exceptional women
and exceptional men, and we have all met male attendants
who have been kind and devoted nurses. Nevertheless, nursing
the sick, the infirm and the helpless, be they sane or insane, is
pre-eminently woman’s avocation. Sir Thomas Clouston
summed up the situation tersely when he said that all his
nurses longed to work in the hospital, whereas all his male
attendants wished to be kept out of it, and preferred to do
outdoor work, and that he never saw a man enjoy sick-nursing
in the same way as many women do.

It has been remarked that only a small proportion of the
male patients are in the hospital wards ; but is not a great
part of the work in an asylum indoor domestic duties which
in a private house are also performed by women ? The
cleaning and decoration of the wards, the bedmaking, the
laundry and repair of the clothing, the serving of the food,
and the social functions, are all tasks which in private life
usually fall to the lot of women. Can it, then, be doubted that
they are as efficient as, if not more so than, men, to perform these
familiar occupations in asylums ?

Moreover, it must not be assumed that female nurses are
only of use for the care of the sick and helpless in an asylum.
One of the surprises of the system in practice has been the
discovery that they can usually exercise more control over

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361

cases of mania than male attendants, and the great advantage
of their management lies in this fact—that it is based on per¬
suasion, and not at all on the show of force or on compulsion.
Excited patients who are ready to fight any man who comes
near them will often do anything they are told by a nurse, and
they will become calm if they receive a word of sympathy from
her. A woman has much the same influence over an insane
man, who is not actually delirious, as she has over one who is
supposed to be in his sound mind, and it is absurd to assume
that all feelings of chivalry and honour die in a man because
he suffers from some derangement of the mind.

The proportion of women it is desirable to employ on the
male side of an asylum is, according to the Scottish Board of
Control, at least 2 5 per cetit. of the total day staff on the male
side, and 1 5 per cent, of the night staff. These figures are con¬
siderably exceeded in several asylums, among which may be
mentioned the Stirling District Asylum. It may be taken as a
typical county asylum in the accommodation it provides, in its
complete organisation, and in the modern methods it employs.
It admits over 250 patients annually, and has a resident popu¬
lation of over 800. Dr. R. B. Campbell, its Medical Superin¬
tendent, has employed for the last years, as I also did for
an equal period, a staff on the male side by day of which 40 per
cent, consists of women, there being three hospital nurses,
including the matron. By night 27 per cent, of the staff con¬
sists of women, including the night superintendent, who is a
trained hospital nurse.

It has been stated that female nurses are more suitable for
asylums admitting parochial than private patients of the richer
classes. That has not been my experience at Craig House.
This is the department of the Royal Edinburgh Asylum for
private patients, and it is quite a separate mental hospital from the
West House, which provides accommodation for poorer patients.
Of the staff of thirty-two employed on the male side by day to
attend to one hundred gentlemen, exactly one-half consists of
nurses, including in this number the lady superintendent and
three matrons, and, of these, three are hospital nurses. By night
six out of a staff of thirteen consist of women, including the
night superintendent, who is a trained hospital nurse. These
proportions vary from day to day, according to requirements,
and they have perhaps been swelled by the war, but there is no

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FEMALE NURSES IN MALE WARDS.

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difficulty in employing 40 per cent, of women by day and 25 per
cent, by night in a private asylum like Craig House. Of course
there are special difficulties connected with private male patients
which are not met with in the case of parochial patients, but
the employment of women in their care on the whole is equally
advantageous. The opinion of the friends of patients is worth
quoting. The most interested relatives of gentlemen consist
chiefly of anxious females, be they mothers, wives, or sisters,
and nothing in my experience gives them greater comfort
than to know that the relatives whom they entrust to our care
will be tended by women. Rightly or wrongly, to them it is a
guarantee that no violence will be employed, and that the most
skilled nursing will be available.

In conclusion, I have to state that these opinions, whatever
may be their value, are founded on twenty years’ experience of
entire female nursing in male wards, and have been gained in
four different asylums of which I have had charge during that
time. I am now more convinced than ever that the mental
hospital, the modern asylum, is only a hospital for the treat¬
ment of a special disease, and therefore requires to be run on
hospital lines, of which the employment of women in the male
wards is only one feature. Although many did not see eye
to eye with me in the past, I have learned to be patient, and
I have had the satisfaction of seeing these views gradually
accepted, and the methods I advocated adopted. The ultimate
hospitalisation of the asylum is now only a question of time,
and that time has been hastened by the action of many medical
superintendents of the English asylums, who, owing to one of
the results of the war, have introduced female nursing in the
male wards of their asylums for the first time. I trust that
the observations I have made may assist others in coming to a
similar decision.

(') Read in London on February 17th, 1916, at the General Meeting of the
Medico-Psychological Association.

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363

“ THE SECRETES OF ALEXIS.”

“The Secretes of Alexis." A Sixteenth Century
Psychiater. By Hubert J. Norman, M.B., Ch.B.

The sceptics maintain with some show of plausibility that
medical treatment—the therapeutics of mental disorder
included—has made little progress with the passage of the
centuries ; and that what is called progress is really preten¬
tiousness, and is more verbal than actual. Some of the new
schools of dogmatists certainly give reason for criticism of this
kind ; they bandy high-sounding phrases one against the other,
until the plain man becomes confused with the welter of
verbiage. It were invidious to specify too accurately. Each
one according to his predilections can annotate the context.
If he favours the neologisms of that school in which the new
oneiromancy and the modified confessional bulk so largely in
their dealings with the mentally disordered, he will exempt
them from criticism ; and he who considers that treatment
should pass along lines less airy and less tenuous will, for his
part, look elsewhere for firm ground from which to aim his
darts at the flitting shadows beloved- of the practisers of
psychomancy. Yet, all this granted, a look backwards suffices
generally to convince us that, when ephemeral and transient
notions are regarded in their proper perspective, there has been
a real and valuable progression towards clarity and truth—
even, in some cases it may be, attainment. If there is,
therefore, such good to be derived from this process of retro¬
spection, one may be forgiven for directing attention for a
short space to former times. As we look backwards, however,
we are almost dismayed at the similarities which we notice
between the errors and follies of those who lived many
centuries ago and those of our time. At the first glance it
appears that almost do we move in a circle. The same old
errors, the same old superstitions in other guises. We are
almost prevailed upon to say, with La Bruyere^ 1 ) “ En effet les
hommes n’ont point change selon le cceur et selon les passions,
ils sont encore tels qu’ils ^toient alors,” more than two thousand
years ago. There seems to be little abatement of what were
designated as the “ animal passions ” ; and along with that
there has been an accompaniment of credulity which the few
master-minds have not been able to overcome. Superstition

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holds its ground in many civilised communities, and as to war
—in a time like the present—it is needless to speak. Yet
withal we are prepared to maintain that enlightenment is being
brought about.

Well, we may “ leave the wise to wrangle,” and turn from
such disputatious matters to the more pleasant subject in hand.
In the year 1580 there was published in London an excellent
and compendious book entitled The Secretes of the Reverend
Maister Alexis of Piemont; and it was translated “ out of
French” by one yclept William Warde. Two years earlier
William Harvey had been born, and some two years later
Shakespeare was married. It is possible, therefore, that both
of them may have perused the Secretes. In their day the
volumes on medical subjects were not numerous, more especially
publications in the English language. Shakespeare’s acquaint¬
ance with insanity was extensive, as a reading of the plays
soon demonstrates. In “ Hamlet,” in particular, he has dealt
at considerable length with matters psychiatric, and incidentally
provided some knotty problems for the specialists in morbid
psychology. Perchance he dipped into Maister Alexis , his
Secretes , in search of material. If he did, he found there some
“ fine miscellaneous feeding ” ; for the Secretes , to quote the
sub-title, is a volume “ Containying excellente remedies against
diverse diseases, wounds, and other accidentes, with the maner
to make distillations, parfumes, confitures, diying, Colours,
fusions and meltyinges.” An Elizabethan homologue of the
Family Physician and of Enquire Within.

Maister Alexis begins by producing his credentials. He
states that he had from his early youth given himself to study,
and had travelled to many places in order to acquire further
knowledge ; and had, in addition, learned Latin, Greek,
Hebrew, Chaldee, and Arabic. As we shall see in the sequel,
a little study of the Hippocratic writings, and a rational
application of the teachings therein contained, would have
been well repaid, and would have saved the reverend Maister
from many of the egregious errors into which his credulity led
him.

His reason for setting down his Secretes is that, having
been called by a physician to see a “ poor Artificer, who was
marvelous tormented with the stone, and had been two daies
without making his urine,” he did not make use of his skill

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365

because he thought the doctor wished to “ use other mennes
things for his owne profit and honour.” However, finally, he
went; but it was then too late—he was just in time to see
him die. It may be the “poore Artificer” was thus saved a
final pang ! So moved was Maister Alexis by the sad death
of this man that he decided to keep his Secretes no longer
hidden. From smallest causes . . . and the world has been
favoured with the “ excellente remedies.”

His artlessness may be gauged from his first Secrete, which
is: “ The maner and secrete to conserve a mannes youth, and
to holde backe old age, and to maintaine a man alwaies in
health and strength, as in the fairest flower of his age.” It
shall remain a secret as far as we are concerned at present :
those who are sufficiently interested may peruse the writings
of the reverend Maister for the details. But if they are
desirous of rejuvenation, it may be safely stated that any of
the other nostrums which have been vaunted as the Elixir
Vitae will equally well serve their purpose. This particular
one was, he tells us, “ taken out of the long studie and diverse
experiences that a Gentleman made by the space of many
years in the service of a Nobel Lady, being a thing most
certain that an old manne of three score and tenne years, all
withered with age, and of a verie evill complexion, and subject
to divers kindes of disease, was altered and changed as into
the age of sixe or eight and twentie yeres.” And yet even
Maister Alexis had to pay his debt to time, secret notwith¬
standing.

However, to the more immediate subject of the present
essay, namely, his views upon insanity and kindred disorders.
Etiology in these matters has provided a fine crop of hypo¬
theses—demons, malignant sprites, black bile and other
morbid humours. Alexis has a theory quite different, at
any rate in so far as children are concerned. To heal them
of the “ Lunatic Disease, which happeneth unto them by
reason of a worme with two heddes that breedeth in their
bodies, the which worme coming into the heart causeth them
to have suche a passion that oftentimes it killeth them,” it is
only necessary to use a powder containing the “ tender stalkes
of a Wilding tree, Gentian root, Peonie and Myrrh.” This
powder is moistened with water, and then placed in the lips
and in the mouth of the child. “ Doe this three or four times

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“THE SECRETES OF ALEXIS,"

and you shall see the worme come out dead with his siege.”
Lest any doubting Thomas should feel inclined to criticise his
worm-theory, he adds : “ This have I oftentimes seen by
experience, and manie children which for lacke of good helpe,
have died with such manner of wormes the which afterwarde
being opened, men have found the Worme sticking upon their
hearts.” With such a worme with its two “ heddes ” one is
at a disadvantage ; it must be difficult to know which is the
business end, that is if it resembled the leech of which the
poet sings :—

“ Perchance, reluctant being, I have placed the wrong side up,

And the lips that I am chiding have been farthest from the cup.”

It must have been almost as troublesome to deal with as
the elusive spirochaete.

His secrets are not confined to the treating of children.
There is a “ notable secrete to heale a madde man, be it
that the madnesse come unto him by a whirlyn or giddinesse
of the hedde or braine, or otherwise.” It is a comprehensive
procedure. “ First of all, make hym fower Glisters, in fower
Mornynges, one after another. Let the first Glister be simple,
that is to saie, made with water wherein ye have boiled or
sodden Wheate, Branne, Common oile, and Salt. Let the second
be of water sodden with Mallowes, Mercurie, Pellitorie of the
wall and Violet leaves, with Oile and Salt. Let the third
be of water boiled with Oile, salt sodden with wine and
Honie. And let the fourth glister be of the like decoction
that the third was, adding to it Endive, Buglosse, and the
toppes of the branches of Walwort. After that this decoction
is strained, ye will put to it an ounce of Cassia Fistula, and
half a quarter of an ounce of Mitridate. Now having given
him these fower glisters, fower sundrie mornyngs you shall
give him this medicine. Polipodium of the Oke well stamped,
a handful or tvvaine, and wryng out the juice of it, and putte
in a glasse the quantitie of twoo fingers hie, puttying to it
twoo unces of Honie roset and a quarter of an unce of
Electuarie roset, and as much of Diasenicon. All these thynges
beynge incorporated together, give them unto the pacient to
drinke at night, when he goeth to bedde, twoo or three howers
after the Sunne is set, and give it him luke warm.” Then
follows an interesting passage anent forcible feeding, should

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the patient prove recalcitrant. “ If in case he will not take
it, binde hym and holde hym perforce, and make him ope his
mouth, put some sticke betweene his teeth, and then poure
the medicine into his throte, as men doe unto horses. And
when he hath taken all, if it be Winter you shall make hym
sitte upon his bedde halfe an hower, well covered round about
to the intent that he take no cold after it: if it be in Summer
ye maie let him goe about the house where he will, but see
that he goe not out. When the medicine hath doen his
operation, take this ointment followyng: that is to saie, a
pound and a half of the juice of Walvvort, whereunto you
shall adde as much butter : boile this together a goode while ;
to this there is to be added Camomile and St. John’s Wort.”
With this ointment the patient is to be rubbed all over.
This has to be carried out, morning and evening, for a month.
On the third or fourth day of the anointing we proceed to
more drastic measures. “ Burne him with a hot iron upon
the seame, or joyning together of the hedde, and at the firste
laie upon the marke a Linnen clothe with Barrowe’s grease,
leavyng it so the space of eight or ten daies : and after wrappe
a great Cyche pease in Ivie leaves, and put uppon the said
Ivie leaves a peece of a sole of a shoe made fine and thinne,
bindyng it under his throte with some bande, or beneath his
hedde, so that it may hold on, and change it always at night
and in the mornyng.” The author does not add—he probably
thought it unnecessary so to do—that during the burning
process it will be essential to carry out the procedure associated
with the feeding—to “ binde hym and holde hym perforce.”
If he does not recover in four months—or “ returne to his
witte ”—the performance must be repeated ; and “ without
doubte (by the grace of God) he shall be whole.” But this
is not all the treatment: diet and other matters have to be
considered. “ He must eate at the beginning Chickens,
Mutton, and roste veale: after you maie give hym roste and
sodde, with potage of amilum, Beets and Mallowes, and also
newe laied egges, puttyng spices unto his meat, causyng him
sometyme to eate (either in his potage or otherwise) Betaine,
sage, Maioram and mint, not sufferyng him in anywise to take
salt, sharpe or eger things, poulse corn, Garlike, Onions nor
such like : ye maie give him white wine with water; let hym
also carry ever about him some sweet odours, and heare

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melodie or musicke ”—he has the authority of Pythagoras
on this point, though he mentions him not—“ speak often-
tymes soberly and wisely unto hym, admonishing him to be
wise and sage, rebuke him of his follie when he dooeth or
speaketh any fonde thyngs.” At this point he gives support
to those who advocate the employment of nurses for attendance
upon him who is disordered in his “ wittes ”: and those of us
who had experience in this direction may readily agree with
him. “In such case,” he says, “the authoritie of some faire
woman availeth muche, to tell him all these things : for good
admonitions are of great virtue and strength, for to establishe
and settle a braine, troubled or disquieted with any sicknesse
or passion.”

He has other remedies if these should fail ; and some of
them are certainly quaint. For example, take the following
suggestions “ against the Phrensey.”

“The body being purged, it is good to shave the heade,
and to lay upon the seame of the crowne of the heade quicke
Pigeons (having first cleft them in the backe, and drawen out
the entrails) leaving them so upon his heade until they waxe
colde : or else little whelps of a Moneth old their garbishe
pluckt out: or, if you will, the lunges or lightes of a shepe or
whether hote. But because one of the principall causes of the
phrensie is the torment of watching, you must labour to pro¬
voke sleepe as much as you can, by remedies meet therefore :
as with washing his legges from the knees downwarde, and his
armes from the elbow downwarde, with the decoction of violet
flowers, of Nenuphar, of the ryne of Mandragora rootes, and
anoynting his temples, the joyntes of the arme even to the
hand, and of the legge unto the foote with the oyle of Nenu¬
phar and Poplar mixt together.”

No medical treatise in the old days was complete without
the Mandrake (or Mandragora) ; so Alexis introduces it—
somewhat surreptitiously—into the remedy. He does not tell
us how it should be gathered ; whether it might be boldly
grasped as if it were a nettle and thus drawn from the ground,
or whether it ought to be fastened to a black dog and thus
torn shrieking from its resting-place—as the fantastic ritual
formerly prescribed as necessary in order to guard against the
malign influence of the anthropomorphic plant. At midnight,
too, had the direful deed to be dene.

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Alexis has a remedy also for what may be described as a
Piemontese form of manic-depressive insanity—for those
“ that be Melancholick, and in a furie or rage.” It contains
borage, bugloss, sorrel, endive, and many other ingredients,
one of which is the “ boane of a Harte’s heart ” ; add to these
Amber and Musk and make an electuary. This the “ sicke
party ” has to take “ mornyng and evenyng two houres before
meate, havyng first made the universal remedies, as purging,
letting of bloud, etc.” Another prescription which would serve
to “ purge melancholic humors, and to remedie the paine of
the heade and stomach,” is comparatively simple and one may
surmise of some utility ; it contained senna leaves, tamarinds,
raisins, borage, violets, melon seeds, ginger, and many other
ingredients. Again, if one should desire to “ drive away the
heavinesse of the minde, to accuate the senses, and to make a
good memorie,” it is only necessary to “ take Balme and braye
it, and stipe it till it becomes soft in good wine in an earthen
vessel well covered and stopped, then distill it by a Limbecke,
and every mornyng give unto the sicke person a spoonful to
drinke.” In order to “expell sadnesse” take of the “ herbe
called Cranes beke, of Rewe, of Pulegium, of eche like
quantitie, bray them into pouder, and with sugar make little
morsels, and use them.” (O, that sadness in these dismal
times were thus easily expelled !) To those who suffered from
the “ Spleen ”—a condition considered by all foreigners to be
much in evidence in England—you might administer the ashes
of “ the wormes called Millipedi, in English Sowes or Horse
Wormes ” ; or “ steel filings in vinegar, Gum ammoniac, and
Syrup of Bisantins.”

Even if matters went further there was still hope ; there is a
remedy against the “ distillation of the brayne and heavinesse
of the head.” It is necessary to “receive the juice of beet¬
roots into your nostrels, and that will drawe unto it all the
humour of the heade, and cause it to come out.” It would
take more than that to cause the humour to come out of some
heads. This remedy would have appealed to the Reverend
Sidney Smith.

For pains of the head there is no lack of treatment; he has
even a prescription “ agaynst the headache by too much drink¬
ing.” One suggestion as to what should be done is to take
the “ brayne of a Crowe, and seeth it, and then eate it; for

VOL. LXII. 24

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there is none so great a payne of the heade, or none so old,
but that it will heale it with a singular virtue.” Another
remedy for “ payne of the head ” contains bay berries,
scammony, saffron, vinegar, and roses. Yet another which
shall “ ease you verye much by God’s Grace ” is made up of
black ivy, vinegar, oil, and wine. There is also a “ most
excellent powder to comfort the sight, and all defects of the
head, of the stomache and the disease called Scotomia and
Vertigo, and the palsie, and all inwardie diseases: it con-
sumeth the superfluous humidite of the braine, it helpeth the
memorie.” A comprehensive remedy! It was used, he in¬
forms us, by “ Frederick the Emperor.” As it contained the
usual herbs, it probably did not do the Emperor much harm.

The chief weapons in his armoury, however, were to be used
to combat epilepsy, morbus comitialis , morbus sacer , the
“ Fallyng Sicknesse.” It is a disease which has always
attracted much attention. It is so sudden in its onset and
it produces such obvious symptoms that it is not surprising
that in old days people looked upon it as obviously one of
the conditions where the sufferer was possessed by a demon.
The Romans regarded it as an evil omen if anyone was seized
with a fit during the discussion of public business. It was
regarded as a supernatural visitation, hence the name morbus
sacer. Hippocrates, with the shrewdness and absence of
superstition which so markedly characterised his outlook upon
pathological conditions, maintained that it was no more super¬
natural than any other disease. ( 2 ) Alexis naturally deals with
the matter at some length. “Take Germander gathered in
Maie,” he says, “ when it is in blossome : drie it in the shadovve
and make it in powder. And when you will use it, take the
yealke of an egge or twaine, and stirring or breaking it with a
spooneful of the said pouder: then seeth it, and give to the
pacient to eate. Doe this mornyng and evenyng, eight daies
long: but all this while he must abstaine from Wine, and
carnall companie of Woman, and from all sorte of Poulse, as
Beanes, Peason, Fitches, Tares and suche other, from Salades,
Salte Fleshe and from all other things which are of a hard
concoction or digestion.” This is, he adds, a “ verie goodly
and notable secrete.” Then there is a “ hevenlie water ” which
is nearly a panacea, so much so that one wonders why it should
be necessary to invent other remedies. It contains, among

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many other ingredients, cloves, nutmegs, ginger, pepper,
juniper, sage, basil, rosemary, marjoram, and also aqua vitae,
“ which must be distilled five times through a Limbecke.” It
is, he informs us, “ meete for greate Ladies and Princesses.”
It will cure “ new wounds and old wounds, Carbuncles, St.
Anthony’s Fire ” ; it is good for the eyes—and here he inter¬
poses a delightful saving clause—“ so that the eye be not out or
loste.” Three drops will cure the stone ; “ Emeraudes ” vanish
before it; “ shrunken and indurate sinewes ” become supple ;
it kills worms “ if a manne rubbe his nostrilles” withal ; it also
“ healeth the King’s evill, and the disease called the Fallyng
Sicknesse, and all other infirmities in the exterior parts of the
bodie, and with this water maie a manne washe himself”—
rather an expensive procedure—“ or els drinke it. It is also
good for every cold sicknesse, and restorative for olde folkes,
or those that are consumed and debilitate with hunger, sick¬
nesse, or sorrowe of mynde. It conserveth the radical moysture
and naturall beate, it maintaineth healthe, and keepeth a man
in long life, whosoever useth it as it ought to be used.” Which
convinces us of one thing—Maister Alexis could even have
given hints to the modern nostrum-vender. Truly may it be
repeated of mankind, “ Us sont encore tels qu’ils dtoient alors !”
The shrewd Alexis finishes again with a saving cause, and one
can imagine him saying to the irritable epileptic who found him¬
self unimproved after a course of the “hevenlie water” that he
had not used it “as it ought to be used.”

Another remedy for the same affection—simple and quite
as ineffective as the others, our ancient friend notwithstanding
—is to take “ wheate floure, and kneade it with dewe gathered
in the mornyng on Midsomer daie, and make thereof a cake,
the which you shall bake, and give the pacient to eate of it,
and he shall be healed.” There is quite a poetic touch which
takes us away from microbes and endotoxins. Some doubt
may have been cast upon the efficacy of his remedies. He is
not downhearted. There are pills containing castoreum,
asafcetida, peony-roots, etc. It is a remedy which “ hath been
often proved.” If the patient is still “tormented with this
disease,” in spite of all that has been done for him, it is good
to make him “ smel burnt fethers, or olde shoes, for that
reviveth and maketh him come to himself”; or “take a
hundred Swallowes, an ounce of Castoreum, as much wine as

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shall suffice and of the best that can be found. Distill all
together, and give the Patient to drink thereof three Dragmes
fasting, this water is also verie good for men that be apoplec-
tique if they be washed with it.” It is to be feared that a
hundred “ Swallowes,” even when distilled, would not make a
cure. Then there is a “very good receipt which Pope Clement
the Seventh tooke in his last Sicknesse.” It contains “Mastick,
Frankincense, Mace, Cloves: leaves of Gold foil and Silver foil:
jacinthes, Emeraudes, Rubies, Granadas, Pearles, red Corall ” :
and “ a pounde of man’s bloode of the bodye of a very health-
full and fleshie man.” All these have to be distilled, even to
the tenth time. It is good for various diseases, including
“ Apoplexia( 8 ) or falling sicknesse, if they washe their necke
with all.” One understands why it proved to be the pious
Clement’s “ last sicknesse.”

There are yet others to the same purpose. There is a
plaster containing Mastick and other substances, which is to be
“ spread on leather and laid upon the crown of the head.” Or
take “ the Lungs of a Wolfe, and wash them with good red wine,
then boyle them,and dress them with Cordiall.and give it in meale
unto the sicke person, and he shall be healed : or els take of
Opoponack, of Castoreum, of Sanguis draconis, of Antimunie, of
eche like quantitie, braze them and give thereof unto the sick
person two scruples, in what maner you will, and this shall be
the quantitie whensoever he taketh it, and you shall see the
success thereof to be marvellous.” Or take of the “ flowers of
Lillies that grow in the plaines, such quantitie as you will, and
infuse them to become tender in wine by the space of fower
weeks, then castyng awaie the flowers, distill the wine five times,
of the which you must drinke a little with sixe grains of Peper,
and a little Lavander water, and you shall be safe from the
Apoplexia. And washing therewith your forehead, the hinder
partes of your head, it comforteth the braine, and causeth a good
memorie, and the quantity of a spooneful thereof beyng drunk,
healeth the pains of the Collicke.” (For the " Collicke ” you
may also try the “ Fat of a Peacocke,” or the “ Liver of a
Porpoise.”)

Still attacking epilepsy he recommends you to take the
“ matrice of a sowe, the whiche being made in powder you
shall give to eate or drynke unto the Patient, and as soone as
he hath received it, the sicknesse will remove from the brayne

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and spread into his fingers, tormenting him very sore ; but
whereas the sayde matter shall assemble and come together,
make a rupture : and the matter will come out as yellow as
Saffron, and he shall be quickly healed.” There is another
prescription against the same, a fine example of polypharmacy,
as it is made up of some sixty ingredients, including “ pigeon’s
dung ” and “ horse’s dung.” It can be used in addition
“against the debilities of Nature and all other infirmities( 4 ).”

For the falling sickness in children, coral, peony, storax,
rosemary, and cobwebs are made into a plaster and put upon
the “ cloasure.”

Another prescription which heals the “ Fallyng Sicknesse
and Melancholie ’’ is useful in other conditions. “ It healeth the
griefes of the head, the disease Vertigine and Scotomia, if the
body be purged, and then the saied oile be given to be drunke
with water of White Lillies, it helpeth the Litergia.” These
conditions he defines as follows : “ Vertigine, Scotomia, diseases
of the head when with dimnesse of sight all thinges seeme to go
round. Litergia is a sore disease of the braines.” To “remedy
the commotion of the braine through falling from some high
place, or through other occasions and cuttes when through the
blowes men lose their speach,” it is only necessary to lay a
plaster containing red roses, myrtle, aloes, etc., on the head.

There are several methods of dealing with insomnia. For
example, if it is desired to cure the “ griefes of the head, which
through the beating of the artiers, doe not suffer one to take
sleepe,” a quantity of wormwood is to be procured. This must
be “ well brayed and boyled in water, and then bound unto his
temples upon the griefe.” This “ presently will mitigate the
paine, and cause him to take a pleasant sleepe.” When the
lack of sleep is due to “ frensie,” it is necessary to “ shave away
the heare with a Raiser, and annoint the heade with the froth
or fome which swimmeth upon Creame,”and the patient “shall
sleepe forthwith.”

To make “ an Apple or ball that provoketh sleepe ” he
suggests “ wilde Poppie, the juice of mandragora, and the lees
of wine as muche of the one as of the other.” Add to this a
civet ; make of the whole a round ball and hold it in your
hand and “ smell to it, and it will make you sleep wonderfully.”

Among the modern practitioners of oneiromancy there are
some who find a difficulty because their patients do not dream.

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Alexis has remedies even for this. In order to cause marvellous
dreams you must rub the temples with the blood of a lapwing
or black plover; or eat at night a little of the herb solatium
or usicaria or some mandragora ; or hyoscyamus * : “ and you
shall see in the night goodly thinges in your dreame.” Or, if
you prefer a more exciting ephialtic vision, including wild beasts,
take the “ harte of an ape, and laie it under your head, and you
shall see marveilous things, and all kindes of beastes, as Lyons,
Beares, Wolfes, Apes, Tigres, and other such like.” The longer
one kept the heart, the more vivid probably would be the
dreams.

A patient afflicted with the palsey is to be treated with a
quaint remedy. A powder is made with myrrh, frankincense,
cloves, etc., with this a “ parfumed Forskin ” is prepared and
this has to be laid on the paralysed part. Then you shall see
a “ marveilous effect.” He does not state whether this has to be
carried out during the period of the Feast of the Circumcision !

Should your memory be indifferent there is a shorter way of
improving it than laboriously acquiring some “ system.”
Simply take the “ tooth or the lefte legge of a Badger or Brocke,
as some call it, and as some other name it a Gray, and binde it
about your right arme next unto the flesh. Take also the gall
of a Partrick and rubbe your temples with it that maie soake
into skine and fleshe, once in a moneth, and it will make you
have a good memorie.”

If diagnosis is difficult in any case whatsoever Alexis will
come to your aid. “ For to knowe a secrete or hydden disease
of any man and to heal the same, take a young whelp that yet
sucketh, and let him lie night and day with the man the space
of three days, duryng the whiche tyme the patient shall take
mylke in his mouthe, and spitte it into the whelpes mouth.
Then take the saide Whelpe and cleave him in peeces, and you
shall know the sicke part of the man by that of the dogge, which
you shall see eyther infected or whole and sound. For
certainly the Whelpe draweth to himself the secrete and
hydden disease whereof he dyeth, and the man shall be healed
and you may bury the Dogge.” The dog it was that died !
Note that you are not commanded to bury it. Perhaps, even
in the days of good Queen Bess, they found at times other
uses for defunct dogs.

* Or " that confounded cucumber ? ”

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He makes some amends to the canine species by setting
forth how one may prevent dogs from becoming mad, or to
cure them if they become mad through being bitten by a mad
dog or wolf. “ If you cutte off the Dogges taile within thirtie
or fourtie daies after he is whelpt, he shall never bee madde.”
If he is bitten and becomes mad he is to be given “Hen’s
dung,” and on the bite there is to be placed roots of wild roses
and some garlic or onions ; and if you are near the sea you
must throw him in two or three times daily for the space of
twenty days, “ because the sea water hath a water against the
madnesse of Dogges.” One wonders what the dog would be
doing all the time.

There is reason in the procedure to be adopted in the case
of one bitten by a mad dog. “You must use all diligence to
get immediately the Liver of the same madde Dogge, and let
the pacient eate it hot rosted, and above all things you must
enlarge the wound with a rasour, and cut awai all the torn and
perished fleshe and cause the blood to issue out abundantly
because it bringeth the venime with it. And to drawe out blood
also with little Cuppes, well flamed, called Cucurbitulae, and to
give him Garlike, Onions and other like thinges to eate, and to
drinke Milke and good sweete wine.” First catch your dog !
If you wish to “ make that no Dogge shall barke at you,” per¬
chance even the aforesaid one, you must “ take a blacke Dogge,
and pluck out one of his eyes, and holde it in your left hande,
and by reason of the savour and the smell thereof the Dogges
will not barke at you.” Nowadays, one would probably be
arrested as a public nuisance.

These are the chief remedies of the Reverend Maister
Alexis for what may be described as nervous and mental
disorders. They form, however, quite a small portion of his
therapeutical armoury. He ranges far and wide and has an
answer to almost every question. If you wish to be “ assured
and safe from all Sorcerie and enchantment,” he tells you how
it may be done ; or how to guard against “ Lightnyng and
tempest.” Nocturnal incontinence must have been common in
those spacious days if we may judge by the numerous remedies
he suggests thereanent. There are many prescriptions for use
against the plague. He gives recipes for hair oils, scents, soap,
dentifrices; for “ Marmelade ” ; for removing superfluous
hairs; for gilding parchments; for making “ Hennes laye

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egges all the Winter.” He tells you how a “ woman that is
wont to have daughters, may beare sonnes also ” ; or how to
make “ one have a good stomache that hath a naughtie one.”
But these are matters which concern us not at present.

It may be interesting to quote his summary of the rules
of health : in his own phrase, “ the whole summe of the
regiment and governyng of a man’s selfe.”

“ I. It is necessarie that you be kept neat and cleane and
all things in your house, flying diligently and as much as you
can, all evyll ayre.

“ 2. Avoyde all excesse and superfluity specially in drinking
and eating, and from women.

“ 3. Also from travayle, and from excesse in sleeping and
watching.

“ 4. Beware of moist meates and corruptible, and of all
things that is cause of rawnesse, and other evill humoures.

“ 5. Live soberly, drinke and eate at ordinary hours, and
in good order.

“6. Take your reste and use some neate and good exercise
or occupation.

“ 7. Mayntayne and keepe your naturall or accustomed
voydyng.

“8. Be merry.”

Many a worse code has been given to mankind !

If a similar quality of commonsense had characterised his
treatment generally, he would have been saved from—what
appear to be—egregious errors. Yet it may be that some
three hundred and odd years hence much that is gravely
written nowadays on etiology and treatment will provide
a subject for mirth for our more enlightened descendants.
It is not impossible.

In the introduction to the last book of his Secretes the
author, now too old for further writing, and having already set
forth his store of learning, warns the public against those
fraudful ones who may produce books bearing his name :
malicious persons with an intent to “ deceive you withall.”
He enjoins his readers also that “ when occasion happeneth
to use my secretes,” they are to take “ the counsell of some
expert Phisition ” in order to make sure that they use them
properly. But he feels that a further warning is necessary.
“ Accustome yourselves therefore to take counsell of such

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Phisitions as are honest, and that practise the Arte withoute
Fraude : and there are seene of that profession many which
being given unto prattle, and tell fables to deceive the people,
doe vituperate the experiences, with saying that they are
wicked and such like.” Diogenes, setting out with his
lantern in search of prattlers, might not have far to go even
in these days : he might even find a few deceivers—or self¬
deceivers—on the way !

Peace be with the Reverend Maister Alexis. If he has not
furnished us with much instruction, he has at least provided
us with some diversion. And withal his final rule for the
“ regiment and governyng of a man’s selfe ” is not unworthy
of our attention in these weary days ; we may at least endeavour
in his company to “ Be merry ! ”

Note. —It has been a matter of some difficulty to ascertain
who the learned Alexis really was. In the notes to the edition
from which these extracts have been taken he is spoken of as
“Alessio vel Alexius—Piemontese pseud. G. Ruscelli vel
Rossellus.” It was taken for granted that he was a medical
man; but further investigation did not confirm this. In the
Bibliotheca Britannica (by Robert Watt, M.D., London, 1824)
he is mentioned as follows: “ Alexis or Alexius, a Pied¬
montese, the reputed author of the ‘ Secretes.’ Haller says the
real name of the author was Hieronymo Rosello. The ‘Secretes’
appeared in Venice in 1557, and have been translated and
published in every European language, and an abridgement of
them was long a popular book at the foreign fairs.” In
the Nouvclle Biographie Generate (Paris, 1862) he appears
under the name Ruscelli. The writer speaks of him as “ a
learned Italian, born at Viterbo, died in 1566 at Venice. His
parents were poor and in humble circumstances; but by dint
of work and perseverance he raised himself to a distinguished
position in contemporary literature.” His learning—which
comprised history, poetry, ancient and modern languages—
brought him into friendly relationship with such men as Tasso.
Of his life little is known. He lived at Rome during the
pontificate of Paul III. He then went to Venice, where he
worked as proof-reader to the printer Valgrisi. He died in
Venice between the ages of forty and fifty. He edited
numerous works; but, so his biographer avers, he was not

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content with editing. “On a reproche a Ruscelli,” he says,

“ d’avoir introduit dans quelques-uns de ces ouvrages des
changements qui en ont plus d’une fois d^naturd le sens.”
Evidently he did not “ avoyde all excesse and superfluity ”
when editing!

I have not been able to find any reference to Alexis or his
Secretes in Daremberg, Bouchut, Puschmann, Sprengel, Le
Clerc; nor even in the Encyclopedia Britannica is the
learned Ruscelli referred to. Such is fame! In Timbs’
Doctors and Patients there is a paragraph on “ Olden Secrets
in Physic and Surgery ” which deals with a “ venerable
volume,” in the frontispiece whereof there is a portrait of,
among others, the worthy Alexis. I have not yet been able to
see this book, which is, according to the diligent Timbs, “of
considerable size and pretension.”

Thus, so far as can be gathered, Alexis had no training in the
art of physic, but was an industrious collector of recipes as well
as an erudite scholar.

I am obliged to Mr. H. E. Powell, of the Royal Society of
Medicine, for his kind assistance in helping to elucidate the
matters dealt with in this note. I may add that there are
three editions of the “ Secretes ” in the library of the Royal
Society of Medicine.

(') J. de La Bruyfcre, “ Caracteres," Discours sur Theophraste. — (*) Hippocrates,
De Murbo Sacro (Sydenham Society’s edition).—(*) “ Apoplexia ” he defines
as “a sicknesse engendered of grosse humors, filling the receptories or vessels of
the braine, and therefore depriveth of feeling, speech and moving."—( 4 ) In the
Syriac Book of Medicine which dates back to the early period of the Christian
Era, there are some curiously similar prescriptions against the falling sickness.
Certain of these contained more than thirty ingredients, and among these are
found pepper, myrrh, ginger, cinnamon, musk. Instead of the brain of a crow
the Syriac physician suggests the brain of a camel; and he is not outdone by
the sage Alexis in what may be described as excrementitious therapeutics. (The
Syriac Book of Medicine, edited and translated by E. A. Wallis Budge, vol. ii,
p. 59. London, 1913.)

The Mechanism of Hysterical Phenomena. Sketch of a
Psycho-Physiological Theory of Hysteria. By Albert
SALMON (Florence), Lecturer in Neurology in the Uni¬
versity of Rome. (By kind permission of the Editors of
Nouvelle Iconographie de la Salpttriere. Trans, by T.

Drapes.)

The problem of hysteria, although for some years past it has
engaged the special attention of the best neurologists and

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psychologists, is yet very far from being solved. The chief
object which authors have had in view at recent congresses has
been to obtain a satisfactory definition of this affection. A
definition, however, as Claparede justly observes, being only a
citation of the characters which constitute the nature of a
thing, should be the crown and not the foundation of the study
of any malady. Hysteria cannot, then, be defined without first
establishing the nature of this affection, without studying the
mechanism of its morbid phenomena. Now, an essentially
pathogenic study of this disorder has not yet been made. It
has been supposed to be the consequence of a narrowing of the
field of consciousness (Janet), the suppression in consciousness
of painful impressions of sexual origin (Freud), of suggesti¬
bility (Babinski), of an exaggeration of the plastic power of
the imagination (Hartemberg), of torpor of the organic cerebral
mechanisms (Sollier), of a tendency to reversion, to atavism
(Claparfede), of disorder of the cortical or sub-cortical reflexes
(Raymond), of an exaggerated emotional reflex (Bernheim), of
perversion of the highest cerebral functions (Bastian); but it
has not been explained by what mechanism all these conditions
are produced, and provoke the morbid phenomena. It is just
here that the chief difficulty of all these theories lies ; it is the
point by which we may judge of their respective value. Even
if we assume, for instance, that hysteria is due to a limitation
of the field of consciousness, what, we may ask, is the primary
cause which determines this modification of the personality ?
By what mechanism does a suggested idea or a painful repre¬
sentation translate itself, or become converted, into somatic
phenomena, or into an exaggerated emotional reflex ? It does
not suffice to tell us that this affection is characterised by a
flexile suggestibility or by an exaggeration of a plastic imagi¬
nation ; we require also an explanation as to what determines
the plastic properties in the case of these patients. What is
the cause which induces the torpor of the organic functions
of the brain as in Sollier’s theory, the disorder of cortical or
sub-cortical reflexes as in that of Raymond ?

I believe that the answer to all these questions can only be
found in the study of hysterical phenomena themselves, such as
are met with in clinical practice, and above all in the con¬
sideration of their intimate mechanism. It is precisely the
study of this mechanism which constitutes the principal object

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of my thesis. I shall afterwards see if there is not some morbid
condition capable of explaining all these hysterical phenomena,
including those which some authors have eliminated from their
descriptions of this complaint. Finally, I shall endeavour to
outline a theory which, far from ignoring the importance of the
principal theories which have been propounded in explanation
of this affection, will gain advantage from the best arguments,
and above all from the facts which have been advanced in
support of their conclusions. I shall be happy if this attempt,
the difficulty of which, moreover, \ fully recognise, will aid in
dissipating the obscurity which envelops the pathogeny of
this interesting malady.

The most important data resulting from the study of
hysteria, and from the examination of the best theories
regarding it, are, in my opinion, the following :—

(i) The importance of the emotions in determining the affection.
—Hysterics in general belong to very emotional, very im¬
pressionable families and races. It is very rarely that all the
phenomena which they exhibit have not as their origin an
affective cause; we occasionally see hysterical troubles, even
those most rebellious to psychotherapy, abruptly disappear
under the influence of sudden emotion. We remark, besides,
as Dejerine has well shown, that a large number of these
phenomena, such as the paraplegias, convulsive crises, aphonias,
vomiting, vaso-motor troubles, etc., are often only the somatic
translation of emotions experienced by the subjects ; it is only
by their permanence that they are distinguished from the
somatic phenomena which are ordinarily observed after the
most commonplace emotions. Suggestibility implies equally
an affective factor ; frigid ideas neither excite nor cure a single
hysterical symptom.

The fact that hysterical troubles are very rare after very
intense and prolonged emotions, initiated by grave cataclysms
(earthquakes, conflagrations, etc.), does not, in my opinion,
controvert the importance of emotion in hysteria; it only
makes us assume that emotions are not the direct cause of the
morbid phenomena; between these phenomena and the emotion
it is necessary to invoke an intermediate element, which loses
all its influence when the emotion is too intense. There are
other arguments which tell in favour of this hypothesis—

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namely, the period of latency which very often intervenes
between the emotion and the development of the hysterical
symptoms, and the fact that the phenomena produced by an
emotion can be reproduced independently of it, for example by
habit, by compression of a hysterogenic zone, etc.

(2) The impulsive and plastic power of affective ideas, by which
these translate themselves into corresponding acts, and some¬
times into somatic phenomena, which are observed with great
difficulty under normal conditions. Thus, the idea of a
paralysis, a contracture, an anaesthesia, involves the realisation
of these phenomena, and sometimes of vaso-motor and
secretory symptoms, which are themselves only the exag¬
gerated somatic translation of ideas conceived by the subject.
Even in this case we observe that the hysterical phenomena
determined by an affective idea may recur independently of it,
for instance on the occasion of an emotion, by compression of
an hysterogenic point, by habit, etc.

(3) The special suggestibility of the subjects, which is to be
distinguished from the suggestibility we observe in other
affections by the fact that the suggested or auto-suggested
ideas are translated into somatic phenomena; this plastic
suggestibility (Hartemberg) is only the expression of the plastic
and impulsive power of affective ideas peculiar to this affection.

(4) The purely automatic mechanism by which hysterical acts
manifest themselves; the modifications of personality; the indif¬
ference, the lack of interest, the adaptability which the subjects
exhibit with regard to their symptoms, as if these were of no
concern to their personality.

Hysterical acts present a strong analogy to voluntary acts
(Brissaud, Paulhan), and more particularly to acts which have
become automatic. Brissaud said that the hysteric produces
nothing that he could not reproduce at will. Paulhan main¬
tains that hysterical acts are effected in accordance with the
general laws which govern all voluntary acts. Now, granted
that the pathogeny of every morbid phenomenon finds its
explanation only in the study of the corresponding physiological
phenomenon of which it is only a modality, we ought, in order
to elucidate the mechanism of hysterical acts, to revert to the
study of voluntary and automatic acts. In connection with
this subject we should bear in mind the very important studies

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of James and of FouilMe, demonstrating that the feeling of
innervation and impulsion to perform any voluntary act are
essentially determined by the representation of the movement;
that is to say, by its kinaesthetic image, which is nothing but
the residue of the muscular, articular, and tactile sensations
which were produced when the movement was previously
accomplished. It is only by this kinaesthetic revival that the
very vivid representation of an act is translated into the act
itself; thus, the billiard player who follows with much interest
the direction of a ball, very often with one of his limbs executes
involuntary movements in the same direction as the ball; and,
similarly, a person who thinks with emotion of a word which
he has heard, or which he wishes to pronounce, often utters
it unknown to himself. All these facts would not, assuredly,
find an explanation were it not admitted that it is precisely
the representation of the act, or its kinaesthetic image, that
determines the automatic impulse which brings about the act
itself. All automatic acts, as Morselli very justly remarks,
imply a kinsesthetic precedent, an organic memory which
replaces the voluntary and conscious memory. It is the
kinaesthetic and muscular innervations — Luciani writes to
the same effect—which by their prolonged exercise govern all
our automatic acts.

The importance of kinaesthetic images in automatic acts is
in quite a special manner confirmed by a curious and interesting
phenomenon which I described at the last Congress of Neurology
in Florence. I have proved that in the case of many healthy
subjects, after a prolonged muscular contraction, they are
capable of executing the same movement by a purely auto¬
matic mechanism. We can elicit this phenomenon in the
following manner. The subject is asked to make a very
vigorous and prolonged movement of abduction with his arm,
while at the same time a strong resistance is opposed to it.
When he is slightly fatigued he is requested to relax his
muscles, and at once to recommence the preceding move¬
ment, but very slightly, and only the initial stage of it. Then
we observe that the movement, almost before it is conceived,
is completely effected in an automatic manner; that is to say
that the subject, independently of his will, raises his arm.
I have demonstrated the same fact, although less markedly,
after flexion of the forearm and of the thigh, or after extension

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of the head. These practical experiments on a large number
of subjects, without previously apprising them of the object
of my observations in order to avoid any possibility of sugges¬
tion, have given me in almost every instance a positive result.
Many subjects, and perhaps the more impressionable and
emotional, have even been able to execute the automatic
movements in question without having had any previous
conception of them at all. In only a small number of subjects
have I found this phenomenon absent: these have, however,
remarked that voluntary movements executed immediately
after muscular contraction in the same direction as this move¬
ment are effected with extreme facility. They feel a strong
impulse to perform them, while almost experiencing the feeling
that the limb was flying. Now, if we consider that the
sensation of innervation and impulsion to perform any volun¬
tary and automatic act are conditioned by the revival of
kinsesthetic images, it is not an illogical hypothesis that the
automatic impulse which we have demonstrated in our subjects
is due to the residue of muscular, articular, and tendinous
sensations which are produced after the muscular contraction;
in other words, to their kinsesthetic images. Just as after
hearing a sound of great intensity, or after seeing a very vivid
light, the hallucinatory image of the auditory or luminous
impression persists for several seconds, so, after muscular
efforts, there remains a kinsesthetic image endowed with a
strong motor tendency, whence arises the automatic impulse to
the act. I have been able to obtain very convincing confirma¬
tion of this view in the case of a neurasthenic who exhibited
a very lively kinsesthetic impressionability. This subject, in
whose case the automatic movements above described were
very pronounced, could accomplish the same involuntary
movements by simply thinking of the act he wished to per¬
form ; that is to say, that the mere representation of the move¬
ment was sufficient to cause the automatic impulse to the act,
which proved clearly that this impulse depended on the
kinsesthetic image which is habitually formed as a sequence
of the very vivid representation of every movement. There
can, therefore, be no doubt as to the importance of kinsesthetic
images in the mechanism of automatic acts.

All these considerations which are derived from the study

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of voluntary and automatic acts explain, in my opinion, the
mechanism of hysterical acts. In fact, if these phenomena
are, in the last resort, only automatic acts, if they are the
somatic translation of the psychical representations of the acts
which the patient has formed in his mind, and if these repre¬
sentations are identical with the kimesthetic images of the
corresponding acts, it would seem perfectly logical, in the
study of hysteria, to attach very considerable importance to
these images, in order to understand the impulse which
hysterical subjects have to perform their morbid actions, and
to explain the plastic power of their representations.

The very active impulsive tendency inherent in kinaesthetic
images is due in particular to their affective coefficient. It
is the representations of markedly affective character which
especially revive our kinaesthetic images and translate them¬
selves forthwith into acts. It may, then, be affirmed that
every hysterical act implies a fixed kinaesthetic image, endowed
with a very lively affective and motor tendency, whence arises
the automatic impulse to the act. An hysterical paralysis, for
instance, is, in my opinion, only the somatic translation of
the strong kinaesthetic impression experienced by the patient
from the idea of the paralysis ; a limb contracture, in the same
way, implies the fixed kinaesthetic image of the movement
which the subject has accomplished; catalepsy could not be
similarly explained if we did not admit the persistence of motor
images (James), etc. The existence of a fixed kinaesthetic
image must be invoked not only in the case of motor, but
also in that of sensory hysterical phenomena, for all sensory
impressions are accompanied by a motor reaction, and by
a kinaesthetic image, which can be revived merely by the
recollection of the impression received (Patrizi).

Hysteria, then, finds its most obvious explanation in kinaes-
thesis, that is to say, in the synthesis of the internal cerebral
sensations which derive their origin from sensory, motor, and
visceral impressions. The fundamental condition of the affection
is, in my opinion, a vivid impressionability of the kinaesthesis,
of this important function reinforcing the mental and affective
life, whence the formation of very affective fixed kinaesthetic
images which, attracting all the dynamic nervous energy,
engender a disequilibrium of the kinaesthesis itself. In this
way we shall succeed in explaining the principal facts observed

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in the study of this affection. For example, we can understand
that the presence of a fixed kinaesthetic image behaves like a
nucleus of crystallisation with regard to nervous energy, and
exercises an inhibitory action on the activity of other such
images, including those which preside over antagonistic move¬
ments. This would furnish a complete explanation of the
powerlessness of the subject to make movements which would
oppose the realisation and the permanence of his morbid actions-
We can, moreover, assume that the patient loses also the
desire to make these movements, for the desire to perform
such and such an act depends on the affective and motor poten¬
tial which is bound up with the kinaesthetic image of the act
itself.

The aloofness, the indifference, the adaptability which the
hysteric shows with respect to his symptoms may be explained
by studying the action of the affective tendencies which are
linked on to the kinaesthetic images. We must, in the first
place, make with Paulhan a distinction between affective ten¬
dencies and emotions. An emotion is merely an affective
tendency which by its intensity, or by its too rapid realisation,
provokes an overflow of nervous energy, and its irradiation
through all the cerebral cortex to the bulb. The emotion, in
fact, arises every time our affective tendencies are arrested
(Paulhan). Every affective tendency, however, does not
constitute an emotion; it may become systematised, fixed,
without exciting any emotion. This latter takes origin from
the antagonism between our affective ideas and the ego, and,
by reason of its wounding our personality, it entails very grave
psychical troubles. Affective tendencies, on the contrary, in
consequence of their systematisation, do not modify our per¬
sonality. Now, the hysteric, possessing a very vulnerable
personality, in consequence of his habitually emotional tem¬
perament, avoids emotions of every kind, and, to defend himself
from these, is chiefly interested in having his affective tendencies
systematised and fixed. It follows from this that when these
subjects, owing to their kinaesthetic hypersensibility, have a
strong impulse to do such and such an act, they have no desire
to check the affective tendency which is bound up with their
kinaesthetic images, and this to escape the emotion which
would be consequent on its arrest.

This view would explain not only the adaptability of the

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subjects towards their symptoms, but, further, even the per¬
sistence of these phenomena, which, without doubt, would find
their strongest opposition in the resistance which the subjects
could offer to them. Confirmation of this idea may be found
in a fact demonstrated in many cases of hysteria, namely, that
when patients have attempted to resist their suggested or auto-
suggested impulses, they have been attacked with the most
violent emotional crises (convulsive paroxysms, etc.), or with
psychical troubles (delirium, etc.), testifying to the change in
their personality. From this point of view an hysterical
symptom may be regarded as a reaction of adaptation, a
defensive reaction (Claparede), in the face of the emotions
and psychic troubles which result from it. For this reason
we are not surprised that hysterical phenomena very often
disappear with the advent of insanity, or that emotions, when
very vivid or excessively prolonged, more readily induce mental
trouble, representing a phenomenon of disadaptation of the
intellectual sphere, rather than hysterical acts, that is to say,
phenomena of adaptation.

Modifications of personality, of consciousness, also find in
my theory their most correct explanation, if we recollect the
very close relations which exist between kinaesthesis and
consciousness. There is no consciousness, writes Bianchi,
without kinaesthetic sensation; we are not conscious of any
sensation whatever unless it is amalgamated with the totality
of internal sensations which form the basis of our personality.
It is, then, quite logical to assume that a fixed kinaesthetic
image, endowed with a very affective coefficient, attracting all
the nervous energy and internal attention of the subject, induces
the loss of the kinaesthetic sensibility of a considerable number
of sensations, and that these, although perceived by the sensory
centres, do not reach consciousness, the personality of the
subject. Thus, the hysteric, the subject of an anaesthesia or
an amaurosis, feels affectively with the anaesthetic skin, or
sees with the amaurotic eye, but these sensations remain
altogether in the region of the subconscious. This would
explain the phenomenon so well described by Janet under
the term “contraction of the field of consciousness.” This phe¬
nomenon is not, however, according to my theory, the primary
cause of hysteria, as Janet supposes, but is the consequence of

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a kinzesthetic disequilibrium, the result of an exaggerated
reactive condition of certain kinaesthetic images.

My theory must also be distinguished from the theory of
Sollier, the only author who assigns great importance to
kinaesthesis in the study of hysteria, by the fact that this
affection, according to Sollier, is the result of a torpor, a
somnolent condition of the organic functions of the brain, while
according to my view it is the consequence of a diametrically
opposite cause, namely, of hyperaesthesia of the kinaesthetic
mechanism, and of the consequent disorder of this important
function. According to Sollier’s theory all the dynamic phe¬
nomena, all the vaso-motor and secretory phenomena which
characterise our affection, remain quite unintelligible, whereas,
as I hope to show later on, the facts find their fullest explanation
in my theory, according to which the origin of hysteria consists
in a hyperactivity of the kinaesthetic centres or of the organic
regions of the brain. It is by a hypercesthesia of kinczsthcsis,
and not by its torpidity, that we are enabled to comprehend the
facts of double personality, or the dissociation of personality,
in the case where a synthesis of very affective sensations,
images, and recollections form a special centre of association,
and a new personality. It cannot be doubted that all cases of
dissociation of personality are always in the closest connection
with the most profound modifications of kinaesthesis (Sollier).

My theory, I believe, perfectly explains one of the most
interesting peculiarities of this affection, namely, the plasticity
of the nervous centres, by which affective ideas are translated
into abnormal somatic phenomena, for instance into vaso¬
motor, secretory, and sometimes trophic disturbances. Cases of
hysterical paralysis and anaesthesia are often quoted which are
accompanied by cutaneous and muscular angiospasm, such that
the deepest punctures of the skin and the muscles cause no
bleeding. In a case of hysteria described by Dejerine the mere
idea of cold sufficed to determine a strong constriction of the
cutaneous vessels. Gerini has similarly observed a subject in
whose case the idea of an electric stimulus induced a cutaneous
and muscular angiospasm so intense that the subsequent
application of a faradic stimulus failed to cause the slightest
muscular contraction. I myself have called attention to the
coincidence in cases of traumatic hysteria between the myas-

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thenic reaction and the presence of vaso-motor troubles, a
coincidence which constitutes a very valuable argument in
support of the hypothesis that I have advanced in the study of
this reaction, namely, that in many patients, and particularly
in the case of hysterics, it is in relation with a vaso-motor
hyperexcitability of the subjects.

Now, this exaggerated vaso-motor reaction which is observed
so frequently in hysteria, this plasticity, this constitutional
docility, which constitutes perhaps the most salient fact of
that complaint, cannot, in my opinion, be explained unless by
invoking a special excitability of the vaso-motor and organic
brain centres, which is in perfect agreement with the kinaes-
thetic theory which I have proposed. It is, in fact, admitted
that the kinaesthetic centres have not only the power of
receiving internal sensations, but also of transmitting the
excitation to the vaso-motor, secretory, and trophic nerves
(Morselli). Many authors even maintain that these centres
have their seat in the somaesthetic zone of Flechsig, which is
the precise situation of the vaso-motor, secretory, etc., centres ;
and it has been remarked, in support of this idea, that every
kinaesthetic impression is linked to a more or less active vaso¬
motor reaction. We can understand, after all these con¬
siderations, how in hysteria kinaesthetic hypersensibility is
very often accompanied by a special hyper-activity of the vaso¬
motor and secretory centres or of the organic cerebral centres,
which completely explains the special frequency of vaso-motor
and secretory troubles in this affection.

The kinaesthetic theory which I have described equally
elucidates the very complex etiology of hysteria. The im¬
portant role of the emotions in its development finds its
explanation in the very close connection between kinaesthesis
and the emotions (Sollier). In fact, if we consider that
kinaesthesis constitutes the domain whence all the emotions
spring, that on the one hand it gives vivacity to all our ideas,
and on the other originates the somatic phenomena of the
emotions themselves (Bianchi), we may suppose that kinaes¬
thetic sensibility becomes more active as emotivity and
affective tendencies become more intense. We are familiar
with the cases of Pronier, Sollier, and Allonnes, where a remark¬
able diminution of kinaesthetic sensibility was associated with

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an absolute loss of emotivity. The emotions, in their turn, have
an enormous influence on kinaesthesis, just as they largely
influence all sensations; there is no emotion which does not
excite disorder or augmentation of kinaesthetic sensibility.
We can, then, readily conceive that hypersensibility of
kinaesthesis, and, consequently, the development of hysterical
phenomena, are more easily determined in proportion as the
emotivity of the subjects is greater. The kinaesthetic image
would thus constitute the intermediate element, which we have
previously assumed, between the emotion and the hysterical
phenomenon, and would explain all the facts which have been
wrongly adduced against the importance of emotion in hysteria.
In fact, a very intense emotion may determine a depression of
kinaesthetic sensibility without thereby causing any hysterical
symptoms. We shall not then be surprised at their absence,
or their rarity, in grave cataclysms, great earthquakes for
instance, after which the unfortunates generally exhibit the most
complete loss of emotivity and affectivity (Gabbi, Sterling).
We may suppose, on the other hand, that kinaesthetic hyper-
aesthesia, that is to say the fundamental cause of hysteria,
would be only with great difficulty determined by a single
emotion, even the most intense, and that it demands for its
production a series of emotions, or rather a constitutional
emotionalism which without doubt engenders the most favour¬
able disposition for the outbreak of this affection. By
assuming an intermediate element between the emotion and
the hysterical phenomena, we can similarly explain how an
hysterical phenomenon created by an emotion may repeat
itself independently of this, for instance through habit, by
compression of a hysterogenic zone, etc. We can also explain
the fact, well illustrated by Dejerine and Gauckler, that many
of these phenomena are the somatic translation of an emotion,
if we reflect that it is precisely kinaesthesis which supplies the
somatic components of every emotion. We may then assume
that a paraplegia, an aphonia, vomiting, etc., which are com¬
monly observed after a vivid emotion, and which ordinarily dis¬
appear a few minutes after the shock thereby produced, remain
fixed in the case of hysterics in consequence of their kinaesthetic
impressionability, independently of the idea or of the suggestion
of these phenomena. Their mechanism would thus present a
strong analogy with that of many automatic acts, such as

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yawning, laughing, weeping, etc., which equally imply kinaes-
thetic antecedents, and are effected without the subject having
the idea of, or the will to execute them.

The special suggestibility of hysterical patients, which is one
of the most characteristic features of this affection (Bernheim,
Babinski), finds too its explanation in my theory, if we consider
that it is characterised by the emotionalism and by the impul¬
sive and plastic power of affective ideas, which imply, as we
have already shown, a lively kinaesthetic impressionability.
It is, in fact, by this ccenaesthetic impressionability that the
suggested ideas promptly translate themselves into correspond¬
ing kinaesthetic images, which possess a strong affective and
motor tendency, and consequently into action. It is owing
to this kinaesthetic hypersensibility that the thought of an
hysteric is always an image so vivid that at times it assumes
an hallucinatory intensity, so that the subject imagines he
sees or hears everything that is suggested to him. It is just
because of his kinaesthetic impressionability that the hysteric
cannot think of any action whatever without feeling a strong
impulse to perform it, even without comprehending the reason
of his impulse. We have a very appreciable confirmation of
the relations existing between kinaesthetic sensibility and
suggestibility in the fact that when the first is very depressed
we find a loss of suggestibility such as is observed in melan¬
cholics, as in the case of Allonnes and others. Suggestion has
sometimes succeeded in inducing abnormal somatic disturb¬
ances, vaso-motor and secretory troubles, which are only the
somatic or kinaesthetic translation of the affective ideas
suggested. These are observed particularly in the hypnotic
state, where precisely a special hyperaesthesia of the kinaes¬
thetic centres has been shown to exist.

The considerations we have advanced with respect to hys¬
terical suggestibility equally explain the mechanism of imitation,
a very striking phenomenon in hysteria, and which is merely
a suggestive stimulus implying, as every suggestion does, a
blind ^impulse to action the moment a subject has received
certain perceptions. In fact, the imitation is the more effectual
in proportion as the kinaesthetic images are more vivid, as is
observed in conditions of hypnosis, where the patients imitate
irresistibly all the movements that they see. The hysteric is

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very often a mythomaniac, who imitates with the complicity
of his organism. Now, this plastic mythomania, or, to use
the expression of Dupr6 and Logre, this mythoplasty, which
reaches its highest degree in catalepsy, would remain quite
inexplicable if we did not assume an active kinaesthetic
impressionability capable of explaining the somatic translation
of the actions observed.

The kinaesthetic theory, finally, illustrates the importance
of organic changes in the development and fixation of hysterical
phenomena. We are familiar with all the relations which
exist between hysteria and physiological and pathological
modifications in the condition of the genital organs; for
instance, the influence which menstruation, pregnancy, par¬
turition, genital maladies in general, have in the determination
of morbid phenomena. Hysteria constitutes one of the most
frequent complications of exophthalmic goitre, as if thyroid
hypersecretion created a disposition to this affection by means
of emotivity. Many hysterical gastralgias have their origin in
genuine dyspepsia. Cases are not rare in which gastric or
pulmonary changes, even of a very trivial nature, induce in
these subjects very serious haemoptysis or haematemesis, with
features peculiar to hysterical attacks. Hysterical crises have
been described which had their origin in hepatic or renal colic,
and which subsequently recurred from a simple suggestion
(Bernheim). A slight laryngitis is sometimes the cause of
rebellious hysterical aphonia. In a case described by Janet
the hysterogenic zones, where compression provoked hysterical
crises, were represented by the points of Valleix of a previously
cured sciatica. In traumatic hysteria there has often been
observed a relation between the most trivial anatomical lesions
produced by trauma and the hysterical phenomena, which dis¬
appear rapidly on the cure of the former. The development
of traumatic hysteria is, without doubt, favoured in many cases
by physiological distress, fatigue, neurasthenia, alcoholic intoxi¬
cation, abuse of tobacco, plumbism, etc. Hysteria, even the
infantile variety, selects as its favourite subjects such as are
of feeble constitution, affected with chronic intestinal intoxi¬
cations (Sainte-Philippe), or debilitating infections such as
tuberculosis and syphilis, the children exhibiting delay in their
physical and mental development, the progeny of alcoholics

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and syphilitics. Not rarely is hysteria associated with some
organic affection of the cerebral and medullary centres; it is
frequently combined with disseminated sclerosis, dementia
praecox, and sometimes with cerebral and cerebellar tumours,
and tabes (particularly in the female sex). Phenomena are
observed in hysteria which seem very closely connected with
vaso-motor disturbance. Cases have been described of hemi¬
plegia, of contracture, of hysterical stammering, which have
not yielded to psychotherapy, and which have disappeared
during the inhalation of a few drops of nitrite of amyl; also
cases of right hemiplegia with motor or sensory aphasia,
which altogether suggested a diagnosis of organic change in
the cerebral centres, and which have been cured by suggestion.
Hysterical blindness is very often preceded by severe headache
and dizziness, as if it originated in some transitory vascular
trouble in the brain. The relation between vaso-motor troubles
and hysterical symptoms is such an intimate one that Savill
and other authors maintain that the origin of these symptoms
should be looked for in vaso-motor conditions of the nervous
system of emotional origin. What is certain is that in many
cases even the most distinguished writers seem exceedingly
puzzled between a diagnosis of hysteria and that of some
vaso-motor affection.

Now, the relations which I have adduced between organic
changes and hysteria could not certainly find their explanation
in a purely psychological theory of this affection, while they
are perfectly explained by my kinaesthetic theory. Kinaes-
thesis precisely represents a psycho-organic co-ordination,
which is responsive to the influence both of psychical and
organic stimuli. It registers, on the one hand, the slightest
changes in any of our tissues, and, on the other, it gives origin
to our representations ; we have the clearest demonstration of
this in dreams—the analogy of which with hysterical phenomena
is well known—where images, the most fantastic ideas, have
very often their origin in feeble kinaesthetic sensations. It
is not, then, a hazardous hypothesis that hysterical phenomena,
like dreams, may derive their origin from kinaesthetic traces
left by organic changes, even of the lightest character, such
as a small peripheral lesion, a vaso-motor trouble of emotional
origin, etc.

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To sum up, I am convinced that hysteria finds its clearest
explanation in the study of kinaesthesis. Just as this function
elucidates the mechanism of all our voluntary and automatic
actions, in the same way it explains the mechanism of hys¬
terical actions, which are effected according to the laws which
regulate all voluntary and automatic acts. The fundamental
condition of this affection is, in my opinion, a hyperaesthesia or
an active impressionability of the kinaesthetic centres, whence
the formation of fixed kinaesthetic images, endowed with a
strong affective and motor tendency, which, attracting to
themselves all the nervous dynamic energy, bring about a
disequilibrium of kinaesthesis, and consequently modifications
of the personality peculiar to hysterics. The relations existing
between kinaesthesis and the emotions (Sollier) explain the
importance of affective causes, and of emotionalism in the
determination of this affection. The kinaesthetic images,
according to my theory, would constitute the intermediate
element between the emotion and the hysterical act, which
would explain on the one hand the absence or rarity of this
malady after very intense emotions which ordinarily cause
kinaesthetic depression, and on the other hand the period of
latency which very often intervenes between the emotion and
the hysterical phenomenon. Finally it would also explain the
capability which hysterical troubles possess, created by emotions
and affective ideas, of repeating themselves independently of
these latter. Similarly, by this theory can be shown the
relations which we have already cited as existing between
organic lesions and hysteria, relations which purely psycho¬
logical theories of this affection are powerless to explain. The
kinaesthetic theory which I have described furnishes us, in
fine, with an explanation of the impulsive and plastic power
of affective ideas, the power by which these promptly translate
themselves into corresponding acts, and sometimes into ab¬
normal somatic phenomena, such as vaso-motor, secretory,
etc., troubles, which are themselves merely the expression of an
exaggerated reactivity on the part of the kinaesthetic centres.
It is, in fact, by a kinaesthetic hypersensibility that we can
explain the sensory impressionability of Dubois, the plastic
properties of the images, consequently the mechanism of the
plastic suggestibility, and the mythoplasty characterising this
affection of Hartemberg and Dupr6. My theory greatly

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DULNESS AND BACKWARDNESS

[April

elucidates the conversion of Freud, by which the affective
element determines the somatic symptoms—which constitutes
the most mysterious point in the theory of the German
neurologist.

In a word, it seems to me that my theory not only is not in
contradiction to the principal theories which have been
advanced in the study of this malady, but that it clears up
the most obscure points in these theories, thus rendering them
easier of acceptance. It is for this reason that I venture to
hope that it will be welcomed by all neurologists, and particu¬
larly by those authors whose names are associated with this
interesting affection.

Relative Degrees of Dulness and Backwardness in School-
Children and their Causation. By H. R. Burpitt, M.D.,
School Medical Officer, Newport, Mon.

The following investigation deals with 400 children (200
boys and 200 girls) between the ages of 7 and 14, considered
by the teachers, and after examination by myself, to be dull and
backward, but not to fall within the meaning of the definition
of feeble-minded as given in the Mental Deficiency Act of 1913
— i.e. t persons in whose case there exists from birth, or an early
age, mental defectiveness not amounting to imbecility, yet so
pronounced that they require care, supervision, and control for
their own protection, or for the protection of others; or in the
case of children, that they by reason of such defectiveness appear
to be permanently incapable of receiving proper benefit from
the instruction in ordinary schools.

The defects, and other abnormal conditions, ascertained in
the case of these children are given in the following table :

Table I.

Family history of mental defect (including in¬
sanity) ......

Family history of dulness . . . .

Family history of epilepsy . . . .

Family history of tuberculosis
Unfavourable home surroundings .

per cent.

3'5

I I
1-25
9

25

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19 1 6.] BY H. R. BURPITT, M.D. 395

per cent.

Irregular attendance . . . . .52

Inherent dulness (not amounting to feeble¬
mindedness) ..... 34'25*
More marked inherent dulness (? mental defect) 175*

Physical Defects.

Adenoids and tonsillar disease . . . 1875

Deafness (apart from above) .... 475

Defective vision ( T C y or worse in one or both eyes) 14^5
Nutrition below normal . . . 15-5

Defective speech ...... 4

A family history of amentia and insanity was present in
3'5 per cent, of cases. Owing to the sensitiveness of people on
this matter, it is probably higher than this.

The ratio of 11 per cent, for dulness in the family, based
largely on the information of teachers who had known older
brothers and sisters, is probably also underrated.

A family history of tuberculosis was obtained in 9 per cent.
of cases. This is nearly twice as great as that for the children
for the area taken as a whole.

Unfavourable home conditions are much more frequent than
in the case of ordinary children.

Irregular attendance is bound up with these, and was the
commonest condition present.

Inherent dulness of all degrees occurred in about one-third
of the cases, and, next to irregular attendance, was the most
frequent condition present.

Of the physical defects, adenoids, tonsillar disease, and deaf¬
ness are more prevalent than amongst the children of the area
as a whole.

The percentage of defective vision is also greater than that
observed in an equal admixture of sexes and ages of the general
population, and includes many of the most marked cases of
errors of refraction, corneal opacities, etc. There is no doubt
that uncorrected defective vision is a common cause of back¬
wardness, which is constantly being proved, according to the
statements of teachers, by the more rapid progress made by
these children after wearing spectacles.

Malnutrition is about three times as great as in the case of

* See footnote on p. 399.

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[April,

ordinary children, a statement which is corroborated by the
improvement in lessons of those put on the free dinner list.

Speech defects are also about three times as frequent as
ordinarily met with.

The absolute degree of retardation of each child was investi¬
gated, and classified according to the number of standards he
or she was behind the normal. For this purpose it was assumed
that a normal child aged eight should reach Standard I
—this errs somewhat on the side of leniency to the child—and,
then progress one standard for each subsequent year thus :

8 years = Standard I. 12 years = Standard 5.

9 years = Standard 2. 13 years = Standard 6.

10 years = Standard 3. 14 years = Standard 7.

11 years = Standard 4.

In the examination of the dull and backward class—in fact
of all the retarded—it is also necessary to ascertain the relative
extent of the retardation. A child may be one standard or more
behind, but a statement to this effect does not alone convey the
true state of things. The age must also be given. A year’s
retardation—real and not apparent, and only ascertained after
elimination of conditions such as shyness, which are more com¬
mon in the younger children—early in school life is more serious
than towards the end of the career. The younger child would
probably be mentally defective ; the older one only a little dull
and backward.

It is better then to express the backwardness by some form
of equation indicative of the degree of backwardness in ratio to
the normal, rather than to use the loose term “so many years
retarded.” A useful system of equations is easily found : sic.,
a 9 year old child should be in Standard 2, and if he has only
reached Standard 1 has lost 1 year. The school life is practi¬
cally always age of child minus 5 ; a few children who are
delicate, or whose parents are of nomadic habits, may start
school later than 5, but their number is negligible, and, where
school is begun earlier, there is no serious teaching.

A backward child of 9 should be expressed fractionally as

-—-, i.e. = or in other words he has fallen behind 1 year
in 4.

Again, a child of 1 3 in Standard 4 is 2 years behind, and is

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BV H. R. BURPITT, M.D.

397

represented qua backwardness by the fraction $. He has lost
2 years in a school life of 8, and is proportionately equal to the
child of 9 who is in Standard 1.

The backwardness of school-children may then be expressed
arithmetically in terms of the number of years behind, compared
with the number of years already spent in school. As the
normal school life is composed of 9 periods of 1 year each, the
lowest unit of backwardness is -g-, and the range from ^ to |,
the higher fractions being only applicable to imbeciles and idiots
who had been retained at school, a practice which, of course, is
not existent in ordinary schools.

The different degrees of backwardness which children under
this definition exhibit are shown in the following table :

Table II

Age J.

Age 8.

Age 9.

Age 10.

Age 11.

Age 12.

Age 13.

Age 14.

Retarded i year

i

i

T

T

i

i

Retarded 2 years

3

¥

*

2

4

i

3

Z

3

T

1

7

0

Retarded 3 years

—

i

*

z

a

Z

*

i

$

Retarded 4 years

—

—

4

4

z

Z

T

¥

i

Retarded 5 years

—

—

—

1

i

\

i

i

Retarded 6 years

—

—

—

§

*

e

6

A

Retarded 7 years

—

—

—

—

—

*

i

i

Retarded 8 years

—

—

—

—

—

8

’8'

ft

JS

Retarded 9 years

r

“

9

V

Reading the lines of this table horizontally, it is seen how
much less serious a retardation of 1 year becomes as the higher
ages are reached ; at age 7 it indicates a half, at age 14 only
one ninth.

In the next line the conclusion is more serious. A 2 years’
retardation in a child who had been in a school 2 years
would mean that it had learnt nothing, and unless there is some
physical explanation the child is an imbecile or idiot.

In the fourth horizontal column the first fractions would
indicate idiots ; the next imbeciles ; the last two would probably
indicate feeble-minded, in the absence of physical causes.

A retardation of 7 years would probably indicate idiocy and
imbecility throughout the line, the fractions being greater than
would be found in children at school of average normal
mentality.

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DULNESS AND BACKWARDNESS,

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It can also be seen readily which of the fractions are of the
same arithmetical value, indicating children of different age, in
different standards, yet on relatively the same mental level.
Thus, first fraction vertical column age 7 = i, second fraction
vertical column age 9 = f, third fraction vertical column age
11=1, fourth fraction vertical column age 13 = 1, all indicate
children on the same mental level.

Of the 400 children reviewed, the boys and girls were
practically equally distributed at all stages, and the groups into
which they fell are shown in the following table, and compared
with the succeeding mentally inferior class—the feeble-minded.

Table III.

1 3

a 3

3 4

4 6

5 0

n 7

7 8

8 9

0 u

u 0

0 0

V 0

U

u w

y u

u u

Dull and backward

48 s

33'75

ii’S

6-

■25

0

0

0

Feeble-minded

5'4

2 4’3

40-5

163

*35

0

0

O

A child more than 3 years retarded, i.e., 3-, unless there
are physical, or other than mental causes, to account for it, is
generally mentally defective (feeble-minded or worse), and
without such causes the children in columns 3, 4, 5 in
Table III come within this category.

Eighty-two per cent, of the dull and backward group are in the
first and second columns above the line of demarcation (■§-), and
70 per cent . of the feeble-minded are below the line. Thirty
per cent, of the feeble-minded come in columns 1 and 2, and
at first sight appear to be wrongly so placed. The explana¬
tion of the anomaly is that it is largely the practice for such
children to be advanced to higher standards than they are
mentally fitted for. This may apply also to the backwards,
but not to the same extent, partly because they are not such
a nuisance as the feeble-minded.

There remains for consideration 18 per cent, of dull and
backwards who are apparently mentally defective. In children,
like others, there are all stages of mental ability. A child
who is backward solely on account of inherent mental
incapacity is suffering in the same way as a mental defective,
but in a lesser degree, and would be adjudged to be feeble-

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BY H. R. BURPITT, M.D.

399

minded only when the amount is excessive. The additional
burden of physical defects, or other detrimental conditions,
would have the effect of raising him from the f to or
higher groups, according to their number and severity, or they
alone, without inherent mental inferiority, might relegate him
to one of these later groups.

To what extent this is true of our 18 per cent. (71) of cases
may now be considered.

Table IV.

Causes.

(«)

(*)

to

OO

to

Inherent dulness only .

„ „ and referred for

further exami¬
nation re M.D.
„ „ and one or more

physical defects
„ „ and employed out

of school hours
„ „ and irregular in

attendance

„ „ and deprivation

(general)*

„ „ and late in start¬

ing school

Late in starting school
Irregular attendance and employed

out of school
hours .

„ „ with one or

more physi¬
cal defects .

(/) Irregular attendance .
Adenoids only .
Inattentive to lessons .

Forty-six

children.

LJ

8

3

7

2

6

o

1

i

4

9

2

2

1

Twenty-four

children.

M

3

o

2

1

8

1

o

1

o

6

3

o

o

* " General,” as distinct from sense deprivation, i.e. where the child has not
received proper attention such as children usually receive, as, for instance, where a
child was kept in a cellar up to the period of adolescence.

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400

DULNESS AND BACKWARDNESS,

[April,

t to £ group.

There is one child only under this, a brother to the child
referred to in clause (e), and the same remarks apply.

(а) We have in this area, as there are in others, children
who are naturally dull only as regards their lessons, and who
may be said to be permanently incapable of receiving proper
benefit from the instruction in ordinary schools, yet they
cannot be considered to be mentally defective within the
meaning of the definition of the Mental Deficiency Act.
Inquiries show that their parents made no better progress at
school, yet have been able to take their places in society, and
manage their own affairs even better than many of those who
surpassed them in scholastic attainment.

( б ) One also had defective vision and adenoids.

(c) Adenoids, defective vision, etc.

(d) One had had phthisis, and four were very malnourished.

(e) One child had only had about six months’ schooling.
He had been living in a caravan. In the six months he had
made great progress, and was able to read.

(/) One child in the $ group had had hip disease,
another in the same group had until recently attended an
unsatisfactory school.

The above are among the reasons why these children,
although they appear in the most advanced groups, are
regarded as dull and backward, and not mentally defective.

Another query as regards backwardness is suggested,^., What
conditions are responsible for the lesser degrees ? What relation
do different causes bear to different degrees of retardation, and
to what extent is the same cause of varying intensity produc¬
tive of slighter or greater degrees ? Is inherent dulness mainly
responsible, or do physical defects, such as adenoids, come
more into play in the production of slighter or more severe
stages of backwardness ? Is there a greater proportion of
single causes in children slightly retarded, and with what
success can the growing intellectuality of the otherwise pre¬
sumably normal child struggle against multiple causes ?

Such are some of the questions which arise, and an attempt
has been made to answer them, firstly, by dividing the 400
children into two groups of slighter, i.e., ^ to $, and more
marked, $ to $, retardation, and, secondly, by inquiry as to the
number of causative factors present.

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BY H. R. BURPITT, M.D.

401

Table V.

Single Causes.

One hundred and seventy cases out of the 400 were due to
a single cause. In 89 per cent, this resulted in a minor, and
in 11 per cent, in a greater retardation.

Number of children 1 5 1

•

19

Retardation .

■

M

Irregular attendance

Si

6

Adenoids

24

2

Defective vision

12

—

Ringworm of scalp .

2

—

Malnutrition .

2

—

Chorea .

1

—

Inherent dulness

59

•

11

Multiple Causes.

Two hundred and thirty children were affected through
multiple causes, and the result of these was to place 77 per
cent, in the minor group, and 23 per cent, in the major.

Number of children

• 178

52

Retardation

• M-

w

Two conditions present

108

27

Three

» J) •

53

16

Four

J) }>

15

7

Five

J> »

. 1

2

Six

f) •

. i

—

The conclusions deduced from these figures are :

Single causes as a rule do not produce backwardness
beyond f . Multiple causes do so more frequently, and pro¬
portionately to the number of causes.

The presence of two more often produces a backwardness
of less than ; the effects of three are approximately equally
reflected in both groups ; and after this there is a much
greater probability of the retardation being severe.

Irregular attendance alone is often a sufficient cause of
children being put in the more markedly defective group.
Physical defects do not usually, of themselves, cause retarda¬
tion beyond first group.

VOL. LXII. 26

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402

DULNESS AND BACKWARDNESS.

[April,

This inquiry had for its object the definition of the degrees
of backwardness and dulness (all were backward, part were
dull, i.e., backward by reason of inherent mental incapacity),
and the causation thereof, but the opportunity is also taken to
briefly survey these causes, and discover what ameliorative
measures are thereby indicated as desirable.

The outstanding aetiological factors are :

Physical defects (53 per cent.), irregularity of attendance
(52 per cent.), unfavourable home surroundings (25 percent.),
inherent dulness (36 per cent .).

Dealing with physical defects first, although they amount
in the aggregate to 53 per cent, (omitting defective speech,
which is a secondary condition), in 10 per cent, only do they
represent the sole cause. This is made up of those cases
where the defect is of such intensity as to produce retardation
in otherwise ordinary children, and of other cases of lesser
intensity, but sufficient to weigh down the balance against
those near the level of what we may call for convenience the
lowerlimit of normal intelligence.

The importance of physical defects as causative factors must
not be minimised, for in the aggregate their effect is very
great. Means are available, and are now’ more or less ade¬
quately provided for by Local Education Authorities, under
the Education (Administrative Provisions) Act, 1907, to treat
such defects in children of school age. The need will not be
entirely met until children under school age are provided for
in similar manner, because untreated defects among them
are often attended with consequences which are permanently
crippling.

Irregularity of attendance was present in 52 per cent, of the
children. As a single factor it was present in only 15 per
cent. Irregularity of attendance will always remain a frequent
cause, until the advent of an improvement in the general health
of the school child, better home conditions, and a more
enlightened and educated body of parents.

Unfavourable home surroundings w r ere recorded in 2 5 percent.
of the cases. It is not given as the sole cause in any instance,
as other fundamental conditions were not difficult to trace.
Unfavourable homes are to a large extent a reflex of mental
abnormality or inferiority, such as ignorance, drunkenness and
crime.

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NUCLEIN ATE OE SODA.

403

Poverty was often the apparent reason, and it must be
understood that, though in many cases this is due to mis¬
fortune, and may be the result of a cruel economic system,
nevertheless it is those most inefficient mentally, or with vices
indicative of instability of mind, who are the first to go under.
Although contributory and aggravative, the influence of this
condition as a primary cause is probably slight. As'regards,
amelioration, ‘education, improved housing, and attention to
public health are essential for this as for other sections of
society, though by themselves they will prove inadequate, unless
other measures are adopted to raise the mental and moral tone
of this class.

Inherent dulness, although only put down after a thorough
scrutiny of all other causes, was present in 36 per cent.

It was a sole factor in 17 per cent, of the 400 children.

A family history of dulness, epilepsy, and mental defect
was obtained in 16 per cent., which, owing to the^.difficulty of
extracting the full truth, is probably an under-estimate.

Because it was easier to assess the extent to which physical
defects and factors other than inherent dulness, operated as
causes, the estimate of the amount of the latter here given is
probably too low, and if it had been possible to trace with
certainty every case to its source, a ratio nearer 50 than 36
per cent, would have been arrived at. This apart, the figures
here given indicate that the chief cause of backwardness in
school children is inherent mental incapacity, and that the
problem of how best to deal with such cases will not be ade¬
quately solved until that respecting the classes from which
they are chiefly recruited— viz., the feeble-minded, imbecile,
idiot, insane, and mentally abnormal generally—has been
satisfactorily adjusted.

Nucleinate of Soda : Its Use in Acute Mental Dis¬
orders. By Colin McDowall, M.D.

At a time when there is a gradual but certain change
spreading through our methods of treatment of the insane,
and chemical compounds are being replaced by other methods,
it may appear unneccessary to record results obtained by the
use of drugs. But this short paper is intended only to give

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404 NUCLEI NATE OF SODA, [April,

my experience as to the effect that nucleinate of soda has
upon the progress of acute mental disorders.

Nucleinate of soda has for its active ingredient a substance
which is a derivative of starch, and has the property, when
introduced into the body, of increasing the number of poly¬
morphonuclear cells in the blood. It has been used in surgery
to increase the resistance of a patient suffering from acute
peritoneal infection, and in similar cases. In order to demon¬
strate what its effect would be if used in persons the subjects
of acute mental disturbance, I tried it in a number of cases,
and this short paper is merely to record the results. Six
cases of excitement, with more or less well-marked confusion,
and six cases of depression, were selected, and it is chiefly
upon these that my remarks are based.

The method of procedure was simple. The patients were
examined on admission, and a quantitative and a qualitative
blood-count made of the white cells. The leucocyte count
in excitement with confusion, and in the majority of cases
of depression, is raised at the beginning of the attack. That
statement is, I think, pretty generally admitted. It is unfor¬
tunate that we do not always get cases of depression as early
as we should, and it is probable that in those cases in which
we find no sign of a leucocytosis on admission an explanation
can be found- in the fact that the more acute symptoms are
passing off, and so the blood changes are not so readily
demonstrated. In excited cases, on the other hand, the
patients are soon found to be too much for the care of
relatives, and they, consequently, come early under notice.

What, or how much importance should be attached to the
leucocyte count is a matter of discussion, and I do not mean
to engage in it, but rather to state simply the results of
raising by artificial means the number of white cells by
nucleinate of soda. The dose varied from 20 gr. to 1 drm.
The drug was dissolved in water, and the solution was boiled
in order to render it sterile. The strength of the solution was
usually half a drachm to one ounce of water. After cooling,
the fluid was injected into one or both arms of the patient.
The syringe, the operator’s hands, and the patient’s skin were
rendered sterile by the usual means. It may be useful to
give the details of one or two cases.

Case i. This patient was a female, aet. 40 ; it was her

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1916.] BY COLIN MCDOWALL, M.D. 405

first attack of acute excitement, but she had shown signs of
mental derangement for some months previous to admission,
and had been treated surgically for a floating kidney. This
operation was not successful in warding off the mental attack,
and when admitted she was in a state of much excitement,
was confused, noisy, and refused food. The blood showed
a leucocytosis of 10,000, and the polymorphonuclear per¬
centage was 80. She was given nucleinate of soda by the
mouth, but this had no result upon the blood-count. Twenty
grains were then injected fnto the subcutaneous tissues of the
arm, and the white cell count rose from 6,000 to 11,400,
while the differential count of neutrophile cells rose from
57 to 75 P er cent. Following the injection the patient, who
had for a month been very restless at night, had the best
night since admission. Three days later half a drachm was
again injected, and again the patient had a better night; she
was quieter, but there was no improvement in her conversation,
which remained rambling and incoherent. Twenty-four hours
after this injection the leucocyte count was 14,600, and two
days later it fell to 7,000. A larger dose was now tried
(1 drm.), and for the two days following the figure reached
was over 13,000, while the percentage of neutrophile cells
rose as high as 88 per ce?it. Two further injections were
given, and blood-counts systematically made for over three
months. On each occasion following the injection of the
nucleinate of soda an increased leucocytosis was found, but
this, when not influenced by the drug, showed a tendency
to fall quickly. The patient slept better, and was generally
less excited when under the influence of the artificial leuco¬
cytosis, but immediately relapsed into her earlier restless,
noisy state when the injections were discontinued. Five
months after admission the leucocyte count was 6,000, and
the percentage of polymorphonuclear cells only 64. At
this observation I noticed an eosinophile percentage of 7,
which is high, and as a general rule a sign of good prognosis.
Unfortunately this has not been borne out by the facts, as
the patient did not do well. She is now a chronic lunatic,
demented, untidy, and self-centred.

The second case is that of a woman approaching the
climacteric period. She had an attack of depression twenty
years previously. The blood was examined daily for five

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406 NUCLEINATE OF SODA, [April,

days following admission. The first observation showed a
leucocytosis of 6,600. Following an injection of 20 grs. of
nucleinate of soda it rose to 13,000, but next day fell to
9,000, and the following day to 8,000. Again 20 grs. were
injected, and the count rose to 13,000. Mentally, on admis¬
sion, she was erotic, noisy, restless and incoherent, and quite
disorientated. She was sleepless at nights; following each
injection she was quieter, and had good nights. The treat¬
ment was continued for six weeks, and in all five injections
were given. It cannot be said that the method was successful,
except as a temporary measure, for as soon as the blood-count
fell, as a result of the influence of the drug becoming less, the
patient was as noisy, restless, and incoherent as ever. This
woman is now a dement, with no prospect of improvement.

The next case I would mention is that of a young girl who
was suffering from her fourth attack of excitement. She had
a leucocytosis of 13,000 on admission, with the high neutro-
phile count of 89. This high percentage of neutrophile cells
lasted for a month after admission. She refused food, how¬
ever, and was very excited, and an injection of 30 grs. of the
drug was tried with very good results. She became at once
quieter, less talkative, and took her food with little persuasion.
Later in her illness she again became very noisy and restless,
and an injection of half a drachm had a very quieting effect.
She ultimately made a good recovery. It is not claimed that
the injections had any effect upon the ultimate issue. This
girl would in all probability, in view of her previous recoveries,
with ordinary care have made a good recovery, but the treat¬
ment certainly had the effect of making the outlook more
certain, and the problem of refusal of food was readily
solved.

Another case was that of a young married woman, who had
at least two previous attacks. The present one was the result
of child-birth, and she was very noisy, restless, and incoherent
when first seen. The leucocyte count was only 6,400 on
admission, with a polymorphonuclear percentage of 67. This
condition continued for four days, when half a drachm of
nucleinate of soda was injected into the arm, and a very smart
reaction followed. The blood-count rose to 13,000 and the
bodily temperature rose to 38’4° C. After the injection the
patient was quieter, less restless, and in every way improved.

Google

Original from

PRINCETON UNIVERSITY

1916.]

BY COLIN MCDOWALL, M.D.

407

Unfortunately, this condition of affairs was not maintained,
and she became again very noisy and restless, the leucocyte
count meanwhile fell to 6,000. Twenty grains of the drug
were then administered subcutaneously, and again a very lively
reaction took place, the leucocytosis reaching 18,000, with a
neutrophile percentage of 83. From time to time the blood
was examined, and the count was always found low when the
patient was not under the influence of an artificially produced
leucocytosis. She did not make any steady progress, but had
intermittent attacks of mild excitement. Her memory was
not to be relied upon, and she was unstable and erratic. This
woman, when I last saw her, was quiet and well behaved, but
somewhat dull and self-absorbed. There was little encourage¬
ment for the patient to recover, because her home life was not
a happy one, and at each pregnancy she had become insane.

The last case of excitement to which attention is drawn is
that of a girl who showed all the symptoms of primary
dementia, together with much restlessness, confusion, and
excitement. Echolalia, echopraxis, and verbigeration were
prominent symptoms. On admission there was a leucocytosis
of only 7,400 ; after five days this was raised to 18,000 by
I drachm of nucleinate of soda. The patient rapidly im¬
proved, and the day following the injection she was quiet, lay
restfully in her bed, and took her food well. After a fort¬
night the blood showed a return to the state on admission,
and 20 grs. were injected under the skin. The reaction again
was very active. The bodily temperature rose to 38° C., and the
effect upon the patient was good. My old notes say “ improved
very much indeed. Coherent.” From this time a gradual
convalescence set in, and the patient ultimately was discharged.

Regarding the employment of nucleinate of soda in cases
suffering from depression, my experience is that it is of no
service, and, indeed, actually a harmful agent. It is not neces¬
sary to give the cases in detail. In each it tended to aggravate
the state of misery, and had no good effect upon the amount
of sleep obtained.

The result of the injection of an aqueous solution of nuclei¬
nate of soda in the skin shows itself in two ways, a local
reaction, and a general reaction. About three hours after the
injection there is a certain amount of discomfort, which gradu¬
ally increases to a maximum at the end of twelve or fourteen

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hours, at which time there is some tenderness, redness, heat,
and swelling, the classical signs of inflammation, but the reaction
is a sterile one, and usually subsides at the end of thirty-six or
forty-eight hours. The glands were not painful, and in no case
was there any suggestion of septic mischief. This is note¬
worthy, as some of the subjects who were operated upon were
very dirty, restless, and troublesome. Constitutional disturbance
was shown by a rise in temperature in every instance of the
cases of excitement. In the cases showing signs of depression
the local reaction was much less noticeable, and indeed some¬
times scarcely showed at all upon the arm. Elderly subjects
gave a less marked reaction than the young. The state of the
blood and the febrile temperature were evidences of the general
constitutional disturbance ; and a leucocytosis, more or less
marked, was found to be produced in all cases.

When one seeks for an explanation as to the method by
which the drug produces its effect the question arises : Does
it act by increasing the number of polymorphonuclear cells, or
are the pain and tenderness the chief agent? In the former
alternative the factor is physical and physiological, in the latter
it is psychical. In the former it is a question of increasing
the resistance of the individual by raising the white cell count,
in the latter the matter is not so readily explained. In depres¬
sion we have already a mind filled with painful thoughts,
everyday events are viewed in a wrong perspective, trivial
shortcomings are magnified into great failures, the individual
is introspectively pessimistic. Add to this state of anxiety
and unhappiness a physical state in which, if there is not actual
pain, there is certainly considerable discomfort, and we only
make things worse, and open the way for delusions to develop
by further drawing the patient’s attention to his unhappy
state. On the other hand, in excitement with confusion there
is a never-ending flight of ideas, a restless crowding out of con¬
sciousness of one thought after another, hallucinations may
arise to further embarrass the patient, and the mind is unable
to concentrate its attention upon any one mental factor. But
let there be created a physical condition, such as can be pro¬
duced by artificial means, which by its persistence demands the
attention of the patient, and this will be accompanied, for a
short period it is true, by a cessation of the rapid flow of
thought, and a concentration on the reality of a physical

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BY COLIN MCDOWALL, M.D.

409

state, rather than on the changing scenes of an unstable
psychical condition. In giving this somewhat crudely worded
explanation, I am fully conscious of my inability to formulate
a theory which is satisfactory, even to myself.

That is one side of the question, and I must say some¬
thing of the other. We know that there are changes in the
blood of those who are the subjects of acute mental dis¬
turbances. The results published by different and independent
observers closely approximate to each other. The variety of
terminology used in describing the cases has made it at times
difficult to tabulate the records, but in excited patients, who
also have signs of confusion, the evidence of results so clearly
points towards the infective nature of the disease that this side
of the problem must not be too readily dismissed. The dry
mouth, foetid breath, febrile temperature, rapid pulse, and,
lastly, the increase of white cells in the blood, are all evidence
of the absorption of bacterial products. The bacteria have
been searched for, but without result as yet. It is the
polymorphonuclear cell that plays the chief part in the
destruction of bacterial toxins, and by raising the number of
these cells we raise the efficiency of the individual to fight
successfully against the invasion of micro-organisms. Scien¬
tifically, we admit that the treatment of disease without a
definite knowledge of the cause of the disease is unsound.
But we have done it in the asylums of this country for many
years, and with some success.

Is it possible that we have in reality two causes in all acute
mental states—a physical as well as a mental factor ? Recently
this thought has forced itself upon me with more and more
persistence. I have been working upon soldiers returned from
the front. These men have been exposed to direct physical
force in the form of shell explosions, and in addition in many
cases a psychical factor can clearly be demonstrated. Here
we have two factors combining to produce one result, and so
it may be in the mental states which I have described. By
creating an artificial leucocytosis we may be adopting a correct
mode of treatment.

Nowadays the tendency in some quarters is to believe that
psychical diseases must have psychical disturbances as causal
factors. The basis for most of the psychoneuroses is a shielded
memory, whose armour it is the duty of the physician to

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pierce. Even so, it is justifiable to use any means that will
render the patient’s mentality more readily capable of being
influenced by psychical methods. A wildly excited, noisy
person has been rendered quiet for a limited period by
nucleinate of soda. Advantage may be taken of this state to
discover and explain the factor causing the mental breakdown.
Pain itself is not sufficient to account for the change in the
mental state. Everyone has seen maniacal patients inflicting
upon themselves a very considerable amount of pain with
apparent indifference. The pain, moreover, caused by the
injection is not sufficiently severe to interfere with the rest of
the patient. As long as the limb is kept at rest, the feeling is
no more than a sensation of heat; the patients do not complain
of throbbing. There is some tenderness, and this is, I think,
one point, while another is that the state of affairs is not under¬
stood by the patient. A certain amount of attention is drawn
to the affected area, and the patient is by force made to do a
corresponding amount of self-examination, during which time
he tries to concentrate his attention upon his present condition.
The disadvantage of the drug is the amount of reaction, and
consequent pain and tenderness it produces. There is thus a
danger, which should be carefully guarded against, that the
patient may regard the treatment as a form of punishment.
There is the greater danger that the staff may think the same.
It is well therefore that the whole operation should be
explained, and that on each occasion a blood examination
should be made. Not only should a blood-count be done for
this reason alone, but also the dose should be regulated
according to the degree of the leucocytosis found before injec¬
tion, and by the subsequent result.

These rather meagre notes and remarks will serve to show
merely my own experience of the use of nucleinate of soda,
and, with my reservations as to the procedure of employing it,
I can say that in excited, noisy cases of acute mental dis¬
turbance it is useful as a means of allaying excitement and
encouraging rest, and I believe produces thus a state of mind
which is, at an earlier stage than would otherwise be the case,
ready to receive further treatment by other methods.

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CLINICAL NOTES AND CASES.

41 I

Clinical Notes and Cases.

General Paralysis of the Insane in Federated Malay
States. By William F. Samuels, Medical Super¬
intendent, Central Lunatic Asylum, Tanjong, Rambutan,
Federated Malay States.

On first coming to the Federated Malay States I was led to
believe that general paralysis of the insane was unknown.
Seeing that syphilis is very common, it seemed strange that
general paralysis of the insane should not occur. Very shortly,
however, after the Central Asylum was opened I noticed some
cases which were extremely like general paralysis of the insane.
These I watched and studied very carefully, and in a short
time became convinced of the existence of the disease. I have
mentioned the presence of general paralysis of the insane in
each of my annual reports, but think it is now time to go
further, and demonstrate, as far as reports of actual cases can,
the existence of general paralysis. Probably the best way to
give proof of its existence is to quote three cases which can
hardly be mistaken for anything else.

Case i. —C. M. S—, a Chinese, set. 39, a detective sergeant speaking
very good English, was admitted to the Central Asylum on January 15th,
1913. He had a history of syphilis and alcohol, and had led rather an
irregular life. The medical certificate said he was exalted; “calls
himself President of Perak Chamber of Commerce.” Suggests his ward
should be connected with all the towns in the Federated Malay States,
saying, “ I want this done immediately.”

On admission he presented the appearance of a well-nourished
Chinese. He was exalted ; called himself Prince of Japan ; was going
to be made President of the Chinese Republic. His pupils were then
regular, equal, and reacted to light. Knee-jerks present. He was rest¬
less that night and noisy, but slept after 2 dr. of paraldehyde.

Next morning when I saw him I noted that “ there was a slight thick¬
ness about his speech with an occasional catch, but no slurring.” He
was voluble, restless, and full of grandiose delusions. A week later he
was restless, and in the highest spirits, showing the condition of bien
etre to a marked degree; declared his intention of going to the moon
and taking us all with him. Speech was jerky, and though he could
say Royal Artillery, he did so slowly and with infinite care. Tongue
tremulous and protruded with a jerk. Pupils equal, regular, and react
to light and accommodation. A week later the light reaction of pupil
had become sluggish. “ His exaltation is marked, and his delusions

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fantastic. He keeps Napoleon Bonaparte in St. Helena guarded by
1,000 men armed with sixty to eighty pistols each.”

Later he became emotional, and then confused and very stupid.
Markedly amnesic. “ He begins a sentence, and appears to forget
before he is half-way through what he is talking about, and his voice fades
out.” His mind soon cleared up from this state, and he again exhibited
grandiose delusions, and became very generous, promising millions to
all and sundry.

In March he was described as “restless, facile, fatuous, and extremely
expansive.” Lips and tongue tremulous. Pupils equal, but light re¬
action extremely sluggish. He went on in much the same state for
another two months or so, when he became very destructive. He was
extremely facile, and though his delusions were more or less forgotten,
he immediately, accepted them when reminded of them.

On April 4th pupils were unequal, the left being contracted, and they
exhibited the Argyll-Robertson phenomenon. Speech slurring to a
marked degree. Knee-jerks were present, as they had been all along.

On June 26th he exhibited marked twitchings all over, especially
noticeable on the left side, and was confined to bed. The next day he
was quite paralysed. Was almost inarticulate. Pupils fixed. Tongue
and lips very tremulous. Control of his bladder and rectum lost.

From that on, though the paralysis passed off to a certain degree, he
remained bedridden, picking at the blankets with trembling fingers;
taking no notice of his surroundings; constantly grinding his teeth;
passing urine and faeces under him.

He died on July 4th, 1913. Unfortunately his friends refused to
allow a post-mortem examination.

In this case we have a very good picture of general paralysis
of the insane, as shown by the exaltation, grandiose delusions,
extreme facility, the tripping now and then over a word ; later,
actual slurring of speech, tremulous lips and tongue, unequal
pupils with loss of light reaction ; lastly, the seizure, with rest¬
less picking at bedclothes, and grinding teeth. Had anyone
seen him at this time, even from a distance, he must have
recognised the case as one of general paralysis of the insane. It
was unfortunate that no post-mortem could be obtained, but I
think the clinical history is clear enough.

Case 2.—L. K —, Chinese, a small Mining Towkay, was admitted to
the Central Asylum on March 23rd, 1912. No history could be obtained.
He was noisy, restless, and exalted on admission. When I saw him he
was full of delusions of an extremely grandiose nature. Declared he
“ owned all the shops in Ipoh and America.” All notes issued by the
Chinese Government required his signature. He became President of
China shortly after this, and then his generosity knew no bounds. Mr.
Ah Fatt, Senior Dresser, Central Asylum, was to become Vice-President,
while I was to receive the revenue of all the Chinese railways. He then
became very restless, and an extreme trouble in the wards, as he con-

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413

tinually became involved in fights, in which, unless rescued in time, he
always got the worst of it.

His grandiose delusions persisted, and his generosity increased. He
became King of Korea, and offered to make Mr. Ah Fatt King of
“ England and Manila.” His expression was at the time described as
fatuous, and his knee-jerks were found to be exaggerated. This con¬
tinued for six months without his speech becoming in any way involved,
or tremors of lips or tongue appearing, though his face was noted to be
rather expressionless and his skin greasy. His pupils remained equal,
and reacted normally. On September 23rd, 1912, however, it was noted
that his pupils reacted very sluggishly to light, that his face was vacuous,
and that he was becoming demented. He had begun to pick his face,
and had two small ulcers on his forehead as a result. His speech now
began to show a slur, though his lips showed no tremor. There was,
however, a slight tremor of his tongue.

There was a steady advance on the road to dementia for the next
three months, and then, on February 28th, 1913, he had a seizure. This
put all doubt at rest. He became unconscious, with pupils fixed,
marked tremulousness all over, passing of urine and faeces under him.
He remained in this state for about two days, and then began to improve
slightly, though he remained demented. He picked at his clothes,
ground his teeth, and remained wet and dirty. By the end of March
he was up and about again. However, at 9 p.m. on April 6th he had
another seizure. The same process was repeated; After this seizure he
was never the same, and he remained quite demented, while his tongue
and lips were now tremulous. He lasted till May 17th, 1913, when, after-
another seizure, he died. The friends in this case refused a post morttm..

Case 3. —S. H—, Chinese, occupation unknown, was arrested for
“ throwing stones in Papan Town,” and admitted to the Central Asylum
on March 30th, 1912. He had syphilitic scars. No history. My first note
on him was as follows : “ His skin is greasy, and he has a distinctly ‘ flat,’
expressionless face; has marked labial and glossal tremor; slurs his
words, as well as clipping the ends; is extremely dull and stupid, and
can give little or no information about himself; pupils are equal and
react to light; knee-jerks present.” A week after, however, his pupils
no longer reacted to light. Later he became very resistive, and if
interfered with shouted loudly. His speech became more and more
involved, gait shuffling, knee-jerks abolished. The next thing noted
about him was that he began to pick at his baju (coat) with tremulous
hands, and without any apparent object.

I find a note dated May 14th, i9i2,whichsays: “Speech much involved ;
complains in a drawling tone, and with a marked slur, that he has had
no food, although he has only just finished his dinner ; movements are
slow and uncertain ; wanders about in an aimless fashion.” On May
27th he had a seizure and became unconscious. Completely paralysed;
twitching of his facial muscles, and to a less extent his limbs ; pupils
fixed; conjunctival reflex absent; knee-jerks abolished; passing urine
and faeces under him. On May 30th he lay in bed making small, rest¬
less, picking movements with extremely tremulous hands. Was quite
inarticulate ; limbs very tremulous tongue tremulous and inco-ordinate ;
pupils fixed. He died on June 6th, 1912.

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A post-mortem was done in this case, and the following found :

There was nothing abnormal noted in the thickness of the skull or in
its structure.

The dura mater was adherent to the skull, and the arachnoid to the
dura to some extent, while there were numerous adhesions between the
pia and the brain. The pia-arachnoid had a milky appearance, espe¬
cially in the frontal area, while there were numerous greyish spots about
the size of a pin-head. The cerebro-spinal fluid was increased in
amount. The convolutions showed some flattening, and the grey matter
was diminished in thickness. There was also a sandy feeling in the
floor of the fourth ventricle in the region of the calamus scriptorius.
My attention was first drawn to this “ sandy feeling ” by the late Dr.
Conolly Norman, of the Richmond Asylum, Dublin, and I have found
it very constantly in cases of general paralysis of the insane.

In Case I there was no doubt about the diagnosis, but the
other cases might be thought to present some difficulty.

In Case 2 the symptoms on the mental side were well marked,
viz.y the exaltation, feeling of well-being, grandiose delusions,
with the peculiar combinations without any clear association
of ideas—for example, he owned all the shops in “ Ipoh and
America,” would make Mr. Ah Fatt “ King of England and
Manila.” Then, his restless, interfering ways, which were con¬
tinually getting him into trouble.

It will be noticed that it was six months before his pupils
showed any abnormality, and that it was only then that his
articulation became defective, and that he showed any tremor
of tongue and lips. Before that his face had lost expression,
and his knee-jerks were noted to be exaggerated ; though the
last symptom does not appear to be of any value, as in general
paralysis of the insane they may be normal, exaggerated, or
abolished.

Though the case was a very suspicious one, one would
hesitate to diagnose general paralysis of the insane without
having more to go upon than the mental symptoms. So that
for six months there was considerable doubt. Then, however,
the pupils became sluggish in light reaction ; at the same time
slurring speech showed itself, as well as a glossal tremor. The
seizure, however, put all doubt at rest. The subsequent history
was very typical. The improvement, followed by another
seizure. This, in turn, being followed by improvement, and
then a third seizure closing the chapter. The small, restless,
picking movements with tremulous hands, and the teeth-
grinding, were very typical too.

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It is unfortunate that no post-mortem could be obtained in
this case, but I think the clinical picture at the end leaves no
doubt as to its nature.

Case 3, too, was not a case such as one would expect from
the descriptions one reads of general paralysis of the insane ;
but to one who has had experience of the general paralytic it
was by no means an uncommon type. Dementia is, after all,
the most constant condition in general paralysis of the insane.
It is more often preceded by a state of exaltation, grandiose
delusions, etc., though at times the disease begins with actual
depression.

This man had the dull, “ flat,” expressionless face, labial and
glossal tremor, and very soon loss of light reflex. Then the
resistiveness, in one place I notice in my notes described as
“ mulish.” Later, the small, restless, picking movements, etc.,
followed by the general paralytic seizure, clinch the case. As
a matter of fact, this demented type is by far the commonest
type seen in the Federated Malay States, as far as my ex¬
perience goes. These three cases, I believe, are sufficient to
establish the fact that general paralysis of the insane is a
disease which does occur in this country, and I now propose
to show that it is not even a very rare condition.

Taking the years 1912, 1913, and 1914, the first three
complete years since the opening of the asylum, we find that,
out of a total admission of 977, there were thirty-three cases
of general paralysis of the insane, which gives a percentage
of 3'38. The majority of cases were males, but there were
three females admitted suffering from this disease. It must be
remembered, however, that the total female admissions are
much less than the male, and, as a matter of fact, the percentage
of general paralytics to total admissions on the male side works
out at 3-7o, and on the female at 2 - 26. This percentage, though
very much less than in England, is by no means negligible.

Thus it will be seen that not alone is general paralysis of
the insane found in the Federated Malay States, but it cannot
even be described as a rare occurrence.

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OCCASIONAL NOTES.

[April,

Occasional Notes.

Female Nursing of Male Insane.

The question of the adaptability or suitability of the method
of female nursing of male patients in asylums, which is the all
but universal practice in general hospitals, if not exactly what
might be termed a “ burning ” question, has been forced into
unexpected prominence during the present crisis of affairs.
The military and naval requirements of a great country fighting
not merely for a great ideal, but for, if perhaps the less noble,
certainly the more urgent and so to say personal object of
maintaining its own existence, necessitated the raising—and at
very short notice—of our two great services to their maximum
strength, and, therefore, a demand on the male population of
the British Empire of such magnitude -as has never been
experienced before. This demand has, as we know, been
promptly and liberally responded to, and by no class of men
perhaps more readily than those serving on an asylum staff,
over 3,000 of whom, as shown in the Journal of October last,
have joined the colours. Such a drain on the at no time very
ample nursing resources of these institutions could not fail to
cause very serious inconvenience. The shortage occasioned
had in some way or other to be compensated for, if even to
only a limited extent. In some cases men of mature age have
been employed to replace those who have left, but these are
probably not procurable in any great numbers owing to the
demand for middle-aged men for munitions and other work con¬
nected with the war, and also for doing the enormous amount of
business—trade, agriculture, etc.—which must be carried on
throughout the country generally. Consequently, resort to the
employment of women as substitutes for male nurses has had
in many instances to be adopted.

The time and the hour, therefore, were not inopportune for
a discussion on this subject, not merely with respect to the
propriety or otherwise of initiating a radical change of this kind
in asylum nursing during circumstances of exigency, as at
present, but as regards the merits and demerits of the deliberate
and permanent adoption as a matter of principle of such a
departure from the recognised practice, which still obtains in

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the large majority of asylums in all parts of the world, and
independently of any compulsory influence such as just now
exists. Dr. Robertson’s paper has, in fact, appeared at just
the psychological moment when minds are more or less in a
state of preparedness to give the subject favourable considera¬
tion.

At a meeting of the Scottish Division at Larbert Asylum
in November, 1901, Dr. Robertson read a paper on “ Hospital
Ideals in the Care of the Insane,” in which he gave a sketch
of the methods of nursing which had been adopted, and were
in actual operation, in that institution for some two years
previously. The nursing of male insane patients by females,
although not an absolutely novel proceeding—for sporadic
attempts in that direction of a tentative nature had been already
essayed but not persevered in—seems to have been for the
first time seriously and successfully employed in the Stirlingshire
Asylum. At the commencement of his paper Dr. Robertson
emphasised what he termed the dominating principle , which
actuated him in his adoption of this system, namely, “ the
desire to make the asylum a medical institution, worked on the
same medical principles and with the same nursing ideals as
our great general hospitals.” The measures which he proposed
to himself, and which we may add he has successfully carried
out, were, briefly: the abolition of single rooms, and the substi¬
tution of associated dormitories (single rooms he regarded as a
relic of the old prison-like organisation of asylums); continuous
personal supervision by night as well as by day, with a large
increase of the night staff; the employment of female nurses
on the male side, supplemented by a number of assistant matrons
to supervise them, and to “do duty within the wards and among
the patients ,” these officials to be well paid and regarded as
filling highly responsible posts to which prestige and authority
were attached, and to be selected from the ranks of trained
hospital nurses. This last proviso he regarded as absolutely
necessary, on the principle that “ one can no more be a skilled
mental physician without studying general medicine than a
skilled mental nurse without studying general nursing.” The
new system seems to have worked smoothly and satisfactorily
from the first, and after two years’ experience of it Dr. Robertson
was in a position to state that he had “ no accident to record,
no assault to describe, no scandal to report.”

VOL. LXII. 27

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In the discussion which followed the reading of the paper
it is to be noted that, while there was some difference of
opinion as regarded the details, not a single speaker expressed
himself as opposed to the principle of the methods of nursing
advocated by Dr. Robertson. The late Sir Thomas (then
Doctor) Clouston, a clinician, as we know, of the very first
rank, whose opinion must be estimated as second to none,
mentioned how, when going round the wards of the Larbert
Asylum at night with Dr. Robertson, he had been deeply
impressed with the quietude, and with the practical success of
the system which he saw in operation. He related one striking
little incident: “ Dr. Robertson had the bad luck to get one
or two of the worse patients in Morningside. He was beyond
measure astonished and exceedingly pleased to find a woman,
who, when in Morningside, was a homicidal dangerous inmate
and a most objectionable woman, and who when there never
slept out of a single room, lying calmly and sweetly asleep in
one of the big observation dormitories.”

At the annual meeting in London, July, 1905, Dr. Robertson
again brought the subject before the members in a paper,
only a part of which was published, on “ The Employment
of Female Nurses in the Care of Insane Men in Asylums.”
His experience in the method had by that time become
considerably extended, and so far from his opinion as to its
value having been shaken as time went on, his belief in its
excellence was stronger than ever. If support for his argu¬
ments was needed, it was ready to hand in the fact that a
number of asylums in Scotland had adopted the system, and
in none of those where the experiment was made had the
practice been abandoned. One point that was brought into
prominence on this occasion, both in the paper and in the
discussion that followed, was what Dr. Bond called the “ crux
of the matter,” viz., that to insure success the staff must be
entirely female, and not mixed. In the early stages of the
movement, when only tentative measures were being tried, at
first attendants’ wives were employed to take charge of the
male patients along with their husbands ; and, later, a mixed
staff independently of any such relationship between the sexes.
Each plan in turn proved more or less a failure. Hence
Dr. Robertson came to the conclusion expressed in his paper,
that “ it is only when women are in complete and responsible

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charge that the full benefits of the system of female care and
nursing can be enjoyed.”

A good deal of water has flowed under our bridges since
then ; and now, for the third time, the writer of the paper
already referred to has come before the Association and
presented the results of a more lengthened period of observa¬
tion, and a riper experience of this method of nursing in all
its details. The project is no longer a mere bantling of
tender growth, as in the early years of its adoption ; it has
developed into a full-fledged scheme, gradually elaborated into
its present condition of complete and thorough organisation.
And no one who listened to Dr. Robertson’s narration of facts
regarding the high state of nursing efficiency which obtains in
Morningside Asylum could be surprised at the warmth with
which he advocated a trial of the plan in other asylums, could
doubt for a moment that his efforts to achieve his object have
been crowned with success. For many years, even in Scotland,
Dr. Robertson had to fight an uphill battle before the system,
which in his hands had proved so efficient, succeeded in
winning the approval of his confreres and leading them to
favour its adoption in the institutions under their charge ; and
the contrast between medical opinion on this subject such as
prevailed in those early days (when the nursing of male insane
patients by females was stigmatised by an eminent member
of the specialty as “ preposterous,” and the adoption of hospital
principles in asylums as “ a great fad ”), and that which is
almost universally accepted in Scotland at the present time is
best expressed in Dr. Robertson’s own words : “ This method
of nursing is now as distinctive and as firmly established a
feature of the Scottish system of care for the insane as the
well-known Boarding-out System. It is employed in some
measure or other in all but two of the important asylums of
the country, and in these the superintendents have so far
failed to introduce it, not because they were opposed to it on
principle, but on account of structural difficulties with regard
to supervision, housing, etc. This wonderful unanimity of
opinion and practice amongst Scotsmen, whose national
proclivities do not tend to concord, is remarkable testimony
in its favour, and points to the manifest practicability and
overwhelming merits of the system.” He speaks in glowing
terms of the beneficial results that have followed the employ-

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merit of hospital-trained nurses in asylums, and does not
hesitate to divulge the nature of his ulterior aim, and what
he means to be the acme and crowning achievement of the
task he has set before him, in these words : “ The trend of
events in Scotland has been such that this employment
of female nursing in the male wards, when seen in its
proper perspective, is found to be only a part of a much
greater scheme or ideal that has flowed like a tide over the
land—that of the Hospitalisation of the Asylum."

It is not a matter for surprise that a thesis such as this
should be regarded by not a few as embodying views that are
revolutionary in character, and to a great extent impracticable.
And yet, there is the broad salient fact staring us in the face,
that the system as advocated has been in practical operation
for some years past in most of the asylums in Scotland, that
there, at least, it can be demonstrated to be an unqualified
success, and—a most important consideration—that none of
those who have made trial of it would, on any account, revert
to the old order of things. That one hard fact alone goes far
to discount most of the objections which have been advanced
against it, and to attach a merely academic value to unfavour¬
able criticism. And it was, perhaps, fortunate that in the
discussion which followed the reading of Dr. Robertson’s paper
the expression of adverse opinion was in the hands of such able
speakers as Doctors Soutar and Brander, than whom few, if
any, are better qualified to take a rational view of any question
that may present itself for their consideration, and to express
their ideas in a fair, unprejudiced, and convincing manner—
and Dr. Robertson would himself be the first to welcome
criticism from such a quarter. And yet there was no
objection advanced by them which is not capable of being
met and overcome in the practical working of the system.
There is room, no doubt, for difference of opinion as to
the relative superiority of male and female attendants, and
there are few who would not be willing to admit that the
male staffs of asylums at the present day, on the whole,
discharge their duties in an excellent manner. But even if
this were universally true, and if every individual male atten¬
dant were, as regards his capacity for the care and manage¬
ment of patients, on a par with an asylum nurse, still that
would not invalidate the claim that as a system female nursing

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is preferable. The chief difficulty is, perhaps, to be found in
the fact that many, if not the great majority of, asylums are so
constructed that the necessary adaptation for such a radical
change would hardly be feasible. This is certainly a formid¬
able obstacle, and in some cases probably insurmountable.
Still, it might not be impossible to make such alterations in
most of them as would admit of the new methods being even
partially adopted. And in the case of new asylums being
erected it ought in future to be made a prime consideration
that they should be so constructed as to afford facilities for such
a scheme of organisation in the nursing department. As a
matter of fact it is scarcely correct to regard this method of
nursing as exclusively Scottish, as since the year 1902 a system
of nursing male patients by female nurses has come into opera¬
tion in several of the London asylums. It was first started at
Bexley, and was subsequently adopted in the Epileptic Colony,
at Horton, and Long Grove. The villa system would be
the ideal one for such institutions, each of the component
buildings forming a unit in itself, having its own independent
arrangements.

The sexual difficulty, on which sometimes stress is laid,
cannot really be said to exist. As regards patients with
propensities of this kind no one proposes that they should be
put in the charge of females ; in their case everyone is agreed
that male attendants are necessary.

On the whole it is probable that most, if not all, of those who
approach this subject in an impartial spirit and with unpre¬
judiced minds, will come to the conclusion that Dr. Robertson
has proved his point, and that the experience of Scottish
asylums has established beyond cavil the advantages of a system
which, without hazarding too confident a prediction, is not
unlikely, sooner or later, to be generally if not universally
adopted throughout the asylum service.

Part II— Reviews.

National Association for the Feeble-minded. Annual Conference Report ,

I 9 I S-

“ The Methods of Examination best Adapted to Ascertain the
Presence, or otherwise, of Mental Defect,” formed the subject of

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discussion at the Conference. The subject is both important and
practical, and the various contributions contained in the report merit
the close attention of those who are called upon to deal with cases
coming under the provisions of the Mental Deficiency Act.

Sir Bryan Donkin, in his introductory remarks as Chairman of the
Conference, brings into prominence the difficulty of attempting to
formulate exact definitions in the differentiation of normal ” and
“feeble-minded,” or of attempting to establish a hard and fast line
between them. Such cases as come under observation cannot be judged
by the intellect alone. He truly points out, “ It is a matter of deject of
mind in all, as evidenced chiefly by careful and often prolonged observa¬
tion of conduct, and by study of the history in each case, leading to an
inference of the incapacity of the subjects to adjust themselves effectively
to their social surroundings.” Actual “ mental tests ” for mental deficiency
can hardly be more than one factor in arriving at a conclusion as to the
status and course of treatment indicated in any given case. The most
reliable test is, after all, actual life, which reveals more truly than
anything else the individual’s mental capacity.

Within the limits indicated in the subject for discussion the papers
cover a wide field. This may be briefly indicated by a list of the titles
and contributors.

“A Scheme for the Detection and Treatment of Mentally Defective
School Children,” Dr. Robert Hughes.

“ The Detection of Mental Deficiency on the Large Scale in School
Children,” W. H. Winch, District Inspector of Schools, London County
Council.

“ Emploi des tests de Binet et Simon chez les Enfants Anormaux
Anglais et Beiges,” Dr. Boulenger.

“ What Tests in Childhood are best Calculated to Throw Light Upon
their Capacities for Future Work,” Dr. W. A. Potts.

“The Value of a Uniform Examination of the Feeble-minded for
Education Purposes,” Dr. Allan Warner.

“Practical Application of the Binet Tests,” R. L. Langdon Down.

“The Binet-Simon Tests as a Means of Grading Mental Defectives
under the Mental Deficiency Act,” Dr. W. B. Drummond.

“The Classification of the Mentally Defective as regarded from a
Legal Standpoint under the Mental Deficiency Act,” Dr. E. B. Sherlock.

“The Characteristics and Identification of the Feeble-minded
Criminal,” Dr. Charles Goring.

“Classification of the Mentally Defective from an Administrative
Point of View,” Dr. H. W. Sinclair.

All these papers are essentially practical in character and will repay
a careful study. H. D.

Wishjulfilment and Symbolism in Fairy Tales. By Dr. Franz Ricklin.
Translated by Dr. W. A. White. New York : Nervous and Mental
Diseases Publishing Co., 1915. Pp. 90. Roy. 8vo.

It is well known that from the Freudian standpoint fairy tales are
constituted in somewhat the some manner as dreams, on the basis of
the unconscious, and that they thus form the material for a psychology
which may be brought into line with that of hysteria and mental disease.

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This idea stimulated Dr. Ricklin, of Zurich, who admits that he was at
the time a novice in the field of fairy tales, to the present investigation.
A student with broader philological and historical knowledge, could, he
believes, have gained much more from the material, for fairy tales are
the expression of the primitive human soul, and they express that general
human tendency to wishfulfilment which in modern fiction appears in a
much more garbled and complicated form.

In his general attitude the author ranges himself with Stoll and other
authorities who refuse to accept the view that fairy tales can be accounted
for by migration from some story-telling centre. They arise among
different people, in different places, and at different times, by suggestive
and auto-hypnotic processes which independently lead to more or less
identical results. “ Only the psychic foundation is everywhere the
same.” It is, therefore, all the more remarkable, in Ricklin’s opinion,
that the sexual element plays so large a part in fairy tales, and that the
sexual symbolism they reveal agrees so closely with that found in
dreams and in psycho-pathology.

As from the Freudian standpoint the unconscious can do nothing but
wish, and as wishing is the business of dreams, Dr. Ricklin finds, as one
might expect, that the fairy tale is, above all, “a wishfulfilling structure,”
often gathering its material from widely separate sources, from other fairy
tales, and from myths. Similarly the psychoses produce wish-structures
in which the patients are rich and powerful and of royal descent, marry
royal personages, and witness the destruction of their rivals and enemies.
Wish-structures can, indeed, occur in a number of clinical forms, in
cataleptic states, in mimic automatism, in the progressive development
of delusional systems.

Innumerable fairy tales (as well as myths) tell of magic gifts and
qualities created by the human wish-phantasy. These are often devised
as the therapy of a sorrowing heart. Ricklin quotes several beautiful
fairy tales of the type of The Shroud in the Grimm collection, which tells
how a mother wept for her dead child until the child came to her in
vision, and told her that he could not rest in the grave for her tears had
made his shroud so wet. The mother ceased crying, the child came
again to say that now he could rest, and henceforth the mother was
comforted. The wish-structure is very evident in the case of the common
fairy tale of the peasant girl who marries a prince, or the shepherd boy
a princess. Other tales reveal a vast variety of methods for bettering
human deficiencies : seven-league boots, gold-producing animals,
enchanted mirrors, magic wands, etc. The stepmother tales, of which
Cinderella is the type, similarly illustrate the wish-structure. In this
way such tales resemble dreams. In reading some of them, indeed, the
author remarks, we find they might well be the relation of the dreams
of a patient with hysteria or dementia praecox.

The author finds illustration of other Freudian doctrines in fairy tales.
Special attention is devoted to “transposition upward,” by which the
lower physical processes are raised on to a higher plane, and the sexual
organs may, for instance, become the mouth. Psycho-analysts have
' found this process common in the dreams of insane, and, indeed, of
normal persons. Ricklin would thus interpret the large number of
fairy tales in which women became pregnant through eating or drinking

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some special food or liquids. With this “ transposition upward ” are
associated infantile sexual theories, also illustrated by fairy tales; it has
indeed been argued that such masking of sexual processes took its origin
in the telling of fairy stories by women Ricklin takes the orthodox
Freudian view that this infantilism, whether in dreams or legends, is the
expression of the censored wish of the unconscious.

The essay is of interest as an early attempt to study a new branch of
comparative psychology, although, as such attempts are apt to be, it is
often more suggestive than convincing. The author makes it quite
clear, however, that fairy tales form as good material as dreams for the
application of Freudian methods, and that indeed the material has con¬
siderable resemblance to dreams.

It must be said that the translation, though fluent and intelligible, is
often careless and sometimes ungrammatical. H. E.

Part III—Epitome of Current Literature.

i. Physiological Psychology.

The Constitution of Ideas and the Physiological Basis of Mental Processes
[ Constitution des idles et base physiologique des processus psychiques\
(Revue Philosophique , No. io, October , 1915.) Delage, Yves.

In this paper M. Delage formulates a theory by which he proposes to
explain mental activity in terms of our present knowledge of the
anatomy and physiology of the brain. Starting with the assumption
that the cortical neurons are the organ of thought, he maintains that by
analysing our ideas introspectively we shall find it possible to reduce
them all, even the most abstract, to combinations of a relatively limited
number of constituent elements. Each of these elements is supposed
to be represented by a single neuron, and an idea is then defined as
“ the cerebral condition created by the entry into activity of the neurons
or groups of neurons corresponding to the several elements that con¬
stitute it.” From each neuron when actively functioning, dynamic
influences radiate in all directions, affecting slightly those neurons which
are in repose, more intensely such other neurons as are simultaneously
active. Further, the conducting paths along which the more intense
influences pass more frequently become thereby more permeable, so
that ideas which have often occurred together, i.e., whose correspondent
groups of neurons have frequently been active simultaneously, tend to
become associated and to call one another up. In this way it is
possible to conceive part of the cerebral mechanism underlying the
association of ideas and the processes of memory and recognition. To
penetrate further into this mechanism, the author goes for an analogy
to Lapicque’s theory of the chronaxial rhythm in muscle and nerve.
Lapicque showed experimentally that the muscles in different animal
species and different sorts of muscle in the same animal differ in their
electrical excitability, and that similar differences exist likewise in motor
nerves ; and on this fact he based the hypothesis that individual motor
neurons also present specific modes of vibratory activity. Extending

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this hypothesis to the psychic neurons, Delage assumes that the
characteristic chronaxial rhythm of each neuron is preserved throughout
all parts of the neuron up to its points of contact with the adjacent
neurons. The readiness with which the dynamic influx from an active
cell will pass this interneuronic barrier depends then on the relation of
the respective rhythms of the several neurons ; if two neurons have very
similar rhythms, a feeble activity in one will suffice to stimulate the
other; while, if their rhythms are widely different, this result will only
follow from a very intense degree of excitement. It may be further
supposed that neurons of different vibratory mode, when they have once
been brought into simultaneous activity, will tend, during the time of
their co-action, to approximate to one another in rhythm; and a per¬
sistence of this “ parachronisation ” in partial degree and localised to
the portions of the protoplasmic processes where the two neurons are
in contact, would explain that increased influence of the neurons on
one another which is the physiological aspect of mental association.

According to this conception, the cortical neuron, instead of being
functionally homogeneous throughout, preserves its primitive functional
characteristics only in its central part and in such of its protoplasmic
processes as are directed towards neurons with which it rarely co¬
operates : in its several other processes, directed towards neurons with
which it is frequently in simultaneous activity, its vibratory rhythm is
modified more and more as it approaches the interneuronic junction, so
as to approximate to the rhythm prevailing on the other side of that
junction.

M. Delage does not pretend to deal with the fundamental difficulties
of a materialist psychology, but he has certainly produced an ingenious
scheme for visualising the conceptions of such a doctrine.

W. C. Sullivan.

2. Psychology and Psychopathology.

The Systematic Observation of the Personality in its Relation to the
Hygiene of Mind. {Psych. Rev., fuly, 1914.) Wells, F. L.

This is a study of method, although illustrated by five examples. The
object is to suggest an approach to quantitative measurement of the
essential factors in the mental adjustment of personality to its environ¬
ment, with relation to the character of healthy mental reactions as dis¬
tinguished from unhealthy ones. The human qualities to be considered
are those that make for the individual’s satisfaction with life, and his
capacity to maintain a wholesome outlook on existence. The immediate
task is to construct an outline of personality that shall correctly state
the factors of importance to well-adjusted character, and make possible
the direct comparison of personalities in quantitative terms. The
scheme here formulated is to some extent based on those of Hoch and
Amsden, of Heymans and VViersma, Cattell, Davenport, etc. The
method of notation recommended is similar to that advised for the
Binet-Simon scale, and affords six steps from “above ordinary" down
to “ marked deficiency.” There are fourteen different groups of ques¬
tions in Wells’s scheme, as follows : Intellectual Processes, Output of

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Energy, Self-Assertion, Adaptability, General Habits of Work, Moral
Sphere, Recreation Activities, General Cast of Mood, Attitude towards
Self, Attitude towards Others, Reactions to Attitude towards Self and
Others, Position towards Reality, Sexual Sphere, Balancing Factors.
Some half-dozen questions are included under each of these headings.

Wells believes that many different types of personality may be clearly
distinguished and formulated by this scheme. While not ignoring the
importance of heredity he considers that the psychopathic personality
probably owes its development as much to modifiable conditions in
early childhood as to heredity and original nature, so that in any scheme
of this kind due weight must be given to tendencies in relation to early
unfavourable environmental conditions. The efficient balance of mental
faculties with surrounding conditions is, he concludes, of transcending
value for normal and pathological application, and the vital character
of the dependent personal and social issues. “The constructive
problem of psychology is mental adaptation.”

Havelock Ellis.

The Practical Applications of Dreams \Portie Philosophique et Valeur
Utilitaire du Reve\ {Rev. Phil., Jan., 1916.) Delage, Y.

The veteran biologist, who admits that he is a great dreamer, and
that his dreams are highly agreeable, discusses in this article (which is
to form a chapter of a forthcoming book) certain practical applications
of dreaming in relation to the race and the individual. He accepts to
the full extent the alleged influence of dreams as a factor in primitive
religious beliefs. They suggested, he believes, the ancient ideas of the
“ shades of the dead,” and the more modern ideas concerning ghosts.
Such ideas would have suggested the belief in immaterial spirits, inde¬
pendent of the body, and, with the aid of philosophical and religious
conceptions, have led on to a faith in the immortality of the soul and
in a future life. Delage recognises at the same time that there are
many other grounds for such a faith.

In the constitution of various abnormal mental conditions, also, the
author holds that dreams have been influential, as, for instance, vam¬
pirism. Dreams may also be invoked, especially when the same dream
is frequently repeated, to explain morbid irresistible impulses in neuro¬
pathic subjects. Such dreams may also have a suggestive action, and
help to account for epidemic delusions. By their auto-suggestion dreams
extend beyond the region of psychology, and arouse grave problems of
responsibility.

The question of the utility of dreams is not new, and has been very
variously argued. Clapar^de holds that it is the function of dreams
to act as a safety-valve, and to afford a harmless outlet to impulses
which moral considerations force us to repress during waking life.
Delage considers that this action of dreams is a rare exception, and that
such dreams are more likely to exercise an unfavourable action on real
life. He admits, however, that artists in every department (poets,
musicians, painters, architects, etc.) may, like Leonardo da Vinci, derive
inspirations of high value from dreams, although the inspirations thus
derived always require much elaboration from waking intelligence. It

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is probable that the part played by dreaming in artistic production is
much underestimated.

The old notion of prophetic dreams is now rightly discredited.
Delage believes, however, that there remains a class of prophetic dreams
which is scientifically admissible, and that these dreams, even though
rare, have a useful practical bearing. Many ideas occur to us in waking
life which are immediately repressed because in some way or another
they shock or wound our feelings. These repressed ideas may be clearly
and brutally presented to us in dreams, and from such dreams we may
be able to derive benefit. For instance, the cumulative trifling indica¬
tions of a person’s dishonesty, which in waking life we have at once
put aside as unworthy suspicions, may be crudely formulated in a dream
and lead to a desirable investigation. In other cases dreams may reveal
some tendency of our own which we had in waking life never realised
and faced. In somno veritas. Although there are no prophetic
dreams in the ancient sense there are premonitory dreams which reveal
dangers to which we risk succumbing. In dreams veils are torn away,
and judgment, and opinions, resulting from unconscious cerebration,
are clearly presented to us. Havelock Ellis.

On the Diagnostic Value of Hallucinations. (Journ. Nerv. and Ment.

Dis., Jan., 1915.) Stearns, A. W.

This study is based upon 500 cases to see, first, how many had
hallucinations; next, the type of hallucination present; and, lastly, to
determine whether there were any which seemed especially charac¬
teristic of any form of disease. The following conclusions are drawn :

(1) The presence of hallucinations is indispensable for the diagnosis
of alcoholic hallucinosis or delirium tremens, but the type of hallucina¬
tions is not a proper criterion for differentiation between these diseases.

(2) The frequency of hallucinations in dementia prsecox and their
rarity in manic-depressive insanity has a bearing on differential diagnosis.

(3) The existence of true hallucinations in manic-depressive insanity
is doubtful.

(4) Hallucinations seem to be rare in sane persons, even though they

be psychopaths. H. Devine.

On the Genesis and Meaning oj Tics. (The Journal of Abnormal
Psychology, Dec., 1915, and Jan., 1916.) Solomon, Meyer.

The earlier investigators of tics were responsible for their differentia¬
tion from such other conditions as chorea, the spasms, the stereotypies,
myoclonias, and other allied conditions, thereby establishing the tics
as a distinct clinical entity. Charcot recognised the psychic origin of
the tic and established the fact that it was a mental disorder, a form of
psycho-neurosis. It has thus two aspects—a psychic and a physical.
The tic itself is the motor expression which relieves an antecedent,
characteristic mental state of doubt, indecision, restlessness, tension,
and discomfort. The tic movement is the symbol of a psychic defect,
a degenerative, neuropathic basis which constitutes the soil for hysterical,
neurasthenic and other reactions.

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The usual conception of tics as laid down by the French school is
that the movements are physiological acts, originally purposeful in
character, but which have become apparently purposeless and meaning¬
less. The tic is thus a pathological habit. More recently the Freudian
school has endeavoured to explain the origin of tics, and to bring
them into line with their theories of the other neuroses, including them
in the group of obsessive neuroses. These theories, which give an
ultimately.sexual basis to tics, the writer is unable to agree with.

He points out that the different varieties of tic movements embrace
the entire field of systematic, physiologically co-ordinated voluntary
muscular activities. The mechanism for such movements is inherited,
and all these movements in their original form had the single meaning
of self-preservation. Their primary, biological significance is to be
found in the phylogenetic, racial history of man. The present life history,
with its varied experiences, act as stimuli to bring into activity these
functions preserved in the organic structure of the nervous system.
The pathogenesis of tics may thus be appreciated by viewing the subject
from an evolutionary standpoint. In our adaptation to the varying
experiences which we meet, we respond by one or more of several
methods of reaction, from the simplest reflexes to written or printed
language. The manner and degree of our response is dependent on
our stage in evolution, and development of our senses, emotions, and
intellect. Unable to find expression by means of writing or speech, we
instinctively fall back on such expressions as are less refined, earlier
acquired, and lower in the scale of evolution. The tic is one manner
of response to certain external invitations or ideas. When the invitation
is oft repeated there is a constant repetition of the defensive reaction,
and eventually the movement may become so habitual that it is repeated
with any mental stress, strain, or discomfort—it is the path of least
resistance, the most immediate method of relief from mental struggle.
The tic is thus, according to the writer, a regression or reversion to a
type of reaction of an infantile, primitive sort, farther down in the scale
of evolution and development. The tic is the emotional reaction of
the individual. The ticquer attempts to meet certain situations of a
disturbing nature, to compensate for his feelings of insufficiency, by
means of his tic.

The tendency for the tic movements to spread is discussed by the
writer, and is regarded as a form of over-compensation to make up for
the conscious defect (the original tic movement) of which the subject is
aware. H. Devine.

3. Clinical Psychiatry.

The Albumen Content of the Spinal Fluid in its Relation to Disease
Syndromes. ( Journ. Nerv. and Merit. Dis., March , 1914.)

Myerson , A.

The usual routine examination of the spinal fluid is confined to the
determination of the presence or absence of globulin, of an increase in
the cellular content, and the Wassermann reaction. The writer considers
that the presence or absence of an increase in the normal albumen con-

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tent should be an essential part of the routine examination. The
results obtained from his own researches in this direction are as
follows:

(1) That in full-fledged general paralysis the relationship of albumen,
globulin, cells and Wassermann is quite constantly one of parallelism,
but that in the remissions the Wassermann reaction disappears first, the
cell count and globulin increase diminish next, and the albumen most
constantly remains at a high level of increase.

(2) In Korsakoff’s disease, in certain cases of tumour, and in other
organic diseases, there is a dissociation of albumen and globulin in this
sense : that there is either marked increase of albumen without globulin,
or that a marked increase of albumen, say 3 +, is accompanied by a
globulin increase of, say, only 1 + .

The writer concludes from the facts obtained that the increase of
albumen is a primitive reaction of the nervous system, and is the first
as well as the most constant of the present known chemical and
biological changes to appear in the spinal fluid. H. Devine.

*

4. Asylum Reports.

Some English County and Borough Asylums.

Dorsetshire Asylum .—This is the last report of Dr. MacDonald, who
has sought rest after a long and successful tenure of anxious office.
We wish him long enjoyment of that rest. His reports have always
been interesting to read, since he has been one of those who have thought
it a duty to publish the results of his observations and thoughts on sub¬
jects of importance to the public.

Dr. MacDonald again adverts to the preponderance of mania over
melancholia among the admissions. We, too, have from time to time
drawn attention to the great variation in these proportions, and we
venture again to point out that when the time comes for further
systematic study of psychiatric aetiology there will never be found a
more striking and possibly fruitful subject than this; in fact, we might
say that no question more urgently calls for some attempt at scientific
explanation than that of “ why should such and such an area supply
more excitement than depression, while its neighbour supplies the two
conditions in exactly opposite ratio ? ” It is not a question that can be
explained away by suggestion of error or of variation in classification, or
of variation in scientific recognition. The two conditions are at the
opposite poles of classification. Further, the differences in each asylum
are apt to be very marked. We have taken at random reports of twelve
county asylums, rejecting borough asylums, and we have extracted from
each the returns of mania, acute and recurrent , and of melancholia,
acute and recurrent. As it happens, seven of these have more
mania than melancholia, viz., Dorchester, Worcester, three Stafford
asylums, Kent (Banning Heath), and Monmouth. The totals of these
are 531 cases of mania and 258 of melancholia; the greatest disparity
being shown at Lichfield, where the figures are 131 and 37 respectively.
At the other five, viz., E. Sussex, two Essex asylums, Northumberland,
and the Kent (Chartham) Asylum, the preponderance is the other way,

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the totals showing 215 cases of mania and 314 of melancholia. It will
be observed that the proportions are very striking—in one set mania
occurs twice as frequently as melancholia, while in the other set melan¬
cholia occurs in three cases to two presenting mania. The marked
difference in the conditions taken together with this marked difference
in proportion suggests that that there is a wide and open field for
aetiological inquiry.

Of early dementia Dr. MacDonald writes :

All quite young, and, to the inexperienced, a most hopeful class of patient, but
the very reverse is the real truth. More often than not the parents are positive
that the cause was some trifling incident or episode, which probably had no direct
connection with the mental breakdown. Frequently lovable, often gifted, it is little
else than the irony of fate that these young people should show signs of an early
mental decadence, and that of a nature which gives but the faintest hope of ultimate
improvement. At the present time we have a most interesting group on the female
side at Herrison, and while in a few heredity may be the bed-rock, there are several
in whose family histories no predisposition can be discovered. Because of having
done well at school, and frequently engaged in trying work, it is hard for the
parent to believe or think that the mental stability has given way. In connection
with these most painful cases it is quite a legitimate question to ask—“ If greater
care had been exercised during school life and afterwards, and a doubt placed upon
the preternatural quickness, would the ultimate breakdown have been averted ? ”
When one listens to the histories given in many of these cases, the conviction is
borne home that it was unwise to have allowed the pressure of school life to follow
an ordinary course, and much more so to have attempted difficult work or a trying
professional career.

Essex County .—The combined reports of Brentwood and Colchester
Asylums form quite an important volume. Both these asylums were at
the time of report suffering from considerable inconvenience, the one
by the removal of the old temporary buildings, which have become
purposeless now that the second asylum at Severalls has been opened ;
while the latter asylum is shorn of its contemplated functions by all the
buildings, other than the main asylum, having been taken over by the
War Office for the use of recruits undergoing training. It is satisfactory
to read that the behaviour of the troops has been exemplary, though
the sanitary arrangements incidental to this foreign population have left
much to be desired. In addition a heavy proportion of staff have gone
to the colours, so that the management of these complicated machines
has been a very anxious task. It speaks well for the soundness and
stability of our system of lunacy treatment that no untoward incidents
out of the ordinary course have arisen. Dr. Turner’s statutory report is
but a dry statement of figures and facts, but on the other hand he
supplies a full and most valuable pathological report. We do not
remember to have come across any such document before, giving such
an amount of post-mortem evidences. It is one thing to give a series of
interesting and instructive findings after death, it is quite another to
furnish a nearly exhaustive statement of the condition of the various
organs in nearly 280 subjects. Such a report is an important gift to the
science of to-morrow, all the more valuable in this case from the known
ability and conscientiousness of its sponsor.

Sclerosis of cornua ammonis was found in 20 per cent, of the male
and 18 per cent, of the female epileptic cases which were examined.
Some considerable tabulation is given of the measurements of the sulcus

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lunatus and stripe of Gennari, following a previous report. The con¬
clusions derived from this appear to be rather indefinite for the present.
The occurrence and seat of local atrophies of the convolutions, and of
softening due to haemorrhage and emboli, are interesting to read. The
parietal in the former and the lenticular nucleus in the latter being the
most frequent sites. The basal vessels were atheromatous (or calcareous)
in 314 P tr cent, of 36 males, and in 29^6 of 48 female cases. Subdural
haemorrhage, films, or cysts were found in 7 per cent, of the males and
5'5 of the females. Tumours existed in 4^4 and 1*2 per cent, respec¬
tively. Several other intracranial conditions have light thrown on them
by the post mortem .results.

The aorta was found affected in a large proportion of cases, being
atheromatous in 68 per cent, of the males and 45 per cent, of the
females, while it was calcareous in 4 males and 16 females. The mitral
valves, too, were affected in 18 per cent, of the males and i 6’2 of the
females, while the percentages for the aortic valves were 11*3 and 4'o
respectively. When we come to the liver we are met with figures which
make one rather suspicious of the contention that this organ is parti¬
cularly favoured in the insane. Among the 115 males examined post¬
mortem it appeared to the naked eye to be more or less natural in 86,
nutmeg in 15, fatty in 8, cirrhotic in 4, one of the latter being typically
hobnailed. Among 162 females the numbers were 95 natural, 47 fatty,
cirrhotic 9, nutmeg 8—all to the naked eye. But in both sexes the
microscope told a different tale. In 23 male cases examined micros¬
copically some degree of cirrhosis (generally slight) was found in 6. In
42 female cases cirrhosis, often advanced, was discovered in 19 cases,
or 43 per cent. Possibly the variation between these demonstrated
facts and the generally accepted belief in the rarity of cirrhosis of the
liver in asylums will partly depend on the proportions of cases in which
the naked eye appearances have been corrected microscopically; but
possibly also it may depend on the fact that out of a total of 317 fatal
cases 22 per cent, were only in residence from a few days to less than a
month. In other words, much that was found in these cases belonged
to the ante-asylum life of the patients. Gall-stones were found in 9 per
cent, of the men and 19 per cent, of the females. The other organs are
dealt with, but presented nothing noteworthy from the asylum point of
view.

Both asylums publish the names of the members of the staff who
have gone on service.

Gateshead Borough .—This is the first report of the asylum, which is
a recent addition to the growing list of English public institutions. The
general administration seems to have settled down quickly and satis¬
factorily to the usual lines. We are glad to note that the full scheme
of the Association’s Statistical Tables has been adopted. We note that
with thirteen deaths only three post-mortem examinations were made,
in consequence of the friends’ refusal to allow others. In view of the
immense amount of trouble and expense which the relatives are
personally spared by asylum care, these relatives should consider it a
matter of honour to repay some little amount by a ready consent to
this examination, which, after all, is the only reward that can be con-

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tributed by the patient for the scientific skill bestowed on his care and
comfort.

The following particulars of a new asylum may be interesting. It is
built to accommodate 200 patients of each sex, with preparation for
another 100 beds in the future, making 500 in all. The designers were
Messrs. Hine and Pegg. Each section is complete in itself, comprising
day room, dormitory, attendants’ room, scullery, kitchen, boot room,
store rooms, sanitary spurs, bath lavatories and W.C.’s. Single rooms,
including padded and half-padded rooms, are in proportion of 1 to 6.
Each infirmary has a solarium 68 x 14 ft. attached to it. Bicycle rooms
are provided on each side for the staff. The engineering plant is quite
advanced. Mechanical underfeed stokers, and a Green’s economiser
serve to economise the coal consumption. Exhaust steam is used again
in the heating system. The latter must be very active and efficient, as
it is circulated by steam-driven pumps. The circulation can be con¬
trolled in the pumping chamber, and, as thermometers are placed on
both flow and return pipes, the engineer can satisfy himself at once
whether the circulation is being carried on efficiently throughout the
asylum. At the same time each block can regulate its own temperature.
The subways for the pipes can be walked through. The system of
distribution is excellent. The mains are carried up to the roof space
in each block, and these descend to the radiators in the two floors.
These mains are in three circuits—one for the day room, one for the
dormitories, and another for the single rooms. Thus at night the day
room circuit is shut off, by day the dormitories are shut off, and the
single rooms can be controlled as may be found necessary. The wards
are heated by under-window radiators, air inlets being behind them,
regulated by internal levers. More than three miles of heating mains
are required. The chapel is heated by Haden’s combined warm air
and hot water apparatus, the radiators only being provided in the
entrance and lobbies. The hot water system for laundry, baths, sinks,
etc., is conducted on much the same system as the heating plant, two
calorifiers being provided—one for live steam, the other for exhaust
steam. The former is only used in case of emergency, as for ordinary
running exhaust steam is sufficient.

Dent’s electric clock system is used, the clocks known as “Pulsynetic”
being synchronised.

Evidently much thought has been given to all these points, and it
will be interesting to note in a succeeding report how far success has
attended the various installations.

Dr. Tighe is to be congratulated on having a well-found machine to
supervise.

Kent, Harming Heath. —Dr. Wolseley Lewis opens his report with
these remarks:

The great war, which has turned the whole of Europe upside down, will no
doubt be reflected in the statistics of the asylum. The immediate effect will
probably be an increased number of admissions ; for we have those conditions of
mental and physical stress which are prominent factors in the causation of
insanity ; indeed we have already admitted Belgian refugees, soldiers from the
front, and women whose state is due to loss of their relatives in the war. At the
same time the number of our discharges is likely to be curtailed, as the circum-

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stances to which we can send our convalescents are less favourable than in times
of peace. The immense sacrifice of blood and treasure entailed by the war, and
the altered social conditions likely to obtain afterwards, are more remote factors
whose influence on the statistics of mental disease in the future it is hard to
foresee. In the meantime, a great crisis like that through which the nation is now
passing has its effect on the mind of the people as a whole, and also tinges the
mental state of many of our patients, who develop delusions such as that “ they
possess a special power to stop the war,” or that “ the Germans are after them to
kill them.”

We note that recreation and mess-rooms with separate kitchen for
the staff have been provided. These are run on very much the same
lines as a club, and so successfully as to invite visits of inspection by the
authorities of London and other areas.

In a survey of the results of the last quinquennium it is related that
the admission-rate has decreased considerably, especially among the
men. This is probably to be accounted for by the request of
the Committee in late years that the Guardians will only send to the
asylum male cases that cannot be treated in the workhouses. The
death-rate, which can be affected by no sucji administrative procedure,
has made the very considerable drop from 12*63 to 8 8. This Dr.
Wolseley Lewis attributes to better hygiene, and to improved nursing.
As further proof of his point he states that while the age of death in the
period has risen from 51 to 53, the death-rate from phthisis has dropped
from 26 to 15 per cent. At Chartham the work has been increased by
the billeting of two batteries of the R.F.A. Dr. Fitzgerald was glad to
offer the advantages possessed by an asylum in the matter of bathing,
cooking, laundry, etc., and the asylum staff endeavoured to make the
billet a pleasant one. On the other hand, much interest was found in
the working and the training of the patients. The nurses were of much
use in supplying several hospital wards in Canterbury with bed jackets
and other garments for the wounded soldiers. The male staff in the
kitchen was depleted by the war, and for some months all the cooking
was done by the nurses, who seem to have risen to the occasion. The
work is now done by female cooks. A house is to be provided for the
Senior Assistant Medical Officer, so that he can marry.

Metropolitan Asylums Board .—The Committee, like other bodies, has
to report the loss of a large portion of the staff, about 1,070 having been
mobilised or volunteered. This tells hard on Darenth, especially where
the work has been seriously hindered by the withdrawal of trade
instructors. The terms given to all who have left for the war appear to
be most generous. The attitude of the managers with respect to mental
deficiency appears all round to be liberal and sympathetic. The Com¬
mittee states its intention to'foster research in connection with mental
disease, and specially in Darenth, on the recommendation of Dr. Sherlock,
to establish a laboratory of experimental psychology. It appears to us
that a more valuable field for such work could not be found. The
industrial work at this institution, as well as that at Bridge, has been
kept up on the old lines, but has been seriously affected, not only by
the shortage in staff mentioned above, but by the great increase in the
price of raw materials. In relation to the value and earning capacity of
mental deficients, Dr. Sherlock tabulates the result of extended obser-
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EPITOME.

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vation of some or his patients at Darenth. He effectually explodes the
commonly prevalent idea that a deficient can be made by training into
a self-supporting worker. He assumes for the purpose, and rightly too,
that the work at Darenth offers the best opportunity for settling the
question. He points out that the deficient cannot make up the normal
number of hours in a week—the effective time spent by patients only
amounting to thirty-five hours. To attain even this there is required an
expensive supervision. At the best the work does not equal that of the
normal labourer, and in consequence it is not easy to find a favourable
market, and so on.

The following table shows the estimated value of work done per week
by a stated number of patients in certain trades :

Feeble-minded.

Imbeciles.

Males

j Bootmaking

48 6/3

44

5/8

(Tailoring

42 5/4

36

61 -

Females-

(Needlework

82 1/4

232

1/8

(Machine and other knitting

18 4/6

6

7/i

It must be admitted, on the above figures, that such labour only helps
to lessen cost, and cannot do so much as the public were led to hope
for when the Mental Deficiency Act was first introduced to the notice
of Parliament. There is another point of interest in these figures. It
will be seen that in all but the first trade—bootmaking—the average
imbecile showed himself to be a better workman than the average feeble¬
minded person, in spite of the relative gradations of educability to be
found in the definitions of these states of deficiency, as laid down in
the Act.

Apart from its work among the intellectual wreckage which is thrown
on its hands, the Board gives evidence of the splendid organisation that
characterises its functions. The declaration of war found it liable to
take charge at short notice of aliens to the number of 363. Then
the irruption of Germany into Belgium brought a large number of war
refugees. On September 4th, 1914, the Local Government Board called
on the Board to provide for them. In twenty-four hours arrangements
were made for the utilisation of the Crystal Palace, which the Board
was led to believe would be available. But on proceeding to make
arrangements for opening it the Board’s representative found that the
Admiralty had forestalled them. Accommodation, however, was found
in the next few days, and on September 10th, six days from the first
call, the Alexandra Palace was secured and opened. The average daily
admission was nearly 500; but on one occasion 1,200 arrived between
1.30 and 3.30 a.m., and on another 1,900 were received in the course
of a night. The Earl’s Court Exhibition premises were secured, and
on October 15th the place was cleared of show cases, booths, and the
general paraphernalia of an Earl’s Court Exhibition, and the staff and
equipment were collected in time for the admission of 1,400 refugees in
the evening. Altogether, from the declaration of war to the end of
June, 1915, 94,005 refugees were dealt with. The Board may well be
congratulated on this wonderful work.

Staffordshire .—At Stafford it is recorded that a contract has been
taken for building a house for the Senior Assistant Medical Officer,

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EPITOME.

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40 per cent, of lymphocytes should be of value, especially if mast cells are also
present.

Secondly.— A total white count, in cases of manic-depressive and confusional
insanity, which progressively shows an increase of white cells, points to a good
prognosis and an ultimate recovery, while a slight polynucleosis over a long period
points to chronicity.

Thirdly. —As regards differential diagnosis, difficulty often arises as to
whether patients showing symptoms of mania or confusional insanity belong to
those forms of disease, or are actively progressing general paralytics, especially
where there is no history of syphilis and bodily symptoms are absent. If a white
count is done at intervals in these cases a large polynucleosis, which increases as
the patient grows worse, points to general paralysis, while a polynucleosis of lesser
degree, which increases as a patient improves with no noticeable increase in
lymphocytes, points to manic-depressive or confusional insanity.

Also as general paralytics make a temporary improvement their total white
counts, although exhibiting a slight polynucleosis, decreases and exhibits a marked
lymphocytosis.

Some Registered Hospitals.

Barnwood. —The Committee note that on the outbreak of war they
placed one of their dependencies at the disposal of the authorities for
the gratuitous maintenance and treatment of private soldiers, and
another for the reception of officers. The offer was not accepted. Dr.
Soutar reports that the number of male applications had fallen off
remarkably for no known reason. He had to refuse one or two on
account of shortage of staff. In place of an average admission rate of
thirty-five of both sexes, only nineteen were admitted.

The Retreat , York. —The war not only made a call on the energy and
unselfishness of those of the staff who were left, but it produced much
evidence of right feeling. A simplification of diet was readily accepted,
and the Secretary was authorised to deduct twopence per pound from
salaries as a contribution to the York Citizens’ Fund. Then the nurses
devoted their spare time to caring for the numerous Belgian refugees
taken charge of at the Friends’ Meeting House, finding night nurses for
the Distribution Home, washing the babies, etc. Dr. Bedford Pierce
records with sincere regret that the cost of maintenance had reached
such a point of increase that it was found necessary to raise the terms.
He was gratified to find that in almost every case the additional amount
suggested was willingly paid. But, in spite of this extra income, we
regret to see that the receipts were slightly below the outgoings. The
bombardment of Scarborough was a terrifying experience for the
inmates of Throxenby Hall, the seaside outlet of the Retreat; but no
ill results followed. Dr. Pierce truly states a fact that has to be taken
into account when considering fitness for parole or special indulgence—
the disease sometimes seems to destroy all sense of honour. As an
instance, a nurse volunteered to take a nice quiet patient for a cycle
ride. But the nice quiet patient was better mounted and a better rider
than the nurse, and going up a hill she outrode her companion, being
subsequently found wandering on the railway.

Some Scottish Royal Hospitals.

Aberdeen. —Dr. Reid, writing in January, 1915, had not been able to
trace any aetiological connection between the war and the mental dis-

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order in his admissions. But he thinks that it has served to accentuate
any existing highly strung tendency, and to produce in some a self-
centred, apprehensive, depressed, fanciful, sleepless and fatigued con¬
dition akin to neurasthenia. We observe that Dr. Reid returns general
paralysis as a cause in all the cases admitted as suffering from that
disease. Some day, no doubt, syphilis will be regarded as the isomer
of general paralysis, and then will be returned as the cause, and thus
one will not have to reflect how a given factor can be cause as well as
result. We note that he adds some useful tables which are not usually
found in conjunction with the former official statistical scheme of the
Association

Edinburgh , Morningside .—The Committee, in their report, state that
when the Mental Deficiency (Scotland) Act was passed it occurred to
them that they might provide some of the accommodation that was being
sought for by other responsible bodies. The General Board of Control,
however, pointed out the section in the Act which forbids the mixing
up in any way of the two classes—the insane and the deficient.
There is a good deal to be said on each side. We take it that while it
would certainly be harmful if the best class of deficients were treated
on the same premises as the insane, some definite connection between
the institutions containing the two classes is very desirable, seeing
that the line is very narrow between some of the best class of the
insane and some of the most active cases of mental deficiency. The
incidence of the war affects this question deeply. It is idle to hope
that much satisfactory accommodation can be provided for the deficients
for a long time to come, while existing institutions might be of great
service in this relation if the law were not so precise. Not being able
to progress in this direction the Managers offered to take in soldiers
and sailors returning from the front suffering from mental collapse, but
the authorities being reluctant to send such cases to an asylum, this
kind offer, though accepted, has not been made use of.

In discussing aetiology Dr. Robertson is able to reproduce from an
admission statement a new name for an old friend. One case was
attributed to “ over-religiosity.” The mental stress cases, which have
formed a steady average of n per cent, of the total admissions, suddenly
rose to 187, the increase being chiefly in the female sex. In the
others Dr. Robertson is chary of accepting the war as a scientific
element in direct causation of insanity. Many of the cases admitted
were attributed to the war, but on analysis it was found to be a very
indirect cause in most cases. On the other hand, Dr. Robertson has
come to look on the war as having been a sort of mental tonic, and
in support of this idea he says that the admissions in Scotland have
fallen slightly below the average since the war began.

With regard to alcohol, Dr. Robertson adverts to the good work done
by the “field worker,” Dr. Ritchie, in investigating the cases admitted
with this aetiology. The number dealt with was small, but in each case
alcoholism was proved in one or other, or both, of the parents. In each
case the men earned good wages ; in one case the young man made
enough to live comfortably and to do himself well with drink. A rise of
ioj. per week was devoted to extra alcohol, with the result of bringing

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on incurable insanity. It is pointed out that in these cases each
drifted away from church connections, and from every influence of an
educational or elevating nature. To our mind this is the most serious
pathological change of all. As in most insanities natural affection is
the first normal attribute to go, so in this toxic affection self-respect is
the first surrender, associated with the carelessness for the respect of
others. Judges and others who denounce the evils of alcohol, as shown
in the production of crimes of violence, do not, as a rule, put sufficient
stress on its slow sapping of mental fibre leading to the commission of
meanness and dishonesty, through the destructionof protective principles.
Among the many interesting examples of the application of the “ war
idea ” to existent insanity, Dr. Robertson instances one woman who is
acquainted with “ Kitchener” and “Smith Dorien,” and gets messages
by “ wireless ” from them. She will “ ring up ” and give one the latest
news from the front at any time. What a valuable asset she would be
to the new “ Opposition ” which it is proposed to establish for the edifica¬
tion of the Government.

Dr. Ritchie, the “ field worker,” whose appointment we noted last
year, is proving to be a success. It is his duty to examine in loco into
the Eetiological factors of the individual admissions. We have in these
columns, on more than one occasion, pressed for the carrying out of this
most useful form of scientific research. Obviously if aetiology is worth
anything in the estimation of pathology, it should be probed thoroughly,
consistently, and meticulously. As an example of the benefits of such
research we append the following extract:

“ Dr. Ritchie found that of fifty-three consecutive admissions from Leith, practi¬
cally a third had no church connection, and many others did not even know the
name of their clergyman. The loss of this influence for good, and for sobriety in
the lives of these persons, was a most serious one. It is one of many points where
the efforts and ministry of the physician and the clergyman touch and even over¬
lap, and there appears to be an opening here for something more to be done.

“ When these patients are discharged they are placed in communication with a
clergyman, as a species of ‘ after-care,’ a duty which is always willingly under¬
taken, and at least one patient attributes her complete reformation to the visits of
the minister and the church worker.”

Glasg 07 v: Gartnavel. —Dr. Yellowlees, in moving at the Annual
Meeting a vote of thanks to Dr. Oswald, recorded the fact that for
nearly four weeks Dr. Oswald ran the whole asylum himself, without
any medical assistance and with a greatly reduced staff. Very few
officers have had more real anxiety and sheer hard work thrown on them
by the war than those connected with asylums. It is undoubtedly the
case that the subordinate staff has risen to the occasion, and we cannot
but think that some sense of patriotism has led the more reasonable
patients to give what help they could, not only by their own self-control,
but also by guiding their less fortunate companions in the right way as far
as possible.

Dr. Oswald shares the opinion that the war has had no influence in
causing mental breakdown, though in numerous instances it has served
to colour the symptoms. On the other hand, though he thinks that an
increase of nervous trouble may be reasonably anticipated, he recog¬
nises that the national need has raised the national mental tone.

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Montrose. —Here, too, the war has caused much trouble to Dr. Shaw,
who has succeeded Dr. Havelock as Medical Superintendent. He had
been without medical assistance for a considerable time, and has little
prospect of securing any. Among the 143 admissions no less than
three had serious self-inflicted cut-throat injuries. Speaking of the
essential need for fostering self-control in early years, as a means of
obviating hereditary tendency, Dr. Shaw says that there seems to have
been in recent years a tendency to minimise parental responsibility and
authority. He hopes that the present national emergency may lead to
increased self-control in the individual, and a greater regard for
discipline in the community.

The Hospital has received ninety extra patients from Bangour on
the latter being taken over by the military authorities.

Some Scottish District Asylums .

Govan. —Dr. Macdonald states that so far from the war helping to
increase admissions, these in his case have been below the average.
At the same time it has to be remembered that cases of mental
disturbance occurring in the hospitals are treated in special military
hospitals, and are thus drawn off from the admissions into the ordinary
asylums. Though among the admissions some war retiology could be
assigned, no case owed its origin directly to this factor. He writes :

" No doubt it is amongst the soldiers and sailors in the fighting lines that the
excessive mental strain will claim most victims. It says much for the mental
stability of the race that our asylums have not already been filled to overcrowding
by demented warriors from our army and navy. There is some satisfaction to be
found in that reflection, especially in view of all that has been written and said in
certain quarters about the mental and physical deterioration of our people. The
pity of it lies in the fact that it is the fitter amongst us who have to sacrifice
themselves in the struggle; and, when the war is over, the ratio of unfit to fit will
be greater than before. Many will lay particular stress on this calamity. Others
will seek to draw comfort from the belief, or rather the hope, that war cannot be an
unmixed curse; that it must be compensated to some extent by consequent and
subsequent revivifying influences—the quickening of the moral and spiritual pulse
of the nation.”

Inverness. —Dr. Mackenzie admitted 19 cases from the naval and
military depots and training camps in the district. All parts of the
kingdom were represented. Of these, 12 were discharged recovered
after an average residence of less than seven weeks, 4 were transferred
to other asylums, 1 sent out on probation, 1 about to be discharged
recovered, and 1 sent to the care of his parents. A fuller report of
the nature of these active cases would be very interesting.

The Twenty-first Annual Report on the Government Hospital for the
Insane at Abassia, Cairo, and the Fourth Annual Report on the
Asylum at Khanka.

In drawing special attention to this Report, I feel bound to speak
of it as a model one, and I have taken the liberty of adding, as
an introduction to it, a letter from Dr. Warnock which appeals to

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me as showing evidence of his unusual power for work and also for
adapting himself to most trying conditions.

Those of us who have visited Abassia and spent some days there
more fully recognise the gigantic energy displayed. The Report itself
gives, in concise terms, all the information which can be desired.

First, the work has had to be done by a staff reduced in numbers
in consequence of the war, and the work has been increased by
requirements for special treatment of British soldiers who become
insane.

Doctor (or I daresay he is a major or colonel) Warnock, in his
letter, points out the most interesting points in the Report and gives
many elaborate tables involving a great deal of work, which I shall not
refer to, as they have only local interest.

During Dr. Warnock’s administration 14,705 patients have been
treated in the asylum, with 3,070 recoveries and 2,277 deaths ; 1,250
examinations have been made of persons accused of crimes, 200
Government employes have been examined, and 100 prisoners have
been examined and reported upon. Large sums have been collected
from patients’ estates, and very large sums have been spent in developing
the old and building the new asylum.

The numbers in residence have risen from 440 to 2,054. The area
appropriated for the treatment has grown from two and a half acres to
700. The staff has risen from 75 to 545 persons.

Nineteen deaths occurred from accident, homicide, and suicide.
During the year Dr. Warnock was appointed consultant to the British
Army in Egypt, and he arranged the subdirector’s house as a special
hospital for these military cases. One hundred such cases were
treated—56 British, 22 Australian, 2 New Zealand, 17 Indian, and
various, 3.

Of these 36 were melancholic and 12 maniacal. Alcoholism pro¬
duced 10, general paralysis only 5. The Indians supplied the largest
proportion of melancholiacs. Of the 100, active service, shock, or
causes of physical exhaustion, such as dysentery, produced 18, alco¬
hol 10. Only one death, and that from septicaemia, occurred.

Part II of the Report gives more fully the statistics, and what may
be called the domestic economy of the asylums. These are very
interesting for superintendents, but one cannot include them in this
short review. Full returns are made of the very complete electric
service which is much used in both asylums. Many patients were
admitted suffering from injuries produced in struggles with friends or
with the civil authorities. Sixteen employees suffered injuries from
aggressive patients.

Dr. Warnock, with natural pride, refers to the reception of voluntary
boarders, and to the fact that patients are decently brought (“ escorted ”)
to the asylum.

With all the medical and administrative work, Dr. Warnock gave
thirteen lectures to students of the School of Medicine, and last April
demonstrated interesting cases to the Law students. This is a splendid
innovation.

A very novel and important part of Dr. Warnock’s work is connected
with crime. He now receives the criminal lunatics, and besides this

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doubtful cases of accused persons are referred to him, as well as a
number of convicts, many of whom are malingerers. A table is given
of the insanity found in thirty-three male prisoners. Pellagra produced
five homicidal prisoners, and one of the nine women was convicted of
murder and was pellagrous.

The various medical tables are of particular interest. The largest
number of admissions was in the summer months and the fewest in
November.

Of 586 male patients admitted, hasheesh was given as the cause of
46 cases, pellagra 75, general paralysis 46.

There are tables giving the race and residence of patients, and these
show the confusing variety of languages and habits which have to be
dealt with.

The death rate was 7-5 percent, on total number resident; this includes
deaths from typhus and typhoid fevers and dysentery. Bilharzia worms
were found in sixteen cases, and ankylostoma in four others.

Most encouraging work was carried on in the laboratory, and the
brains and other organs of ten pellagrous cases were collected and
prepared for examination.

The importance of syphilis in the causation of mental disease is now
acknowledged, and Dr. Warnock was able to get Wassermann tests
carried out by the Public Health Authorities, and interesting results
are tabulated. The percentage of positive reactions in general paralytics
was 68; this seems to be rather below our experiences.

With pellagra there were 11 per cent, positive, and with the other
various forms of insanity 23 ; this appears high.

Details of treatment are given, and Dr. Warnock is a strong advocate
of out-of-door treatment, and prefers some forms of restraint to the
chemical control by drugs.

And here we must conclude the report on Abassia.

The new asylum at Khanka is still in a developing stage. Dr.
Dudgeon recognises to the full the importance of outdoor occupation,
and his report points out clearly the developing work he is carrying
out.

Here, too, the number of the patients exceeds the accommoda¬
tion.

The asylum will ultimately be adapted for 2,000 patients.

The communication with Cairo is unsatisfactory, and the Director is
much cut off from European society.

His work is interesting, and his practical ability is well exercised in
his work. G. H. S.

Abassia, Cairo,

March 1 6th, 1916.

Dear Sir George, —I enclose my “ hardy annual,” the twenty-first.
I can hardly believe I have done twenty-one years’ “ hard,” seven days
a week, and never a week-end’s rest. However, I don’t complain of the
hard work ; it’s the continual worry and “ struggle against adverse circum¬
stances,” as the old Commissioners’ reports put it. However, the twenty-
one years are completed, and, like old Horace, I would sing “exegi

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monumentum aere perennius,” etc., but I know it’s not “aere perennius,”
but only a bubble on the advancing wave of civilisation. Well, it’s some
satisfaction to have got through with it, with all its failures and loose
ends. Look at p. 6 and realise what a mass of work has been got
through. Quantity , if not quality ! Abassia Asylum admits nearly
double as many cases as any other asylum in the British Empire—1,036
a year against Winson Green Asylum at Birmingham 577, the nearest
approach I know; and our cases are all so violent! And as though
one hadn’t enough work, I was bound to take up the care of the insane
soldiers in Egypt, and make a good home for them ; their statistics
(p. 7) are interesting. For about six weeks, December, 1915, and
January, 1916, the work was the heaviest I have ever known, from
9 a.m. to midnight, seven days a week, with but one and a half hours
for meals. Luckily a lull came, but the overwork made one feel older.
The summer of 1915 was very trying; very hot, and there was an
unprecedented inrush of new cases, nearly all in camisoles and acutely
maniacal, or dying, or infected with fever; twenty new cases admitted
in twenty-four hours ! One hundred and twenty new cases a month, and
an epidemic of typhoid and typhus fever on the top of that, affecting both
patients and staff. No subdirector to help me; my best native assistant
away at Khanka to replace Dr. Dudgon on three and a half months’
leave. Still, we got through somehow; but after eighteen months’
work without a single day or even night off duty, I feel inclined to kick.
The Report for 1915 is not exhaustive. No time for writing reports
nowadays. The temperature chart is omitted this year. Remember,
all the administrative work is done by one man here; no asylum com¬
mittee as in England to make contracts, pay cheques, decide administra¬
tive questions, vote money, etc.; every bill paid has to be signed by me.
All the work passes through one narrow funnel. Half of my work would
be done in England by the asylum committee. The result is one lives
in a “ rush.” “ Life’s fitful fever ” is not merely a poetical expression
here. At times one asks : “ Is it worth it all ? ” Of course it is. The
greatest pleasure in life is the overcoming of obstacles, and there are
plenty here ! And now for the Report:

On p. 4, note that the combined lunatic admission-rate of Abassia
Asylum and the local general hospitals all over the country is falling—
1,087 in 1915, 1,227 in 1914, 1,325 in 1913. So it looks as though
we had got most of the wandering dangerous lunatics under care, and
as though the extension of asylum accommodation to 2,000 beds was
having some result.

The recoveries (245) are low, because the improving cases have to be
prematurely discharged.

Pellagra is the chief reason for our high death-rate, but syphilis
(general paralysis) helps.

As stated on p. 5, Khanka Asylum should now receive about half the
total male lunatics of the country; but until a road is made to it from
Cairo we can’t use it thus.

The cost of maintenance of a pauper patient is at Abassia ^25 iox.
(p. 12), at Khanka £24 7 s. (p. 34).

[Khanka takes the quiet cases and Abassia has all the acute destructive
cases and all the women and criminals.]

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On p. 11 a welcome improvement is mentioned, viz., the installation
of complete water-carried sewage drainage at Abassia.

Note: On p. 14 we admit voluntary patients, yet a county asylum in
England is not allowed to !

The paragraph marked “escort ” on p. 14, is a sign of civilisation
after many years. Patients now sent by train are separated from the
ordinary passengers.

The criminal work (p. 15) is very laborious, and entails the reading
of the long Arabic dossiers of each case, and then prolonged cross-
examinations of the accused. Malingering prisoners are also a great
tax on one’s time.

On p. 20 note the steady influx of new cases, 86 per month all the
year round, and the continual discharges (40 a month), and the death
on every alternate day.

Page 21, note that hasheesh insanity and general paralysis are now
level—46 per annum for each disease among the males. Twenty-one
years ago it was very different—much hasheesh and apparently very
little general paralysis.

Page 2i, Races : Note the lonely Chinaman ! His first appearance
in my reports.

Pages 22 and 24: Pellagra caused 44 deaths; general paralysis 30.

Page 23, Table VIII, shows that our cases come mainly from the big
towns. Country lunatics stay at home mostly.

Page 24, Table IX: I have come to the belief that real epilepsy is
only possible in the neuropath, and that adolescent insanity (dementia
prsecox) is always a hereditary affection, showing itself by mal-
development chiefly of the brain, but often of the bones, etc.

The huge total of “ causes unknown ” (347) vitiates all conclusions
to be drawn from this table.

Page 25 : In spite of overwork, heat, and all, we did forty-four post¬
mortems.

To fill up our cup we developed a case of smallpox, which meant
general re-vaccination and quarantine.

Page 26: At length we got some work done in the laboratory by a
most decent Egyptian doctor, who has now gone to Cambridge. He
did Wassermann test, Widal test, blood-films, etc., and was a great asset.

The tables on pages 26 and 28 shows results of systematic Wasser¬
mann tests done at the Department of Public Health Laboratory; in
1916 every case admitted is being so tested.

Page 27 : Seclusion is still high, and to lessen it I require better
attendants and a cooler climate, both impossibilities.

Artificial feeding. —One case for eight years continually.

Hypnotics. —Very high; but why is not a record of hypnotics
required in asylums generally—“ chemical restraint ”—as there is of
mechanical restraint? I have heard that sulphonal is used to an
enormous extent in some asylums (a drug I allow only sparingly here).
It may be that seclusion has been eliminated by perhaps worse methods !

Page 28 : Mechanical restraint. —I think this is more humane in
cases of broken arms, infectious wounds, etc., than fighting with an
attendant, or being stupefied with sulphonal. Mechanical restraint is a
sort of bogie-man in England.

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Wet-pack .—Why is this given up in England ? It is a great sedative
in furious cases.

Suicides .—The patient had swallowed all these things before
admission ; he vomited the spoon and passed the clothes-peg and nail
per rectum.

Well, so much about reports ! I often think of printing my views on
a number of lunacy matters, and when I retire from this pandemonium
I may do so. You may be interested to hear how experience in this
isolated place has moulded the views of a medico-psychologist.

Here is a sample :

(1) There will never be harmony between the law (or the lawyer) and
lunacy doctors until they meet on the same mental platform. They can
only be made to meet by both sides passing through the same training
in lunacy. Thus all lawyers should attend lunacy lectures and asylum
wards for at least a year before qualification (I believe lectures are
given to lawyers at Konigsburg Asylum). The whole position is
open to ridicule. We should push until we get lawyers educated in
lunacy, and then we’ll get a proper lunacy law in England instead of
the existing repressive and insulting law. Thank God, there’s no such
law in Egypt. The lawyers have all the power nowadays, so let us
educate our masters. That is the first thing necessary.

(2) “ Lucid intervals.” I think all the legal talk on this subject is
trash and should be cut out of legal text-books. Lawyers think a
chronic dement may be insane at any moment; indeed, often is. In
my experience, lucid intervals are almost like Icelandic snakes.

(3) The examination of accused lunatics at police-courts and prisons
in England appears to be often done by doctors who have no lunacy
experience. In backward Egypt every accused person suspected of
insanity is examined by a lunacy expert, and every suspected
convict, too.

(4) The imprisonment of quiet, slightly weak-minded people in
English country asylums is an expensive hobby, when they might be
boarded out in the country, as in Scotland, eg., in Devonshire and other
western agricultural counties.

(5) The 4 in. opened windows in English asylums (is it still the
rule ?) may be a cause of asylum tuberculosis there.

(6) Promotions of asylum medical officers in England should be for
scientific work ; until the Medico-Psychological Association and the
Commissioners insist on that point, lunacy won’t progress. That’s the
pivot of the thing. Nomination of superintendents should require
Commissioners’ approval and Commissioners should call for the list of
candidates and see that the most scientific man gets the post.

(7) A curse of medico-psychology is the loose use of terms. Every
writer and speaker uses each term in his own special sense. The
Medico-Psychological Association should appoint a committee to issue
a lexicon of psychological terms with exact definitions of each term,
and that definition should be accepted by English countries. At
present we are in a muddle, eg., “confusional insanity” is a movable
feast, and with some writers refers to nearly everything, including
general paralysis, senile dementia, etc. Others limit it to toxic states—
by the way, no toxins have been shown to cause this state, it’s all

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NOTES AND NEWS.

445

theory. “Dementia” has spread all over the field. “Melancholia”
is a term for idiopathic melancholia, for symptomatic melancholia, for
melancholic general paralysis, etc.

(8) I don’t believe we make ourselves insane by absorbing toxins
from our intestines. The most constipated of all (old ladies) are not
specially liable to be insane. First catch the toxins and show their
effects. Until then I won’t use the term autoxic insanity.

But I spare you; you have had probably more than enough. Well,
I don’t often “ take the cork out,” so excuse this overflow.

Yours truly,

John Warnock.

Part IV—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly General Meeting of the Association was held at the
Medical Society’s Rooms, No. 11, Chandos Street, Cavendish Square, London, W.,
on Thursday, February 17th, 1916, Lieut.-Colonel David G. Thomson, M.D.,
President, in the chair.

There -were present: Drs. Fletcher Beach, David Bower, A. Helen Boyle, R.
Brown, P. E. Campbell, J. Chambers, R. H. Cole, M. Craig, Emily L. Dove, T.
Drapes, J. H. Earls, A. H. Griffith, H. E. Haynes, R. W. Dale Hewson, H. A.
Kidd, N. Lavers, R. J. Legge, T. S. Logan, W. H.C. Macartney, H. J. Mackenzie,
A. W. Neill, W. F. Nelis, H. Hayes Newington, J. G. Porter Phillips, H. Rayner,
G. M. Robertson, Sir George H. Savage, J. N. Sergeant, G. E. Shuttleworth,
R. Percy Smith, J. G. Soutar, R. C. Stewart, W. H. B. Stoddart, J. Tattersall,
W. R. Watson, H. Wolseley-Lewis, and R. H. Steen (Acting Hon. Gen. Sec..).

Present at Council Meeting: Lieut.-Colonel David G. Thomson (President) in
the chair, Drs. James Chambers, R. H. Cole, Thomas Drapes, Neil T. Kerr,
Norman Lavers, H. Wolseley-Lewis, H. J. Mackenzie, H. H. Newington, G. M.
Robertson, J. Noel Sergeant, J. G. Soutar, and R. H. Steen (Acting Hon.
Gen. Sec.).

Apologies for absence •were received from : Drs. T. S. Adair, R. Armstrong-
Jones, R. B. Campbell, H. Devine, J. W. Geddes, J. Keay, G. D. McRae, G. E.
Peachell, G. S. Pope, T. E. K. Stansfield, and F. R. P. Taylor.

Minutes.

The President asked the meeting to confirm the minutes of the meeting of
November last, which had already appeared in the Journal of Mental Science.

The minutes were accepted as correct and duly signed.

Obituary.

The President said the first business which arose out of the meeting of the
Council just held was to ask members to approve of a vote of condolence being
sent to the relatives of members of the Association who, he regretted to say,
had died sincp the last meeting. They were Dr. O’Neill, of Limerick ; Dr. Fox,
who was one of the oldest members of the Association, his membership dating
from the year 1861—almost a record probably; and Dr. Morrison, of Hereford,

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who succumbed quite recently. He asked members present to approve of a vote
of condolence being sent to the relatives of the deceased.

This was agreed to by members rising in their places.

- Thanks to Dk. Macdonald.

The President then asked the meeting to accord a vote of thanks to
Dr. Macdonald, of Dorchester Asylum, who had been good enough to present
to the Library of the Association a complete collection of the journal Brain since
its first issue, which would constitute a valuable present to the Library.

The vote was carried by acclamation.

Election of New Member.

Dr. Cole and Dr. Mackenzie acted as scrutineers for the election of the following
lady as an ordinary member: .

Murray, Jessie M., M.B., B.S.Durham, 14, Endsleigh Street, Tavistock
Square, London, W.C.

Proposed by Drs. A. Helen A. Boyle, Robert Armstrong-Jones, W. H. B.

Stoddart.

The election was unanimous.

Paper.

" The Employment of Female Nurses in the Male Wards of Mental Hospitals,
Dr. George M. Robertson (Physician-Superintendent of the Royal Edinburgh
Asylum, Morningside). (See p. 351.)

Dr. W. H. B. Stoddart said he had been asked by Dr. Robertson to say a
few words on the subject, not, he imagined, because he had had any special
experience of it, for he had none except as an onlooker at certain institutions.
The reason probably was connected with a letter which he, the speaker, wrote
suggesting that female nurses might be substituted in some of the asylums, during
the war, for male nurses. He was very pleased to hear that that had been done;
and he considered that Dr. Robertson had done members of the Association a
great service by pointing out that it was an anachronism to have male nurses in
male wards, and that the custom really dated from a time when the insane were
regarded as being dangerous people. The reasons given were a kind of
rationalisation somewhat similar to the treatment of hysteria by valerian, although
that too was still carried on. With regard to the difference between the
auxiliary and the entire system of female nursing, it seemed to him that, to begin
with, the auxiliary system pointed the way in which nervous superintendents of
asylums might try to start female nursing in the male wards ; they could then pass
gradually to the establishment of the complete system. Dr. Robertson had
referred to the use of general nurses in asylums, i.e., those of hospital training;
and in one sentence of his paper he said it was a great advantage to place a
hospital nurse with asylum experience in charge of the nurses. Personally, he,
Dr. Stoddart, would have preferred that Dr. Robertson had put it the other way
round, and said it would be a great advantage to place a mental nurse who had
hospital experience in charge of the nurses. His own experience convinced him
that the nurse who started with a general experience never became as good a
mental nurse as one who started as a mental nurse ; the two kinds of nurse did
not seem to accept their responsibility in the same way. Dr. Robertson said that
one of the objections urged against the system was that a male insane ward was
not the place for a woman to be in. He took that to mean that it was on
account of the woman’s influence on the patient. But the female had a con¬
trolling influence on the male patient. As a matter of fact, one knew, from
observation in institutions where female nurses were so employed, that the
proximity of male patients did not exert any bad influence on the female
character. One noted the effect of the presence of a female even in institutions
where female nurses were not employed. He believed most members of the
Association would prefer to take a lady friend round the male side of an asylum,
rather than round the female side. Male patients controlled themselves much

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better than did female patients. It seemed to him that there was more to be said
in favour of the employment of male nurses in a general hospital than in a mental
hospital. The patients in a general hospital were usually suffering from physical
pain, and in moving them the strong arms of a man caused them much less
distress than when weaker woman essayed the task. A further point which
occurred to him was, that in any asylum one found that the decoration of the
wards on the female side was better and more tastefully done than on the male
side where male nurses were employed; there were more flowers, and the
general aspect of the place was much brighter. He therefore thought that it
must be a distinct advantage from that standpoint to have the female touch and
atmosphere on the male side in a mental hospital.

Dr. Soutar remarked that Dr. Robertson had spoken with great enthusiasm,
and with very strong conviction. Having converted Scotsmen to his views, he had
come south to convert the still heedless southerners. The opener gave an interest¬
ing historical sketch of the evolution of the employment of women in the male wards
of asylums. In the course of it he mentioned that they were first so employed
many years ago in the Gloucester County Asylum. What seemed to be significant
in regard to that was that, after Dr. Hitch resigned, the succeeding superintendents
found that his system was not suitable, and so ceased to make use of it. It could
not be said that these were men who were not open to the consideration of
improvements that were possible in regard to the care of the insane. In Dr.
Robertson’s sketch he omitted to mention one of the most remarkable papers
ever published in the Journal of Mental Science. It \vas published in 1866, and
was entitled “ Sisterhoods in Asylums.” It was based upon a report of the
Commissioners in Lunacy which had been issued a few years before, namely,
in 1859. It specially dealt with the status and quality of the work of attendants.
In the course of that report it was pointed out that they were not as perfect as
they might be. The writer of that remarkable article went very much further,
and made such statements as that it was unanimously agreed by medical superin¬
tendents that their great trouble was with their attendants, and went on to say
that, in the mass, the male attendants were “ coarse, harsh, passionate, indifferent,
untrustworthy, and intemperate.” All he had to say, in passing, was that if
this was a fair report of the male attendant fifty years ago, no more extraordinary
reformation or revolution—for as such it must be regarded—in the moral and
ethical sphere had taken place in our social system, for if one were to characterise
the male attendants of the present day, epithets would be employed which, in
their meaning, conveyed the exact converse of those which he had quoted. The
author of " Sisterhoods in Asylums ” gave it as his reason why women should
be employed in male wards of asylums that the attendants were utterly bad; and
he spoke of the humanity and gentleness of women, and of their virtues generally,
as contrasted with those of men. Dr. Robertson had stated that women were
employed as auxiliaries in various county asylums; they were employed in one
of the great Lancashire asylums for a time, and they were the wives of the
attendants, and he believed their duties consisted largely in household work, the
men still looking after the patients. The point in the historical review which
appealed to him was that, as this question had been brought prominently before
the specialty during many years by its advocates, and at a time when it could
be said with some truth, what cannot be said to-day, that male attendants as
a body were of poor quality, the general employment of women in the male
wards of asylums would have been an accomplished fact long ago had it possessed
the advantages which Dr. Robertson claims for it. Its value would have been
recognised by those competent and progressive-minded men who have presided
over our asylums, and who have shown themselves ever eager to benefit those
under their care. Dr. Robertson also talked of the hospitalisation of asylums.
This word “ Hospitalisation ” seemed to bring to some minds a balm and a
soothing calm very much as the blessed word “ Mesopotamia ” did to the dear
old lady of legend. But asylums could not be run on shibboleths. The
notion which underlay the hospitalisation of asylums was due to a misconception,
based upon a failure to differentiate between the conditions and purposes of two
classes of institutions. The inmates of hospitals and infirmaries were persons
who were, in the ordinary sense, sick physically ; and they were patients who
were amenable to direct dietetic and medicinal treatment. On the other hand,

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the majority of those who came into asylums were not sick in the ordinary
acceptation of the term. It was true they were abnormal, but not sick. They
were, rather, what Sir George Savage called "misfits”: people who were
incapable of adjusting themselves to the ordinary environment, and unable to
care for themselves in the ordinary way. Provision was therefore made for
them, and the environment was adapted, as far as possible, to their needs. That,
of course, was a totally different thing from the case of a patient in an ordinary
hospital. These patients, instead of being kept in bed, doctored and nursed,
were brought into a community and into surroundings which were suited to their
needs, and their physical integrity was taken advantage of in employing them in
workshops, farms, and gardens. The environment was regulated by those who
understood the inmates’ abnormalities. That applied to the great majority of them.
There was another set of patients whose mental condition was the expression of
definite illness, and these were treated as sick persons. But he did not see that
Dr. Robertson had proved that those persons could be, or were, better nursed by
women than by men. The opener did not attempt to show that his experience of
male nurses was in fact an unfavourable one, and Dr. Soutar’s experience led him to
the conclusion that by proper selection and training male nurses of the highest degree
of excellence can be and are obtained for the care of these cases, and that they
possess, in an equal degree with the best women nurses, all the gentler qualities and,
in addition, that physical strength and endurance which on occasion are impera¬
tively essential for the proper management of cases of acute mental disorder.
There was another set of patients in asylums—sick persons and feeble persons,
cases of ordinary illness, such as occurred in hospital wards. Here women nurses
could more appropriately be engaged. But his own experience had not been that
male nurses were so deficient in the gifts and skill of nursing that he would feel
justified in ousting them and putting women in their places. Dr. Robertson also
spoke of the superiority of women in household duties, but male nurses ought not
to be employed in the discharge of household duties. If male attendants were
employed to make beds, clean out dormitories, and polish up brasses, it was an
absolute misuse of them, and their energies were thus misapplied. There should
be an ordinary domestic staff for that work. That women make better house¬
maids than men is no argument for their employment as nurses in the male
wards. The final consideration which he wished to submit was that if woman’s
influence was so absolutely invaluable in asylums, if it was the one thing which
was going to humanise the whole system, which was going to hospitalise it or
make it the ideal thing which Dr. Robertson desired and believed possible, then,
inasmuch as it was certain that the character and tone of an institution very
largely depended upon the influence which was exerted by its chief, it became
the duty of himself and Dr. Robertson, and all his brethren in the specialty holding
similar appointments, to at once tender their resignations, and ask that women
doctors might be appointed in their stead, in order that the feminine influence
might fully prevail.

Dr. Sergeant said he had listened with very great pleasure and interest to
Dr. Robertson’s paper, more particularly because he happened to be an English
disciple of the Scottish school. Four and a half years ago he was fortunate
enough to be appointed to the charge of a small private asylum in the Metropolitan
area j and he commenced with an antipathy to things as they were, and set about
to see in what way he could alter them. He claimed that he approached this
question of the employment of female nurses for male patients with an open mind.
He first considered the problem of having a solely male staff, including the cook
—for he knew there was generally a difficulty between the male and female staffs
when they mingled. He realised that a most important thing was to get a capable
male attendant. He was advised by the Board of Control to write to the Superin¬
tendents of the Scottish Royal Asylums, and that he regarded as a tribute to
them. He accordingly wrote to those Superintendents, and most of them, in their
reply, said the class of male attendant was not now so good, because the Scottish
asylums were appointing matrons in supreme charge; hence there was not now
the same inducement for the male attendant to enter asylums. After a brief
period of experimenting with a totally male staff, he came to the conclusion that
the system was not good, and he, therefore, switched off to the other idea, namely,
that of having an exclusively female staff. He had now had a four-years’

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experience of it, at first tentatively, and then in complete degree. At present
he had only sixteen patients, all of them male, and his whole nursing staff was
female. A member of the English Board of Control, who was visiting the house
some time ago, said he was interested in the method, as he understood that one
learned gentleman said it was impossible to nurse difficult male insane patients
with female nurses; and he added that there were some troublesome cases
among those he saw there, and he confessed that they were excellently nursed by
female nurses. Judging from his, Dr. Sergeant’s, small personal experience, he
was of opinion that female nurses in asylums were infinitely better than male ones.
Papers were read and discussions held on the subject as if the nursing of male
patients by females was something odd ; yet it seemed to him perfectly obvious
that male patients should be nursed by female nurses; and he would welcome the
day when the nursing of male patients by men would be the subject for discussion.
Because male patients had been nursed by males, it had passed into the accepted
order of things, and so it was probable that, for many years to come, the ablest
men in the specialty would be devoting time and trouble to defending the system
because it was the accepted one. That was at the bottom of Dr. Soutar’s con¬
tention, that because it had been before their specialty for many years without
having been adopted, it was therefore wrong. It was, however, conceivable that
the view of this branch of the profession on the subject was wholly wrong.

Dr. Legge (Derby) said that the subject dealt with in Dr. Robertson’s paper
had received his close attention for the past four years. His Committee decided
to build a new asylum at Mickleover, at a cost of a quarter of a million pounds,
and they asked him to advise them as to the type. He was present at the
Association’s meeting ten years ago, when Dr. Robertson read his former paper
on the same subject. He remembered that the reception it was accorded was not
a favourable one, and he did not then agree with it himself. He felt that he
could not advise his Committee well on the projected asylum without studying
the systems which were in vogue in various countries. He paid some visits to
Scottish asylums, on four of which he took his Committee with him. After
studying the subject with an open mind, he became enthusiastically convinced
that the Scottish system was many years ahead of anything obtaining in this
country; and he felt quite certain that no one who had tried the Scottish system
would go back to the other. He had not heard objections to it from anyone who
had given the female nursing of male patients a fair trial. He convinced his
Committee of this, and the plans were now ready, although their execution had
been delayed by the war. Provision was being made for 1,000 patients, and it
was intended that half the nursing on the male side would be done by women.
He was fortunate in having a very intelligent and business-like Committee, and the
members of it became as enthusiastic as he was himself. As the system was some¬
what of an experiment in England, they asked him whether the Scottish system
could not be adopted at Mickleover. He replied that he could not adopt the
Scottish system in its entirety, but he promised to try it on a small scale; and
he got two wards, holding about forty patients each, which were now entirely
nursed by women. Dr. Robertson drew a distinction between the auxiliary
employment of women, such as was advocated to carry asylums over the war
time, and the thorough adoption of female nursing, a very important distinction.
At Mickleover the system was adopted fully. Ninety per cent, of the recent
acute male patients as they came in were put straight into bed in the wards and
nursed by women, both by night and day. At first he was anxious about the
result, but he was now certain there was no thought of reverting to the old
system. The improvement in the patients was wonderful. There was no
arrangement of night-clocks, or any of the fetishes seen in this country; the
patients were calm, less troublesome, and in every way better than under the
old system ; that he could affirm most confidently. Those who had not tried
the system would scarcely believe what a difference it made. And one got rid
of some things one was ashamed to have; one was not troubled with com¬
plaints from patients, for it would be obviously ridiculous for a male patient
to aver that a little woman had struck him. Under present conditions, patients
were very much more amenable to suggestion than they were in the care of men.
Dr. Robertson had now become so used to the Scottish system that he had not
enlarged on many points of comparison which he might have done. It was

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essential that new patients should be kept in bed. In the cases in Scotland
he had seen this was always done, and he had adopted it himself. It implied
having a much larger night staff than was usual in England. At his asylum
there were five night attendants on the male side and five on the female side, with
a population of 800. But instead of ten there should be twenty-five. He wondered
whether members had really thought what was the condition of the night
nursing in English asylums ; was it not the fact that patients who were sick
were more or less neglected at night? (“No.”) He was speaking of large
asylums ; the staff at night was not sufficient for the purpose. At Mickleover
there was at first a staff of five for 400, and one of these walked about the
place at night, one was in the infirmary ward, two were looking after epileptics,
and one was looking after suicides. Was one man sufficient for so many sick
people ? He would be glad to be corrected if he was mistaken. He felt that
the night nursing in English asylums was not efficient, and, with the staff allowed,
he did not think that was very wonderful. And, of course, the Commissioners
did not make night visits. And there were other things in English asylums
which should be got rid of. How many were proud of their “foul laundry”?
It was regarded as a blot on the system. In the Scottish asylums the foul
laundry did not exist. What was the cause of the foul laundry ? It was due
to patients of filthy habits being kept in their ordinary day clothes. In Scottish
asylums those patients were invariably kept in bed, so that the chief necessity
for a foul laundry ceased to exist. English asylums were controlled by an
elaborate series of night-clocks, and he considered they were a loss. In
Scottish asylums there was the responsible night matron, a lady who was not
at all likely to form intimacies with any member of the staff, and could be trusted
to see that everyone was doing her duty. These difficulties disappeared auto¬
matically when the asylum was staffed by female nurses. He could not too
strongly express the satisfaction he found in the system, which was in working
order a considerable time before he left.

Dr. Wolseley Lewis said he was not prepared to agree with Dr. Legge

in eulogising the Scottish asylums at the expense of the English to the extent

which that gentleman seemed anxious to do. He was, however, in a position to
endorse all that Dr. Robertson had said in favour of female nursing on the male
side of the asylum, i.e., in regard to infirmary wards. For a good many years he
had had the infirmary wards on the male side of the asylum of which he was in
charge nursed by nurses, and he had every reason to suppose that it was an entire
success. When he introduced it he had some few difficulties, such as Dr. Robertson
hinted at, as it was a new departure. He had letters from the parents of nurses

who were going into the infirmary ward, asking whether he thought it was a

proper thing that nurses should be asked to nurse sick male lunatics. He had
many difficulties of that kind, and after a year or so he discovered that, so far
from there being any disadvantage to the nurses, he had found, as Dr. Robertson
had, that his nurses actually liked being in male wards ; the work was interesting,
and they stated that the male patients were better conducted and better behaved,
and they were more grateful to the nurses, than were female patients. He had
had no experience of female nursing in other wards than the infirmary ones,
because, unfortunately, structural difficulties stood in the way of it being done
in other parts, because it would mean mixing up the male and female staffs.
His infirmary wards were entirely nursed by females, by both day and night, the
male staff taking no part except in bathing those patients who were well enough
to be bathed in a bath weekly. Any washing of the patients in bed was done by
nurses. He could also confirm, from experience, what Dr. Robertson said with
regard to the class of patient that female nurses were willing to nurse ; they were
delighted to nurse any patient who was confined to bed; but in the case of men
patients who became unruly, who could get up and run about in their nightshirts,
they did not like them, especially if they were of an objectionable class. One
thing which Dr. Stoddart took exception to he also wished to take exception to,
namely. Dr. Robertson’s disposition to advocate the employment of hospital-
trained nurses in asylums. He was very much in opposition to that. His own
view was that their duty as an Association—and it was set out as one of their
aims—was to train their own nurses. He was not at all willing to accept the
suggestion that because a nurse had been trained in a hospital, she was a better

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nurse than was one who had been properly trained in an asylum. If that were
so, it constituted a very grave reflection upon the Association; it meant they
were not conducting the nurses’ training in the proper way unless that training
had the result of producing a more efficient article for asylum purposes than
hospital training could do. The reason, he thought, why women were so much
better in the nursing of sick people was, as Dr. Robertson so happily put it,
because there was implanted in them the mothering instinct; and there were very
many cases in his experience in which he had found that women had a most
beneficial effect upon the patients, not only sick patients, but recent cases. There
were many recent cases of melancholia, etc., in the nursing of which he found
women nurses infinitely better than men for the purposes of getting the patient
well. One thing which had very much struck him, as it had probably struck
everybody who had had experience of this kind of thing, was the remarkable
improvement in the tone of the patient under these circumstances. One took
an isolated patient, and, with some feeling of dread lest he should grossly
misconduct himself, placed him under the care of a female nurse ; but it was
soon shown that he improved in a remarkable manner. And it seemed, as the
author well said, that even in very bad patients the spirit of chivalry was not
entirely lost, and the mere fact of being placed under the care of a woman
reawakened that spirit, with the result that these patients, under the care of
a woman, were extremely well conducted. Yet, while not agreeing with
Dr. Soutar's contention, he was not prepared to suggest that there were not,
in English asylums, a large number of the most excellent male attendants ; but
he thought it probable that the latter were used more than they need be. He
believed that a very large number of the quieter patients, if in charge of female
nurses, woilld be much better conducted than they were now under the care of
male attendants.

Dr. Brander said he did not desire to encroach on the valuable time of the
Association, but the subject now under discussion was a contentious one.
During the last few years he had himself been severely tried by having a
number of male wards staffed by female nurses; and they had been more trouble
to everybody who had anything to do with the administration of the male side
than all the other wards in the place combined. He did not know how those
who so strongly advocated the system arranged the administration of these
wards: Were they under the matron, or under the head attendant, or under
both ? In the event of anything going wrong, did they mutually cast blame
each on the other ? He considered that the arguments which had been
advanced in favour of the introduction of female nurses into male wards were
fallacidus to a degree. It had been said that the mothering instinct of females
enabled them to nurse male patients better than male attendants could nurse
them. That his sad experience enabled him to utterly disagree with. He
admitted that female nurses would not attempt to employ violence towards male
patients ; they were not going to break any patient’s bones ; but, on the whole,
he thought their kindness towards male patients was not as great as that of
properly trained male nurses. Those who said that male attendants could not
nurse male lunatics as well as female nurses could, either were unable to choose
their attendants and train them, or they could not control them. If they could do
those three things, they would get male nurses who would do just as well, and
treat the patients quite as kindly, as would any female nurses. The argument
based upon economy had been advanced from time to time in this controversy;
and if anybody cared to go fully into that matter, he would find that while
female nurses were staffing male wards, patients did more for one another in the
way of personal attention, washing, feeding, etc., than would be tolerated in
a ward where female nurses were not employed; and wards could do with many
fewer male attendants than would be required in the case of staffing with females.
He remembered on one occasion transferring a male melancholic stuporous case
to a ward in which there were female nurses, and the patient’s wife came to the
speaker in a state of great agitation, asking why he had been moved to that ward.
His reply was that he had transferred him to a ward where there were female
nurses, who would treat him kindly. She replied that she was herself an asylum
nurse for a number of years, naming the asylum, and she knew that the male
attendants were kinder to the men than were the nurses. He regretted he could

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not argue against her point of view. One also had to consider the effect that
being in a male ward had upon the female nurses, and it was a very considerable
effect, one which could not be ignored. If the employment of female nurses was
restricted to looking after male patients in bed, he would not grumble. He
would like to learn the statistics as to how many female nurses in this country
had protested against going to do duty in male wards of asylums. He knew of
numbers who had resigned rather than go into such wards; and he sympathised
with them. The^ did not mind looking after the sick, but they did object to
attending to the sick who were up and about. Many times he had been asked
by patients who had been transferred to wards where there were female nurses to
transfer them back to those in which were male attendants, because they were
happier there. The tact and forbearance which women could admittedly exercise
quickly disappeared when the patients were unable to appreciate them ; and it
was replaced by harshness and irritability. With regard to the feminine touch in
male wards, there was no doubt that female nurses kept the wards tidier and more
artistic than did male attendants; they were instinctively given to it. But did
that add in any way to the comfort of the patients ? He could not see any
advantage in having female nurses in male wards, but he saw many disadvantages
in it. Dr. Robertson had said that at Morningside Asylum the attendants were
under a female staff, and he would like to know what inducements Dr. Robertson
gave them to improve themselves. They had no prospect of rising to a superior
position, nor, presumably, of increased pay ; consequently, either the staff did not
stay long, or they must be of a grade of intelligence from which a high standard of
nursing would not be expected. During the war an attempt had been made to
place male attendants temporarily in wards with females to assist them ; but any
persons of intelligence who were there in the institution would not remain in a
subordinate position under nurses, and he believed that was the case all over the
country. He did not know whether it was the experience of other people, but it
was his own, and he felt somewhat strongly on the matter. He hoped that from
what he had said members would be able to glean what had been his personal
experience of female nurses in male wards.

Dr. Hayes Newington said the terms of Dr. Robertson’s address rather
put him, the speaker, out of court, for he was discussing the employment
of female nurses in male wards in mental hospitals, of which he, Dr. Newington,
had no experience for many years. Still, Dr. Robertson asked him to say
a few words on the subject. The first thing which struck one was, as the
last speaker mentioned, that the subject was a contentious one. But he
thought both sides were right, and that both were wrong. He did not
think any man was in a position to say a woman could 'not do a large amount
of good on the male side of an asylum, but he thought it would be most
dangerous to accept the principle that the woman nurse was essential on the male
side. He would be willing to propose a general abstract resolution stating that
females should be used as much as possible in nursing male patients. But Mr.
Gladstone was wise enough to warn one against anything like a general abstract
resolution, because it was found to be very inconvenient when it was turned into
practice, and that was the case here. There could be no doubt that female
influence was extremely useful on the male side : and one might say that there
were cases in which a little male influence on the female side might do some good.
Some female patients were always better with the doctor than with members of
their own sex. But he thought it would be an intolerable nuisance if it were to
get abroad that it was the opinion of this Association that the female nurse was
an essential, because she could not be so in any way. There were many draw¬
backs. For instance, one could not be sure that all patients cared to be under
,emale nurses; they were not all sick people; many of them had retained the use
of their brains. He tested that two or three days ago by asking one of his gentle¬
men whether he would like to be nursed by a female, and he replied : “ By all
means.” The speaker found afterwards that this young fellow was in the habit of
discussing the attractions of the nurses. He was told that if he did have a female
nurse he would have to take her with him on his outings to Hastings, and his
views changed at once. The sexual question, though a serious one, could be dis¬
counted to a considerable extent; but in mental institutions one found sexual cases
which did not admit of females coming within measurable distance of them. He,

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the speaker, had some. They got on well amongst men, but he had several ladies
on his staff, and when they were going about he had to take special precautions
that those patients did not encounter them. If female nursing were adopted as a
general principle, cases such as he had mentioned must be moved and kept in
appropriate places ; and it might be that thereby much hardship would be caused
to those cases by the segregation owing to there being female nurses about. The
fact was that the question was hedged about by limitations, which must not be
forgotten in assessing the value of female nurses in the nursing of male patients.

Dr. Drapes said members would feel indebted to Dr. Robertson for reading his
paper and giving the Association an opportunity of discussing this most interest¬
ing subject. Pioneer work was always work which encountered opposition, and
that was natural in the case of a subject like the present one. But one fact was
worth a thousand arguments; and those members who had not had experience of
the employment of female nurses in male wards of asylums were scarcely in a
position to judge, or to come to a decision as to what was the best method to
adopt. The facts which Dr. Robertson had brought forward could not be put on
one side. The experience which the opener of the discussion related was not of
mushroom growth, but was one which, as the author said, had extended back for
sixteen years. And when Dr. Robertson said that he and his institution would not
revert to the old system on any account, he must have a strong conviction in his
own mind ; and he had brought forward sufficient material to warrant the conclu¬
sion that the system he had adopted was superior to the old one. Dr. Legge had
also become so impressed with the advantages of the system advocated by Dr.
Robertson that he, too, although at one time opposed to it, said he would not now
go back to the old one. He could not altogether agree with Dr. Soutar when he
said that insane people were not to be regarded as sick persons. How did one
know that a person was sick ? Was it not because he had disturbance of function ?
The mind was a function of the brain, and when a man's mind became disturbed
he was just as much a sick man as a man with albuminuria was the subject of
kidney disease. Members should not give up the idea that every insane person
was a sick person. Deformed and undeveloped persons, although not “ sick,”
were found in orthopaedic and other hospitals, and were quite analogous to cases
of congenital brain affections. He therefore thought that the " hospitalisation ”
of asylums came in as a natural sequence. And although Dr. Soutar’s speech
included some good-humoured banter directed against this idea, he thought it was
good to try to bring the routine of asylums into harmony as much as possible
with that of hospitals. And although he had no experience of it, he thought that
this system of female nursing in male wards of asylums would not improbably
constitute the keystone of the arch of the humane treatment of the insane in a
possibly not very distant future.

Dr. Fletcher Beach said that for six weeks he had had to put female nurses
into male infirmary wards at Cane Hill Asylum because so many of the male
attendants had been taken out of the asylum to serve the country. During that
period of six weeks he had watched to see how the change worked. He asked the
female nurses whether they wished to return to the female side, or would they
prefer to nurse the men; and their unanimous answer was that they preferred to
nurse the men, who were so much more amenable to treatment than were the
female patients. Dr. Robertson mentioned in his paper that on no account must
young nurses be put into the male wards. He, the speaker, did not agree with
that. In his infirmary wards he had four junior nurses—eight altogether in two
wards. He had carefully noted how they managed, and had asked the men
patients which they preferred, and they answered in favour of female nurses.
There was one man employed in the wards, and he attended to the bathing pf the
patients, shaving them, and such small duties. He would like to hear from
Dr. Robertson whether he would put his female nurses in charge of acute male
cases, such as acute mania, delirious mania, etc., because he mentioned that he
had two male attendants in some of his wards ; and possibly that was the reason.
Another point was that many patients were sent out to work on the land ; and he
assumed that Dr. Robertson would not put a female nurse in charge of such a party.
He would like to add his word of protest to that of others who had spoken against the
placing of the hospital nurse over the mental nurse. The Association’s nurses, having
had three years' training, were certainly as good as any hospital-trained nurse.

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Dr. Neii.l said that one of the points which certain gentlemen objected to was
the placing of a hospital-trained nurse in charge on the male side. That course
might not be essential later on, but in the commencement of the system of the
nursing of males by females it seemed desirable, because the ordinary asylum-
trained nurse had had no previous experience in nursing males, whereas the
hospital-trained nurse had, and she could instruct the asylum nurse in those
matters which were needed for the proper conduct of the ward. In an experience
extending over seven years he had never, at any time, found any difficulty in
respect of the management of the male patients by the female nurses. These
patients were usually quite amenable, and with a little persuasion gave in to any
instructions which the nurses gave them. He had spent many hours a day in
those wards, and he had never seen anything in the matter of behaviour which
could be taken exception to. Nor had he seen, among the nurses, any backsliding
in moral tone, a point which several speakers had laid stress upon, giving the impres¬
sion that they had been somewhat unfortunate in the nurses they had. He found that
with female nurses a great improvement took place in the appearance of the
patients; they were better cared for and were tidier, and the whole tone of the
ward was much raised as compared with the former conditions. The language,
which on occasion was very objectionable, always ceased with the appearance of
the nurse on the scene, and it was not indulged in when she was present. There
was the point raised as to the nurses who objected to being placed on the male side.
When the new system was started at the asylum with which he was then con¬
nected, the matron and the nurses were selected, and they were told of their
selection to serve on the male side, and were asked whether they had any objection
to going. No objection was raised by any of them. After they had been on duty
on the male side a few days they said they preferred working with the male
patients, and expressed the hope that they would not be transferred back again to
the female side. The reason given was that they found the men patients very
amenable, and that the male patients followed their instructions very much better
than did the female patients. It had been said that sometimes relatives objected to
female nurses looking after their male relatives. In talking with relatives of male
patients he had never heard such objections urged. Many of them, on the contrary,
were pleased that their sick relatives—and his experience was that many of the
patients admitted into asylums had some disturbance of their physical condition
too, and that when the physical condition was improved the mental condition often
cleared up—were being looked after by females, either while in bed or when they
were up and about the wards. Relatives were also, he found, pleased when they
knew a matron was in charge of the ward, because they considered it meant that
many of the little things which make so much difference to the happiness and
comfort of the patients would be attended to, when such was not likely if male
attendants were in charge.

The President: Before calling on Dr. Robertson to reply, I would just like to
thank him for re-introducing this interesting subject and giving us the benefit of
his extended experience since he first brought up the matter ten years ago, especi¬
ally now, as, owing to the shortage of male labour, many asylum superintendents
have nolens volens to employ women nurses in work hitherto done by men. In
such a controversial matter as this it appears to me that the point of view of the
advocates on each side is the main determining factor. Those who believe that
asylums are institutions sui generis, containing but a small proportion of actually
sick persons who are nursable by women, but the great proportion of whom require
attendance rather than nursing, will not agree with, or certainly will not go so far
as, Dr. Robertson in his strong advocacy of complete staffing of male wards by
women ; whereas those who believe, like Dr. Robertson, that the nearer a mental
hospital is made to approach a general hospital in ideals and practice will follow
him con amove. Personally I am a convert, with limitations—although, unlike most
’verts, not a bigot—to the nursing of recent and acute mental cases, as well as those
chronics in whom active bodily disease or infirmity accompanies mental disorder,
e.g., children, seniles, and some epileptics, by women nurses, but these should be
asylum trained; if hospital trained in addition so much the better; but I protest
most strongly against only hospital-trained nurses being placed over those only
asylum trained, either as officers or sisters; otherwise our system of training our
mental nurses is vain. I think “ hospitalisation," as Dr. Robertson calls it, is apt

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to become a fetish, an over-ridden hobby, and a man must be blind to common-
sense and facts who looks upon, and provides for, the great mass of asylum patients
in the same way as he would for general hospital patients. If asylums were divided
into the two classes of recent acute hospitals for mental disorder, and chronic institu¬
tions for chronic, non-recoverable cases, it would be different, and I for one would
be in favour of “hospitalising ” the former to any extent, but at present we have
not yet attained that ideal. As officer in charge of a war hospital, I have renewed my
acquaintance with some 200 general hospital-trained nurses, and, with the excep¬
tion of their technical skill in dressing surgical cases, the more I see of their general
ward work and management, the more highly do I think of asylum-trained nurses.
This discussion has been more on the lines of general principles than on individual
pros and cons, but I would like to refer to one “ pro ” in support of Dr. Robertson's
case which has so far not been mentioned in papers and discussions on this subject,
vis., I think it is a misuse and waste of male attributes to see a stalwart young man
training as an attendant doing his year in the sick wards, feeding an advanced
general paralytic, say, with sop, and carrying out other nursing duties, which,
without any shadow of doubt, are women’s work. Again thanking Dr. Robertson
for bringing this important and interesting subject before us for discussion, I will
now call upon him to reply.

Dr. Robertson replied to the points raised in the discussion.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

A Special Meeting of the Council of the Association was held on March 2ist,
1916, at 11, Chandos Street, Cavendish Square, W., to consider “ the grave situa¬
tion which it is feared will shortly prevail in asylums owing to the shortage of
experienced male staff.” The Council had before them a report from the Acting
Secretary which is appended herewith. A useful discussion took place and a
certain mode of action was adopted which will in due course be communicated to
the Association.

Report to Council.

2 1st March, 1916.

Mr. President and Gentlemen,

As many of the members of this Council are aware, on March 15th I sent
out circulars asking for certain information, so that I might have something definite
to place before the Council this afternoon.

These circulars were sent to the Medical Superintendents of the County and
Borough Asylums of England and Wales, numbering 86, and replies were received
from 73. From these replies we have to deduct 12—namely, 4 sent letters and no
figures, and 8 sent figures which were of considerable value, but certain questions
were unanswered, and it would have confused the averages to have included them,
so that the results are founded on 61 correct replies. The circulars were also sent
to all the registered hospitals, which number 14, replies being received from 10. A
few private asylums selected by myself were also asked to co-operate. I think it
gives distinct evidence of the business-like methods of many asylum superinten¬
dents that answers were in the greater number of cases received by return of post.
That the replies were so numerous is to my mind evidence of the great interest the
matter is arousing; though, it may be remarked here, that one member sincerely
trusted that this would be the last table he would be asked to supply on this subject.

The circular was arranged somewhat hurriedly, and the nature of some of the
questions, therefore, undoubtedly lend themselves to criticism. No. 4, for instance,
is ambiguous. The question I wished to put was this: “Suppose all your men
of military age leave, including those for whom the Commissioners have recom¬
mended exemption for only three months, how many men will you have left ? " In
some cases, no doubt, by the time all the men have been called up other temporary
men will have been obtained, and these should be included in the number. But
most superintendents are like myself, in that they are unable to procure temporary
assistance of any kind. By the notes attached to many of the replies, the question
was understood as stated. Still, no doubt the figures must be regarded as not
strictly accurate, but as giving a rough indication of the future state of affairs.

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Again, question 5, the number of "trained” men left, was one which could be
interpreted in a diverse manner. If the member replying had made a list by name
of those in his employ, I doubt if any difficulty would have been found as to whether
a certain individual should be classed as “ trained ” or " untrained.” Take, for
instance, a man of sixty years of age, with no previous asylum experience. He is
more a watchman than anything else, and in case of emergency would have little
idea what to do. By no stretch of imagination could he be called a “ trained ”
man. However, it must be confessed that the results afforded by this must not be
taken too literally, though they give a general idea of the straits in which many
asylums will be.

The following are some of the results of the circular in County and Borough
Asylums of England and Wales:

(1) Before the war the proportion of male staff to patients was 1 to 7 - 8.

(2) In the near future, unless the Board of Control will allow further total
exemptions, the proportion of attendants to male patients will be 1 to 13*1.

(3) The proportion of trained or experienced men will be 1 to 24'i.

if put in a different form, we have this average result: An asylum has 500 male
patients. There is a head attendant and deputy head attendant and four night
attendants. Before the war broke out there were 58 day attendants, picked
men in the prime of life, few being over 55 years of age. The expectation is
that shortly there will be 32 men, or three to each ward of 50 patients.
Many of these are old, with physical defects, and the whole asylum will only have
16 trained men for day duty. In these circumstances two questions arise:
How is any leave to be given ? and—What will happen when the staff are at their
meals? An outbreak of influenza would be a calamity.

In all 823 men were proposed by Visiting Committees for exemption, and total
exemption was recommended by the Board of Control in 203 cases, and partial
(for three months in most cases) for 406.

The number of female nurses employed in male wards is at the present time 225.
This is 6 per cent, of the male attendants in pre-war days, or one to 141 male
patients.

There are several specially hard cases which may be here mentioned. One
asylum expects to be left with one trained man to 122 patients. In other cases the
proportion will be one to 97 and one to 54. The proportions of less than one
to 40 were numerous.

One member asks indignantly—What is the use of discussion if it is considered
that “all men are equal” ?

With regard to registered hospitals, it is evident that some have been very
hardly hit. One correspondent, who has a fair number of male patients, many of
them suicidal, dangerous, and infirm, writes: “You can imagine our plight when I
tell you that an under-gardener and the chauffeur are the two best attendants I
have at present, and I expect to lose at least one of them.”

The requests for exemptions seem to have been generally sternly dealt with. In
all 63 were asked for, and 14 absolute and 24 conditional were recommended.
The result will be that cases will be refused. One member reports that already
he has been compelled to refuse a case of acute mania owing to insufficient staff.

The private asylum figures were found to be of no value. In the first place, too
few inquiries were made by me, and, secondly, each private asylum is run on
individual lines, which prevents any satisfactory summary.

Of-course it must be remembered that registered hospitals and private asylums
can " shut down ” either partially or totally if they desire, thus rendering the con¬
dition of affairs in county and borough asylums still more acute.

As will be noted in the circular, comments were asked for, and as many of the
communications were marked “ private and confidential,” it will, I think, be best
to treat all as such and mention no names.

Some of these comments were extremely interesting, and I am strongly tempted
to quote several in full, but am deterred by the length which this report would
then assume. I shall have to be content with a summary, which diminishes the
vigour, but will, I trust, give an indication of the feeling which prevails in asylums
on this matter.

There is a point which will create no surprise, but still it is only right to mention
it, that all the writers expressed the greatest desire to assist the country in obtaining

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as many men for the Army as possible. The Council does not need to be reminded
of the great sacrifices made by asylums in the matter of men, but it seems to me
that it might be advisable to bring the matter more prominently before the public.

In not a few cases no comments were given. No doubt the members felt that
the figures spoke for themselves; in fact one member actually said so.

The comments may be easily divided into two groups:

(1) A small one, in which the writers were satisfied.

(2) A very large one, in which great dissatisfaction was expressed.

Group I .—One member writes : " I feel bound to protest as strongly as I possibly
can against the policy of medical superintendents who desire to have any ward
staff at all exempted from service.” He states that his temporary staff are doing
their work well, and he seems to be about the only upholder of the value of these men.

A second, who is quite satisfied, may well be so, as he expects to have a staff of
145 men as compared with 158 prior to the war.

The third, who is apparently satisfied, has more men than he had prior to the
outbreak of hostilities.

A fourth, who has no complaint to make, intends to shut two male wards and
overcrowd the remainder.

Another will have 57 men in place of the normal 68, 35 being trained men.

Yet another thinks he will be able to manage. He applied for exemption for
24 men of military age, and the Tribunal granted absolute exemption, though the
Board of Control recommended only temporary exemption.

Group II is a large one, and, however impartial such a report as this should be, 1
cannot help being struck with the note of despondency and fear for the future
which the letters contain.

They all state that they have done their best to obtain temporary assistance,
and such temporary men as they have been able to procure have been unsatisfactory
in the highest degree. In country districts the needs of agriculture are paramount,
and in industrial centres where there are munition works the high rate of pay
attracts every available man, woman, and child. Applications, as suggested by
the Board of Control, to the regimental depots for discharged soldiers, have in many
cases not been acknowledged, and in no case has a man been obtained. One member,
who expects to have 20 instead of his normal staff of 45, has inserted 1,000
advertisements with little result. What will happen in case of fire or a
Zeppelin raid is a point mentioned by not a few. All the strong young men
have gone, and their places taken by old men or others with severe physical defects.

One member writes : " The responsibility for accidents or other undesirable things
during this period of disturbance of our staff I have definitely disclaimed to the
Board of Control, who agree with my contention.”

One member, who has 402 male patients, states that he had 44 day attendants.
He has now 32, and it is proposed that he should be left with 16, 4 of whom are
quite inexperienced. He has advertised in local and London papers, communicated
with record officers, military hospitals, and convalescent homes, and has been able
to get only one man.

Another member, with 568 male patients, is appealing to keep 28 day attendants
in place of 60, but expects to be reduced to 24.

They nearly all refer to the increased numbers, the result of receiving patients
from asylums used as war hospitals. These numbers are brought out well by the
statistics, which show that in 61 asylums before the war there were 28,568 male
patients and there are now 31,896, an increase of n - 6 per cent.

In concluding this report I feel that the greatest thanks are due to the gentlemen
who so kindly supplied the information asked for.

I am,

Mr. President and gentlemen.

Your obedient servant,

R. H. Steen,

City of London Mental Hospital, Acting Hon. Gen. Sec.

NEAR DaRTFORD, Kent.

[Dr. Steen regrets that he has found it impossible to reply individually to the
many letters sent to him on the subject of the shortage of staff. He trusts that
the writers will take this short notice as an acknowledgment of their communi¬
cations.]

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Cnv of London Mental Hospital,

Near Dartford, Kent,

March 26th, 1916.

Medico-Psychological Association of Great Britain and Ireland.

Sir, —At a special meeting of the Council of the Medico-Psychological Associa¬
tion, held on March 31st, returns were considered from asylums, registered hos¬
pitals, and licensed houses, which revealed an alarming shortage of experienced
male attendants in these institutions. This shortage has been caused, and is daily
becoming more grievous, through the absorption of attendants into the Army.

It has been ascertained that Local Tribunals throughout the country are
sheltering themselves behind the recommendations of the Board of Control, and
that they have almost invariably refused exemption for indispensable men solely
on the ground that they have not been recommended by the Board of Control.

It is the opinion of the Council of the Medico-Psychological Association and
of superintendents of asylums, if it was intended that the list of recommenda¬
tions should be used in this way, that the number of exemptions recommended
by the Board of Control is wholly inadequate for the requirements of the asylums.

The view which the Local Tribunals take of the intention of the recommenda¬
tions deprives asylum authorities of the legitimate force of the arguments which
they submit to these bodies for the detention of men whom they deem to be
indispensable.

However sympathetic they may be, and however strongly they feel that the
application is a just and reasonable one, the Tribunals consider that they must not
go beyond or outside the recommendations of the Board of Control.

It is believed by the Council of the Medico-Psychological Association that the
intention of the Board of Control in issuing the lists of recommendations was
merely to secure the exemption of a nucleus of able-bodied and experienced
attendants, but that they did not intend that exemption should be confined to
these, or that the omission of a name from the list was tantamount to a decision
by the Board in opposition to the claim of his employer that the man appealed for
was not indispensable.

I have been asked to call the attention of the Board of Control to what is
believed to be a misuse of their list of recommendations in the hope that the
Association may receive an assurance from them, and that Local Tribunals may
be directed that the force of a claim for the exemption of attendants who are not
mentioned on the list must not be prejudiced by that fact.

The experience of members of the Medico-Psychological Association has made
it certain that, without such a direction to the Tribunals, asylums will be deprived
of the minimum number of efficient attendants, upon whom—as the Board of
Control, in common with Asylum Medical Officers, have hitherto recognised and
insisted—the humane and efficient care and treatment of the insane absolutely
depends.

I am, Sir, your obedient servant,

The Secretary, R. H. Steen,

The Board of Control. Acting Hon. General Secretary.

The Board of Control,

66, Victoria Street, S.W.

April 4th, 1916.

Sir, — I am directed by the Board of Control to acknowledge the receipt of your
letter of the 26th inst., and in reply I am to say that in approaching their duties
with respect to recommendations for exemption from military service, in order that
they might be placed in possession of the full facts of the position of the various
institutions as respects their staffs, they called for a return showing the names
and other particulars of every member of the male staff, divided into the following
divisions:

(1) Medical staff.

(2) Male attendants.

(3) Clerical and stores staff.

(4) Engineering and artisan staff.

(5) Farm and garden staff.

(6) Miscellaneous.

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The Board decided that their powers of making recommendations for exemp¬
tion only extended to Division 2, i.e., " Attendants on Lunatics in Institutions for
Lunatics.”

As was, it was hoped, made quite clear to the authorities of every institution for
lunatics, the absence of a recommendation by the Board with respect to any
member of the staff in Divisions i, 3, 4, 5, and 6 left it still open to the Visiting
Committee to urge freely their own claims before the Local Tribunals and
military authorities as respects these officers and servants; nor have the Board
any evidence before them that there has been any general or frequent tendency on
the part of Local Tribunals or military authorities to regard the absence of recom¬
mendations by the Board as being a primd facie reason for them to oppose
recommendations made by the institution authorities.

In a very few instances (not more than three in all) where some misapprehension
has been brought under the notice of the Board, they have communicated with the
Local Tribunals, pointing out that, as regards engineers, gardeners, artisans, etc.,
whose principal and usual occupation is not in relation to the patients, the Board's
view is that the Visiting Committee should at once apply direct to the Recruiting
officer or to the Local Tribunal for such exemption for these employes as they
may deem requisite ; and that in these cases the absence of any recommendation
from this Board should not in any way prejudice the hearing of the claim by the
Local Tribunal.

With respect, however, to Division 2, though independent application for
exemption may be made for special reasons not connected with a man’s work as
an attendant on lunatics (as set forth in Section III of the Regulations under the
Military Service Act and Section III of the Instructions to Tribunals as to volun¬
tarily attested men), it is not open to the asylum authorities to make application
for the retention of an attendant’s services qua such, or to the Tribunal to grant
exemption, unless such application has been supported by a recommendation from
this Board ; because, apart from such recommendation, attendants in asylums do
not fall within the class of exempted occupations.

I am to say that as regards Division 2, in making their recommendations for
exemption the Board did not contemplate that Asylum Authorities would, in fact,
endeavour to obtain exemption for any men in whose cases the Board had not felt
justified in making a recommendation.

While, from their several circular letters and the interviews they have had with
many of the asylum authorities concerned, the Board’s attitude towards the matter
is, it is hoped, generally understood, I am to say that, in the exercise of their
functions under the Military Service Act, the Board’s duty has been a divided one
—first, to ensure that no asylum should either be without a sufficient number of
trained able-bodied attendants, and, second, to facilitate the release of the maximum
number of men, compatible with the safety of the institution, for service in His
Majesty’s Forces. Due regard to the urgent needs of the latter fully justifies, in
the Board’s opinion, risks being faced, amenities being curtailed which would not
be permissible under ordinary circumstances, and a reduction in the high standard
of comfort and efficiency which has very properly characterised asylum manage¬
ment for so many years.

The Board regret intensely to be obliged to take up this position, which they
realise to the full must, in addition to causing anxiety and difficulties to Visiting
Committees and Medical Superintendents, react unfavourably to some extent on the
patients; but it is confidently hoped that this set-back will only be of a temporary
character and that its duration will best be shortened by the prompt release, for
the service of their country, of the maximum number of those who are likely to
make efficient sailors and soldiers.

I am to add that in case of any untou’ard event occurring, which is shown to
be due to the depletion of the male nursing staff, the visiting committee con¬
cerned can rely upon the active support of the Board, who, in the circumstances,
must indeed be regarded as primarily responsible.

I am, Sir, your obedient servant,

(Sgd.) O. E. Dickinson, Secretary .

The Acting Hon. General Secretary,

Medico-Psychological Association of Great Britain and Ireland.

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IRISH DIVISION.

The Spring Meeting of the Division was held by the kind invitation of Captain
Benson at Farnham House, Finglas, on April 6th, 1916.

The following members were present:

Dr. Hetherington, Dr. Drapes, Dr. J. O’C. Donelan, Dr. Rainsford, Captain
Lawless, Captain Benson, Dr. W. Eustace, Dr. Leeper (Hon. Secretary).

Dr. Hetherington having been moved to the chair, and before the business was
proceeded with, the Chairman drew the attention of the members to the loss the
Division had sustained by the death of Dr. O'Neill, Superintendent of Limerick
Asylum. Dr. O’Neill was always a regular attendant at the meetings of the Divi¬
sion. The following resolution was proposed by Dr. Drapes, seconded by Dr.
Rainsford, and passed in silence, the members standing in their places :

“That the members of the Irish Division desire to record their sincere regret at
the loss the Association has sustained by the death of their late esteemed friend
and colleague Dr. O’Neill, and wish to tender an expression of their sympathy to
the members of his family in their bereavement.”

The Hon. Secretary was directed to forward a copy of the resolution to Dr.
O’Neilf's family.

The minutes of the previous meeting were read and signed, and some correspond¬
ence dealt with. On a ballot for the office of Hon. Secretary and two representative
members of Council for the Division being held, Dr. Leeper was elected Hon. Sec¬
retary, and Drs. Nolan and Rainsford were unanimously elected representative
members of Council for the ensuing year.

Dr. Rainsford and Dr. T. Adrian Greene were elected examiners for the Associa¬
tion’s Certificate in Psychological Medicine.

Joseph O'Carroll, M.D., F.R.C.P., Physician, Richmond and Whitworth Hos¬
pitals, Lord Chancellor's Visitor in Lunacy, and Allan S. Grimbly, B.A., Lieut.
K.A.M.C. (S.R.), M.B.Univ.Dub. (unconferred), Assistant Medical Officer, St.
Edmundsbury, Lucan, were both unanimously elected members of the Association.

The following dates were fixed for meetings of the Division for the ensuing year :

Autumn meeting, November 2nd.

Spring meeting, April 5th, 1917.

Summer meeting, July 5th, 1917.

It was decided that the summer meeting should be held at Ballinasloe Asylum,
at the kind invitation of Dr. Kirwan.

After somewhat lengthy deliberation it was decided that at the autumn meeting
of the Division a discussion would be introduced by Dr. W. Eustace upon “ General
Paralysis of the Insane,” with especial reference to recent modes of treating the
disease.

Dr. Rainsford proposed and Dr. Drapes seconded a cordial vote of thanks to
Captain Benson for his kindness and hospitality in entertaining the members of
the Division. The Chairman, in putting the resolution to the meeting, which was
passed by acclamation, remarked that all the members felt greatly gratified by the
kind action of Captain Benson, who had come back from his military duties expressly
to be with them, and for the hospitality they had all received.

Captain Benson having replied, and having expressed the wish that the Division
should revisit him, the proceedings terminated.

SCOTTISH DIVISION.

A meeting of the Scottish Division of the Medico-Psychological Association
was held in the Hall of the Royal Faculty of Physicians and Surgeons, St. Vincent
Street, Glasgow, on Friday, March 17th, 1916.

Present: Drs. Buchanan, Carre, Clarkson, Crichlow, Donald Fraser, Henderson,
Hotchkis, Kcay, Kerr, Ivy Mackenzie, Oswald, Richard, Jane Robertson, Ferguson
Watson, Yellowlees.

Lieut.-Colonel Keay occupied the chair.

The Chairman stated that Dr. Campbell, Divisional Secretary, was prevented,
owing to illness, from being present at the meeting, and that Dr. Campbell had
arranged with Dr. Clarkson to act as Secretary at the meeting.

The minutes of the last Divisional meeting were read and approved, and the
Chairman was authorised to sign them.

Apologies for absence were intimated from Drs. Carlyle Johnstone, Turnbull,
Easterbrook, Alexander, and Tuach Mackenzie.

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1916.]

The Secretary submitted a letter of acknowledgment received from Lady
Clouston, thanking the members of the Division for the kind letter of sympathy
sent to her.

Drs. J. C. Orr and C. C. Easterbrook were unanimously elected Representative
Members of Council for the ensuing year, and Dr. R. B. Campbell was elected
Divisional Secretary.

Dr. R. Dods Brown was nominated as an Examiner for the Certificate in
Psychological Medicine.

The following candidate, after ballot, was admitted to membership of the
Association : William Blackley Drummond, M.B., C.M.Edin., F.R.C.P., Medical
Superintendent, Baldovan Institution, Dundee; proposed by Drs. Campbell,
Clarkson, and Keay.

Dr. D. K. Henderson read an interesting paper on “ Catatonia as a Type of
Mental Reaction,” which was discussed by Drs.Ycllowlees, Fraser, Hotchkis, and Ivy
Mackenzie. (A copy of the paper will appear in the July number of the Journal.)

Dr. D. K. Henderson also showed three cases of organic brain disease
(syphilitic), which were interesting from the point of view of onset, sympto¬
matology, and course.

(1) A depressed, self-accusatory, vague hallucinatory state in a man, set. 57, who
had well-marked physical signs of tabes dorsalis. The points which seemed to
warrant one in keeping the case separate from the usual case of general paralysis
were (1) the age of the patient; (2) the content of the psychosis ; (3) excellent
preservation of memory ; (4) retention of personality as evidenced by good insight
and judgment; (5) on the physical side—relative intactness of speech and writing,
and a negative Wassermann reaction both in the blood and cerebro-spinal fluid.

(2) A woman a:t. 46, who was first admitted to the Glasgow Royal Mental
Hospital in April, 1898, with acute hallucinosis. At that time she had certain
physical signs indicative of tabes dorsalis. She made a good recovery, worked
efficiently for four years, and then was re-admitted in 1902 in a euphoric, grandiose
state, and with very well-marked signs of tabes dorsalis. At the present time she
shows considerable mental deterioration, but her general health is well maintained,
and the Wasserman reaction is negative both in blood and cerebro-spinal fluid.
The initial state appears to have been a psychosis, not general paralytic picture,
associated with tabes, but now the condition has progressed, and the case is one
of tabo-paralysis.

(3) In contrast to the above two cases, this case is one of tabo-paralysis in which
the tabes and the paralytic process developed coincidently. The case, however, is
now of eleven years' duration, the memory is splendidly preserved, and the
Wassermann reaction is negative both in the blood-serum and cerebro-spinal fluid.

Dr. Jane Robertson read an interesting paper on "The Higher Type of
Mental Defective," which was discussed by Drs. Henderson, Clarkson, and
Yellowlees. (A copy of the paper will appear in the July number of the Journal.)

A vote of thanks to the Chairman for presiding concluded the business of the meeting.

MENTAL AFTER-CARE ASSOCIATION.

Report of the Council (Abridged).

' From January 1st to December 31st, 1915.

The Council of the Mental After-Care Association for Poor Persons Con¬
valescent or Recovered from Institutions for the Insane again has pleasure in
presenting the Annual Report.

The work of the Association, in spite of the war, has progressed satisfactorily,
and the Council takes this opportunity of thanking those subscribers who have
continued or, in one or two instances, increased their contributions, and also those
who have rejoined in response to the appeals sent out early in the year. As it is
impossible to hope to arouse much fresh interest during the war, and meetings are
deemed inadvisable, the continued support of all donors is earnestly requested,
and it is suggested that each subscriber might endeavour to secure one new sub¬
scriber of at least five shillings per annum. This would relieve the Finance
Committee of their possible anxiety respecting loss of income formerly received
from those who have found it necessary to retire from the list of subscribers.

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The Council feel that this unique charity, which is doing work untouched by
any other Association, should appeal to all those who have true philanthropy at
heart. The cases are very sad, often exceptionally difficult, and many patients
would have no possibility of relief from their perplexity or trouble but for the
help of this Association. That the work is greatly appreciated by those for whom
it is intended is abundantly proved by the willingness with which they endeavour
. to pay part, and sometimes the whole, of the expenses incurred in giving them
their fresh start in life, and by the way in which those who have been previously
helped, frequently of their own accord, when in happier circumstances, send
donations to help other cases.

Staff .—The Council has the deepest regret in announcing that owing to ill-
health, which has prevented Mr. Thornhill Roxby from taking an active part in
the work of the Association for nearly fifteen months, he has felt it imperative to
resign the Secretaryship of the Association, which he has held for twenty-eight
years. Throughout the whole of that period Mr. Roxby has worked in the most
indefatigable manner in the interests of the Association. In addition to the heavy
routine work, he has gone to much expense of time and money in visiting distant
asylums in the endeavour to interest the Medical Superintendent and others, in
establishing local branches and in arranging local meetings. Much effort has also
been expended in the visiting and inspecting in various localities of Cottage
Homes, on the character of which so much of the success of the work depends.
Mr. Roxby’s self-sacrificing devotion in these and other ways has very materially
contributed to the success of the Association. The Council, in accepting Mr.
Roxby's resignation, tender to him their high appreciation of his work during so
many years, and express the hope that, with restored health, he may continue to
take part in the work, to the success of which he has so largely contributed.

The Staff, under the direction of Miss Vickers, who throughout the year has
carried on the work of Secretary, has most successfully continued the activities of
the Association, and has dealt equally successfully with the new work arising from
the inclusion in the scope of our efforts of patients discharged on trial from asylums,
and the increased inquiry work entailed by the arrangement in relation to the
Adelaide Fund, alluded to elsewhere.

The Council has unanimously decided to appoint Miss Vickers to the Secretary¬
ship vacant by the resignation of Mr. Thornhill Roxby, and is confident that from
her long familiarity with the work of the Association, and the efficient way
in which she has carried it on during his absence, they are fortunate in securing
her services.

Cases .—During the past year applications on behalf of 379 persons were
received; of these, 270 were women and 109 were men. This total is only 6
more than in 1914, but as 46 more women applied than in the preceding year,
it seems likely that, had the conditions of the labour market been normal, there
would have been a correspondingly large increase in the number of men helped.
The result of the work has been very encouraging.

The finding of suitable occupations for persons who, although recovered, would
probably have great difficulty in restarting in life, is one of the most important
functions of the Association. The bestowal of a large amount of personal care
and individual attention to each patient is necessitated, and careful investigation
of the suitability of those with whom he is placed. The result of this part of the
work is far greater than the mere supplying of temporary homes, clothing, or
grants for maintenance and tools, important though these may be. The strongest
possible evidence of the utility of this charity is shown not only in the comfort
and aid given, but in the prevention of relapse, many who have had previous
attacks remaining well since they have been under the influence of the staff of the
Association.

Although only 379 were considered by the Council, this total does not at all
represent the number dealt with, as a large number of old patients wrote to or
called at the Office during the past twelve months, none of whom are included in
the above total.

Although suitably restarted in various spheres of work, many also require and
seek counsel from time to time. Advice is freely given enabling such patients to
overcome their difficulties satisfactorily, and tending to prevent mental strain,
which is particularly undesirable in the cases with which the Association deals.

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Conference with the L.C.C. Asylum Board .—After some correspondence, it was
arranged that a conference should be held at Spring Gardens, on Monday, Novem¬
ber 25th, when Lady St. Heliers presided, and this Association was represented by
the Chairman (Dr. Rayner), Dr. Percy Smith, Mrs. Marriott Cooke, and the
Assistant Secretary. Mr. H. F. Keene, Clerk to the L.C.C. Asylum Committee,
explained that the Trustees of the Queen Adelaide Fund wished to apprdbch the
Mental After-Care Association with a view to its co-operation with them to ensure
a more useful distribution of that fund. It was suggested that in future this
Association should be asked to visit all cases discharged from the L.C.C. Asylums,
where there existed any doubt as to the advisability of a grant or as to its amount.
It was felt that the wide experience of this voluntary Society would be useful in
visiting and reporting on the home conditions of such cases, and although this
will, it is hoped, eventually mean a largely increased scope of work, the Council
at their next meeting unanimously agreed to adopt the suggestion.

It is hoped that this scheme will be iri working order early in 1916.

Vice-Presidents .—During the year the Association lost a valued friend and
supporter by the death of Mr. H. D. Greene, K.C., but the Council is glad to
state that Mrs. H. D. Greene has kindly taken an interest in the work and
promised to become an annual subscriber. Canon Gildea, D.D., a Vice-President,
has also passed away.

Council .—The Council received with much regret the news of the death of Sir
James Moody, for a very long time one of their number, who had taken much
interest in the work from its earliest years. Miss M. G. Wilde, Poor Law
Guardian (Kensington), has kindly consented to fill one of the vacancies.

A list of a large number of institutions from which cases have received assist¬
ance from the Association is appended, and the Report concludes with acknow¬
ledgments to various bodies for their support, including the Corporation of London
and a number of the City Companies, several Boards of Guardians, mostly in the
neighbourhood of the Metropolis, with a few more distantly located, and the Guild
of Help ; also some asylums where collections are regularly made on behalf of the
Association, and a few parishes in which contributions from the offertory funds
have been allocated to the same good object.

The Association serves a quite unique and beneficent purpose, which no other
charitable organisation fulfils, and deserves wider and more general recognition
from all those who have the welfare of the mentally afflicted at heart. Its Presi¬
dent is the Earl of Meath, Dr. Henry Rayner its Chairman, with Miss Vickers as
Secretary. _

OBITUARY.

Dr. C. S. Morrison.

The death of our late colleague while he had scarcely passed the prime of life
occasioned the sincerest regret on the part of his medical brethren and of those
of the public who had the privilege of knowing him. The following tributes to his
worth on the part of friends who knew him well have already appeared in the local
press, and we feel we cannot do better than reproduce them here :

“ With great regret we record the death of Dr. Cuthbert Stanislaus Morrison,
Medical Superintendent of the Hereford County and City Asylum, who, after an
illness extending over several months, passed away on December 17th, 1915, at
Clifton, Bristol, whither he had gone for the benefit of his health. Fifty-five years
of age, he leaves a widow but no family, and for Mrs. Morrison in her bereavement
the greatest sympathy will be evoked.

“The late Dr. Morrison was compelled to relinquish his duties at the asylum in
July last owing to a complete breakdown in his physical condition, brought on by
extra strain caused by additional work thrown upon him by the call for doctors
for the war, coupled with a large transference of patients from Cardiff, also neces¬
sitated by the war, on account of the accommodation there being required for
wounded soldiers. This influx occurred in May, and brought the total number
of patients at Burghill Asylum up to nearly 600, of which some 70 were from
South Wales. The reception of these patients and the work entailed in becoming
acquainted with the nature of the individual cases naturally imposed much addi¬
tional responsibility on the Superintendent, whose health had already become

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indifferent. As a matter of fact, but for these pressing duties, Dr. Morrison would
have taken leave at an earlier date, which would probably have had the effect of
prolonging his life. The Committee of Visitors, who manage the asylum, recog¬
nised his need for recuperation, and were quite ready to grant him extended leave
for the purpose, but the doctor's high sense of devotion to duty would not permit
of his doing other than remaining at his post under the special circumstances.
Dr. Morrison was regarded by the Visitors as an extremely capable superinten¬
dent, with not only a highly scientific, but also a practical, turn of mind, which
showed itself in various ways, much to the advantage of the economical working
of the institution, and, more satisfactory still, the benefit derived by the patients.
That his loss at the age of fifty-five will be very much deplored by the Asylum
Visitors need hardly be said, and those of the patients who are in a condition to
appreciate kindly and efficient treatment will likewise realise that they have lost a
good friend. One is supported in this by the fact that cases have been by no
means infrequent in which discharged patients have taken the trouble to write
to the late Superintendent acknowledging with gratitude the benefit they have
received while temporary inmates of the institution over which he presided with
distinguished success.

“ By the members of the medical profession in the city and county his great
capabilities as a mental specialist were recognised and highly appreciated, and
though he was not a man who sought to make many friendships—the nature and
extent of his duties hardly permitted of this—yet those he did make were deep
and lasting; and those who were closely acquainted with him held his forceful
character in the highest esteem.

“ Dr. Morrison received his medical training at Edinburgh University, where he
qualified in 1888, and where he was late demonstrator in anatomy. He was
appointed assistant medical officer at Hereford County and City Asylum, before
securing a similar post at the Derby County Asylum ; in later years he was
destined to return to his first love. This was some twenty-four years ago, when
he took the place of Dr. Morris as senior assistant under Dr. Chapman. About
four years later Dr. Chapman resigned ; Dr. Morrison was selected from among a
large number of highly qualified applicants as his successor, and thus held the post
of Superintendent for about twenty years. He was shortly due to retire on a full
pension. He wrote voluminously and with much force and enlightenment on
mental diseases. * The Inference of Local Degeneracy by Comparison with the
Vital Statistics of its People,’ which appeared in the Journal of Mental Science
in 1907, attracted much attention. A Fellow of the Royal Society of Medicine,
he was also a member of the Medico-Psychological Association, in whose affairs
he took a keen interest. In 1911 Dr. Morrison became Vice-president of the
section for Neurology and Psychological Medicine of the British Medical Asso¬
ciation. Of the Hereford and Worcester Branch of this body he was also an
ex-President, and for many years acted as Hon. Secretary. On one or two
occasions he came into the public eye. Once it was in connection with the
Aymestrey murder trial, when the prisoner Haywood was sentenced to death for
killing his wife. Dr. Morrison gave evidence for the defence as regards the
prisoner’s mental condition. A man must have been insane to commit such a
diabolical crime as was laid to his charge, the doctor urged; but the jury
found other circumstances to outweigh his evidence. The doctor held strong
views on the relation of alcohol to mental disorders, and emphatically protested
against the practice of some parents in the rural districts of giving cider to their
children as part of their midday meal. Dr. Morrison was an adherent of the
Roman Catholic faith. He was present at the sacerdotal jubilee celebration of the
late Bishop Hedley at Belmont, some years ago, and had the privilege of doing
honour to the venerable prelate in the recognised episcopal form.”

“An Appreciation by a Medical Colleague.

“ By the death of Dr. C. S. Morrison the medical profession of this county has
lost one of its most popular and distinguished members. Although it was gener¬
ally known that his health had not been satisfactory for some time, it was con¬
fidently hoped that a prolonged rest from his arduous duties as Physician-
Superintendent of the County and City Asylum would restore him to his former
vigour, and bring him back amongst us for further usefulness. To the great

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regret of all his friends this hope has not been realised, and we have to deplore his
demise at a comparatively early age.

“ In the profession generally, and also in the medico-psychological branch of it,
Dr. Morrison was regarded as a sound authority in his speciality and a successful
superintendent and administrator. He was for many years a prominent member
of the Medico-Psychological Association and the British Medical Association, and
for a considerable period he acted, with much acceptance, as Secretary to the
Herefordshire and Worcestershire Branch of the latter body, and quite lately as
its President.

“ In 1911 he was Vice-President and Secretary of the Neurological Section at the
annual meeting of the British Medical Association, and he also gave valuable
service to the old-established Herefordshire Medical Society. In these capacities
he proved himself to be a man of many parts and generous sympathies.

“ During his occupancy of the office of Superintendent at Burghill he saw great
additions and improvements, with every one of which he was associated and for
which he had unflinchingly laboured, thinking always of the comfort and well¬
being of the unfortunate people under his charge. For the welfare of the institu¬
tion he gave of his very best, and so high was his sense of duty, that even trivial
details were not deemed too unimportant to engage his personal attention. The
result of such devotion to duty, and the extra strain in several directions which he
lately encountered no doubt contributed largely to his breakdown in health. In
the committee room and at Association meetings Dr. Morrison was a forceful and
convincing speaker. He upheld his views strongly when once convinced that they
were sound, and was not slow to unmask anything which savoured of opportunism.
Whatever he undertook he did it with all his might, without a thought of self or
reward. Dr. Morrison did not make a great many really intimate friends; but to
the few who had the privilege of his intimacy he gave the firm hand of friendship
which lasted for all time. His was a large-hearted and generous nature which
radiated sympathy and kindness to all those who came within its reach. Upright,
unselfish to a fault, with a high sense of duty and universally beloved, he possessed
a personality which will live in the memory of all who knew him.”

Dr. W. H. Macfarlane.

On August 2nd, J915, from heart failure, Dr. W. H. Macfarlane, Medical
Superintendent of the Hospital for the Insane, New Norfolk, Tasmania. (Com¬
municated by Dr. G. F. Read.) _

CORRESPONDENCE.

To the Editors of The Journal of Mental Science.

Sirs, —Dr. Mercier, in your January issue, defines "cause” as “the necessary
connection between an action and the sequent change, or accompanying unchange,
in the thing acted on.” He had previously suggested that any circumstance which
prevents a change should be called the " reason ” rather than the cause of the
“ unchange.” This is a good distinction, though it seems to put out of action the
alternative clause in his definition. I do not, however, write to find fault, but to
show how it is possible to come still nearer to the basis of the idea of causation by
recognising yet another distinction—namely, that between cause and occasion.
For example, in the case of Newton’s traditional apple, the cause of the fall was
gravity, the occasion was doubtless the giving way of the stalk. The following
considerations will explain the distinction and show its importance.

Change is not supposed to take place per saltum ; it is always regarded as a
continuous process. A process of change in any system may be called complete
when it begins from one state of static equilibrium and ends in another such state.
Every process takes place by virtue of an expenditure of energy, and (when the
whole of the system involved in a complete process is taken into account)
the potential energy of the final state is always less than that of the initial state.
Any process may be considered under two aspects, either (1) as a change from the
equilibrium of greater potential energy, or (2) as a change to the equilibrium of less
potential energy. Under the former aspect it is called the cause; under the latter
aspect it is called the effect.

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The relation between cause and effect being that of different ways of looking at
the same process, we have next to trace the relation between “ occasion ” and
“ consequence.”

A balanced system may have its equilibrium either stable, or unstable; in neither
case can it begin to change without external interference, yet there is a marked
difference between the two. If the equilibrium be stable the system has no
potential energy, and any process of change which it undergoes must be the equiva¬
lent of (i.e., be caused by) the process of change in another system which may, for
purposes of calculation, be merged with it into a single composite system.

On the other hand, when a system is in unstable equilibrium, it does possess
potential energy, and if the balance be upset by the action of another system this
potential energy may be liberated, and a process of change may be initiated which
has no equivalent in the disturbing system. The changes in the two systems are
then related, not as cause and effect, but as “ occasion ” and “ consequence.” For
example, in a motor engine the movement of the machinery is the equivalent of,
and caused by, the motion of expanding gas in the cylinders, and the expansion,
again, is caused by the combination of the petrol with the oxygen of the air, which
supplies all the energy; but this combination is occasioned by the ignition, which
has little energy of its own, yet liberates a large quantity of potential energy from
the unstable mixture of air and petrol.

George Shann.

To the Editor of The Journal of Mental Science.

Dear Sir, —You will remember that in a weak moment I consented to review
some psychoanalytic literature for the Journal. In response to your request for
a paper for the Journal I find that the style of psychoanalytic writers has so
infected my mind that I am unable to write anything but the following, which I
am afraid you will regard as a descent from the sublime to the ridiculous
(sublimation). Your unhappy contributor, X.

The Psychoses.

It is entirely owing to the wonderful discoveries of the great master mind of
the day (Freud) that we owe the fact that the psychoses are now understood.
For did he not show us the way that when discussing paranoia a case of
dementia praecox should prove useful as an example? When an idea rises into
consciousness it is apt to be repressed into the preconscious, and finally submerged
in the unconscious, with at least one censor and sometimes two ready to pounce
upon it should it raise its unhappy head.

Our critics who fail to understand our position weakly ask for some proof of
such a statement. Thereby they show their ignorance and unwittingly reveal that
they themselves are suffering from unconscious complexes. If they refuse to look
down the telescope of Galileo psychoanalysis cannot be held accountable. Besides
this there are numerous cases in the literature which can be made to prove any¬
thing you like if only apperceived from the proper view-point. As a paradigm
the following case may be quoted :—

A boy of six years of age, physically healthy, suddenly developed an acute
psychosis lasting a few hours, with great depression, emotivity, and stereotyped
movements. The family history revealed little of importance, except that a
maternal grandfather had developed arcus senilis at the age of 70. The anamnesis
was that one afternoon he earnestly desired some chocolates, the property of his
little sister. Undeterred by parental warning a conflict ensued. He seized the
chocolates (wish-fulfilment) and greedily ate them, while his little sister cried
bitterly. He did more, for he repressed the dearly-beloved doll of the sister into
the water-butt at the corner of the house. On the return of his father from the city
the boy denied having stolen the chocolates, and even if he had taken one or two,
said he, it was because they were bad for the sister (rationalisation). Punishment
was decided upon and duly administered by the father, during which the symptoms
of agitation, stereotyped movements, etc., made their appearance. In addition a
strong hatred-of-father complex appeared (CEdipus complex), which lasted about
the same length of time as the symptoms just detailed. The psychosis lasted but

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a few hours in this case, but the boy, who was polymorphous-perverse, sublimated
his libido by teasing the cat, and recovery ensued. Such a case as this proves
the value of psychoanalysis, for had he been psychoanalysed he would undoubtedly
have recovered. That he was not psychoanalysed was not the fault of psycho¬
analysis, but because of the fact that no psychoanalyst was on the spot. I could
go on writing like this for yards if you like. [" Please don’t.”— Editor J. M. 5.]

BALLINASLOE ASYLUM.

In publishing the following item of news, which appeared in the daily press in
Ireland, we think it only fair to express our conviction that the deplorable state
of things described as existing in Ballinasloe Asylum is altogether exceptional as
regards Irish asylums generally. The fact that both the Medical Superintendent
and the Senior Assistant Medical Officer are absent on military service may
possibly be regarded as an extenuating circumstance. But, while admitting that
some derangement of management may have been due to this cause, it is difficult
to account for such a general demoralisation of an asylum staff as would permit
of the occurrence of the reprehensible conditions disclosed in the Inspectors'
report. We shall await with interest the result of the sworn inquiry which is to be
held into the circumstances:

Ballinasloe Lunatic Asylum.

The Inspectors’ Report.

Sworn Inquiry asked.

(From our Correspondent.)

Ballinasloe, April 3rd.

At the meeting of the Ballinasloe Asylum Committee to-day the report of the
Lunacy Inspectors on their recent inspection of the institution was read. It stated
that the patients in some of the male and female divisions were huddled together,
practically naked, in a cold ward, lying on wet straw,and the condition of things was
scandalous. They did not think that in any civilised country such a condition of
things existed as they found in the wards visited. It was hard to realise that
creatures who could neither speak nor act for themselves would be left in such a
manner.

The Chairman said it was a very strong report.

Mr. Millar asked who was responsible for the awful state of things.

The Clerk said that Dr. Kirwan, R.M.S. (who was in the R.A.M.C.), had said
that it would take £3 nightly to keep clothes on the patients and furniture in the
divisions referred to.

The Acting R.M.S. (Dr. English) said that she was not aware that the patients
were treated in the manner stated, and it had never been reported to her. The
proper thing was to hold an inquiry.

It was decided to call for a sworn inquiry on the Inspectors’ report.

ASYLUMS ROLL OF HONOUR.

We have been requested by Dr. Tighe, of Gateshead Borough Asylum, to state
that Dr. Hubert Shield, First Assistant Medical Officer, joined the R.A.M.C. in
November, 1914, and that fourteen members of the male staff have joined the
colours.

[This should have appeared in the January issue of the Journal, and we regret
that it was omitted through oversight.— Ed.]

THE LIBRARY.

Members of the Association are reminded that the Library at 11, Chandos
Street, W., is open daily for reading and for the purpose of borrowing books.
Books may also be borrowed by post, provided that at the time of application
threepence in stamps is forwarded to defray the cost of postage. Arrangements
have been made with Messrs. Lewis to enable the Association to obtain books from

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[April, 1916.

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the lending library belonging to that firm should any desired book not be in the
Library. In addition, the Committee is willing to purchase copies of such books
as will be of interest to members. Certain medical periodicals are circulated
among such members as intimate their desire to be included in the list.

The Committee desires to record the following recent additions to the Library:

Donations. —A complete set of Brain, presented by Dr. MacDonald; The New
Psychiatry, by W. H. B. Stoddart, presented by the Author; The Physical Basis
of Will ; Common Source of Error in Seeing' and Believing ; Introductory Lecture,
University College ; Heredity Variation and Genius, also an Essay on Shakespeare,
a^id an Address on Medicine, by H. Maudsley, presented by the Author, per Dr.
Rayner.

Purchases.—Dreams (1915), by H. Bergson; Interpretation of Dreams (1913),
by S. Freud ; Sixty-fourth Annual Report, Inspectors of Lunacy, Ireland (1915).

Applications for books should be addressed to the Resident Librarian, Medico-
Psychological Association, 11, Chandos Street, Cavendish Square, W.

Other communications should be addressed to the undersigned at the City of
London Mental Hospital, Dartford, Kent.

R. H. Steen,

Hon. Secretary, Library Committee.

NOTICES BY THE REGISTRAR.

Nursing Examinations.

Preliminary.Monday, May 1st.

Final ...... Monday, May 8th.

Professional Examination Certificate in Psychological Medicine and Gaskell
Prize, first week in July.

Essays for Bronze Medal must be sent to Registrar on or before June 14th.

NOTICES OF MEETINGS.

The next General Meeting will be held at 11, Chandos Street, Cavendish Square,
W., on Tuesday, May 16th, 1916.

The date and place of the Annual Meeting will be fixed at the Quarterly
Meeting on May 16th.

Irish Division. —July 4th, 1916; November 2nd, 1916.

The Annual General Meeting of the Asylum Workers’ Association will be held
at 11, Chandos Street, Cavendish Square, W., on Wednesday, May 17th, 1916,
chair will be taken at 3 p.m. by Sir John Jardine, Bart., K.C.I.E., M.P., LL.D.,
President of the Association.

The Annual Report will be submitted, Officers elected, and Presentations will
be made of Medals for Long and Meritorious Nursing Service.

Matters of much importance to Asylum Workers will be discussed, and it is
hoped that there will be a large and representative gathering of members and
friends of the Association.

Tea and coffee after the meeting.

J. F. Powell, M.R.C.S.,

_ Hon. Sec.

APPOINTMENTS.

Erskine, W. J. A., M.D.Edin., Medical Superintendent of the Isle of Wight
Asylum, Newport.

Graves, T. C., M.B.,"B.S.Lond., Medical Superintendent of the Hereford County
and City Asylum, vice Dr. Morrison, deceased.

Fulton, Miss J. M., M.B., Ch.B., R.U.I., Assistant Medical Officer, Barming
Heath Asylum, Maidstone.

Irwin, Peter Joseph, L.R.C.P.I.&L.M., L.R.C.S.I.&L.M., Medical Superinten¬
dent, District Asylum, Limerick.

Fitzgibbon, Michael Joseph, L.R.C.P.I.&L.M., L.R.C.S.I.&L.M., Assistant
Medical Officer, District Asylum, Limerick.

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JOURNAL OF MENTAL SCIENCE, JULY, 1916.

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G. T HINE, F.R.I.B.A.

Ad tar,/ fr ll'est Newman.

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THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.']

No. 258 [ n, n w 0 .“T‘] JULY, 1916. VOL. LX 11 .

Part I.—Original Articles.

Occasional Notes on the Mental Deficiency Act. By Sir
Bryan Donkin, M.D.Oxon., F.R.C.P.

The purpose of this article is to review briefly a few of the
many questions that have arisen directly or indirectly out of
the interest taken of late years in the matter of the care and
control of the feeble-minded, and to comment on some of the
aspects of the legislative measure, known as the “ Mental
Deficiency Act,” which has ultimately resulted from that
interest. Some reflections by the way on this subject, about
which at the present moment there is necessarily but little
practical activity, may, I trust, be regarded as not wholly
inopportune. In offering to the readers of this Journal the
following remarks on some difficulties that have been raised
regarding the interpretation and working of the new Act, and
in noting certain misconceptions and more or less irrelevant
discussions that seem to have obscured the practical side of the
subject, I have but the excuse of a long-continued interest in
the matter of the due recognition of mental failure in all its
varieties, and* of my personal experience, gathered from the
study of criminals, touching the part played by mental defect
or disorder as a factor in the production of crime. These notes,
which are at least meant to be practical, will therefore tend to
circle chiefly round the questions of the actual diagnosis of
such mental defect in persons of all ages as is now officially

VOL. LXII. 30

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4/0 OCCASIONAL NOTES ON MENTAL DEFICIENCY ACT, [July,

registered under the term “ mental deficiency,” and of the rela¬
tion that seems to exist between mental defect generally and
criminality.

Before taking in detail the special points needing comment,
a short account of the happenings that led up to the passing
of the Act of 1913 may be useful, seeing that now, for the
first time, a legal import has been given to the term “ mental
deficiency.” We need not look back further than to the
beginning of the present century, when the National Associa¬
tion for Promoting the Welfare of the Feeble-minded, the
Charity Organisation Society, and some other bodies, strongly
urged upon the Government their belief that a great need
existed for placing under care and control large numbers of
both children and adults, who, by reason of mental defect, were
harmful to themselves or others, but, although neglected and at
large, were neither certified, nor deemed certifiable, under the
law of lunacy. As a result of a Conference, appointed by the
Home Office, on which several departments of Government and
other authorities were represented, a Royal Commission was
charged in 1904 to inquire into the whole matter. The
reference given to this Commission having a distinct bearing
on certain points to be mentioned presently, it seems useful to
recall it as follows : “ To co?isider the existing methods of dealing
with idiots and epileptics , and with imbecile , feeble-minded , or
defective persons not certified under the Lunacy Laws; and in
view of the hardship or danger resulting to such persons and the
community from insufficient provision for their care , training ; and
control , to report as to the amendments in the law or other measures
which should be adopted in the matter . . . ; and also to

inquire into the constitution , jurisdiction , and working of the
Commission in Lunacy and of other Lunacy Authorities in
England and Wales , and into the expediency of amending the
same or adopting some other system of supervising the care of
lunatics and mental defectives , and to report as to any amend¬
ments in the law which should , in their opinion, be adopted

The Royal Commission, after a /ong and minute inquiry,
reported in 1908. The following points in the Report,
immediately relevant to my purpose, alone concern us here.
First: The actual recognition of a large class of “ mental
defectives ” (thus specified in the reference) who were not
certified under the Lunacy Laws, but required care and control,

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471

Second: The finding that the largest class of such uncertified
persons consisted of “ mental defectives ” to whom the term
“ feeble-minded ” had been widely applied, at least in this
country, in distinction from the lower and more easily recog¬
nised grades known as idiots and imbeciles, many of which
could be, and some were, certified under the existing laws.
Third: The recommendation that the widely and duly
comprehensive term “ mental defect ” should be adopted as
the title of a new Act intended to cover all cases of mental
failure that needed care and control, while retaining as far as
possible, and somewhat clarifying, the existing terms now
applied to “ insane persons and idiots,” and bringing in, as by
far the chief addition to the content of the Act, the important
group of “ feeble-minded ” as indicated above^ 1 )

The adoption of the first two of these conclusions forms the
kernel of the new Act, and it is abundantly clear that the term
“ mental deficiency ” or “ mental defect,” as now used in the
Act, practically denotes such persons as were not, and are not
now, certifiable under the existing Lunacy Act. The third
conclusion, or rather recommendation, arrived at by the Com¬
missioners with a view to some amendments of the laws regarding
mental defect generally on a logical and practical basis, was, in
my judgment, unfortunately and unreasonably rejected in the
drafting of the Bill which ultimately became law in 1913.
The Act, as it now stands, tends to lead to the drawing of an
inappropriate line between “ mental defect ” and insanity,
while it leaves at least the lowest grade of the “ deficient ”
group, i.e., that of “idiots,” to be dealt with indifferently under
either the new or the old Act. One of the consequences of
this decision has been that the new Board of Control is, in
effect, composed of two parts, viz. (1) the pre-existing Com¬
missioners in Lunacy, and (2) some additional members, con¬
stituting a small minority of the Board, who were appointed
specially to deal with the subjects of the new Act of 1913. I
cannot but think that this want of coherent unity in the
constitution of the new Board may probably account for a con¬
siderable part of the difficulties that have been felt in the
working of the Act.

I. The first misconception to be noted out of those that may
have been, either directly or indirectly, occasioned by the Act,
is possibly in some degree attributable to the very title of the

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472 OCCASIONAL NOTES ON MENTAL DEFICIENCY ACT, [July,

Act itself, in which, as I have just said, the general term of
“ mental defect ” is used to denote only a certain class of
persons who are defective in mind. Such a use of these words
is certainly unscientific and likely to mislead. All “ insanity,”
“ mental unsoundness,” “ mental disorder,” “ mental deficiency,”
from whatever cause arising, involves, of course, defect in
mind. The only practical distinction between the new and the
old certifiables is that the former are mainly the subjects of
such defects as are described in the first section of the new Act,
and the latter mainly such as are named, but, be it noted, not
further described , in the Lunacy Act, as “ persons of unsound
mind.” These two groups, indeed, roughly correspond to the
old dichotomy of “ lunatic ” and “ idiot ” ; the first indicating
him who has been, but is no longer, compos mentis ; the second,
him who is fatuus naturalis or a nativitate mente captus. In
modern days this distinction is commonly made by the use of
the popular but inaccurate terms, “ acquired ” and “ congenital."
In former times some legal distinction was set up between the
two groups of cases comprised then under the comprehensive
and correct term of non compos mentis , which may well be
translated “ mentally defective ” ; for there were distinct writs of
de idiota inquirendo and de lunatico inquirendo. This differentia¬
tion was abolished many years ago ; but now we have again
two separate legal instruments, each professing to concern
distinct groups, but nevertheless showing by their contents that
some cases are dealt with indifferently by both.

However little the title of the Mental Deficiency Act may
be credited with causing the particular misconception now to
be noted, some commentators on the Act have fallen into the
surprising error, avoidable, it should seem, by even a small
acquaintance with the ordinary terms of psychology, of using
the words “ mind ” and “ intelligence ” as synonymous. Some,
on the one hand, have drawn the conclusion that the practical
recognition of mental defect depends on intellectual tests alone,
while, on the other hand, those responsible for the Act have
been accused of ignoring the fact that “ true mental defectives ”
do not form the whole of the subjects whom it is proposed to
control under the Act. The slightest study, however, of the
first section of the Act itself will show clearly that there is no
ground given in the Act for either the conclusion or the
accusation, The test by observation of conduct is clearly

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473

implied in the descriptions given of the various sub-groups
intended to be dealt with. Moreover, it is equally clear that
this test is really used implicitly in most certificates given under
the Lunacy Acts, as well as in the diagnoses or opinions formed
in many cases of mental disorder of any kind, even by non¬
specialists, or by ordinary observers. Further reference to
this matter will be made later in another connection. It needs
only to be said here that the word “ mental ” is employed in
its correct and accepted psychological sense throughout the
descriptions in the Act ; and that it duly denominates all
persons intended to be brought under the operation of the Act
II. The introduction of questions on the nature and origin
of mental defect has in various ways tended to raise unneces¬
sary difficulties in discussing the Mental Deficiency Act, and
has led to many diversions and disputes about heredity. The
Act as it stands has, however, clearly excluded the only practical
matters on which problems of heredity might bear, i.e., the
segregation or sterilisation of defectives for the main purpose
of preventing their reproduction and rendering illegal all sexual
intercourse with mentally defective persons. Any attempt at
comprehensive treatment of the various views regarding either
the causes or the modes of transmission of mental defect would
be quite outside the scope of this paper, which purports to be
as practical as possible. It must be recognised that, at present,
legal control of the “ mentally defective ” is, in effect, confined
to those who, left uncontrolled, either suffer themselves or are
the cause of suffering to others. Those of us, therefore, who
have been convinced by experience and by massive evidence
that obvious incapacity for efficient mental development, like
other capacities or incapacities for development, tends to “ run
in families,” and that in a vast number of cases signs of such
incapacity are observed in very early life, need not trouble
ourselves, when engaged in detecting or grading cases of
mental defect, either in children or adults, about any questions
concerning the origin or transmission of mental defect generally.
He who adheres to the Mendelian school of biologists may
conceive, if he will, that “ congenital ” or early mental defect is
due to the absence of the “ unit ” factor of “ mental normality,”
and that this absence is transmitted in accordance with the
Mendelian formula. The disciple of the biometrical school
may regard the cases called “ feeble-minded ” by clinical

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observers as but extreme cases of low capacity at one end of a
continuous line reaching at the other end to extreme cases of
high capacity. And all the biologists who reject the Mendelian
doctrine of unit-segregation (whether or no they admit that
mental defect tends to be transmitted on Mendelian lines),
may consistently hold the opinion that such mental defect may
often be a spontaneous germinal variation, possibly of the
nature of a reversion, and as such transmissible ; or that some
cases may be due to an arrest of development, cerebral and
otherwise, of later origin, including injuries and other bodily
affections occurring in foetal life or at birth. Yet those who
may hold these various views are not thus forced to disagree
seriously about the practical recognition and certification of
cases that need control under the Mental Deficiency Act. It
should always be borne in mind, when discussing the question
of heredity in this connection, that the Act, as we have seen,
has nothing to do with the proposal of segregation of mental
defectives with the express object of preventing their reproduc¬
tion, although incidentally, of course, segregation for any purpose
must necessarily have some considerable effect in this direction.
Yet a eugenic object of this kind in the Act seems to be
assumed by some critics. Prof. Pearson, for instance, in a
lecture on the “ Graduated character of mental defect, and on
the need for standardising judgments as to the grade of social
inefficiency which shall involve segregation,” first assumes
erroneously that those responsible for the Act regard the terms
“ mental ” and “ intellectual ” as synonymous, and then proceeds
to charge them with the consequent duty of obtaining accurate
knowledge of the nature, definition, treatment and source of
“ feeble-mindedness,” which term he employs as equivalent to
intellectual defect. This accurate knowledge he considers
necessary for the purpose of “ segregating the mentally defec¬
tive for life.” Professor Pearson, in this lecture, admits that he
has no direct experience of the mentally defective either as a
medical observer or as a teacher in special schools. But in
explanation of his taking this particular subject of “ feeble¬
mindedness” as prominently illustrating his opening announce¬
ment of a “ new scientific Renaissance which will cause much
scientific and medical work to be looked upon only as dogma
and quackery,” he states that some censores scientiarum or
watch-dogs of science are needed to warn the public against

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ignprance that parades as knowledge. His own censorship in
this instance amounts virtually to this : that the Commissioners
who administer the Act are bound to have accurate scientific
knowledge of the nature and source of feeble-mindedness,
because they appear to him to have espoused the Mendelian
doctrine which, he states, has so completely taken root regarding
it. Now it is certainly not true that any definite theory what¬
ever about the origin of feeble-mindedness has influenced the
framers of the Mental Deficiency Act; and it is unnecessary
to insist further on the fact that any practical difficulties which
may have occurred in connection with the Act’s working have
not been caused by such questions about the mode of origin or
inheritance of mental defect as are here referred to. Doubtless
it is possible that Mendelian doctrines may have partly
influenced some supporters of the original movement that led
up to the Act who were specially desirous of some definite
enactment, directed towards the diminution, or even, as some
enthusiasts seemed to think possible, the extinction of mental
defect. Some explicitly “ eugenic ” measure might well appear
to them to be favoured by the teaching that mental defect as
such is hereditarily transmitted in the germ-cells as a “ unit ”
character on a definitely detectable plan, and could, therefore,
be eliminated with apparent ease by segregation or otherwise.
Indeed, in a book on Feeble-mindedness : Its Causes and Con¬
sequences, Dr. Goddard, Ph.D., of the Training School at
Vineland, New Jersey, comes to the conclusion that normal
intelligence is a “ unit character ” transmitted in true Mendelian
fashion, and that the absence of this unit-character is the
“ cause ” of feeble-mindedness. And I have read somewhere in
a serious article, of which I can recall neither place nor author¬
ship, that “ anarchists ” are definite mutations and therefore
ought to be prevented by law from producing offspring.
Against all such unscientific assumptions as these no protest
can be too strong ; and Prof. Pearson’s criticisms in so far as
they may concern only Mendelian doctrines as applied to this
subject may be regarded as quite appropriate.

At present we have but little definite knowledge of the
cerebral and other organic conditions which we believe to
underlie mental manifestations generally of all kinds and
grades, normal or irregular, healthy or disordered ; and we are
forced to rely mainly on the clinical observation of individuals

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for indications of such mental defect as seems to render it
desirable or necessary that they should be placed under care or
control. Some knowledge has indeed been acquired by studies
of the minute histology of the brain ; and the researches of
Dr. J. S. Bolton, seem to indicate the possibility of demon¬
strating the close association of histological differentiation with
individual differences of mental potentialities—an association
which has, clearly, a high degree of probability a priori. Dr.
Bolton maintains that there is a decided difference between
the condition of the cortex of the pre-frontal region of the cere¬
brum of an “ ament ” and that of a “ dement.”( 2 ) He defines,
however, from the anatomical standpoint the term Amentia as
signifying “ the mental condition of a person suffering from
deficient neuronic development,” and the term Dementia as
signifying “ the mental condition of those suffering from perma¬
nent disability due to neuronic degeneration following insufficient
durability ”; while, from the clinical standpoint, his use of
these terms is apparently special to himself, and seems to
depend to some extent on the histological condition he would
expect to find on examination.

It is possible, again, that some future comparative study of
the brains of human defectives and anthropoids may throw
some light an the question whether manifest degrees of mental
deficiency can be regarded as truly reversional in character ;
but it must be admitted at present that from the point of view
of direct physical examination, and clinical investigation of
cases of feeble-mindedness generally, we'are without means for
fixing any definite standard by which to measure accurately
what we recognise as mental defect. I would insist, however,
that in practice degrees of “ mental defect ” justifying the
control of persons for the benefit either of the community or
of themselves, or with both these objects in view, can be dis¬
covered in each individual case that may come in question by
the study of their conduct, and capacity to learn what is
fundamentally necessary for a human being to acquire in order
to live sanely and safely, and more or less successfully, with
his fellows ; and, further, that such mental defect may justly
be regarded, for practical purposes, as a recognisable condition,
involving faults of mind and brain, equally with cases of what
is known as “ insanity,” and equally without the aid of any
definite intellectual standard.

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477

III. VVe come now to some difficulties that have been felt
or raised in the matter of certification under the Mental
Deficiency Act of both children and adults.

(i) It is to be noted, first, that the descriptions of the various
clinical groups of persons deemed to be “defectives” within
the meaning of the Act are placed prominently in the first
section, and that an inference has been drawn (partly, it is
possible, from this fact) that the Mental Deficiency Act
requires strict demonstration that the mental defect in question
has existed from birth or from an early age in any given case.
It is perfectly clear that in a large number of adult cases,
especially in criminals, no such absolute demonstration of the
congenital or other early origin of the defect can be given ; but
it seems to be no less clear that such an interpretation of the
Act cannot be insisted on, and should not give rise to
difficulty. The practical diagnosis of early or congenital
mental defect is of course made in a large number of instances
on the grounds of the similarity of the case under considera¬
tion to other cases known to be attributable to the origin in
question. This statement needs scarcely any expansion. It
is of general application ; and it is sufficiently illustrated by
the evidence as to insanity, based on expert opinion, that is
usually accepted as valid in courts of law. It cannot, indeed,
be doubted that the correct diagnosis of mental defect arising
from life-long incapacity is, as a rule, quite as readily made by
expert observers as that of any other class of mental unsoundness.
There is, it is true, nothing in the Lunacy Act that requires a
certifier to state explicitly to what date he can trace back
the origin of the patient’s disorder; but the absence of
this condition by no means renders him exempt from diffi¬
culties quite as great, or even greater than he might encounter
in the matter of certifying persons under the Mental Defi¬
ciency Act. Most expert evidence constantly accepted in
law courts, not only from doctors in cases of mental and
physical diseases generally, but also from witnesses on many
other kinds of technical questions, consists largely of opinions
based on reasoned inference. The law, of course, deals exten¬
sively with such opinions as facts, and expert counsel’s opinions
are frequently main factors in settling the fate, albeit not the
personal liberty, of many a suitor. Instances of difficulty will
doubtless arise in both groups of cases, and perhaps in the

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case of “ mentally deficient ” adults may more often require
some prolonged observations before a just conclusion is
reached.

It seems to me that where the difficulty of certification now
in question has really been felt, it may be partly attributed to
the possibility that some of those accustomed to certify under
the Lunacy Act, which contains no specialised description of
the cases it deals with, have now for the first time thought that
they had, in virtue of the descriptions in the new Act, to give
a decision of their own based on something more than “ facts ”
either observed by themselves or reported to them by others,
and that they have thus felt themselves somewhat at a loss.
It is, perhaps, also possible that an excessive tendency to juggle
with words might induce a counsel to seize an opportunity
which he may think this Act affords him for baffling a witness
and making a score.

It would have been almost unnecessary for me to dwell
on this particular point had I not met with some instances of
skilled observers who hesitate to certify cases of the nature of
which they are in no doubt, owing to a fear that if their
opinion were at any subsequent time called in question they
might be confronted with a fresh allegation which they could
not directly disprove, that there was nothing the matter in
early life with the subject of the certificate. It is, however,
hard to see why a difficulty of this sort should be more likely
to occur in the matter of this certificate than in some other
questions depending on reasoned inference. Before leaving
this subject I would note * here that the descriptions now
standing in the first section of the Mental Deficiency Act were
first proposed, though in a somewhat different form, in the
Report of the Royal Commissioners, and were intended to
serve as descriptions or convenient interpretations for practical
use of the current terms “ idiot,” “ imbecile,” “ feeble-minded,”
etc., and not as strict definitions of separate morbid states.
However, as I have said, I do not regard the difficulty in
question as highly important from the practical standpoint,
though I incline to think that it might not have arisen at all
had the substance of the measure of 1913 been incorporated in
one revised Act covering all cases that are now dealt with by
two. It is to be hoped that in time this anomaly may
disappear, in the interests of both science and practice, and

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that the law on the whole subject may thus be uniformly
interpreted and administered.

(2) The questions that have arisen concerning the due
certification of young children under the new Act are on the
whole somewhat different from that which has just been
noticed, and turn much on the difficulty of distinction between
cases of mentally defective children, properly so called, and of
children whose subsequent history practically shows them to
belong to the class which the terms of the Act would certainly
exclude. Now in a very large proportion of the cases of
children coming under question, ample and ready evidence is
available touching their history from birth upwards, both as to
their conduct and grade of intelligence, as indicating, together
with the actual examination of the expert, such a degree of
permanent mental defect as makes it unsafe to leave them
without proper care and control, and thus renders them
certifiable under the Act, either as “ feeble-minded ” or as
“ moral imbeciles.” But in many cases, suspected or roughly
classed as subjects of mental deficiency, there is doubtless a
considerable difficulty in rightly placing them ; and this diffi¬
culty necessitates not only careful and repeated observation,
but also a thorough testing, by properly chosen educational
experiments, of whatever faculties they may possess. The
more experienced the observer, the sooner may be detected the
difference between the congenital defective and the child who
is sufficiently teachable. There is a further question of con¬
siderable, but, in this special context, of somewhat subordinate
importance, viz ., that which concerns the proper grading of
feeble-minded children in schools adapted for such instruction
as they can receive. Into the first of these two questions has
been imported to some extent the confusion, already mentioned,
of the terms “ mind ” and “ intelligence,” “ mental ” and
“ intellectual ” ; and there has been a great tendency to forget
that in children, as well as in adults, the inference of their being
the subjects of “ feeble-mindedness ” is, and must be, drawn not
only from their low powers of learning what they are taught
in school, but also from the further positive evidence, gained
by observation as they grow up, of their deficiency in that
sphere of mental function which is commonly called “ moral,”
and concerns especially the question of fitness to live in society
without causing harm to themselves or others. Of course,

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even in young children there are cases where great incapacity to
learn, i.e., to understand or to retain what they are taught, is
quite enough by itself to settle the question of their “ mental
defect ” without waiting for the more overt acts, or omissions
to act, that may, later, afford prominent evidence of mental
defect, not only in these cases, but also in many others where
the defect of intelligence alone is not sufficiently apparent to
allow the correct diagnosis to be made. The practical differ¬
ence between the intellectually feeble and the- “ moral imbecile ”
has been known for long. Moral imbeciles were quite properly
introduced into the new Act as a group by themselves on
account of their importance as a practically recognised class ;
but they would certainly have been far better and more logically
placed as a sub-group of the “ feeble-minded.” Prof. Pearson
condemns, as we have seen, the application of the term
“ mental defective ” to the subjects -of the Mental Deficiency
Act generally, on the strength of his own use of the term
“ mental ” as exclusive of all the faculties of the mind except
that of the intellect, and appears not to have detected the
presence of the “ moral imbecile ” in the Act under the guise
of “ mental ” deficiency. He therefore proposes “ Social
Inefficiency ” as a term in substitution for “ Mental Deficiency,”
and apparently considers this proposal as important. But such
a mere change of terminology is neither useful nor, indeed,
practicable ; nor does it add to the means we have for distin¬
guishing the persons who should be cared for or segregated
under the Act ; and although Prof. Pearson seems to look for
the invention of some definite method of “ standardising
judgments” on grades of “Social Inefficiency,” he gives no
indication at all for devising any such scheme. The truth is
that all those who are conversant with the subjects with which
the Act deals are well aware that there is no standard, no hard
and fast line that can be laid down for fixing the qualifications
for the legal control of “ mental defectives ” any more than in
the case of other mentally disordered persons. The due
diagnosis between the feeble-minded and the normal-minded
with a view to certification is only to be made after a careful
study of each case. No definite method of standardisation is
to be expected. In saying this I fully recognise the difficulty
which must often exist in differentiating between such young
children as appear only at first sight, or for some time longer,

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BY SIR BRYAN DONKIN, M.D.OXON.

48 I

to be mentally defective within the meaning of the Act, and
such as prove to be really thus defective. For very often there
is no concomitant bodily defect or physical sign to assist the
diagnostician even after very careful search, and sometimes
there is a very doubtful previous history. Observation and
experimental attempts carried out by careful teachers will go
far towards elucidating the question of the likelihood of any
improvement. In no case of any difficulty should an
attempt be made to decide the question of certification in
a child without observation prolonged over a considerable
period.

It was remarked in one of the papers read before the Annual
Conference, in 191-5, of the National Association for Promoting
the Welfare of the Feeble-minded, that a school doctor is
expected to determine at a single interview whether a child he
has never seen before is mentally defective, or is simply
“ backward ” (t.e., as I suppose, suffering from effects of
neglect, ill-health, etc.). The writer correctly insisted that
many mistakes would thus be made by reliance on any standard
tests for intelligence. But we may surely trust that this pro¬
cedure by single interview is neither enjoined by authority on
any medical observer whatever tests he may use, nor allowed,
if its employment be known, to be repeated.

Concerning the general question of the use of standard tests
for grading intelligence in children, I can express only my
opinion, based on what I have heard or read, that there is good
evidence to show that the use of such tests as those known
under the name of “ Binet-Simon,” or others of like nature,
may be of value in practice by affording a ready means for the
preliminary grading of children in classes ; for recording cases
with a view to making a report, or to their transference from
one school to another ; or for serving as a help to observers
towards recalling the results of the successive interviews found
necessary in arriving at a decision. Although I have no
personal experience of this method of grading intelligence either
in children or adults, I have learned enough, especially from
papers read at the above-named Conference, at which I had the
honour to preside, to recommend to those who are interested
in this matter a study of' the report of the Conference ; and
also to infer that, short of being regarded as providing any
royal road to diagnosis or certification under the Act, or to

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giving evidence in a law court, these tests, cautiously employed,
may prove to be of practical use in some directions.

To sum up on the general question of testing a person’s mental
capacity in order to determine whether he is or is not “ feeble¬
minded ” within the meaning of the Act, I would repeat that
no mere sitting examinations can be expected to suffice. The
Act describes feeble-minded persons as those in whom there
exists from birth or from an early age mental defectiveness not
amounting to imbecility, yet so pronounced that they require
care, supervision, and control for their own protection or for the
protection of others, or, in the case of children, that they, by
reason of such defectiveness, appear to be permanently incapable
of receiving proper benefit from the instruction in ordinary
schools. The only way to determine whether the examinee
can do a thing is to observe whether in fact he does it. The
description points to defect in the way he manages his life in
all its circumstances and aspects, and this cannot be investigated
by any verbal examination. It can be tested only by observing
him in the circumstances of his life, and determining how he
behaves in regard to them ; how he deals with them, and how
far he succeeds or fails. In other words, the test is conduct.

IV. At the risk of some repetition, I desire to lay further
emphasis on the important conception of disorder of conduct
as the essential factor in the diagnosis of all kinds of what is
called mental defect. This concerns not only the matter
already passed in review, but also that which will follow in
treating of mental defect in relation to crime and responsibility.
Many years before I had much practical conversance with the
subject of mental disorder I became convinced that Mercier’s
now well-known teaching on this question was not only plainly
true, but also immeasurably useful in attaining to clear notions
of what insanity consists in, and of the right way to recognise
and describe it in individual cases ; and the strength of my
conviction of its importance has grown with increasing experi¬
ence. I had long been accustomed to hear that insanity could
not be defined, and at the same time to find, in books on the
subject, numerous and usually discordant accounts of it
purporting to be definitions ; but Mercier’s definition seemed to
supply all that was wanted by intelligent students as an intro¬
duction to a subject that previously appeared to many almost
as hard of approach as an uncharted land. It is now, I think,

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483

widely accepted that disorder of mind does exist outside
insanity ; that insanity cannot be defined as disorder of mind ;
and that the disorders of mind which take part in insanity are
inferred or discovered by observation of disorders of conduct,
without which the diagnosis of insanity cannot be made. Not
only skilled specialists, but also all medical men, as well as the
laymen who often form provisional judgments on a person’s
sanity, do virtually draw their inferences and opinions from
observations of conduct, not of mind ; not from what is thought
or felt, but from what is said or done. These inferences, which
may, of course, lead to still further inferences regarding the
cerebral and other bodily states that accompany or underlie or
more or less proximately cause the mental disorder, are based
primarily on the observation of defects and aberrations of
conduct, or, in other words, of a person’s action or inaction in
relation to circumstances. It would seem, indeed, that the
very formulation of this doctrine is its sufficient proof. Yet it
appears, not alone from a passage in the preface to the last
edition of Dr. Mercier’s Text-book of Insanity and other
Mental Diseases, but also from other indications, that the
explicit acceptance of this doctrine may not have made much
progress during the many years that have elapsed since its
promulgation ; and that, therefore, many persons may be
acting upon it, as M. Jourdain spoke prose, without knowing it,
or even when actually denying it, and thus hiding the truth in
their hearts while the words of their lips are far from it. I
certainly cannot corroborate the allegation of this doctrine’s
slow progress from my own observations, which seem rather to
indicate a fairly general recognition of the truth and utility of
Dr. Mercier’s teaching ; but, on the other hand, I am not in a
position to challenge it. Should it be true, I can but say,
miror magis. That very condition of the lunacy certificate
which demands the statement of “ facts observed ” implies the
fundamental truth of this doctrine. We cannot observe the
contents of another man’s mind or the function of those parts
of his brain which we surely conceive to be affected. Nor even
even if our knowledge should so far grow as to demonstrate
still further links in the chain of causation, such as metabolic
changes originating in other internal organs, would disorder of
conduct be any the less important as an essential element in
any clear concept or practical definition of insanity.

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In concluding this section of my notes I would shortly refer
to the importance of the conduct test in its special bearing on
the question of duly assessing degrees of responsibility in
persons charged with committing criminal actions, but appa¬
rently not rightly liable to the full penalty for what they have
done. Some cases of this kind come, of course, within the
category of “ mentally defective,” and especially “ feeble¬
minded ” persons, including the “ moral imbeciles.” Others
would be included in the long-recognised clinical class of
“ morally insane ”—a class which perhaps has been the chief
subject of dispute between physicians and jurists on the matter
of criminal responsibility. Now, this group of “morally
insane,” properly regarded though it may be by some jurists,
is still not legally placed or duly recognised, and is likely still
to cause trouble and confusion unless the well-known concep¬
tion of criminal responsibility nominally accepted in law under¬
goes material modification. It must be remembered that in
cases of each group we are considering there is very often
difficulty in proving defect in intellect by ordinary tests, or
indeed by any tests apart from considerations of conduct, t\e.,
of the actions of the persons in question, studied in their rela¬
tion to all the discoverable circumstances in which the actions
were done. The importance of the conduct test is thus seen in
connection both with the matter of the diagnosis of non¬
criminal cases of mental defect where the defect of intellect,
though existent, is not readily demonstrable ; and with that of
deciding the degree of responsibility in a person charged with
crime. In Mercier’s work on Criviinal Responsibility, published
over ten years ago, some important amendments of the usually
accepted legal formula concerning responsibility were suggested,
one of which was the addition to the clause concerning “ know¬
ledge of the nature and quality of the act,” of the significant
provision that in order to incur full responsibility a man must
not only know, but also appi'cciate , the nature and quality of the
act, and also know and appreciate the circumstances in which the
act was done. This addition, recommended by the joint com¬
mittee appointed to report on the matter, was adopted, as is
well known to the readers of this Journal, at the General
Meeting of the British Medical Association last year ; and will,
it may be hoped, secure as wide an acceptance in legal quarters
as has been accorded for so many years to the unamended

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doctrine which was an indirect issue of the Macnaghten case.
The only way to discover whether the criminal did know and
appreciate the circumstances is to study his action in those
circumstances, i.e., in other words, his conduct. It seems,
therefore, that full consideration of the acts done, and all the
circumstances in which they were done, will often be of great
assistance in cases of special difficulty, and will enable medical
witnesses to show that, although the accused knew , in a limited
sense of the word, that the act he did was wrong, he did not
appreciate all the circumstances and consequences of his act,
and thus misconceived and under-estimated its wrongness ; in
short, did not know how wrong it was. There are, of course,
many cases which, in spite of the too rigid conception of
criminal responsibility that has hitherto prevailed, are now often
dealt with by greatly modified sentences. Offenders of this kind,
though they may not be classed as strictly insane, should be
subjected to other and more appropriate treatment than ordinary
imprisonment. A case which is illustrative of these remarks
has very recently been under my observation, and I hope to be
in a position to refer to it in some further notes on “ Mental
Defect and Crime,” which, by the courtesy of the Editors, may
appear in a subsequent number of this Journal.

(') It may be noted here that Dr. J. S. Bolton in his recent book on The Brain
in Health and Disease represents the new Act as using the term “ mentally
defective ” instead of “ feeble-minded ” to denote the highest of the three speci¬
fied grades of defect. A reference to the Act would have shown that the contrary
to this statement is true.—(*) See Brain, Part cxxiv (1910). Journal of Mental
Science, 1905-1908, and Dr. Bolton's book already referred to.

Cases of High Grade Mental Deficiency By Jane I.
Robertson, M.B., Beit Memorial Fellow, Eastern
District Hospital, Glasgow.

There is a class of individual loose upon society whose
presence and significance in our midst seems, as yet, insuffi¬
ciently and improperly appreciated. These people are usually
of pleasant address, with all the outward show of civil social
observance; they are fluent of speech, readily adaptable to
circumstances, superficially in every way most plausible. How
does it come, then, that on closer acquaintance they prove to
be the scourge of their relations and friends; that many of
VOL. lx 1 1. 31

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them have a prisoner’s acquaintance with the police courts ;
that they are frequently embezzlers of money ; are guilty of
theft, drunkenness, and immorality of every kind ; that slander,
with all its miserable train of disintegrating influences,
emanates from them as a miasma ? Punishment is no deterrent
to their anti-social activities; they are supremely unaffected
either by the teachings of past experience or the forewarnings
of future suffering.

What are these people, then, and how should they be
regarded ? Briefly, they are cases of high grade ( 2 ) mental
deficiency that, for their own protection and that of society,
should be diagnosed and segregated as such. One case studied
in detail will provide a sufficient basis for further discussion.

G. N—.( s ) G—, a:t. 25 ; the eldest of a family of six ; from
birth till she left school at 14 in the sixth standard her health
and conduct were apparently normal; at school she was
intelligent, learnt quickly, and never had trouble in preparing
her work ; her games were fairly imaginative; reading books
of travel and adventure was always, and still is, a passion with
G—; needlework and housework have always been irksome,
but are done skilfully enough under pressure; G— has always
been of an irritable temper, and careless in details of personal
niceness.

Family history. —Except for one cousin who committed
suicide, no history of nervous or mental disease in other
members of the family is obtainable. The mother is a delicate,
highly-strung woman; the father, a master mariner, enjoys
good health; the other children are all small made, more or
less delicate individuals; G— is by far the sturdiest-built of
the family.

General physical condition. —G— is short of stature (4 ft. 11 in.),
well built, well nourished (8 st. 6 lb.). Her features are
rather heavy, but the expression is predominantly intelligent,
though frequently sulky and sometimes furtive. Irregular
movements of the eyebrows are noticeable, and sometimes
biting of the lower lip. The patient’s bodily movements are
alert, easy, and well co-ordinated.

There are no abnormalities of the circulatory, digestive,
respiratory, or nervous systems, and no outward physical signs
of degeneration.

Patient's career. —After leaving school G— remained at home

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for about two years, helping somewhat unwillingly in the
house, and attending night school to learn shorthand, book¬
keeping, and English. At this time her family learnt that she
had been telling untruths about her bad health, and the unkind
treatment she received at home. Shortly after she was 16
G— obtained a post as clerk, and her people discovered that
for the six months preceding this she had not attended night
school, though she had obtained money for fees, books, etc.,
and had left the house of an evening ostensibly to attend the
classes. Six months later the family moved to another house,
and G— went as clerk to another firm, where she remained
for two years. During these two and a half years G— gave
her mother her entire salary at regular intervals.

In the autumn of 1910 G— left her situation for no definite
reason and declared she had another, but after this only odd
sums of money were handed to her mother with prevaricating
statements. G— was not at work at this time at all, and the
money she gave her mother was borrowed from girl friends.
During this period she left the house in the morning, returned
for dinner and went out again, as though at work, but actually
spent her time with girl friends and wandering about ; she
gave tea-parties in other people’s houses and drove in taxicabs,
etc. In May, 1911, her mother first learnt of her conduct, and
remonstrated with her about it. G— promptly ran away next
. day, and spent the following eight months with friends in
Glasgow, completely out of her parents’ ken. In December,
1911, she was in the hands of the police for obtaining money
under false pretences from her friends, and her parents got into
touch with her again. To a lawyer who saw G— in prison she
related the following tale, the only commentary on which is
that it is entirely imaginary:

“About two years before May, 1911, accused was employed
in the office of a Mr. Wilson, and while in his employment
became acquainted with Archibald Colquhoun, Grand Hotel.
Colquhoun acquired an influence over her, and told her that he
had compromising letters written by her mother to a gentleman
in Cardiff, and had induced accused to leave her home.
Colquhoun instigated the offences under continuous threats of
disgracing accused’s mother. Accused was shown the letters
but was not allowed to read them, and the vile insinuations of
the man Colquhoun so worked upon the girl that she came

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completely under his influence. Colquhoun showed her certain
documents which bred the suspicion that accused was not her
father’s daughter.”

The charges in the indictment against G— may be sum¬
marised thus: “ On various occasions you did pretend to
A. M— that you were a Doctor of Science, and had been
elected a Professor, and carried on business as Dr. Garey ; that
you had been left £600 by a friend and £6,000 by your grand¬
mother; that your medical adviser was Prof. McCormick of
St. Andrews and Edinburgh ; that your lawyer was laid up
with fever in the house of Prof. McCormick at St. Andrews,
and was thus unable to send you money, and that you would
repay to the said A. M— any sums he advanced to you as soon
as your lawyer was able to attend to business, and you did thus
induce the said A. M— to deliver to you at various times and
places sums amounting in all to £74 5s., which you appropriated
to your own use,” etc. It is difficult to know which to admire
more, G—’s fertility of invention or her friend’s easy credulity.

In January, 1912, after completing a sentence of thirty days’
imprisonment, G— returned home; here she remained, restless,
irritable, and unoccupied, till May, 1914. During this period
she became acquainted with a Mrs. R—, wife of a seafaring
man ; in the husband’s absence at sea G— would often spend
the night with Mrs. R—, a gentle, affectionate, simple woman,
from whom and from whose father-in-law she wheedled sums
of money amounting to some £60. G— was to receive a large
legacy; she was a doctor and had a post at the Royal Infirmary;
she was setting up in practice at a very good address in Glasgow,
and had a motor and chauffeur and a staff of servants; a book
of housekeeping accounts, and of large sums spent on house-
furnishings, was left lying about for the admiration of her
friends. While intimate with Mrs. R—, G— had “ fits ” that
always came on when she was safely in her friend’s house; they
were characterised by sighing moaning respirations, aimless
movements of the arms, rolling of the head and eyes, while the
latter had an unseeing stare, movements of the tongue, and signs
of much physical exhaustion. These “ fits ” might be prolonged,
and alarmed Mrs. R— very much, who treated them with
petting and the application of hot cloths; apparently the
climax usually consisted of a cup of tea and toast, and not
infrequently a poached egg, which the nurse, not the patient,

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was too worn out to enj'oy. G— at this time purchased and
read medical books, and probably the “ fit ” had been read up.
When annoyed, G— would threaten to take her life, usually by
jumping from the fourth floor window, but no one, not even
Mrs. R—, ever took her seriously ; it was her method of getting
Mrs. R— to promise not to tell her parents about her, and Mrs.
R— kept faith with the girl, believing she had an unhappy
home.

In May, 1914, Mrs. R—’s father-in-law began to make
inquiries about G—, and when the girl was told she evinced
much alarm and fear, but no sort of contrition, and decamped
next morning to London, taking, without permission asked or
granted, 30s. from her hostess. G— remained in London,
living partly on money her mother sent, and partly on the
charity of a lady on whom she imposed for a short time, and
then about the middle of July she sent her mother her London
address, and the latter went and fetched her home to Glasgow’
at the end of the month.

G— remained at home only a week ; owing to the outbreak
of war, St. Pancras Parish Hospital, London, was short of nurses
and advertised in Glasgow for probationers, and her mother,
thinking it would satisfy the girl’s craving for change, sent her
back to London as a probationer nurse. Naturally no word of
her previous career leaked out. For a time things seemed to go
well, once G— had recovered from the shock to her self-conceit
when she discovered she was in a Poor Law establishment. In
May, 1915, however, her mother was summoned to London. It
seemed that G— had borrowed money amounting to £11 from
her fellow nurses, that she had run aw r ay on May 22nd, leaving
a note threatening suicide, and giving her address till that
evening, that she had promptly been captured and brought
back to hospital, and was being cared for as a suicidal patient
and under constant observation. G— seems to have been much
surprised and annoyed at being taken so literally, but on
May 28th she was certified, and admitted to an asylum as a
suicidal case. The hospital nursing staff spoke nicely of G—,
whom they seem to have liked, and whose tales as a sea-
captain’s daughter of many voyages they had admired and
believed ; her experiences in an American leper colony had been
particularly interesting. Here, as in Glasgow, interesting
letters, to and from utterly imaginary people, had been left

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lying about where her fellow nurses would be likely to see and
read them.

In the asylum G— was considered as an “ exhaustion
pyschosis,” and was discharged “ recovered ” on June 15th,
and, after some confused arrangements, allowed to travel alone
to Glasgow, under care of the guard, with a shilling or two in
her pocket. G— left the train in the suburbs of Glasgow,
instead of proceeding to the terminus, where her parents
awaited her, and spent the night in a hotel. Next day, how¬
ever, she met her parents accidentally in the street and went
home with them, to be sent on the following day to the Eastern
District Hospital Observation Wards, as her parents considered
her utterly beyond their control.

Under observation G— has been found to be of an irritable
temper, requiring discreet control; on the whole, however, she
is a very active, not unkindly girl, pleasant with the children
and old patients; the restless, changing activity of ward life
suits her fairly well, until the confinement irks her. In
November, 1915, she seized a favourable opportunity and ran
away to a relation in a neighbouring town, but was persuaded
to return next day. Residence in the Infirmary has not dulled
G—’s gift, of vivid narrative. A number of the nursing staff,
seniors at that, have been much interested in her accounts of
pre-war visits to the Belgian towns, since destroyed by the
Germans; others were entertained with accounts of her
wedding trip to various Italian ports in her father’s ship, etc.

This account, much condensed, and with many quaint
touches necessarily omitted, brings G—’s history up to date,
and some of the more significant features of her case may now
be briefly indicated.

Summary.

(1) The time of onset of the romancing habit. With G—
it was first noticed by her sister about the age of sixteen, but
probably it had been in progress for a year or two before this.

(2) The mental alertness in childhood; the easily prepared
lessons; the voracious reading of tales of adventure and travel.

(3) The absence of any capability for concentrated sustained
mental effort which became apparent after G— left school
about the age of fourteen, and which, if anything, has become
more marked with increasing age.

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491

(4) The irritability of temper which leads to outbursts when
G— strikes. The greater frequency of these states of irrita¬
bility of late years. The marked physical restlessness. Mrs.
R— said that G—’s constant coming and going in the house,
and inability to settle to any occupation, were wearying in the
extreme to the onlooker. The idleness, combined with con¬
siderable manual dexterity when the particular occupation, for
any reason, proved entertaining.

(5) The need of attracting attention and admiration, which,
while it led to the purchasing at times of extravagant articles
of dress, etc., never in G—’s case overruled her habits of
personal carelessness, and even uncleanliness; she still needs
supervision in order that she may conform to the ward sister’s
standards in these matters. It was a source of grief to the
girl’s mother when she was called to London to find that G—
had failed to procure the artificial denture for which she had
been sent money, and that her hair was verminous.

(6) The absence of any warm affections; for instance, her
cruel tales about her people; the lack of real emotion at the
pain and trouble she has cost her family; her unabashed
attempts at resumption of intimacy with her victim, Mrs. R—;
this lack of affection is a point on which her relations, friends,
lawyer, and her nurses are all singularly at one.

(7) The absence of any real consciousness of guilt or shame.
There is annoyance and irritation, and even fear, displayed
when the situations in which G— always finally lands herself
become impossible, but neither in her letters nor in her conver¬
sation, when actually charged with her fabrications, is there
any genuine contrition or shame. There is no intellectual
appreciation of the significance of her conduct. Charged in
round terms with lying, G— either lapses into sullen silence
after doggedly asserting the truth of her fictions, or she prevari¬
cates with disarming skill and invention round the charge,
weakening its significance in every possible way, or else she
sometimes ends the matter with a half-helpless grin, and the
remark that she did not think that the first lie in any one
particular chain of fabrications would be believed, and then,
as she herself says in one of her letters, “ one lie means
thousands before you finish.” G— might thus be considered
either as an unscrupulous cynic deliberately playing with the
gullible fools who seem so numerous along her path, or as an

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impish child, whose naughty ballon d'essai having met with
incredible and unexpected success, is passively impelled deeper
and deeper into a sea of deceit by the culpable stupidity of
incompetent adults. Unfortunately, the problem is not so
simple as this, though there is an element of truth in the latter
view.

Though incapable of adhering to the truth herself, G— is quite
aware of the difference between truth and untruth, and is quick
to resent any report concerning herself of which she is made
aware, and which she says is “ untrue.” In a letter she writes,
“ I have always been off the straight.” G— knows it is wrong
to tell untruths, to take money under false pretences, to tell
unkind lies about her mother, etc., but all in an impersonal,
detached, external fashion; the wrongness of it has no vital
importance for her mentality, and therefore cannot act as a
deterrent when by telling untruths some immediate gratification
can be obtained.

(8) The curious lack of real cunning, as shown by the absence
of adequate precautions to prevent the lies being detected; they
are told as freely and unguardedly to acquaintances of the
family or to officials of the hospital where G— is under obser¬
vation, as they are to strangers whom they might be expected
to deceive. Again, the same individuals will be lied to re¬
peatedly after exposure. As her lawyer exclaimed in exaspera¬
tion when trying to analyse this aspect of her conduct, “ as a
criminal she is contemptible.” Mrs. R— put it that G—never
heeded where her tales led, but always trusted to “ something
turning up ” opportunely to save her from their inevitable
consequences. There has been superabundance of lying, of
inspired and plausible mendacity, but no sign of really intelli¬
gent criminal subtlety. G—’s offences are of the self-limiting
type of crime from sheer lack of wisdom, and inevitably lead
to the police court.

(9) The vices in which G— has not indulged. Theft does
not seem to have been committed in the ordinary vulgar
acceptance of the word, except perhaps twice, and that fairly
recently in her career. Deliberate theft is, however, one of the
declensions that G—’s morality, already not too high, will pro¬
bably undergo unless artificially prevented. Sexual immorality
does not seem to have been indulged in; nor is there any
evidence of any alcoholic habits.

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(io) The complete remembrance of the lies told and the
things done, of the money borrowed and spent, of the flights in
all their details, coupled with the inhibitory control, probably
very far from complete, of the lying habit when in contact with
her home circle. That is, the complete continuity in conscious¬
ness of the lies.

(n) The irregularly occurring flights that seem in each
instance to have been determined not by any real anguish of
mind, agony of regret, or paroxysm of shame, or any ascertain¬
able fits, but simply by annoyance, or fear, at a situation that
has reached an impasse.

(12) The absence of any anaesthetic skin areas, or of any
definite fits or emotional crises beyond what have already been
noted.

(13) The pleasant, intelligent, rather engagingair and manner
of the patient in her more even moods. When G— feels
important she fairly irradiates happiness, and manifests a rather
striking physical alertness and poise. G— seems to be attrac¬
tive to the people with whom she comes in contact, and is well
liked in hospital. Nevertheless, there is at times something
vaguely repellent about her that makes the accounts of her
irritable temper easily credible.

(14) G— has no delusions and no hallucinations that have
been discoverable during 7-8 months’ observation ; neither has
she manifested any real depression or exaltation.

Discussion.

G— may be considered as very fairly typical of all such
cases. The age at which the condition becomes apparent may
be even earlier, one case that has been reported lately in the
newspapers concerns a boy aet. 11. The precocity and the
voracious reading are typical, so are the lack of concentration
and persistent effort of any kind, and the curious busy idleness.
The irritability may or may not be excessive or defective.
Emotional and moral indifference, and an unjustifiable self-
conceit, are constant characteristics; as is the plausible yet
essentially stupid lying. The vicious habits indulged in vary,
of course, in number and degree. A pleasant, rather taking air,
combined oddly enough with something repellent, is also typical,
and is remarked on by numerous observers. The picture as a

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whole is always amazingly the same, but the colour gradations
vary within wide limits.

These cases are baffling, really more by reason of their
high degree of mental attainment than by their deficiency.
Figuratively, the vulnerable heel of Achilles is in his head and
so well concealed that the essential weakness due to its presence
there is just at first not easily appreciable. Minds such as
these are working at lower, more automatic level than the
average, and they are endowed with everything except the
power of earning by concentrated effort and industry the right
to the higher grade gratifications of civilised life. This more
automatic or reflex character is indicated in two ways; first,
by the typical physical restlessness, frequently exhibited as
spasmodic muscular movements, which in some cases may
develop into definite attacks of chorea ; second, by the need for
an immediate and indiscriminate satisfaction of any given desire.
Patients of this type are flotsam, at the mercy of impulse and
desire, over which they are unable to exercise any selective
control. They are incapable of not responding to the stimulus
of any passing whim, and they become guilty of technically
immoral actions, owing to their being non-normal, irresponsible
creatures in a moral society of responsible individuals. What
these people cannot earn, however, they covet, and if they
cannot earn the just rewards of effort, such as wealth,
respect, admiration, fame, or glory, etc., they nevertheless
can and do assume them. In these matters they even improve
upon the cynicism of Hamlet’s advice to assume a virtue
though one have it not. The amazing thing, however, that
is almost as interesting sociologically and pathologically as
the patient, is the number of supposedly competent people
who accept unquestioningly, nay, with admiration, the claims
he puts forth. No normal individual, of course, could support
life without the enjoyment, in some degree, of the higher
grade gratifications, sanctioned at least by his own, and prefer¬
ably supported by other people’s judgment. Thus there may
be in this, so to speak, insane theft of unearned gratification,
an element of a sense of deficiency on the part of these
patients; a concealment from others, and perhaps ultimately
from themselves, of an organic “ fault ” which causes an
unpleasant sense of personal inferiority. This view recalls at
once Janet’s (i) definition of the “ starting point of hysteria,”

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that it is “ a depression, an exhaustion of the higher functions of the
encephalon .” In the writer’s opinion, however, the cases under
discussion are suffering from a developmental absence of the
highest cerebral levels, and this brings them at once within
comparable distance of some of the manifestations of hysteria,
though it does not in any way identify the two conditions.
The relations between hysteria, epilepsy, and insanity are not
yet understood, nor are the confines of their territories settled.
In this connection it is worth noting that of seven cases of
which I have been able to obtain accounts, one has a family
history of insanity and epilepsy, one of insanity and “ nerves,”
one has already been the victim of an attack of acute insanity
as distinct from her permanent mental deficiency, and two at
least present to the trained eye the epileptic facies with its
suggestion of impulsiveness. The‘early manifestation of the
condition, however, in cases whose career can be completely
traced, seems to me a strong argument against considering them
in the light of hysteria ; these patients are suffering, in the
writer’s opinion, from a deficient development, from a degree of
primary amentia, not from a secondary dissociation of a possibly
feeble but complete mentality. Further, the permanent and
apparently incorrigible nature of the affection also supports
this view.

It is probably clear enough that G—, and all her numerous
brothers and sisters in affliction, are cases of insanity of arrested
development, of feeble-mindedness, or high grade mental de¬
ficiency, and, as in all really high grade deficients, the moral
manifestations of the condition are the most striking. That is,
G— is morally an imbecile, but the moral imbecility is probably
due to a mental deficiency, and is only its most striking mani¬
festation. As Maudsley (2) writes of cases of moral alienation :
“ One cannot truly say, however, that the intellect is quite
clear and sound in any of these cases, while in some it is
manifestly weak.”

Till the age of 12-14, G— was apparently normal enough;
she had an intelligent, ingenious child’s quick superficial
apprehension and love of the marvellous; a child’s lack of
wisdom and of appreciation of the relations of means to ends ;
the vague, arbitrary, externally imposed conceptions of right,
which have at first no emphatic internal sanction in a child’s
mind; a child’s simple, rather unintelligent emotionalism, frank

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selfishness and self-importance, lack of control, lack of con¬
centration, love of display and need of immediate gratification ;
a child’s uncertainty and indifference as to where falsehood and
truth begin or end; the low standard of personal cleanliness
that many children have ; a child’s utter lack of insight into its
own mentality. In spite of this, however, G— was probably
never normal, though her essential abnormality did not become
apparent till circumstances gave it scope for development.

Any child set. 12-14 will present any of the above qualities
more or less clearly marked according to the varying rates of
individual development, etc., but no normal child presents at any
one time quite so unpleasant and incongruous a mental whole
as do G— and her like. This is because the more primitive
phases of mental development in normal children are only
appreciated as dissolving views progressing steadily to adjust¬
ments more developed, co-ordinated, and harmonious. A
deficiency or redundancy barely becomes irksome to the
observer before it is found to have been more or less recti¬
fied ; its place, it is true, may be taken by another as glaring,
but it too in turn becomes appropriately co-ordinated, and, with
a sigh of relief, the parent realises that the child is no longer
the “young savage” of earlier stages. In G—’s case, how¬
ever, there has been no gathering up of the reins of cerebral
government by the highest intellectual levels, owing to the
developmental deficiency of those levels, and there results the
grown-up abnormal child with its insubordinate mental acquire¬
ments stereotyped and emphasised in all their unharmonised
crudities. It must be remembered that these cases are not
only suffering from the negative effects of a deficiency of the
highest grade mental levels, but also from the positive effects
of an abnormally uninhibited action of the lower grade levels.
The child that never grows up must keep eternal normal
childishness of body as well as of mind not to be an ineffably
tragic figure in a grown-up world.

Dr. Mercier (3) puts it thus in discussing these cases. “If
we pass in review the qualities that have been described as
characteristic of the persons in question, we cannot help being
struck by their similarity to the qualities of uncivilised man.
The fundamental defect in their nature, the incapacity for steady,
continuous, persistent industry, is eminently and emphatically
the defect in which the savage is most conspicuously inferior

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to the civilised man. The other qualities which are defective
in them are defective in the savage ; those which they possess,
they possess in common with him. In their shallow clever¬
ness ; in their manual dexterity; in their addiction to crude
artistic performances; in their fondness for sport; in their
sedulous care of their personal appearance; in that colossal
mendacity which indicates, not so much a disregard for truth
as a want of perception of it ; in their personal conceit and
vanity they proclaim aloud their kinship to the savage. Two
other qualities only are needed to complete the parallel ; and
neither is wanting. The lack of intelligent foresight, which
renders the life of the savage an alternation of orgies of gluttony
with intervals of starvation, is paralleled by the equal lack of the
same quality which his modern representative exhibits when
he squanders upon luxuries in a fortnight the means which, if
properly husbanded, would have kept him from penury during
the remainder of the half-year. And the complement and
obverse of this lack of foresight, that forgetfulness of past dis¬
tress which deprives the savage of his incentive to provide for
the future, not only performs the same office for the class of
men here dealt with, but prevents them from experiencing that
normal and proper depression and loss of self-esteem which
these repeated failures ought to produce. Even the impulsive
ferocity of the one is represented by the short-lived outbreaks
of anger in the other. In all essential respects the person
whose character has been sketched is a reproduction, at a
later date, of the qualities of his remote ancestors. He
* throws back ’ to his forefathers. He is an example of atavism,
of reversion. As a civilised man he is a failure, but he is a very
fair savage.

“. . . . This, then, is his position : he is out of adjustment
to his circumstances; moreover, there are no circumstances
to which, if left to himself, he can adjust himself. The unad¬
justment is due, not to disorder of the process of adjustment,
but to defect of the process. He is as wanting in the ability
to conserve his own life by his own efforts as is the imbecile
who cannot be taught the difference between a shilling and a
farthing. His defect is not of the same nature, it is true ; it
is not an inability to perceive the true relations among simple
phenomena; it is an inability to forgo immediate indulgence
for the sake of greater future benefit; and if we regard this

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inability as the foundation of morality, he may be classed with
scientific precision as a moral imbecile.” This extract con¬
tains probably both an over- and an under-statement of the
problem. The normal savage and the abnormal civilised man
are not essentially comparable, the latter does not make “ a very
fair savage,” but the picture drawn of him is so vivid that in
general terms it may well be accepted.

These cases then belong to, if they do not form, the class or
highest grade mental deficients ; they are of quite frequent
occurrence and are found in every social class, and in each are
accounted, for a time at least, among the clever and gifted.
Individual cases vary naturally in the exact degree and mani¬
festation of their mental handicap, but essentially, until the
deterioration due to evil habits sets in, they are an intelligent
set of people, usually of pleasing address, and, as would be
expected, showing few if any of the outward stigmata of
degeneration. Ironically enough, these high grade defectives
are ultimately much more severely penalised by society than
those of a lower grade. It requires little acumen to diagnose
the child who steals aimlessly and openly, who wears stolen
jewelry in the sight of the owner, who tells unnecessary lies,
who is idle, stupid, and uncleanly, and that individual is
promptly and properly segregated and placed under due
restraint before she has come into serious conflict with society.
The intelligent precocious youngster, however, whose plausible
fabric of lies is based on a not impossible foundation, whose
aberration from the normal is too subtle at first for proper
appreciation by the untrained, is rarely diagnosed in time to
prevent disaster to his victims, his relations, and himself. It
is only after prolonged experience of the insane irresponsibility
of these cases that they are sometimes considered in a proper
light, and it is fortunate indeed if by that time the patient has
not found himself in prison, or suffered social ostracism,
acknowledged of no man, and accepted of no institution. He
has all the mannerisms of sanity, but none of its principles,
and unfortunately his mannerisms are accepted at their face
value by most people until betrayed by the lack of principle,
i.e., the insanity; and then it is the machinery of punishment,
of retribution, not of sympathetic analysis, that is promptly
set in motion against him. The average individual eventually
sees in G— and her like merely social parasites of the worst

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description, battening on their more naive neighbours, and
does not pause to inquire why they should be parasitic, nor
what is the rational treatment that should be meted out to
them.

Bandied about finally between legal and medical authorities,
these people still remain round pegs in the square holes
whether of prison or asylum. The prison authorities regard
them as incorrigible and constantly-recurring nuisances, the
asylum authorities have little love for them owing to the diffi¬
cult atmosphere their peculiar mentality at once creates in
such specialised surroundings; in both institutions they are
sources of constant trouble and expense, and can hardly ever
be permanently detained even in the asylum. Yet these
patients are not criminally responsible, neither are they sane.
A third type of segregation would therefore seem imperative,
which, to be of any practical value, however, should come into
operation before ever the tedious and expensive medico-legal
conflict over the patient arises. It is therefore a matter of real
social importance that these highest grade defectives should
be recognised early in their career, and suitably cared for.
Their whole lives are anti-social, and they have a markedly
disintegrating effect whatever their social rank, and it is this
that makes them a social menace. At school and college they
exercise an evil influence over their companions, an influence
that is rarely fully appreciated by parents or guardians. I
know personally of one harum-scarum lad who was adjured by
his parents to take as his model a flagrant example of this type
of defective, so pleasantly had the latter impressed them with
his easy manners and accomplishments. Among the better
educated classes these cases almost always become involved in
dishonest pecuniary transactions of more or less magnitude,
money being so essential a factor for the gratifications of
modern life. As time goes on, more and more vices are
indulged in, and these people “ go under ” in various ways, are
cast off by outraged relatives, dismissed to the colonies, and
descend the social scale with much rapidity. The socially
inferior cases are less seldom involved in pecuniary trans¬
actions, at any rate of any magnitude, but their inveterate
mendacity in itself is always a disruptive factor in their lives,
and this, and their incapability of sustained effort, sets them
drifting from one temporary occupation to another. These are

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some of the people who swell the ranks of casual labour of all
descriptions ; men who drift from one more or less skilled job
to another ; women in domestic service who pass without a
“ character ” from one situation to another. Wherever these
people go, they create ever-widening circles of antisocial
influences based on irresponsible lies and actions. Much time
and money, often ratepayers’ money, is spent on each of them
before they pass out of existence, and it is spent in a manner
profitless to all concerned. Amazingly few ever seem to reach
proper institutional care. Out of 7 cases of which I have
been able to obtain accounts, 1 is in an asylum, 1 is under
observation, 1 has lately been compelled by his relatives to
enter the army, 2 are domestic servants, 1 was in service but
has died of cardiac disease, 1 was a partially-trained hospital
nurse but is now married.

Treatment of such cases in the sense of aiming at a cure is,
on the face of it, impossible. Treatment can only be directed
towards protecting these individuals from themselves and from
society, and society from them, and this means some kind of
suitable restraint. They are, however, an exceedingly difficult
people to deal with, and their detention must have a clear legal
sanction, as their endless chicanery and unfathomable plausi¬
bility render essential an absolute authority for the proper
control of their activities. As already suggested, the need for
this control is twofold, as there are at least two people con¬
cerned in the matter, that is, the patient himself and his
victim. It is in no flippant spirit that reference has already
been made to the havoc that these high grade mental defectives
can make in other people’s lives. There is a large proportion
of the community that needs active protection from the sinister
endowments of these by-products of civilisation. So firmly,
pace modern cynicism, are the foundations of civilised society
based on the convention of mutual trust and good faith, that it
is only a fairly small proportion of people who have insight
enough to suspect its insane abuse by these cases. The his¬
tory of every one of these high grade defectives shows that the
simple, the gentle, and the stupid, are their victims in purse,
reputation, and peace of mind, yet these form a large section
of our eminently respectable and industrious, and, therefore,
valuable citizens. The less astute members of society have as
good a right, and a greater need, to be protected from the

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subtle machinations of insanity as they have from the obvious
depredations of the ordinary criminal.

The cost of segregating these cases is always a matter for
anxious thought, but much has to be carefully considered before
the problem is dismissed as insoluble on those grounds. Against
the cost of providing suitably for them must be put the profit¬
less expense with which such cases always, sooner or later,
burden the State as embezzlers, “ in and out ” prison cases,
temporary asylum inmates, patrons of various anti-social vices,
parents of illegitimate children, and last, but by no means
least, as instigators of crime and vicious living in others.
Also it must be remembered that these individuals under
discreet guidance are capable of much-skilled manual, and
quite an interesting amount of mental, work, and it should not
be impossible to make them defray much of the cost of their
own keep. Again, many cases are of comparatively wealthy
parentage, and suitable maintenance fees might be charged.
The proper control of these high grade defectives would
undoubtedly be an economy for everyone concerned.

Environment during childhood does not seem to exercise
the slightest influence on these patients ; they occur in families
of good social position, of good parentage, and in which, under
exactly the same circumstances, several other children of vary¬
ing temperaments grow to happy, normal adult development.
The true mental defective, of whatever grade, is born, not made.

Granted, then, that these cases of defective mental develop¬
ment are a social menace, and require restraint of some kind :
how, and when, and by whom should we expect them to be
recognised ?

The mental defect in these cases only becomes apparent
during the years of late childhood or early adolescence. It
might therefore be considered that the parents would be the
surest observers of the condition, but this, except very rarely,
is far from being the case. Several things militate against
this. Not infrequently the parents are elderly people and the
children precocious and active, whose rapidity of development
utterly blinds their parents to their later shortcomings; or, as
in G—’s case, the parents are more or less shut out from the
child’s real life, which goes on at its debased level outside their
ken. The awakening in either case is a long and difficult
process and usually comes too late.

VOL. lxii. 32

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As a matter of practical fact it should be the schoolmaster
or mistress, failing really intelligent parents, who should be able
to warn the relatives of the developmental anomalies that they
are witnessing in the child. This is certainly the case in
boarding-schools where the leaving age is 16-18 or more; in
board schools the condition may hardly have begun to assert
itself before the age for leaving school, i.e., 14. All teachers, of
whatever social class, however, should be capable of recognising
the various indications of mental deficiency in their pupils
occurring at any age. The difference between these high grade
defectives and the lower forms is after all only one of degree, but
there are one or two points especially suggestive for the early
detection of the former, and not usually connected in the lay
mind with mental deficiency.

First, and perhaps most important of all, precocity of any
kind. Precociousness may be due to one of two causes, and
always requires judicious examination and treatment; it may
be due to a real and unusual development, or it may be due to
an absence of normal inhibitions, in consequence of which there
is temporary overaction of certain powers suggesting an apparent
precocity. The latter cases always end, as they begin, in mental
disability, the former in many instances also, except under very
favourable circumstances.

Second, voracious reading. Habits of excessive reading
should always be suspect; in itself reading frequently signifies
little, occasionally it may indicate a budding literary talent,
but, associated with other signs, it sometimes points to an
unoccupied indolent mind, of intrinsically poor imaginative
power, and a craving for constant external stimulation. The
large vocabulary and apparently great imagination of the cases
under discussion will usually be found to be merely reproduc¬
tions from sundry of their literary adventures.

Third, an unusual facility and flow of language, uncorrelated
with any attempts at original literary composition save that of
letter writing, which may, however, be excursive.

Fourth, a growing discrepancy between a child’s intelligent,
alert manner, and apparently quick apprehension, and its power
of reproducing good work of its own initiative; it is the
discrepancy that is important. Children merely of poor
mental initiative are rarely alert in manner, or apparently
quick of apprehension, and never clever at mere verbiage. That

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is to say, the ordinary child of average but slow mentality, the
perhaps “ stupid ” child, does not present at all the same
picture as the high grade mental defective.

Fifth, the permanence of an emotional and moral indifference,
not uncommon as a transient phenomenon in children.

Sixth, the permanence and expansion of a habit of ingenious
lying; most children are untruthful more or less, but the habit
is discarded as a stupidity during normal mental growth ; here
it is the ingenuity and plausibility of the lies, and the perma¬
nence of the habit, that are important.

Seventh, teachers should always consider carefully the child
whom, though to all appearances normal, its companions
tolerate good-naturedly as “ queer,” but treat as something
other than themselves. The more intelligent school and
college companions of most of these cases are usually well
aware of their oddity, and this in itself should constitute a
matter worthy the careful scrutiny of responsible people.

All educationalists hold that mere instruction does not con¬
stitute education ; the function of education is, as far as pos¬
sible, to prepare the individual for “ complete living ” (4); and
observant teachers, with this ideal in view, will find that it is
in this respect that they fail utterly with these high-grade
defectives. It is possible to convey to them a very considerable
amount of instruction, but they cannot be educated. It is
impossible to cultivate in these minds a proper apprehension
of the connection between actions and results, whence disorder
of conduct must be the inevitable outcome. After a given time
the proper continuous organisation of acquired knowledge
ceases to take place, there is no further real mental assimilation,
and no development of discrimination. Later still, of course, no
further knowledge at all is acquired. These cases cannot even
achieve the educational conventionalism that steers the stupid
individual safe through life; they are indeed refractory to
education in that they cannot accept it passively, nor benefit
by it actively. These children are not in normal reaction to
their social and moral surroundings, and it is of this conflict
with, and lack of progressive adaptation to, their surroundings
that the teacher should be aware whenever it becomes at all
serious. After some given point no further development occurs
in the individual in his preparation for the duties of life,
and it is this cessation of educational development that is the

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danger signal, and that, occurring sporadically in one child
amongst other children of normal progressive development,
should be fairly easily noticeable by the skilled and interested
onlooker. The suggestive indications are many, and their occur¬
rence should at least lead to the investigation and discussion of
their possible significance in every instance.

Thus the cases that are under discussion fail, owing to their
comparatively high grade development, to obtain classification
as defectives under the Binet-Simon (5) tests. Healy (6) attri¬
butes this largely to the fact that these tests call so much for
“ language responses,” in which he considers this “ verbalist
type of defective ” to be specially gifted, as some defectives are
gifted in arithmetic, etc. Some German observers share this
point of view, and crystallise their opinion in the irresistible
name of Pseudologia phantastica. The verbal fluency is un¬
doubtedly one of the signs that tend to conceal from the lay
mind any suspicion of the mental deficiency that it cloaks, but
it is after all only a facet of that very subtly-cut diamond, the
mind of the highest grade defective.

Reported, then, to the senior school authorities, to the
parents, and referred to suitable medical observation, it should
be possible to ensure the proper recognition of the greater
number of these high grade defectives, hitherto so largely over¬
looked and misunderstood, and to ensure their proper care, to
the mutual advantage of themselves and of the community.
The urgency lies in the early recognition of these cases before
they have come into any serious conflict with society. Cases
that escape the observation of the educational authorities should
be capable of being detected early in their career through the
agency of properly administered juvenile offenders’ courts. A
small number of such individuals will always, probably for a
time at least, slip through the meshes of both these sieves ;
ultimately, however, even these will be convicted, so to speak,
out of their own mouths, and suitably and safely provided for.

The crux, perhaps, of the whole question lies in the proper
education of school teachers, of all classes, in the elements of
normal mental development, and in some of the manifestations
of the more frequent and simple aberrations; seconded by the
frank recognition on the part of the medical and legal pro¬
fessions of the mental deficiency of such high grade cases, of
the utterly incurable, uncontrollable nature of the affliction,

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new disease to offer beyond a little more sexual excess. The
only nervous diseases that were not then attributed partly or
wholly to syphilis were tabes and general paralysis. Some
five-and-twenty years ago, when an eminent physician was
about to lecture upon the causes of insanity, I hazarded the con¬
jecture that we should hear a good deal about masturbation,
and I had no reason to repent of my prophecy. We may be
pardoned a little natural exultation when we contrast the
present state of aetiological doctrine with that which prevailed
in those dark ages. We had then no more reason for our
belief than Aristotle had for the belief that all heavy bodies
tend to the centre of the universe, but now we know that the
mental diseases that we used fondly to ascribe to sexual excess
and syphilis are, in fact, due to repressed complexes and
infantile incestuous longings. How foolish were our pre¬
decessors ! How enlightened are we !

Without impugning in the least the startling discoveries that
we owe to the cleanly imagination of Freud, I think it possible
that they may be supplemented by researches less recondite.
When I study his efforts to discover the causes of mental
disease, I am irresistibly reminded of the story of the Purloined
Letter. The detectives knew that it must be in the room, so
they groped up the chimney, pulled up the floor, sounded the
walls, probed the furniture, and ripped up the cushions, without
finding the letter, which was lying displayed prominently under
their noses all the time. It has occurred to me that our diffi¬
culty in discovering the causes of mental disease may possibly
be of the same kind. We may perhaps be looking in the
wrong places, and instead of searching for them in the privy
and groping in the night-stool, on the system of Freud, we may
possibly find them on the dinner-table, and in the sugar-basin
and the butter-dish. At any rate, we can pursue this method
of investigation without filing our minds ; and even if we are
unsuccessful, we can leave off with clean hands.

To this line of investigation I was directed by several con¬
siderations. First, it is beyond question that certain things,
when taken into the stomach, are capable of producing mental
disease. Alcohol is an example. Second, the defect of certain
constituents of the blood does produce mental disease. Creti¬
nism and myxcedema are examples. Third, whatever the
immediate source of these constituents, their ultimate source is

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in the food. If the ingredients of the products of the ductless
glands are not in the blood, those products will not be pro¬
duced ; and if the ingredients are not in the food, they must
be absent from the blood also. Moreover, fourth, it may be
that there are certain ingredients in the blood, and therefore in
the food, that are necessary to mental health, even without
elaboration and transformation in the ductless glands ; for
investigation has now discovered the existence and the
astonishing properties of vitamines. Whatever the nature and
whatever the mode of action of these puzzling substances, it is
beyond question that their absence from the food does pro¬
foundly affect not only the physical health, but the mental
health also. Hence I conjectured that it was possible investiga¬
tion might discover, in the antecedents of some cases of mental
disease, some error in diet that might have a causal connection
with the disease.

At this point a great difficulty presented itself. Granted that
one or more errors or peculiarities in diet were found among the
antecedents of mental disease, how would it be possible to
assure oneself that such errors or peculiarities were actual causes,
and not mere casual associates or antecedents of the disease ?
To ascertain this I naturally turned to the writings of logicians,
all of whom, and they are many, discuss this matter in their
chapters on Induction ; but alas ! I found that upon this
topic the logicians are as inept and as manifestly erroneous as
they are on every other topic that they discuss. Not one of
them affords any trustworthy criterion or test by which a cause
may be distinguished from a mere antecedent or associate, and
on this matter their writings are as confused and self-contra¬
dictory as they are on every other. It became necessary,
therefore, to examine afresh the whole subject, not only of the
nature of causation, but also of the methods by which causation
can be ascertained ; and the results of this examination are
embodied in the articles which have already been published in
the Journal of Mental Science. From this I may extract for
the present purpose the following principles, which are all that
have a direct bearing on the subject now under discussion :

First, that a cause is, strictly speaking, an action, more
loosely speaking, an agent exerting an action, on the thing in
which the change that we call the effect is produced. That
thing in the present case is the patient.

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Second, that before we can call an action upon a thing the
cause of any subsequent change in that thing, we must prove a
connection between the action and the change.

Third, that this connection may be proved in at least a dozen
different ways, the only ways applicable to the case under con¬
sideration being those included in the Method of Association.
When an action upon a thing is associated with a subsequent
change in that thing we must not infer that the action is the
cause of the change unless—

(a) We can isolate the action—that is to say, unless we can
be sure that it is the only action upon the thing at the time
that could have produced the change ; or

(b) The association is constant—that is to say, the effect
always follows the action, and is never present unless the action
has taken place ; or

( c ) Though neither isolable nor constant, the action is
associated with the effect more often than casual concurrence
will account for ; or

(d) Though the association is neither isolable nor constant,
yet when the effect is associated with the action, there is a con¬
stant peculiarity in the effect.

By applying these principles we can ascertain whether a
disease that is associated with what we may conjecture to be a
cause, is or is not due to that cause. Such testing of con¬
jectural causes has never yet been performed, except in the
case of infectious diseases. With the discovery of parasitic
micro-organisms the causes of a large class of diseases have
been ascertained, but our speculations as to the causes of non-
microbic diseases are much the same as they were forty years
ago. With respect to these diseases the custom is to hazard a
conjecture, and to speak of the conjectural cause as if it were
an ascertained cause ; and with respect to mental disease our
attribution of cause is chiefly determined by fashion. At one
time, as I have said, the only causes attributed were sexual
excess and syphilis. These were followed by heredity ; heredity
was followed by toxins ; toxins were followed by repressed
complexes. In vain have I called on their supporters for
evidence of the truth of these doctrines. Truth, as Dr.
Johnson said, is a cow that will yield them no milk, so they
are gone to milk the bull. The utmost and the only result of
my endeavours has been that the Medico-Psychological Associa-

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tion has altered the title of its Table of Causes, and now calls
it a Table of ^Etiological Factors. I do not think the change
was made merely for the sake of euphony. It was made, I
believe, with the intention of eluding my criticisms. Alienists
have the most profound and complete conviction that they can
alter the nature of things by altering their names, and that
when a new name is given to a thing a new thing has been
discovered. Thus, when that which has been known for many
years as primary dementia is called dementia praecox, they are
lost in admiration at the brilliancy of the new discovery, and
can scarcely find terms strong enough to express their admira¬
tion of the discoverer. They seek to abolish the terrors of
madness by calling it lunacy ; they seek to abolish the terrors
of lunacy by calling it insanity ; they seek to abolish the terrors
of insanity by calling it unsoundness of mind, which it isn’t, or
mental breakdown, or neurasthenia. I look forward hopefully
to the time when they will call it Mesopotamia. • They seek to
' abolish the terrors of mad-houses by calling them asylums ;
they seek to abolish the terrors of asylums by calling them
retreats ; they seek to abolish the terrors of retreats by calling
them sanatoria or mental hospitals. The last title carries a
subtle suggestion of self-complacency, for how great must be
that mind which can contain an entire hospital! I suggest,
with some diffidence, that it would be still more impressive to
call the hospital after a part or faculty only of the mind. We
might call it, for instance, an imaginary hospital. Following
the same easy and efficacious method, alienists propose, when
I show that what they call causes are not causes, to nullify my
criticism by altering the name and calling them cetiological
factors. One of my ways is to call a spade a spade, but
alienists prefer to call it an agricultural implement. It is
indeed a people that do err in their hearts, for they have not
known my ways.

So far I can follow Moses, but when he loses his temper and
proceeds to swear at his recalcitrant people, I must renounce
his leadership. Falstaff declared that he was as poor as Job,
but not so patient. I, on the other hand, may justly claim to
be more patient than Job, though perhaps not quite so poor.
His period of affliction was but brief. His friends sat by him
in silence for a week, and the whole of the subsequent discus¬
sion on Moral Conduct as a cause—I beg pardon, an zEtio-

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logical Factor—in Good Fortune could scarcely have lasted for
more than another week, after which his trial came to an end ;
but I have suffered my fellow alienists, as gladly as I possibly
could, for forty years, and for the whole of that time they have
erred in their hearts and have not known my ways.

Moreover, though Job was less irritable than Moses, and did
not go as far as actually to swear in his wrath at those who
were so wrong-headed as to take the other side in the discus¬
sion, and to refuse to adopt his views, yet it must be confessed
that his patience and forbearance have been a good deal
exaggerated, and fell far short of the meekness of Patient
Grizzel or the Nut Brown Maid. More than once he was
within an ace of losing his temper. “ No doubt," said he,
“ but ye are the people, and wisdom will die with you. But
I have understanding as well as you,” and so on. No one can
accuse me of such petulance, even towards psycho-analysts. If
they were to bring forward an argument, or anything that could
be passed off as an argument, or even anything that colourably
resembled an argument, in favour of their crazy system, I should
examine it, I trust, with patience, and with what gravity I couid
muster; but though it is my way, it is not their way to give
a reason for the faith that is in them. It is a people that do
err in their hearts, for they have not known my ways.

The following cases have occurred in my practice in a period
of about three years :

CASE i. —Footman, set. 27. Suffered for years from severe
headaches, and for the last four weeks from that form of
sleeplessness which consists in inability to get to sleep. For a
few days suffered from attacks of dizziness, and one very hot
afternoon, in one of these attacks, he acted so strangely that
he was taken to Bethlem, where he talked a great deal about
the country being infested with foreign spies. (This was
before the war.) He eats but little meat, but is very fond of
fat—fat meat of any sort, butter, and dripping, which he
spreads thick. Has four cups of tea per diem, with three
lumps of sugar in each, or nearly a quarter of a pound in all.
He was told to knock off his fat, butter, dripping, and sugar,
and to eat more meat. During the next week he had one bad
attack of headache and dizziness, and two slight headaches.
During the second week two slight dizzy attacks, but no head¬
ache. In each of the next weeks he had one bad headache,

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and after this they finally ceased. He was now sleeping well,
and completely recovered.

Case 2.—Woman, aet. 53. She feels muddled and dazed,
and the feeling is so severe that it keeps her awake at night.
With this there is pain in the head, which also is severe.
These symptoms have been gradually increasing for three
years, and are now bad enough to prevent her from working.
She does not care for meat. Eats it only at one meal a day,
and not more than five days a week. She is fond of fat, but
says she does not eat a great deal. Does not eat much butter
or sweets. She is told to regulate her diet, and soon ceases to
attend. Presumably her symptoms are relieved.

Case 3.—Clerk, aet. 26. A wave of confusion comes over
him, and he falls down, but does not lose consciousness or
hurt himself. For many years he has suffered from severe
headaches, coming on once a month, so severe that they
compel him to lie down. He goes to sleep and awakes pro¬
strate. Even if they come on in the street he feels inclined
to lie down then and there. His sight is not affected. He
does not care for meat, lives chiefly on milk puddings. He is
very fond of fat, and when he does have meat he eats the fat
and leaves the lean. Takes very little exercise. Has had the
headaches for fourteen years, and they have been gradually
getting worse. He is told to stop the milk puddings, to reject
fat. and to eat lean meat at least twice a day. At the end of
a week he reported himself greatly improved, and then ceased
to attend.

CASE 4. —Telephone operator, aet. 30. Very nervous. A
sudden noise or being suddenly spoken to makes her start
violently. She is losing her business memory—that is to say,
she forgets what she has to do. She is so nervous that she
screams when a dog comes near her, and cries when she enters
a church. She suffers much from throbbing pains at the back
of her head. She works in an underground room by electric
light from 9 to 6. Her breakfast consists of bread-and-butter
and tea. Lunch, tea and a bun. The same for tea. For
supper she has three or four days a week a chop or eggs and
bacon ; on the other three or four days bread-and-butter.
She is told to adopt a different diet and eat more meat, but as
her wages are only 14 s. per week she says this will be difficult.
She ceased to attend, and the progress of the case is unknown.

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Case 5. —Married woman. She has been depressed for
several years. The depression is now so severe that she con¬
templates suicide. Sleeps very badly, and has awful dreams.
Cries for hours every day, and can take no interest in her
work nor in her child. She eats little of anything ; lives
chiefly on bread-and-butter ; does not care for fat, but is very
fond of butter, and eats a great deal of it. Drinks much tea,
and likes it sweet. Told to leave off sugar, to reduce her
bread-and-butter to bread-and-scrape, and to eat meat. For
the first week she did not improve, but it appeared that she
had not modified her diet except in leaving off sugar. The
necessity of complying with instructions was impressed upon
her, and the following week she admitted, with evident surprise
and reluctance, that she was better. She had not cried once,
and now had hopes of recovery. Hitherto she had been
certain that she would either die or go mad. From this time
she improved so much that she slept soundly every night,
became quite cheerful, and spoke with enthusiasm of the treat¬
ment, saying it had worked a miracle. She was told she need
not attend any more, but three weeks afterwards she appeared
again, having suffered a relapse. She said she was as bad as
ever, but this was evidently an exaggeration. She was, how¬
ever, very depressed ; and upon inquiry it appeared that she
had become pregnant. During her pregnancy she continued
depressed, but with wide fluctuations. She dreaded her con¬
finement, having had a very bad time with her previous child.
However, it passed off fairly well, but she attended again with
her month-old baby, with all her old symptoms as bad as ever.
She was told to wean the child, and on the next visit she
had improved, though the child was only partly weaned. She
was urged to wean it entirely, which she did, and this time
she rapidly improved, and in two or three weeks was completely
well.

CASE 6. —Married woman, aet. 26. She is very depressed
at times, but her chief trouble is that she is so muddled about
her work. She has always been such a good manager, but
now, though she knows what she ought to do, she cannot do
it. She has to be told what to do even in the simplest
domestic duties, such as getting the baby’s bottle ready.
She is depressed by the sense of her own unworthiness, and
imagines that her home, her husband, and her children are

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dirty, and that it is her fault. She has two children, and her
husband, who, when in work, earns about 24 s., has been out of
work for six months. She has been managing her mother’s
house as well as her own, and has half-starved herself in order
that the children might have enough. The almoner’s services
were requisitioned, work was found for the husband, the patient
was enjoined and assisted to get proper food in proper
amounts, and in a month had lost all her symptoms.

Case 7.—Salesman, aet. 27. For seven years he has had a
gradually increasing confusion of mind. When he hears people
talking he does not understand what they say ; it is as if
they were speaking in a foreign language. When told to do
anything he stands and looks stupid, until after a time it
dawns upon him what is meant, and he does correctly what he
is told. He is sometimes told that he does not know what he
is talking about, and he says it is quite true that on these
occasions he does not know. On one occasion on his way
home he asked twenty or thirty people to direct him, though
he knew the way quite well. He has only two meals a day,
and meat at only one of these, and then not much. He had
six cups of tea per diem with two lumps of sugar in each—
nearly a quarter of a pound in the day. He was told to leave
off his sugar and eat meat twice a day and more of it. At
the next visit he was much better, and then ceased to attend.

Case 8. —Married woman, aet. 25. She says: “I have a
funny feeling in my head, I feel half dazed, and don’t know
what I am doing. I feel I can’t settle myself; I am so rest¬
less, I can’t keep still. I feel as if I want to get about and
do my work, but I am half silly, and can’t do what I want to.
I go off into screaming fits as soon as I am left alone ; I don’t
know why, I am not afraid of anything. And I am so depressed.
I suffer much from shooting pains through my head.” She
has meat always once a day, and sometimes twice, but not
much. Has six cups of tea, with two lumps of sugar in each,
and is very fond of butter. Eats the best part of half-a-pound
per day. She is told to knock off almost all her butter, and to
eat bread-and-scrape, and to increase her ration of meat. In a
fortnight she was much better. Her head, she said, was not
quite as it should be ; every other day she feels all right, but
on alternate days she is much troubled. In another fortnight
she was practically well, and thereafter ceased to attend.

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Case 9.—Dressmaker, set. 28. For three years she has
become more and more depressed and nervous, and during
the last six months has been very bad. She is subject to
attacks of pain in the head which used to last a few hours
and went off if she lay down and kept quiet; but now they
last two or three days and nights, and sometimes for a week.
They are brought on especially by railway journeys, even if
brief. She is alone all day from 6.30 in the morning until
8 at night. Does not like sweets, but is fond of fat and eats
a great deal of butter, fat meat, and fat bacon. No instruc¬
tion as to diet was given to her on her first visit, and for the
next fortnight she did not improve. Then she was told to
reduce her butter to a scrape, to renounce fat in all forms, and
to eat more of the lean of meat. In the following fortnight
she had but one attack, but this was very severe. The journey
by rail from Surrey gave her no discomfort. In the next week
she had no attack until she took the journey to see me, which
brought on a very slight one. In the following fortnight she
had several attacks, one of which lasted all day and part of
the night ; the other three were slight. In the next fortnight
she had but one attack, which, however, lasted all day, and a
slight one brought on by the railway journey. In the next
fortnight she had no attack, and then ceased to attend.

Case 10.—Married woman, set. 33. For three months she
has suffered from “ nervous debility,” by which she means that
she is low-spirited, weeps for no reason, trembles, and imagines
that something awful is going to happen. She is worst in the
morning, improves as the day goes on, and is all right by tea-
time. She is much alone, her husband being a clerk and
absent all day, and she has no children. No note was made
of her diet, but it must have been found faulty, for she received
instructions to alter it. At the end of a week she was no
better, but on inquiry it was found that she had not followed
the prescribed diet. She was told to observe it strictly, and
at the end of a week she reported that she had no depression
to speak of. At the end of another week she reported herself
well.

CASE ii. —Married woman, aet. 55. A feeling rises from
her feet to her head, where it becomes a tightness, and she
feels sometimes as if she had had a blow on her head, some¬
times as if her brains were being drawn out. The strange feeling

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in her head often wakes her in the night. She lives chiefly on
bread-and-butter, but does not take very much butter; does
not care for fat or sweets. Eats very little meat, never more
than 2 oz. per diem, and some days none. She was told to
eat meat twice at least every day, and in larger quantity. She
did not attend again, but three months afterwards I heard from
her that she became so rapidly better that she did not think it
worth while to attend any more.

Case 12.—Labourer, set. 45. For twenty years he has
suffered at increasingly frequent intervals from severe pains in
the head, coming through to the eyes. It comes on in the
morning and lasts all day. Sleep is the only thing that relieves
it. He looks much distressed, and says it drives him distracted,
and he loses many days’ work through it. Cannot eat fat,
does not like it, but is very fond of butter. Lives chiefly on
bread-and-butter and cake. Drinks about three pints of tea
per diem, in which he takes, I find by calculation, from 2^ to
3 lb. of sugar per week. He was told to knock off his butter
and sugar and to eat more meat. He returned in a fortnight
in high spirits, extolling the treatment enthusiastically, and
reporting that he had had no headache at all for ten days, a
longer interval than he had known for many years. After
this he ceased to attend and may be presumed to have
recovered.

Case 13. —Married woman, jet. 28. Three weeks ago she
had some “ silly fancies.” Turned against her husband and
accused him of trying to poison her. Had a friend to visit
her, and when the friend was gone the patient had a horrid
fear that she was not gone. The patient had quarrelled with
this friend and called her a liar. She now says that her hus¬
band is one of the best fellows going, and so is the friend she
turned against. She has no such silly fancies now, but her
memory is bad and her mind is confused. When she puts a
thing down she cannot remember what she has done with it.
She does not always know where she is, and sometimes gets
out of a tram when her journey is only half complete. She is
alone all day, her husband leaving home at 7 a.m. and not
returning until 6.30 or 7 p.m. She has meat always twice a
week, but not always three times. Lives chiefly on bread-and-
butter. She was told to regulate her diet, but I do not
know whether she did so. She attended for a month,

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during which time she did not improve, and she then ceased
to attend.

CASE 14.—Married woman, set. 44. She suffers much from
pain in the head, which keeps her awake at night, so that some
nights she does not sleep at all. In addition to this she hears
voices and sees visions. She constantly hears people talking,
all day and all night. The voices are quite distinct, sometimes
loud, sometimes a whisper ; some of them are the voices of
people she knows, others are strange to her. They repeat
everything she says and threaten her. Once she was told that
her husband was at Paddington Station waiting for her, and
she took a cab and went to meet him. The voices abuse her,
and their language is cruel, dreadful. Besides this, she sees
faces at the window and at the door. Once a woman met her
on the stairs, addressed her by name, and asked her about a
ring she was wearing. The woman then went into a closet on
the stairs. The patient followed her into the closet, but found
it empty. The same night when she went into her own room
she found three men there. One was a chef whom she knew,
the others she did not know. One of these demanded money
of her; and the chef said he was doing a dinner at Covent
Garden and asked her to help him. She was about to give
money to the man who asked for it, but when he stretched out
his hand there was nothing to drop the money into. She
could see the carpet through his hand. Up to that moment
she had thought the men were real, but then she knew they
were not. She put down the money and fled. She first began
to see visions and hear voices eighteen months ago. They are
so real that she cannot help thinking they are real people
talking to her, though she tries to think they are only fancy.
She is not fond of meat, goes without it three days a week, and
on the other days eats very little, and then only the fat. She
is very fond of fat and butter. Lives chiefly on bread-and-
butter, the butter spread thick, and puddings. She used to
like meat, but left it off two years ago. She was advised to
alter her diet, to eschew butter and fat and eat meat. She did
not attend again.

Case 15.—Married woman, set. 50. Has suffered as long
as she can remember from incapacitating headaches. Wakes
with them in the morning, and they go off towards night.
She eats meat every day, but “ so little,” not more than 2 oz.

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Cannot eat sweets, but is very fond of butter ; spreads it thick
upon her bread, and lives chiefly on bread-and-butter. Advised
to alter her diet. Did not attend again.

Case i6. —Mechanic, jet. 27. “My mind,” he says, “is
always concentrated on myself. I suffer from a pressure at
the back of my head. I am always wondering what is going
to happen—whether I am going to fall down or faint away.

I cannot sleep ; never go to sleep until 2, and wake at 4 or 5.”
He never eats meat more than four days a week, and for the
last two months only in the form of a ham sandwich, which
constitutes his dinner. Eats but little fat, and not much
butter, but is fond of dripping. Was told to modify his diet,
but the progress of the case is unknown.

Case 17.—Married woman, aet. 53. Constant pain in head,
which keeps her awake at night. Her mind wanders, and she
pictures horrible things, such as people drowning. She sees
these things when between sleeping and waking. Forgets
what she has to do. Eats meat not more than three times a
week, and then very little. Is fond of butter, spreads it
thick, and eats a good deal, for she lives chiefly on bread-and-
butter. Told to eat meat daily and reduce the bread-and-
butter to bread-and-scrape. She did not carry out these
instructions very faithfully, but slowly improved until in three
months she ceased to see the pictures, slept better, and lost
the pain in the head. After this she relapsed, the pain
returned, and she saw people in her room at night. I then
set the almoner at her to see that my instructions were
carried out, and again she improved, this time rapidly and
much. Subsequently, on the supervision being taken off, she
again relapsed.

Case 18.—Married woman, jet. 36. For eighteen months
she has had attacks about the time of her periods of laughing and
crying, with a feeling of suffocation. She forgets that she has
done a thing, and does it over again repeatedly. She suffers
much from headache at a spot on the right side of the fore¬
head. Husband has been out of work for eighteen months.
She has had no meat for a long time. Never buys any. For the
last eighteen months has lived on oatmeal and rice. She ceased
to attend, and further progress is unknown.

Case 19.—Widow, aet. 70. Fain in the head, giddiness,
sleeplessness, shocking dreams. Between sleeping and waking
lxii. 33

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has visions of murdering people. Lives chiefly on milk
puddings and a little fish. Meat once a week, fish twice, and
but very little of either. Does not get to sleep till between
3 and 4, and sleeps only for two or three hours. Told to eat
meat every day, and a larger ration. In a week she had
increased her sleep to four to five hours. In a fortnight she
lost the visions. In three weeks she was sleeping well and
did not dream. In four weeks she vyas sleeping ten to twelve
hours, but still suffered from pain in the head. In seven
weeks she lost her headache, slept well, and did not dream.
Volunteered that she was better than she had been for three
years.

Case 20.—Married woman, aet. 42. Headache and throb¬
bing of the head. Very nervous. Imagines things—that some¬
one is fumbling with the handle of the door, and trying to get
in ; that her husband is unfaithful. Has no strength, and can
take no interest in things. Bursts out crying without reason,
and is depressed. Cannot give her mind to anything. Every¬
thing seems too much for her. It is becoming too much
trouble to wash her child. She has meat once a week only—
on Sundays. Told to eat meat daily. At the end of a month
her depression had nearly gone, and she had no difficulty in
attending to the child. Went for days without crying. She
continued to improve, and in two months ceased to attend.

Case 21.—Servant, set. 56. Pain and pressure on top of
the head. Sleeps badly. Depressed. Cries a great deal, and
thinks everyone is against her. Eats fat and butter, but not
in excess. Is fond of sweets, and eats much cheese. Told to
eschew cheese and sweets and eat more meat. She improved
slowly and irregularly. In six weeks she was able to sleep
“ quite well.” Her spirits improved a great deal: she lost her
headache, but she was not well when, at the end of four months,
she ceased to attend.

Case 22.—Married woman, aet. 24. Her nerves are bad.
She cannot bear to be alone. Feels that if left alone she
would commit suicide. So depressed that she always wants
to sit down and cry. Terribly irritable. Has fits of panic
with trembling. Lives chiefly on bread-and-butter and milk
puddings. Eats a little meat every day, but very little, as she
is not fond of it. In a fortnight she reported herself a little
better. She had been eating more meat, but still not much.

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She was told that she must eat more, and at the end of a fort¬
night she reported herself very much better. In six weeks
she could sit alone in a room if she knew there was someone
else in the house. Had ceased to cry and had no trembling
fits. In another fortnight she was practically well and ceased
to attend.

Case 23. —Unmarried woman, jet. 22. Three years ago
she was left by the death of her mother in charge of the house
and of two younger sisters. For twelve months she has
been out of health. Wanted to shut herself up and be away
from everyone. During the last few weeks she has become
worse. She imagines things, sees ghosts—her mother and
brother, both of whom are dead. Last week she cried a great
deal, and the week before kept laughing without provocation.
One day she lay on the floor all day. She sleeps very little.
No headache. For many weeks past her appetite has been
very bad. For a fortnight she has eaten scarcely anything,
and for the last three days nothing at all. Her sister was
told to urge and compel her to eat plenty, especially of meat,
and carried out the instruction. In three weeks she was suffi¬
ciently improved to be sent to a convalescent home in the
country, with instructions as to diet, for three months. She
returned quite well. Said she feels all right, never cries
or laughs irrationally, never sees ghosts ; eats and sleeps well.

Case 24. —Male. Pain in the head. Depression. Feels
as if he were going out of his mind and as if he must do
away with himself. Sleepless. No reason for the depression,
and he cannot understand why he should feel it. Eats no
breakfast, but has two raw eggs in milk. Not fond of fat,
but very fond of butter and eats a great deal of it. Two eggs
in milk for tea. Told to revise his diet, omit the butter and
the yolks of the eggs, and to eat meat. In a week the pain
in the head was lessened, but the depression and other symptoms
continued. In another three weeks the headache was still
further improved and he felt “ much brighter.” He then ceased
to attend.

Case 25. —Housemaid, set. 28. She has “dreadful thoughts.”
Her mind is confused. She “ feels desperate.” Cries a good
deal and mopes. Cannot sleep. Cannot bear to be left alone,
but people being with her irritates her. This has been gradually
coming on for a year. She has not touched meat for eighteen

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months. Has no breakfast and lives chiefly on bread-and-
butter and milk puddings. She never has headache. She
was told to revise her diet and eat meat, but she was not
efficiently supervised, and it is doubtful whether she carried
out the instructions very faithfully. At the end of a month
she reported herself “ certainly improved,” and then ceased to
attend.

Case 26.—Widow, aet. 77, says : “ My head is in a muddle.
I sit down to write a letter and I know what I want to write,
but I can’t write it. I often find I have written it wrong. All
of a sudden things go blank and I leave words out. I am of
a very worrying disposition and am always depressed.” She
suffers much from headache, and has to spend one day in every
week in bed on account of it. For two years she has eaten
no butcher’s meat, but occasionally she eats an egg, or a little
fish or chicken. Lives chiefly on milk puddings. Took to a
vegetarian diet on account of indigestion. Does not eat
much fat or butter, but drinks large quantities of milk. Seen
once only.

Case 27.—Married woman, aet. 32. “I am tired of every¬
thing and everything is a worry. I can’t think. I have such
pain in my head it makes me forget everything. I sleep
badly, and all night my mind is on the work. There is some¬
thing in my head that causes everything to be jumbled up.”
She eats large quantities of raw rice and starch. She eats
more than a teacupful of rice every day (a tablespoonful of
rice will make a pudding large enough for four people).
She does so because it is company for her and stops her from
thinking. She goes without her meals and eats rice instead.
Seen once only.

CASE 28.—Farmer, set. 34. Lacks confidence in himself.
Cannot concentrate his mind upon his work. Incapable of
mental exertion. Little things worry him excessively and
unreasonably. Sleeps well, but dreams much. No headache.
Bad family history. Has been a vegetarian for three years,
living chiefly on grape-nuts, bread-and-butter, rice, macaroni,
sago, and tapioca. Cannot eat fat and is very moderate with
butter. Told to rearrange his diet and eat meat two or three
times a day. In a month he returned much improved. He had
an assured and confident demeanour ; said he had a better
grip on his work and had no difficulty in concentrating his mind.

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Case 29.—Married woman, aet. 35. Has horrid thoughts
and feels as if she were going out of her mind. Silly things
come into her mind. The knives on the table suggest to her
to do horrible things—injure herself or someone else. She
thinks she has done things that she knows she has not done—
things like injuring people. She has frequent headaches, with
“ golden zigzags.” Never eats breakfast. Dislikes meat, often
goes without, and when she takes any it is very little. Does
not like fat, but is fond of butter and spreads it thick. Seen
once only.

Case 30.—Married woman, aet. 48. “ I can’t think. Every¬
thing seems altered. I can’t remember what things look like.
I have two children, and I can’t remember what they are like.
Oh, yes ; I know them when I see them. Everything seems
getting more and more strange.” Husband says she complains
much of headache and sometimes of giddiness. Eats very
little meat and a great deal of butter. Lives chiefly on milky
puddings and bread-and-butter. Seen once only.

Case 31.—Married woman, aet. 37. Has a muddled feel¬
ing in her head and is apprehensive that something dreadful is
going to happen, and such awful depression. Becomes fright¬
fully tired after trifling exertion, but the worst is the confused,
muddled, dazed feeling in her head. Suffers from headache.
Has lived in India, where meat or poultry has been on the
table two or three times a day, but the quality being so bad
she rarely took it. Not fond of sweets or fat, but eats much
butter and cream, and her chief diet is milky puddings. Seen
once only, but I heard some months afterwards that she had
taken my advice about her diet and was “ almost well.”

CASE 32.—Man, aet. 42. Insomnia and depression. Has
attempted suicide three times. Becomes confused in mind, so
that he cannot take orders in his own shop. Not a great eater
of meat; once or twice a week he goes without, and when he
does take any it is only once a day, and then very little—not
more than 2 oz. Fish twice a week. Drinks much milk.
When he feels low, which is pretty often, he eats nothing.
Seen once only.

CASE 33.—Schoolmaster, aet. 29. Breaks down and cries
for no reason ; has to rush out of the room to save himself
from making an exhibition of himself by an outbreak of weep¬
ing. On one occasion he rushed off to a doctor, and as soon

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as he reached the consulting-room he broke down and wept.
There has been some tendency to this for three years, but he
has easily overcome it until the last month, during which it
has become intolerable. I saw him on May 1st, just after
Easter, and he had been keeping Lent very strictly, but pre¬
viously he had eaten very little meat, never more than one
cutlet or an equivalent amount in a day. No other error in
diet. No headache. Seen once only, but I heard from his
doctor a month after I saw him that he had reformed his diet
and was greatly improved.

Case 34. —Man, set. 66. Looks much older than his age,
and complains of loss of memory of the usual senile type.
Forgets in five or ten minutes an occurrence, such as a visit
from a friend. Begins to be suspicious and to fancy that his
money is being kept from him. He is very careful of his
money, but forgets where he puts it. Forgets the names of
his children. Suffers much from neuralgia. Is very fond of
sweets, jams, and puddings. Spreads sugar on his bread-and-
butter. Eats meat only once or twice a week, and then very
little. Seen once only.

Case 35.—Male, oet. 18. “I can’t work. I can’t do any¬
thing. I can’t apply my mind to 'anything. I have a diffi¬
culty in getting up in the morning. It sometimes takes me
an hour to dress. I get thinking about other things.” A
friend says there are times when the patient seems lost in
thought and stands stock still, doing nothing ; but when spoken
to he can rouse up and go on with his work. He says he is
a very bad meat eater. Never eats as much as there is on a
mutton chop, nor anything near it. Not nearly as much as a
slice off a sirloin, Lives chiefly on puddings, cakes, and bread-
and-butter. Not fond of fat or butter. No headache. He
is 5 ft. io| in., and still growing. Weighs 10 st. 5 lb. Seen
once only.

Here are recorded a number of cases of persons who have
sought relief from mental disease ; and the first comment that
they call for, that they cry aloud and clamour for, is that, of
thirty-five cases of mental disease, only one could be certified as
insane. I insist upon this with special emphasis because of the
universally accepted doctrine that disorder of mind is equivalent
to insanity—that disorder of mind and insanity are the same

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thing. The contention that I have urged for so many years,
that unsoundness or disorder of mind is not necessarily mad¬
ness, has always been received by the people that do err in
their hearts with contemptuous incredulity and open derision.
Now, whatever my faults, and whatever my fads, I think even
this people will admit that a patient must be undeniably sane
if I cannot certify that he is insane ; and of these thirty-five
patients I could not have certified more than one ; that is to say,
3 per cent. Of course, I do not expect this to make any
impression upon my alienist friends, but I beg them to note
this indefeasible demonstration that mental disease, mental
disorder, or unsoundness of mind, is not the same thing as
madness, but that many and varied mental disorders are
compatible with complete sanity.

The peculiarities in diet which preceded and accompanied
the mental disorder in these patients were mainly of two kinds
—deficiency of meat, or excess of fat, starch, or sugar. Accord¬
ing to current practice, the peculiarity of diet would be
regarded as unquestionably the cause of the mental disorder ;
but so to regard it would be quite unjustifiable unless the asso¬
ciation of the peculiar diet with the mental disorder satisfies
one or more of the conditions stated above ; and the reason is
clear. Vegetarianism is common enough: mental disorder is
common enough. On the doctrine of Probability it is certain
that the two must coincide in the same person in a certain
number of cases—in a number that cannot be exactly ascer¬
tained for want of exact figures. There is, besides, another
source of possible error. It is quite rare for vegetarianism to
be the only fad of the vegetarian. Almost always he has a
stock of fads. He cultivates a number of what may be called
anti-isms. He is anti-alcoholist, anti-vivisectionist, anti-vacci¬
nationist, anti-capitalist, anti-bellumist, anti-patriotist. He is
anti-penalist, and would provide all gaols with pianos and
newspapers, beer and skittles. He is anti-restraintist, and would
abolish all lunatic asylums, rightly from his own point of view,
for so he would escape the risk of losing his own liberty. It
is, no doubt, possible to hold some of these opinions with
reasoned conviction, and after examination of the evidence ; but
it is not so that the faddist holds them. He holds them as
mere prejudices. He attaches to them a very disproportionate
importance. He advocates them in season and out of season,

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and with intemperate zeal. He erects them into a religion, of
which he is a fervent missionary, and of which he is proud to
be a martyr in any small way which does not interfere too
much with his comfort, or if it does, brings him a consoling
notoriety. He regards any means of proselytising as justifiable,
and lies conscientiously in furtherance of his fads. A mind of
this nature is unbalanced. It is not insane, but it occurs in
people who have insane relatives, and who are apt themselves
to become insane. We should expect, therefore, to find among
vegetarians an undue proportion of insane persons. For this
reason I have omitted from the cases adduced every case in
which abstention from meat was a fad, and have included those
only in which meat was eschewed either because it was dis¬
tasteful or because it was not procurable.

That very definite peculiarities in diet did precede and
accompany the mental disease in the cases I have recorded is
unquestionable. What is now to be determined is whether
this antecedent and accompaniment can rightly be considered
a cause. To this end we must make four inquiries :

First, is the action that we conjecture to be the cause, that
is, the action of the diet upon the patient, isolable ? In other
words, can we separate it from other actions on the patient so
as to ascertain beyond doubt that the change in the thing acted
on is due to that action, and to that alone ? At first sight it
seems that we cannot, for we know very little of what other
actions tending to produce mental disorder may or may not
have been incident upon the patient at the time. In some of
the cases—viz., Cases 10 and 13—the patient was alone from
morning till night six days in the week, which we may con¬
jecture was inimical to mental health ; in other cases there had
been worry, anxiety, and other stresses. While, however, we
never completely isolate the action, we can produce an approxi¬
mate isolation by withdrawing the action that we surmise is
the cause, and noting any difference in the effect during its
absence, and, it may be, allowing it to act again and noting the
effect of the addition. In several of the cases the rectification
of the diet was followed by improvement of the mental health,
and in some cases this improvement was rapid or immediate,
and was great. In this respect Case 5 is extremely instructive
This patient improved very decidedly within a week of the
rectification of her diet. She continued to improve, until at

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length she spoke of her recovery as a miracle. Then she had
a relapse. The relapse was not coincident with a return to the
faulty diet, but it was coincident with what, for the purpose in
hand, amounted to much the same thing—that is to say, with
her pregnancy. She now took, it is true, enough proteid to
nourish her own tissues, but it was not allowed to nourish her
own tissues. It was seized upon at once by the growing foetus,
whose demands were paramount, and she was deprived of it.
Nor did she improve when the child was born, but then, when
the child was born, it was still her own food that nourished it.
When, however, she weaned the child she rapidly recovered.
It is difficult to avoid the conclusion that in this case the mental
disease was dependent on the deficiency in the ration of protein,
whose fluctuations it followed so closely.

It is one of the disadvantages of consulting and hospital
practice that a largd proportion of the patients are seen once
only, and the result of one’s advice remains unknown. Of
the thirty-five cases here recorded, fourteen were seen only once,
and nothing certain is known of their progress ; but of other
cases seen only once inquiries were made, and it was found that
they had so greatly improved that they did not think it worth
while to come again. It is a fair inference, therefore, that some
of those who were not heard of had the same reason for ceasing
to attend. Taking, however, those only whose subsequent
history is known, all but one recovered, or very greatly im¬
proved, when their diet was rectified; and these were more
than half of the whole number seen. The total number is too
small, it is true, to draw any very large or confident conclusion
from, but as far as they go they show, among those as to whom
the result is known, a rate of between 94 and 95 per cent, of
recovery or of very great improvement, and this is too striking
to be ignored.

Application of our second principle, that of constancy in the
association of the effect with the possible cause, does not yield
such a favourable result. It is certain that the positive asso¬
ciation of an excess of fats or carbohydrates, or a deficiency of
meat, in the diet with mental disease in the consumer is not
constant. The denizens of Arctic climates, who live largely
upon blubber, are not known to suffer disproportionately from
mental disease, nor are those considerable populations of
Eastern countries who live upon an exclusively vegetarian diet;

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526 DIET AS A FACTOR IN MENTAL DISEASE, [July,

but then it is clear that the circumstances are not the same,
and no principle of logic is more important, though it is not
mentioned by Aristotle nor acknowledged by professors of
logic, than that circumstances alter cases. That indulgence in
fat which may be disastrous to the dweller in a temperate
climate need not be anything but beneficial amid eternal ice
and snow ; and that abstinence from meat which may be fatal
to an individual or a member of a race that is accustomed to a
carnivorous diet may be innocuous to one who and whose
ancestors have never tasted meat. Moreover, there can be little
doubt that what is harmful in the absence of meat is the
absence of protein, and this may be made up by consumption
of vegetable proteins.

Nor is the negative association in the least degree constant.
There is abundant experience that mental disease is by no
means confined to those who indulge excessively in fats and
carbohydrates and those who refrain from eating meat.

The third principle cannot be applied for want of data.
When there are a great many people who suffer from mental
disease, and in the same population a great many who commit
these errors of diet, the doctrine of Probability assures us that
there must be some in whom the two will be combined casually ;
and among the cases recorded No. 13 seems to be such a case.
But it is quite impossible to apply this principle, and to dis¬
cover whether or no the combination of mental disease with
error in diet is more than casual concurrence will account for,
until we know (1) the total population ; (2) the number of
cases of mental disease ; and (3) the number of cases of error
in diet, in the population. In the absence of data no conclu¬
sion can be drawn.

The fourth principle, however, is more fertile in results. It
assures us that if a certain change in a thing follows, though
only occasionally, an action on that thing, then, although from
the mere occasional sequence we are not justified in calling the
action the cause of the change, yet if in each case of the sequence
the change exhibits a constant character, we may then properly
infer that the sequence is causal. To take a cognate instance:
insanity follows, though only occasionally, excessive and pro¬
longed drinking of alcohol ; but since insanity often occurs
without this antecedent, and since the antecedent often occurs
without insanity following, it would be quite unjustifiable to

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assert, on the mere ground of antecedence and subsequence,
that the drinking was the cause of the insanity. When, how¬
ever, we find that whenever insanity does follow prolonged and
excessive drinking the insanity always has certain peculiar
characters, which are never found in insanity otherwise occurring,
the case is different. This constant quality in the result does
justify us in presuming that the constant antecedent of that
quality is the cause of the insanity. Can we then apply this
principle to the cases before us ? I think we can. Here it
becomes necessary to separate the two factors of excess of fats
and carbohydrates on the one hand and defect of meat on the
other, and to consider each by itself.

If the cases in which an excess of fat was consumed are
examined it will be found that whatever other symptoms they
complained of, they all suffered from severe headache. This
is not a new observation. The connexion has been thoroughly
established by Dr. F. Hare in his excellent book on the Food
Factor in Disease . The cases here adduced are a mere adden¬
dum to his observations, and pretend to no originality. They
are, however, of value as corroboration by an independent
observer of his views. While, however, the headache is the
most prominent and troublesome symptom in these cases, it is
not the only one. It is well known that attacks of migraine
are often accompanied by mental confusion, and it appears from
some of the cases here recorded that excess of fat in the diet is
accompanied in them by confusion of mind, which occurs even
at times when the patient is not suffering from headache.
There is no case among those here recorded in which headache
was complained of when there was no excess of fat in the diet.
From this it must not be supposed that I suggest excess of fat
as the only cause of headache ; I suggest merely that deficiency
of meat alone is not a cause of headache.

It seems, however, that it is a potent cause of confusion of
mind. In case after case in which the diet was subsequently
found to be deficient in meat, the mental state is described in
almost or quite the same terms : “ I feel muddled and dazed
“ A wave of confusion comes over me ” ; “ I am so muddled
about my work ” ; “I have such confusion in my mind ” ; “I
feel half-dazed, and don’t know what I am doing ” ; “ My mind
is confused ” ; “ My head is in a muddle ” ; “I cannot think ” ;
“ I have a muddled feeling in my head ” ; “I cannot apply my

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mind to anything ” ; “I am half-silly ” ; “ There is something
in my head that causes everything to be jumbled up ” ; and
so on.

Depression is almost as common, and is in some cases very
severe. In several cases it led to contemplation of suicide, and
in one to repeated attempts ; perhaps, since they were repeated,
they were not very determined, but still they were attempts.

Screaming fits and motiveless weeping and laughing occurred
in several cases among the women.

Defects of memory, especially of the business memory—that
is to say, forgetting to do things at the proper time—was noted
in several cases. It is a part or a form of the mental confusion.

In three cases there were hallucinations, and in one of these
the hallucinations were extraordinarily vivid, and were of sight
and hearing coordinated. Case 14 would of itself serve as a
text for a discourse upon the origin of ghosts and the nature of
ecstatic visions, of celestial visitors, of supernatural revelations,
and so forth. It is unfortunate that I was unable to follow up
this case, and I may say that its very peculiar character makes
it doubtful whether the mental state owed any of its origin to
the diet, which, however, was certainly very defective. On the
other hand, it could be urged that Cases 17 and 20 are halfway
houses on the road to the same destination.

Many other inferences can be drawn from these cases, and
there is one inference that will certainly be drawn, however
much I may deprecate it and protest against it, and that is
that I have asserted that every case of mental disease is due
to excess of fat or to deficiency of meat in the diet. I make
no such assertion. Obviously the cases here related form but
a small proportion of those that have come under my notice
since I first began, several years ago, to investigate the diet of
my patients. In only a small proportion of cases could I find
any definite fault in the diet; and where a fault existed, it was
not always excess of fat or deficiency of meat. It surprised
me to find in how many cases people live very largely on milky
puddings, and I was in doubt in many cases how far the sym¬
ptoms were due to deficiency of protein, and how far they were
due to excess of starch and sugar. In Case 27 I have little
doubt that much was due to excess of starch, and I always
made a point of inquiring into the relative proportions of all
the constituents in the diet.

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A word may be said as to the method of inquiry. In this,
as in all things, it is most important to avoid leading questions
in opening the examination. My practice is to ask, What do
you have for breakfast ? and so on for each meal. The next
question is, Is there anything to eat that you are particularly
fond of? Meat? Sugar? Fat? Milky puddings ? Then,
Is there anything you particularly dislike? It is important to
remember that people do not reckon butter as fat. Many
patients declare that they dislike fat, and never eat it, but when
the question is put to them, they will admit an inordinate fond¬
ness for butter.

It should be remembered also that there are wide differences
in the capability of different persons to dispose of the fat,
starch, etc., that they consume, so that what is moderation for
one may be gross excess for another.

A point that, to economise space, is not brought out in the
cases here recorded is that those symptoms that seem to be
due to excess of fat, starch, and sugar in the diet, and that are
relieved by diminishing these constituents, are almost always
worse in the morning, clear up towards afternoon, and are
often absent in the evening. Hence I never omit to inquire,
What time of day are your symptoms worst ? and whenever I
hear that they are worst on waking in the morning and
diminish as the day goes on, I make very stringent inquiry
into the diet, no matter what the symptoms may be.

Finally, let me assert once more that I do not hold that
there is only one cause of mental disease. If I did so hold, I
should be little better than a psycho-analyst. My contention
is, and I think it is borne out by these cases, and by the appli¬
cation to them of the true principles of ascertaining causation,
that in a certain number of cases of mental disease, small in
proportion to the whole, but considerable in the aggregate, the
disease is due to error in diet, and can be cured by rectifying
the error in diet.

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Zola's Study of Heredity. By J. Barfield Adams,
L.R.C.P., L.R.C.S, M.P.C.

In studying a case of insanity, the family history of the
patient is a matter of considerable interest. But it is often
difficult to obtain reliable information on the subject. In such
researches one has to contend with ignorance and prejudice.
Many people know very little about their ancestors or collateral
relations. And further, the idea that insanity is a disgrace so
pervades all classes of society, that a man is shy of speaking
about the mental condition of his relatives, if it should chance
to be, or have been, diseased.

For a good many years I have made careful inquiries into
the family history of the cases of insanity or eccentricity which
have come under my observation. It has been necessary to
pursue these inquiries with patience, for often months and some¬
times years have elapsed before I have been able to supply
myself with certain missing details. Frequently I have been
put on the right scent by mere accident, or by a bit of ill-
natured gossip, for, although people don’t like talking about
their own insane relatives, they have no objection to discuss the
psychical failings of their friends. But I cannot congratulate
myself upon the result of my researches. Even now I have
only three mental genealogical trees that I can look upon as in
any way complete.

In the absence of the cadaver, well-drawn plates are of some
assistance in studying anatomy. One can at least refresh the
memory from them. All depends upon the faithfulness and
skill of the artist. In like manner, seeing the difficulty there is
in collecting data of family history, the fiction of a realistic
novelist, who writes upon the subject, is not an unprofitable study.

In his Rougon-Macquart series of novels Emile Zola unrolls
before us a genealogical tree, and he proceeds to demonstrate
with great clearness and considerable detail the mental and
physical characteristics of the individual members of the family.
His object is to show the result of the fusion of a neurotic and
degenerate race with, first, a stolid and healthy one, and second,
with another which, though comparatively healthy, has become
vitiated by alcoholic and other excesses. The various branches
springing from such stocks are grafted on others more or less

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I916.] BY J. BARFIELD ADAMS, L.R.C.P. 531

healthy and are subjected to the stress of circumstance and
environment, and the results noted.

No one ever painted from nature so honestly as Emile Zola
did, and his pictures of disease, both mental and physical, have
something of the accuracy of cases recorded in a physician’s
note-book. But, realistic as he is, Zola is an artist, not a photo¬
grapher. Whatever be the medium in which he works, and
sometimes it is horribly filthy, one can always see the strokes
of the brush. In literature he is as great a master of chiaroscuro
as Rembrandt is in art, although it must be confessed that in
his work, as in that of the Dutch artist, the shadow not unfre-
quently overbalances the light. The composition of his pictures
is admirable, though this is not always evident to the superficial
observer, for in several of the novels of the series the minor
characters appear to be over-elaborated, and to be placed in too
prominent a position. But each story is not complete in itself,
it is but a shred of a vast canvas, and when the work is viewed
as a whole it is seen that every figure falls into its proper place,
and that all the requirements of proportion are complied with.

But it is Zola’s very excellence as an artist that mars for us
his studies in disease. To increase the value of his high lights,
necessary no doubt from a dramatic point of view, he lays stress
on details, which, from a scientific standpoint, are of small
importance, while others of greater interest to the physician he
suppresses or passes over with brief notice. Perhaps, however,
one may say that in doing so he is unconsciously true to nature.
In the college lecture hall and in the pathological museum we
can classify our patients, and label our specimens. In practice
it is otherwise. Disease is rarely true to sample. It is the
exception rather than the rule to meet with a case in which
there is no symptom missing, no lacuna which we have not to
bridge over with a plausible tag of theory..

Let us then study these novels of Zola as one does a series of
anatomical plates, only remembering that the pictures are drawn
by a man who, though firmly resolved to delineate every detail
with scientific truth, could not divest himself of his artistic
individuality.

It may be added that when one regards these books as
biological studies, their grossicreti fades away, as does that of
the writings of the Elizabethan age when looked upon simply
as literature, and one has no longer to concern one’s self with

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the question whether such physiological descriptions as are found
therein are advisable or even permissible in works of fiction.

The scene where the story of the Rougon-Macquart family-
opens is placed in Plassans, a little city which is supposed to
be situated somewhere in the region where the last spurs of the
Alps lose themselves in the lowlands of Provence. Those oi
us who have spent our summer holidays loitering among the
out-of-the-way parts of France will remember several sleepy
towns which would answer to the description that the novelist
gives of Plassans. We recollect the belt of ruinous ramparts ;
here converted into pleasant boulevards, and shaded with trees;
there encroached upon by neighbouring gardens. One or two
of the ancient city gates are still standing, with their crenellated
battlements fringed with grasses and wild-flowers.

In the very oldest part of the town rises the cathedral, an
ancient structure dating back to the period when the arch en
plcin cintre still struggled with the ogive. Push open the
padded doors, which swing back so silently behind you, and
enter the church. When your eyes have become accustomed
to the gloom, you see that the architecture of the interior is
very plain. But the glass in the windows is wonderful. The
sunlight as it filters in is stained with hues of purple and gold,
of sapphire and emerald.

The other public buildings of the city are not numerous.
There is the Sous-Prefecture —for the town, in spite of its
episcopal dignity, holds only a second-rate position in the
department —an ugly, modern building standing on the Place ,
and in a side street one comes upon the Mairie , which is only
distinguished from the neighbouring houses by the flag of the
Republic floating above the main entrance.

The early morning is the best time to explore the city, for
there is some life in it then. There is a daily market in the
open space behind the cathedral, where peasants bring fruit and
eggs and salades and other country produce for sale. One
rambles on through the narrow streets, and suddenly one comes
upon a little square, a veritable blaze of colour, where the stalls
of those who sell flowers are grouped about a wonderful
fifteenth century fountain.

In the afternoon the whole city goes to sleep, and in the
evening it turns Out to enjoy the cool of the day on the ram¬
parts, or under the trees of the Place de la Sous-Prcfecture.

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Imagine all this, and you have some idea of the city of
Plassans and the life of its inhabitants.

In the latter part of the eighteenth century a peasant, named
Fouque, lived just outside the walls of Plassans. He cultivated
his own land, and was one of the richest market-gardeners in
the neighbourhood. This man was the last male of his race,
which had become so degenerate that Nature seemed about to
end it. He died mad in 1786, and we are given no further
particulars of his case.

Fouque left one child, a girl named Adelaide, born in 1768.
In her childhood she had the manners of a little savage, and as
she grew up her behaviour became still more strange, so that
the neighbours said that she had the cracked brain (cerveau felf)
of her father. Physically she was strong. She was tall and
slender, had a pale complexion, and was undeniably handsome.
The women of Provence have the reputation of being the most
beautiful in France. Many of the Artesiennes, for example,
are endowed with the regular beauty of an ancient Greek
statue.

In spite of the feebleness of her mind, this beautiful heiress
had several opportunities of marrying well. But she rejected
all the young and wealthy suitors, and six months after she
was left an orphan, when she was about the age of eighteen,
she married her servant, a man named Rougon, who came from
the department of Basses Alpes. He was a rough, uneducated
peasant, strongly built and healthy, slow witted, but, like most
of his class, thoroughly alive to material advantages.

Of this union one child was born, a boy named Pierre. Three
months after his son’s birth Rougon died of a sunstroke,
which he received one afternoon when he was weeding a
carrot-bed.

After the death of her husband Adelaide lived for some years
in illicit union with a man named Macquart, who was a
smuggler and a poacher. This man was physically strong and
healthy, but he was lazy, had the instincts of a vagabond, was
very dissipated, and drank heavily. He was killed in an affair
with Custom House officers on the Swiss frontier.

Adelaide had two children by Macquart, a son, Antoine,
born in 1789, and a daughter, Ursule, born in 1791.

Before her marriage with Rougon, Adelaide may be regarded
as merely a feeble-minded woman, but one in whom the possi-

LXii. 34

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Genealogical Tree of the Rougon-Macqnart Family.

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Jacques-Louis.

fThe broken line indicates the insane, epileptic, or otherwise degenerate members of the family.]

1916.]

BY J. BARFIELD ADAMS, L.R.C.P.

535

bilities of profound mental trouble lay dormant. Soon after
her first confinement she appears to have had an epileptic fit,
and subsequently these attacks occurred regularly every two or
three months. During the years that she cohabited with
Macquart she gave herself up to drink and other excesses.
After the death of her paramour she became subject to long
periods of depression, marked by delusions, hallucinations, and
thoughts of suicide. Finally, after one brief gleam of affection
for her grandson, Silv&re, she sank into dementia, and was shut
up in 1851 in the asylum at Tulettes, near Plassans, where she
died in extreme old age.

Pierre Rougon, the eldest and only legitimate child of this
woman, had a robust father, and was born when his mother
was young, and at her best in mental and bodily health.
There is no sign of insanity in his case. He resembled his
father in body and mind, though possibly he was a shade more
intelligent. One can easily recognise the man who, as Zola
relates, swindled his mother out of her property, as the son ot
the rough peasant who married a feeble-minded and unprotected
girl for her wealth.

In 1810 Pierre Rougon married F&icitd Puech, the daughter
of a rich oil merchant of Plassans; olive oil was the staple
commerce of the city. At the time of her marriage F£licit£
was nineteen years old. Socially her husband’s superior, she
was a small, dark-complexioned woman, such as one often sees
in the South-East of France. She was of a different type
altogether to the handsome Proven^ale, represented by Adelaide.
She was clever and ambitious, and loved intrigue for the sake
of intrigue. Her chief mental characteristics were envy of
those who were better off than herself, and an invincible
determination to obtain her own ends. There was no trace of
insanity in her or in any of her ancestors.

This couple had five children, three sons and two daughters :
Eugene, born in 1811; Pascal, in 1813; Aristide, in 1815;
Sidonie, in 1818 ; and Marthe, in 1820.

Pierre Rougon, with the money of which he had swindled
his mother, bought a share in his father-in-law’s business, of
which later on he became sole proprietor. In spite of his own
cunning and his wife’s cleverness, Rougon’s affairs did not
prosper, and he only succeeded in paying his way. Despairing
of her husband as a social success, F£licit£ transferred her

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ambition to her sons, and she struggled bravely with financial
difficulties in order to give them a good education. She sent
them first to the college at Plassans, and afterwards to Paris,
where Eugene and Aristide studied law, and Pascal medicine.

Zola remarks at this point that “ the race of Rougon was
refined by the women. Adelaide had made Pierre a man of
average ability, fit for low ambitions ; Felicitd had endowed her
sons with greater intelligence, capable of great vices and of
great virtues."

Eug&ne Rougon resembled his father physically. He had
the same massive, powerful body, with a square head and large
features. But he presented “ the curious case of certain of his
mother’s moral and intellectual qualities buried in the thick
flesh of his father. . . . He had high ambitions, the

instincts of authority, and a singular contempt for little methods
and little fortunes.” As an advocate at the bar of a provincial
city such as Plassans he was a failure ; but at the first breath
of the political disturbances, which culminated in the coup
d't'tat of 1852, he went to Paris, and succeeded in making
himself so useful to Napoleon III that he rose to the highest
offices of state.

Zola has been criticised as being untrue to nature in making
a statesman out of this brutal grandson of a peasant. But
such criticism is unjust. Eugene Rougon was not intended to
be the portrait of a statesman. Statesmen are very rare, and
were particularly so in France at that period. Even if we
include Charles de Morny, it may be doubted whether among
all the men who surrounded Napoleon III there was one who
was worthy of the title. But if statesmen are very rare, bullies
are very common, and in Eugene Rougon Zola has painted the
portrait of a successful bully. For it must be remembered that
between the village bully, the hector of a Municipal Council,
and the strong man of a Cabinet the difference is only one of
social veneer, and sometimes not that. Bullies love power for
its own sake ; statesmen as a means to an end.

Pascal Rougon, the second son, was intended by Zola to
represent a member of a family who bore no resemblance to
either ancestors or collaterals. “ Pascal,” says the novelist,
“did not appear to belong to the family.” His was “ a case
which gave the lie to the laws of heredity.”

He was a physician, and devoted to science. Physically,

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we are told, he was unlike the Rougons, and, mentally, he had
none of the intense love of wealth and power which charac¬
terised his father and mother and brothers. But, it may be
asked, was not this intense devotion to science only another
form of the love of wealth and power—intellectual wealth and
intellectual power? Pascal was undoubtedly the most amiable
and unselfish of the family ; but in the development of his
character Zola has been more true to nature than he intended,
and has allowed traits to reveal themselves which show that
the physician sprang from the Rougon stock.

Pascal died of angina pectoris in 1874.

Aristide Rougon, the third son, resembled his mother
physically, and he possessed also her mental characteristics of
avarice, envy, and love of intrigue. But he had the sensual
instincts of his father, and he loved wealth, not only for its own
sake, but also for the enjoyment that it brought.

After wasting his time for years at Plassans he followed his
brother Eugene to Paris, where, with some little help from the
latter, he succeeded in making a fortune as a speculative
builder on an immense scale. Losing this fortune, he turned
to the Bourse. He established a wonderful joint-stock bank,
with which were connected certain other mad schemes, such as
the exploitation of a silver mine on Mount Carmel. The
affair caused a furore. It was a veritable South Sea Bubble.
Then came the inevitable crash, followed by a panic and
harrowing tales of misery and suicide. But Aristide rose again
from the ashes of the catastrophe, and when we last hear of
him he is the all-powerful director of one of the leading news¬
papers of Paris under the Third Republic.

In 1836, while he was still at Plassans, Aristide married
Angele Sicardot, the daughter of a retired captain, who occupied
his leisure with politics. This soldier, Zola says, was not a
man of genius, but he was honest and energetic. Angele was
a frail, placid woman, chiefly remarkable for her love of dress
and good living. She bore her husband two children : a boy,
named Maxime, born in 1840, and a girl, named Clotilde.in 1847.

Angele died of pneumonia in Paris before her husband made
his first fortune. After her death Aristide Rougon changed
his name to that of Saccard, and married a second wife, by whom
he had no children. But he had an illegitimate child, named
Victor, by a poor dressmaker.

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Maxime Rougon or Saccard, the eldest child of Aristide, is
the most villainous figure that Zola has drawn. In his
character, compounded of vice and selfishness, there is not a
redeeming feature. Physically he resembled his mother,
mentally his father. He was educated at a miserable school
at Plassans, where he early acquired immoral habits. When
little more than a child he was plunged into the Sodom and
Gomorrah of Parisian high life, as it was during the palmy days
of the Second Empire, to which his father’s wealth gave him
the entree. At the age of seventeen he had an illegitimate child,
named Charles, by a maid-servant. He married an extremely
wealthy girl, who was suffering from phthisis, from which
disease she died a few months later. After his wife’s death
Maxime lived a life of egoism and luxury, and died of
locomotor ataxia when he was little more than thirty years
of age.

Charles Rougon or Saccard, the illegitimate child of Maxime,
was an imbecile. At the age of fifteen he had the mind of a
child of five. But he was extremely beautiful, and bore an
extraordinary resemblance to his ancestor Adelaide. He suffered
from haemophilia, and died in his fifteenth year of profuse epi-
staxis.

Clotilde, the second child of Aristide, was brought up at
Plassans by her uncle, Dr. Pascal Rougon. Physically she
resembled her mother, from whom she inherited a certain love
of dress and a tendency to day-dreaming. But she was also
endowed with the uprightness and energy of her grandfather.
Captain Sicardot. She was healthy in body and well balanced
in mind, and Zola more than suggests that what was evil in her
heredity was eradicated, and what was good was cultivated, by
the happy life she led in her uncle’s house, and by the care
which the physician exercised over her education.

Victor, the illegitimate son of Aristide, is said to have borne
a remarkable physical likeness to his father. Thrown as an
infant on the streets of Paris, and living, or rather herding with
the lowest of humanity, he early developed the vicious precocity
of the street arab.

When he was twelve years old he was rescued and placed in
an orphan asylum. But it was too late to reform him. He
sulked and thieved, and after having committed an unspeakable
crime, he made his escape from the institution. He returned to

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the life of an apache , and Zola leaves us in pleasing uncertainty
as to whether he ended his days in penal servitude or under the
knife of the guillotine.

We now return to the other members of Pierre Rougon’s
family.

Sidonie, the elder of his two daughters,'resembled her mother,
Felicity both physically and mentally. She married a lawyer’s
clerk at Plassans, and the pair went to Paris to endeavour to
establish a trade in olive oil and the fruits of Provence. The
affair was a failure, and Sidonie was deserted by her husband,
who died soon afterwards. This did not appear to distress the
woman very much. She set up for herself in a mysterious
sort of business, which was probably not very reputable. She
devilled, in the fullest sense of the word, for her brothers,
Eugene and Aristide, who were now influential men, and
indeed for anyone else who chose to employ her.

Clever as Sidonie was, she revealed some signs of degeneracy.
She was lacking in sexual instincts—the woman appearing to
be lost or absorbed in the man of business to an unnatural extent.
Such unsexed females are by no means uncommon at the
present day, and may be the product of unnatural civilisation.
Further, she had once been entrusted with the affairs of a
ruined noble family, who believed that they had an interest in
a debt, supposed to have been contracted by the Government of
England with that of France in the days of the Stuarts. Sidonie,
by the obscure process of reasoning common to superior
degenerates, came at last to identify herself with the claimants
of this debt. She exaggerated it to the sum of three milliards.
It became a fixed idea. She bored everybody with the details,
and even spent a good deal of money in investigating the
matter.

At this point occurs what one cannot help regarding as a
flaw in Zola’s scheme of heredity. In Le Reve we are told that
fifteen months after her husband’s death Sidonie had a child by
an unknown father. This is clearly an afterthought, for no such
event is hinted at by the novelist in La Curie, the story in which
Sidonie originally figures. This child is Ang^lique, the heroine
of Le Reve. After having been abandoned by her mother, and
reared by L'Administration des Enfants Assistes, she finds herself,
when she is nine years old, in picturesque destitution in the
little city of Beaumont in Picardy. The rest of her life is pure

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romance. The very names of the good man and his wife,
Hubert and Hubertine who rescue her from death in the snow are
redolent of the lays of the Trouveres. We see Ang&ique, now
a beautiful girl, seated at her loom embroidering priestly vest¬
ments. She reads Les Vies des Saints, and La Legende Done
of Jacques de Voragine. She talks to her princely lover from
the balcony of her bed-chamber as Juliet talks to Romeo, while
the moonlight floods the garden beneath. She visits the poor
and suffering like an angel of mercy, and she dies, clinging to
her husband’s neck, as among the plaudits of the people she
comes out of the cathedral after her marriage. It is a fascinating
story, but Ang^lique and her lover, Hubert and Hubertine,
priests and princes are all as unreal and fantastic as the shadowy
characters that flit across the pages of a mediaeval romance.
Imagine such a conte de fee thrust into the midst of the horrors
and tragedies of Zola’s realistic novels ! It is like finding a page
of the Golden Legend bound up by mistake in some sordid
History of Crime. Humanum est errare, and Zola, great artist as
he is, has erred. No, one cannot accept the pure-minded, saintly
Angelique as the daughter of the miserable old female pander,
Sidonie Rougon.

Marthe, the youngest child of Pierre and F^licite Rougon,
did not resemble either her father or mother, but she was
remarkably like her grandmother, Adelaide, or “ Tante Tide','
as the old woman was called at Plassans. Speaking of this
resemblance, the neighbours would say of Marthe, “ Void Tante
Tide qui crac/ie." This likeness appeared to have jumped over
one generation, for Pierre Rougon in no way resembled his
mother.

In her youth Marthe suffered from severe headaches and
attacks of giddiness. From some of the symptoms, which she
herself relates, one comes to the conclusion that about her
twentieth year she passed through a mild attack of melancholia,
with the delusion that her skull had been opened and the brain
removed.

She married her first cousin, Francois Mouret, of whom
more anon. The pair lived at Marseilles for fifteen years,
during which time they had three children. Having amassed
a small fortune, Mouret and his wife returned to Plassans, where
they settled down to a life of retirement and ease.

When Marthe was about forty years of age she began to

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show signs of mental disorder. A certain school of psychiatry
would, no doubt, consider that many of her symptoms were the
manifestations of a repressed complex. She was in love with
a priest, and her passion, concealed at first not only from its
object, but even from herself, found expression in a mystical
form of religion. Later on in the course of the disease she
suffered from convulsions, and from hallucinations of sight,
hearing, and touch, and finally she died of phthisis.

Let us now turn to the Macquart branch of the family.

Antoine, the elder of Adelaide’s illegitimate children, grew
up a strong man, in whom the faults of both his parents early
showed themselves. From his father he derived a love of
vagabondage and drink, and a tendency to outbursts of brutal
passion. These vices, which in the case of the father had been
relieved by a sort of good-natured frankness, were made worse
in that of the son by a cunning full of hypocrisy and cowardice.
This modification of character was due, according to Zola, to
the influence of the mother’s diseased nervous system on her
offspring. From Adelaide, Antoine also inherited “ the selfish¬
ness of a voluptuous woman, who will accept any bed of
infamy, providing that she can lie at ease and sleep warmly.”

The leading trait of the man’s character was laziness. “ His
continual dream was to invent a fashion of living well without
doing anything.”

Drawn as a conscript in 1807, he served in the army until
1815, and ten years later, when he was thirty-six years of age,
he married Josephine Gavaudan, a hard-working woman of
Plassans. Josephine, who was six years younger than her
husband, was strong and healthy, but unfortunately she was fond
of drink. She worked hard all the week, and she drank so hard
on Sunday that she was dead drunk by the evening. She loved
work by instinct, and she seemed to love drink by instinct also.

At first Antoine and his wife got on fairly well together.
The man even worked a little. Soon, however, quarrels began,
and when they were both drunk Antoine beat his wife brutally,
and she, being a strong woman, retaliated. It was not long
before the man resumed his lazy habits. He spent his days
loafing in public-houses, and allowed his wife to work for him
and the family.

There were three children of this marriage : Lisa, born in
1827 ; GervaiSe, in 1828 ; and Jean, in 1832.

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Josephine died of pneumonia in 1850, and in consequence of
her death the home was broken up. After experiencing many
vicissitudes of fortune, Antoine Macquart compelled his half-
brother, Pierre Rougon, over whom his knowledge of certain
shady antecedents of the family allowed him to exercise the
power of blackmail, to buy him a small estate close to the
asylum of Tulettes. He lived on his property for many years
in comparative luxury, employing his leisure in a steady course
of drinking. He died at the age of eighty-four years of spon¬
taneous combustion. The sad event bore a great resemblance
to the death of the late Mr. Krook of Chancery Lane, as related
{>y Dickens in Bleak House , but Zola describes the tragedy
with more detail.

Lisa, the eldest child of Antoine and Josephine Macquart,
was born about a year after the marriage of her parents, when
they were living together in comparative peace and sobriety.
She was a fine, healthy girl, and physically she resembled her
mother, from whom she inherited something of her love of work.
To her father she owed a desire for comfort and bien-itre. As
a child she would work all day long, if she knew that at the end
she would be rewarded with a cake. In short, she was
endowed with that appreciation of future pleasure and pain
w'hich we call prudence. When she was about seven years of
age the postmistress of Plassans took a fancy to her, employed
her first as a little servant, and afterwards adopted her. When
the postmaster died, his widow went to live in Paris, taking
Lisa with her. This life of comfort, which she was well able
to appreciate, and the protection which it afforded from gross
temptations, naturally affected the development of the girl’s
mind and body. It suppressed the vices, and strengthened the
virtues, which she inherited from her ancestors.

In 1852 Lisa married a pork butcher, named Quenu, who
had a large business near the Halles in Paris, and whose father
was a peasant from Yvetot, in Normandy. Quenu took more
after his father than his mother, who was a native of the
department of Gard. Under the appearance of stupidity he
concealed the astuteness of a Norman peasant, and was
exceedingly fond of comfort and good living. Physically and
mentally he was quite normal.

Lisa bore her husband one child, a girl named Pauline, born
in 1852, who was strong and healthy in mind and body.

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Pauline Quenu is the finest female character that Zola has
placed upon his mimic stage.

Gervaise, Antoine Macquart’s second child, was lame from
birth. She was born after her parents had resumed their
drunken habits. “ Contone dans Fivresse , sans doute pendant une
de ces nuits hontenses oil les cpoux s'assommaient, elle avait la
cuisse droite divide et amaigrie , itrange reproduction heriditaire
des brutalitis que sa mere avait eu a endurer dans une heure de
lutte et de soulerie fnrieuse.”

She was a puny child, and her mother gave her spirits with
the idea of strengthening her. She grew up tall and slight,
and, in spite of her delicacy, she was not without her share of
good looks. Her father treated her brutally.

The girl took to bad habits. When she was not quite
fourteen years old she became pregnant by a working tanner,
named Lantier, who was only four years her senior. The next
year she had another child, and three years later a third, all
three children being by the same father.

Lantier was a typical Provencal, small, dark-complexioned,
and good-looking. He was intelligent, but idle, and'did not
care who suffered so long as he was comfortable. He had a
cynical disregard for the rights of others, and a marked ability
in making them work for him.

After her mother’s death Gervaise went to Paris with Lantier
and two of her children, leaving the second child, Jacques,
behind at Plassans. Soon after their arrival in the French
capital Lantier deserted Gervaise. Want brought out the best
in the woman’s character. She inherited a love of hard work
from her mother, and she had her own ideas of cleanliness and
order. She found work in a laundry. Later she married a
man named Coupeau, a plumber by trade, and who was steady
and respectable. By this man Gervaise had one child, a girl
named Anna.

A year or two after the child was born Coupeau fell from a
roof, on which he was working, and broke his thigh. After the
accident his character changed. He became lazy and took to
drink. He may have inherited a tendency to alcoholism, for
we are told that his father died from the result of an accident
which happened to him when he was drunk.

Gradually Coupeau and his wife fell in the social scale.
Gervaise returned to the drinking habits that she had abandoned

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for years. Their home was broken up, and finally the man
succumbed to an attack of delirium tremens , and a few years
later the woman died in the greatest destitution.

Of Gervaise we may say that she inherited a love of drink
from both her parents. From her mother, in addition, she
inherited a love of industry and a pride in its results. This
latter trait revealed itself especially when she had a happy
home and a steady husband. Afterwards, misery and ill-
treatment drove her back to drink.

She had four children. By Lantier she had three boys :
Claude, born in 1842 ; Jacques, in 1844: and Etienne, in
1846. By Coupeau she had one girl, Anna, bom in 1852,
when she was living a sober, hard-working life, and when she
loved her husband, who at that time was also steady and
respectable.

Claude Lantier, Gervaise’s eldest son, showed signs of being
an artist while he was quite a child. An old gentleman, who
saw some of his early daubs, adopted him, and took him home
to Plassans, where he had him educated at his own expense.
When the old man died he left Claude a sum of money, the
interest of which was enough for him to live upon. The young
man returned to Paris to pursue his study of Art. He was
recognised as a genius by his fellow students and others, but
there was something lacking in his mental make-up. He
never achieved success. One might almost say that his hands
could not execute what his brain conceived. He married a
handsome girl, Christine Hallequin, socially his superior, who
was devoted to him, but who was not strong enough to help
him conquer his defects. Claude Lantier’s want of success as
an artist preyed upon his unstable nervous system, and in the
end he committed suicide.

In this case Zola touches upon a point of some interest.
The old adage, nullum ingenium sine mist uni dementia , is utter
nonsense. One might as well say that every healthy man is
diseased, every strong man feeble. Real genius is normal; it
is lopsided genius which is abnormal. The lopsided genius, be
he artist, musician, or writer, is the man who is only too likely
to become insane. He is lacking in equilibrium. Unable or
unwilling to recognise his defects, he attributes his want of
success to the malevolence of others, and easily becomes the
subject of a fixed delusion. Absolutely devoid of modesty,

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which is an essential attribute of true genius, he is obsessed
with his own vanity, and dies its victim.

Claude and Christine Lantier had one child, a boy, named
Jacques-Louis, born in i860, and who was said to have
physically resembled his father. He was feeble in mind and
body, and died of hydrocephalus in 1869.

Jacques Lantier, Gervaise’s second son, had been left behind
at Plassans in the care of his godmother when his father and
mother went to Paris. He was intelligent, and, having followed
the course of the Ecole des Arts et Metiers , he became an
engine-driver of the first class. Physically he resembled his
mother. He was healthy, good-looking, and had remarkably

small hands and feet.

Intelligent and healthy as Jacques Lantier was, he suffered
from what Zola calls the felure hereditaire, which, in his case,
took the form of sadism in its most hideous manifestation. The
horrible impulse appears to have been periodic. When the
desire seized him, “ il ne sappartenait pltis, il obeisscnt a ses muscles,

d la bete enragee

The'novelist paints vividly the torture that the man suffered
during his periods of mental health, dreading the moment when
the terrible impulse would return and master him. One has
been told by victims of epilepsy and dipsomania how they also
dread the approach of their attacks. Once Jacques Lantier
remained free from the disease for so long a time that he
believed himself cured, and it is pathetic to read of the misery
with which he recognised that after all his enemy had only left
him for a season. The struggle of an otherwise healthy man
with such a perversion, the depression which occurs if he be
victorious, and the temporary peace which follows the yielding
to the temptation and the accomplishment of the crime, are

graphically depicted by the novelist.

Jacques Lantier always seemed more liable to an attack of his
affliction after a drinking bout, and Zola is probably correct when
he attributes the disease to the habits of chronic alcoholism, to
which the patient’s ancestors had been addicted for generations.

Etienne Lantier, Gervaise’s third son, was brought up in
comparative comfort by his mother during the first years of
her married life with Coupeau. At first Etienne served an
apprenticeship in some iron works in Paris. Then he became
a mechanic in certain engine works at Lille, and afterwards he

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found employment as a miner in the coal mines of French
Flanders. He was physically strong and mentally intelligent,
and resembled his mother rather more than his father.

In this character it appears to have been Zola’s intention to
present us with the study of a dipsomaniac. But in this he has
failed. He tells us, indeed, that Etienne, having given way to
drink, was dismissed from his situation at Lille for striking his
employer in a fit of drunken fury. He also describes Etienne’s
fear of tasting alcohol on account of the effect it had upon him.
But on several occasions the man drinks gin freely, and does
not appear to have been very much the worse for it, and there
is no evidence that he suffered from a periodic craving for drink.
It is true that he committed murder, but he did so almost in
self-defence, and was certainly not under the influence of alcohol
at the time. Apparently Zola was so carried away by the con¬
templation of the moral debasement and physical misery of the
miners’ lives, which he paints so vividly in Germinal, the
strongest of his novels, that he forgot to develop the character
of the hero as he intended to do.

Anna, the youngest child of Gervaise, and the only one she had
by Coupeau, was “ Nana,” the heroine of the notorious novel of
that name. She was born when her mother was living a healthy
life, and before her father had taken to drinking. As the result
of the moral and material degradation into which her parents
gradually fell, she was thrown early on the street. Her beauty,
which she probably inherited from her great - grandmother,
Adelaide, was remarkable, and she became for a time the
recognised queen of the demi-monde .

In the genealogical tree, which he has drawn up of the
Rougon-Macquart family, Zola indicates that Anna was tainted
with the alcoholism of her parents. But he has not worked
this out in the novel.. Indeed, until the woman was damaged
by her vicious life, she appears to have been mentally and
physically sound. Even in the midst of her debauchery she
evinced traits of a better nature, and one may look upon her
faults as due in a great measure to education—for there is an
education of the street as well as of the schoolroom—and to
environment.

Anna died of confluent smallpox in 1870. She had one
child, Louis, or Louiset, by an unknown father. The boy was
scrofulous, and died in infancy.

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Jean Macquart, the youngest child of Antoine and Josephine,
was strong and healthy. He resembled his mother more than
his father, but it was the peasant ancestry of the family which
principally revealed itself in his character. He was not very
intelligent, but he was well endowed with useful, though obstinate,
common-sense.

He was at first a carpenter by trade. Having been called to
the colours, he served through the Italian war, and fought at
Solferino. Afterwards he bepame a farm labourer on the
Beauce, where he married. After losing his wife under tragic
circumstances, he rejoined the army at the outbreak of the
Franco-Prussian War. He was present at the battle and the
capitulation of Sedan, and he fought during the days of
the Commune on the side of the Versaillais. After the war
was over Jean Macquart returned to the neighbourhood of
Plassans, where he married Melanie Vial, a healthy, intelligent
girl, who was the only daughter of a peasant in easy circum¬
stances.

In Jean Macquart, Zola has drawn one of the best of the
human race—an honest countryman, brave, patient, and
resourceful. When we last hear of him, he and his wife are
leading a hard-working, comfortable life, with a large family of
healthy children growing up around them.

We have now to go back almost to the root of the Rougon-
Macquart family tree, and to consider the case of Ursule
Macquart, the younger of Adelaide’s two illegitimate children.

Ursule resembled her mother mentally and physically.
“ Boi’n the second ” of this branch of the family, “ at the hour
when the tenderness of Adelaide dominated the love, already
calm, of Macquart, Ursule seemed to have received with her
sex the more profound imprint of the temperament of her
mother.” As a girl she was fanciful, passionate, and much
given to day-dreaming. Sometimes she suffered from pro¬
longed periods of sadness, at other times she was unreasonably
gay, and surprised the neighbours with outbursts of nervous
laughter. She inherited her mother’s beauty, but not her bodily
strength. At the age of nineteen years she married a journey¬
man hatter named Mouret. The pair went to live at Marseilles,
where they had three children—Francis, born in 1817, H£l£ne,
in 1824, and Silv&re, in 1834.

Ursule died of phthisis in 1839. Her husband, Mouret, was

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broken-hearted at her death. He brooded over his bereave¬
ment for a year, spending all the money he had saved, and
neglecting his work and family. One day he hung himself in
the wardrobe where his late wife’s clothes were still preserved.
He seems to have been one of those amiable, uxorious men, in
whom the emotions dominate the other faculties of the mind.
They are not of much use in the world. If they are subjected
to mental strain, they frequently break down, and become the
victims of melancholia. Should they commit suicide, they are
extremely likely to murder their loved ones before taking their
own lives.

Francois Mouret, the eldest child of Ursule, not only
physically resembled his mother, but also his grandmother to a
remarkable degree. After his father’s death he went to
Plassans, anci was employed as a clerk by his uncle, Pierre
Rougon. He married, as has been said above, his first cousin,
Marthe, whose extraordinary likeness to their grandmother,
Adelaide, has also been previously pointed out.

After his marriage, Francois Mouret went back to Marseilles,
where in fifteen years he amassed a small fortune in the olive
oil trade. He and Marthe had three children : Octave, born
in 1840; Serge, in 1841 ; and D£sir£e, in 1844.

Satisfied with the money he had saved, Francois Mouret
sold his business and returned to Plassans, where he bought a
house and garden and settled down to the life of a petit rentier.

Until he arrived at middle age this man appears to have
been sane enough. But the hereditary weak brain was there,
and it gave way to the stress of jealousy caused by his wife
falling under the influence of Abb6 Faujas. He became more
and more irritable, the carefulness of the middle-class house¬
holder developed into avarice, and later he became too weak-
minded even to be avaricious. He, who had been very fond of
his fellows, gave up society and sat moping alone. His love
for his wife and children, for he had inherited the affectionate
disposition of his father, showed itself only by fits and starts,
except in the case of his imbecile daughter, D6sir£e, whom he
loved to the last.

Finally, he was sent to the asylum at Tulettes, though it is
questionable whether he was certifiable at the time of his intern¬
ment. But he undoubtedly became insane afterwards. Some
time later, by the connivance of one of the attendants, he

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escaped from the asylum, and returned by night to his own
house in Plassans. There he was seized with a sudden
impulse of vengeance. He set fire to the building and
perished in the flames together with the man of whom he was
jealous.

Octave Mouret, the eldest child of Francois and Marthe, was
born in the first year of his parents’ married life, when they,
and especially his father, were at their best physically and
mentally. He was healthy in mind and body. He inherited
his father’s business capacity, and a great deal also of his
maternal grandmother’s cleverness. After sowing his wild oats
at Marseilles, Octave went to Paris, where he succeeded in
developing a small drapery business into a colossal emporium.
He married a strong and healthy girl, Denise Baudu, who came
from Valognes in Normandy, and who was as intelligent and
chaste as she was beautiful. She is Zola’s most charming
heroine.

Octave Mouret was exposed, and exposed himself, to almost
every kind of stress, but he showed no sign of the family
mental taint. When we last hear of him he is living the life
of a successful tradesman. His wife has borne him two
children, one of whom died in infancy, but the other is strong
and well.

Serge Mouret, the second child of Francois and Marthe,
resembled his mother mentally and physically. In his boyhood
he was amiable and studious, and when he became a man he
entered the priesthood. At puberty a passionate enthusiasm
for religion awoke in him, which increased during the period of
adolescence, and culminated, when he was about twenty-four
years of age, in an attack of brain fever accompanied by
delirium and hallucinations.

Serge Mouret’s case bears considerable resemblance to that
of his mother. In both the mental crisis occurred at periods of
life recognised as being those of exceptional stress; in the
son’s case at puberty, in the mother’s at the climacteric. In
both, religion appeared to be the outward expression of an
inward eroticism.

From the symptoms described by Zola—though it is some¬
what difficult to follow him at this point, for he himself becomes
delirious, the delirium taking the form of the most marvellous
passages of colour writing that ever flowed from a writer’s pen

lxii. 3 5

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—one concludes that the brain fever from which the young
man suffered was the condition described by French alienists as
“ Confusion mentalepseudo-meningitique'.'

D£sir£e, the youngest child of Francois and Marthe Mouret,
was an imbecile.

H^lfcne, the second child of Ursule Mouret, nee Macquart,
showed no sign of insanity. She grew up a fine, strong woman.
In 1841 she married Charles Grandjean, a clerk in a business
house at Marseilles. This marriage with a poor working
hatter’s daughter was disapproved of by Grandjean’s family, so
that the first years of the married life of the young couple
were passed in comparative poverty. Afterwards Charles
inherited a fortune, and he and his wife removed to Paris to
enjoy it. Soon after their arrival in the French capital the
husband died of acute bronchitis. He was passionately fond
of his wife, but on her part the marriage was one 6f con¬
venience.

They had only one child, Jeanne, born in 1841. She was
afflicted with epilepsy, and died of tuberculosis at the age of
fourteen. She was a frail but beautiful child, and was said to
bear a remarkable likeness to her great-grandmother, Adelaide.

Silv&re, the youngest child of Ursule Mouret, was very
delicate as an infant. But after his mother’s death he went to
live a wild, outdoor life with his grandmother, Adelaide, in the
country around Plassans, and he grew up a strong youth. He
was exceedingly intelligent, and spent much of his time
reading. But unfortunately his education was too poor for him
to understand all that he read, and many of the ideas that he
thus acquired were warped and distorted.

In his case, as in that of Serge Mouret’s, the enthusiasm of
adolescence passed beyond the border line of sanity. In the
case of Serge it took the form of mystic religion ; in that of
Silv&re of an idealised republicanism.

“Ah! que tu es bien le petit-fils de ta grandmerc! hysteric 011
enthousiasme, folic honteuse ou folic sublime. Toujours ces diables
de nerfs ! ” exclaimed his uncle, Dr. Pascal Rougon, as he
listened to one of Silvere’s outbursts of fervent but visionary
republicanism.

After having been the hero of one 01 Zola’s most charming
idylls, the poor lad died a martyr for his beloved republic.

Such is the family history which Zola lays before us, and,

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allowing for social, historic, and local differences, and, of course,
for the exaggerations, the high colouring, if you will, required
by a novelist’s art, it is not very different from one which
might be compiled from the note-book of a practitioner of
medicine of the present day.

Ethnological considerations creep into every study of man¬
kind, and although they did not probably enter into the original
conception of Zola’s scheme, yet they reveal themselves every¬
where in his history of the Rougon-Macquart family. Some¬
thing of this is due to the region in which he has placed the
cradle of the race, a region where even now, after centuries of
fusion, the types of widely different peoples can be recognised.
And, in its turn, this choice of locality was the result of
accident. Although he was born in Paris, the novelist spent
the greater part of his youth in the South of France, where his
father, an Italian engineer, was employed in professional work.
Zola knew Provence thoroughly. He was acquainted with all
the ruined monuments and all the old-fashioned streets of its
ancient cities, and he had studied its people in every rank of
society. It was quite natural, therefore, that he should make
use of this local knowledge in his series of novels.

When we think of Provence we think of troubadours and
Courts of Love, of Laura and Petrarch, and of the fountain of
Vaucluse; or, if we are more modern in our ideas, of Fr£d£ric
Mistral and his great poems Mircio and Calendal. But it is
not all poetry and passion in this beautiful corner of France.
There is another side to the Provencal character, and that is
the commercial.

From earliest historic times the trade of the Mediterranean
peoples penetrated the uncivilised regions of western Europe
by the Rh6ne valley. The ubiquitous Phoenicians came and
went, but the Greeks from Phocea left more permanent traces
on the land. They founded the great trading city of Massilia
(Marseilles). And, later on, fresh colonists from Greece built
Antipolis (Antibes), Nicea (Nice), Agatha (Agde), and other
towns on the southern coast of France. The infusion of Greek
blood into the native Ligurian and Celtic races must have been
considerable, and may be recognised even at the present
day. The ArRsiennes are said to owe their beauty to their
Greek ancestors.

In the days of the Romans, Provence (Nostra Provincia)

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was still the trading centre of the west. Caesar tells us :
“ Fortissimi sunt Beiges, propterea quod a cultu atque humanitate
Provincics longissime absunt, minimeque ad eos mcrcatores sa-pe
commcant, atque ea, quee ad effeminandos pertinent, important .”

Lastly, the Visigoths and Saracens passed by, leaving, no
doubt, traces of their passage, but doing little to modify the
trading instincts handed down to the Provencals from the days
of the early colonists from Greece.

In Felicity Puech, the scheming wife of Pierre Rougon, Zola
has, consciously or unconsciously, painted the representative of
a race deeply imbued for centuries with commercial instincts ;
for intrigue, for which alone the woman seemed to live, is the
soul of trade. The influence of her character reveals itself in
several of her descendants, particularly in her sons, Eugene
and Aristide, and her daughter, Sidonie, and in her grandson.
Octave Mouret, modifying, and to a certain extent dominating,
the characteristics of the other stems grafted on this family
tree.

In Rougon, the husband of Adelaide and the father of
Pierre Rougon, the novelist has drawn the representative of a
widely different race. He was a short, stout, square-headed
boor, and he came from the valleys of the lower Alps, where
to-day we find the descendants of the short, brachycephalic
Ligurians. Eugene Rougon, the statesman, is a skilfully drawn
portrait of a man resulting from the cross-breeding of the brutal
Ligurian with the wily Provencal.

It would be possible, if space allowed, to point out the
influence exercised by the Norman peasants and certain of the
mixed peoples of Paris, with whom members of the Rougon-
Macquart family become allied, on its mental and physical
development.

In studying heredity as a cause of insanity, the question
arises whether the paternal or the maternal influence is most
potent in transmitting mental disease to the offspring.
Authorities differ. Esquirol considered that the father’s con¬
dition was the most important, and Baillarger agrees with him,
but Orchansky and others hold the opposite view. The family
histories of mental cases which I have been able to investigate
are, of course, too few to be of much value, but, as far as they
go, they point distinctly to the conclusion that insanity is
generally handed down from the maternal side of the house.

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and also—and this is an important point—that the mother is
more likely to transmit the taint to the child that she nurses
than to the one for whom she does not perform this duty, even
when the disease has not revealed itself in her, the mother’s,
generation.

There is an analogous series of facts which supports the view
of the potency of the maternal factor. If a man of genius has
children, it is rare for them to be talented. But such a man
has generally had a mother who has been distinguished for her
sound common-sense, and sometimes has been remarkable for
her intelligence. Even when it is not a question of genius, but
only of ordinary success in life, it is a matter of common know¬
ledge that men, who have attained high positions in the pro¬
fessions or in commercial pursuits, have very second-rate sons
in the majority of cases. It is, however, rare to find a man,
who has been able to rise in the world by his own efforts, who
has not had a level-headed mother.

If, then, the sound brain be generally handed down by the
mother to the offspring, may not the unsound brain be so also ?
Or to put it in another and more forcible way, is it not the
individuality of the nervous system of the mother rather than
that of the father which is impressed upon the offspring ?

Zola, in the Rougon-Macquart family history, illustrates this
theory, both with reference to the transmission of mental
superiority and of insanity. As to the former, I have already
pointed out the influence of the clever mind of F£licit£ on the
characters of her descendants, while it will be remembered that
Pierre Rougon was of very average intelligence. Josephine
Gavaudan is a further illustration, for she transmits her love of
hard work to her three children, while their father, Antoine
Macquart, was an exceedingly lazy man. With regard to
insanity, the evil influence of Adelaide’s mental disease is
shown throughout the whole family history, although her
husband, Rougon, was of sound mind. Marthe Mouret hands
down her unstable brain to two of her children, though in her
case the mischief is doubled by her marriage with her first
cousin. So that here the potency of the paternal and maternal
factor appears to be equal. Though it may be observed that
the type of mental disease from which one of the children,
Serge, suffered, was the same as his mother’s. The case of
Gervaise is still more disastrous, for her three children by

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[July,

Lantier were more or less insane. Whereas Lantier himself
showed no sign of mental aberration.

There is another point, upon which Zola lays considerable
stress, and that is the position of the child in the sequence of
the family. The healthier the parents are at the time of the
procreation of the child, the more likely is it to be healthy, cela
va sans dire. The younger the parents are, after they have
arrived at maturity, the more likely they are to have healthy
offspring, because they have not yet been exposed to the pro¬
longed strain and fatigue of life. And consequently the older
children of a family are more likely to be healthy in mind and
body than the younger. In the fictitious pedigree before us
we see that Pierre Rougon is healthier than his half-brother,
Antoine, and that Antoine is decidedly healthier than his sister,
Ursule. In Pierre Rougon’s own family this is still clearer.
Even in the case of Franrjois and Marthe Mouret, Octave, the
eldest child, is normal, while the two younger ones are mentally
diseased. This is, I think, in accordance with general experience.
In only one instance have I met with the case of a family in
which the eldest child was insane and all the younger children
mentally sound. And this case is explained by the fact that
the birth of the eldest child Was a difficult instrumental one,
and that consequently the congenital imbecility from which it
suffered may have been due to violence.

But when the parents are too young things are different, and
the older children are likely to be more feeble both in mind
and body than those who come after. In the case of Gervaise,
we are told that she had three children by Lantier, who was
only four years her senior, before she was eighteen years old.
Even allowing for the early development of a southern race,
this is very young. In a northern race the matter would be still
more serious. And it may be observed that Gervaise’s two older
children, Claude and Jacques, were mentally more unstable than
he youngest, Etienne.

The part played by alcohol in the development of mental
disease, and the tendency of alcoholism to become hereditary',
is fully worked out in this series of stories. We see that
Adelaide, at the time of her marriage with Rougon, who
appears to have been a temperate man, was not addicted to
drinking to excess. And consequently there is no evidence of
alcoholism in the Rougon branch of the family. But after-

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tgi6.] BV j. BAllFtElLD ADAMS, L.R.C.P.

wards, when Adelaide cohabited with the drunkard, Macquart,
she gave way to drink, and the result is evident throughout the
Macquart branch of the family. Antoine, the elder of
Adelaide’s illegitimate children, was a drunkard, and although
Ursule, the younger child, does not appear to have developed
any great love for drink, yet she was feeble in body, and
exhibited in her own case and transmitted to her offspring the
diseased mentality which she inherited from her mother and
grandfather. For alcoholism in the parent, even when it is not
handed down as such, seems to facilitate the transmission to
the offspring of taints which might otherwise have lain dormant,
or have been suppressed altogether.

Antoine Macquart, unfortunately, married a woman who was
addicted to drinking to excess. Their daughter, Gervaise, was
a drunkard when a child and a young woman, and though in
middle life, and under favourable circumstances, she gave up
her evil habit, yet she returned to it under the strain of misery,
and at last it killed her. Three of her children were insane.
In Etienne the insanity took an alcoholic form. In the case of
Jacques it took that of criminal impulse. In this latter case
Zola has indicated what one so frequently observes in studying
the history of a morbid family, namely, how closely alcoholism
is linked with troubles of the will.

The influence of environment in the development of character
reveals itself constantly throughout this long series of novels.
But Zola is true to Nature. He recognises that environment
can only modify ; it cannot change the natural temperament or
constitution of the mind of the individual. Cultivation of
flowers increases their beauty ; cultivation of weeds adds to the
rankness of their growth. In like manner, favourable circum¬
stances bring out all that is best in some people, and all that is
worst in others. Lisa, the daughter of the scoundrel Antoine
Macquart, is taken from miserable surroundings at the age of
seven years, and placed in a good home, and is well fed. She
grows up a strong woman, marries a normal individual, and
gives birth to a healthy child. Even her sister, Gervaise, when
she lives in comfort, finds the best of her nature assert itself.
But in the cases of Aristide Rougon and his son Maxime,
success and affluence lead to the development of all that is bad
in their characters.

The effect of stress on an unstable mind is illustrated by the

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cases of Frangois Mourct and his wife Marthe. In the case of
the latter, it appears probable that even had she not fallen
under the influence of Abb£ Faujas, she would have developed
some form of erotic eccentricity at the oncome of the climacteric.
But in that of Francois himself, it is possible that had he not
been exposed to the strain of jealousy he would not have
become insane. No doubt senility would have come on early,
and, had he lived long enough, he might have sunk into
dementia, but he would have been spared the attack of mania.

In spite of beautiful descriptions of scenery, of a realism
which clothes with flesh the phantoms of romance, and a keen
penetration into the motives of men and women, Emile Zola’s
books would be but sorry reading if it were not for the hope
of the ultimate regeneration of the race, which vibrates through
every story. The novelist shows how self-destruction, alco¬
holism, and disease, especially phthisis, weed out the unfit from
a family, but he also points out that in those that survive there
is always the possibility of improvement. The germs of good
are even more tenacious of life than those of evil, and when
they are favoured by circumstance, such as the temporary
health of a parent, or the infusion of healthier blood, they are
ready to struggle on towards that which is better.

Zola was not a pessimist. Could anything be more hopeless
than the future of a family sprung from such a degenerate as
Adelaide ? Yet among the crowd of murderers, suicides,
visionaries, sexual perverts, and people rotten with consumption,
the novelist shows us gentle scientists like Dr. Pascal Rougon,
unselfish, level-headed women like Pauline Quenu, and honest
citizens like Jean Macquart.

Catatonia as a Type of Mental Reaction By David K.
HENDERSON, M.D., Resident Physician, Royal Mental
Hospital, Gartnavel, Glasgow.

IN 1896 Kraepelin first introduced and defined his concep¬
tion of the manic-depressive psychoses and dementia praecox.
It has been fairly generally admitted that his was a brilliant
piece of work, but since that time he has been led, in certain
more or less minor respects, to modify his views. Briefly put,
Kraepelin described in a very thorough and detailed way the

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symptomatology of these disorders, and then, according as the
case was one of manic-depressive insanity or dementia praecox,
the prognosis was held to be either good or bad respectively.
Such a simple method of differentiation and of deciding on the
prognosis seemed too good to be true, and although it must be
admitted that in the main it holds good, yet in certain funda¬
mental respects it fails. We all know that certain types of the
manic-depressive psychosis do not get well, and on the other
hand we all probably have seen cases which, symptomatologically,
were cases of dementia praecox that recovered. In no group
of cases has this been more clearly seen than in catatonia.

The term catatonia was first employed by Kahlbaum to
denote a group of alternating cases, a good many of whom
tended to get well. When Kraepelin came to use the term he
modified and enlarged its meaning, and included it as a sub¬
group under the more general term dementia praecox. Krae¬
pelin of course recognised that catatonic states occurred in
various other disorders, such as epilepsy, toxic-exhaustive states,
brain tumour, general paralysis, etc., but he held that in these
conditions the catatonic symptoms were essentially of a tran¬
sitory nature, and then he went on to make the sweeping state¬
ment that all catatonias not organic in nature were indicative 01
a deteriorating process. In later years Kraepelin has consider¬
ably modified the above generalisation, and now admits that
about 13 per cent, of cases of catatonia recover, but still he
holds that these recoveries should be looked upon more as
remissions than as absolute recoveries. Wilmans (quoted by
Kirby) in 1907 reviewed Kraepelin’s Heidelberg cases, and
found that a good many of the cases diagnosed by Kraepelin as
catatonia had recovered, and stated that catatonic symptoms as
evidence of a deteriorating process had been greatly over-rated.
In 1913 Kirby, in a paper on “Catatonia and its Relation to
Manic-depressive Insanity,” reported four cases, all of whom had
shown the characteristic catatonic state, but subsequently de¬
veloped quite typical manic features and recovered. Devine
has also reported two cases who have passed through catatonic
periods, and who from time to time have shown a fairly frank
excitement. Devine apparently believes that his cases are
more allied to manic-depressive states than to dementia praecox,
but in my opinion his cases are very much less conclusive than
those reported by Kirby.

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Enough has been said to show that a rather anomalous state
of affairs exists, and on account of it there have been some who
have not hesitated to assert that we would have done quite as
well if we had continued to employ the terms mania, melan¬
cholia, adolescent insanity, stupor, and the rest, and who have
further asserted that the term dementia praecox, carrying with
it as it does a poor prognosis, was apt to foster a pessimistic
spirit. It would be far outside the scope of this paper to enter
into a discussion of the classification of mental disorders, but it
may be maintained that Kraepelin by his conception infused
new life into psychiatry, and that his analytical genius brought
together into the groups of manic-depressive psychoses and
dementia praecox cases which, on the whole , showed very dis¬
tinctive symptomatic pictures, which up to a certain point could
be used prognostically. Where Kraepelin failed was in not
allowing for the personality in whom the psychosis developed,
and in not giving sufficient consideration to the genesis of the
disorder.

Adolf Meyer was one of the first, if not the first, to recognise
this defect, and he accordingly formulated his conception of
reaction-types, whereby a psychosis was looked upon in terms
of situation, reaction, and final adjustment. For instance, sup¬
pose a person to be suffering from some form of bacterial
infection (the situation), nature reacts by developing anti-bodies
to counteract the injurious or poisonous effects of the toxins,
and the final result depends either on an overcoming of the
toxins, or absolute failure, or else a compromise, whereby the
organ is injured but still is able to function. So it is with the
mind ; we have to train ourselves to meet the different situa¬
tions that arise in our lives in healthy, aggressive ways, and
should we fail we have to inquire into the why and wherefore of
our failure, and have to devise means to safeguard ourselves in
the future. Let me give you a concrete example: A young
married woman, set. 33, following the birth of a baby, was
found to be quite blind, the result of a retinitis. On attempting
to take up her household duties she found that she was quite
unable to cope with the situation, became depressed, and made
several determined attempts to commit suicide. In consequence
she was sent to the hospital for treatment, where, by a gradual
building up of her interests, she was finally able to make a
satisfactory adjustment, and eventually was discharged with a

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very much better sense of her responsibilties. Such a case
shows how a healthy-minded woman may, under certain dis¬
tressing circumstances, react to her difficulties in a faulty way,
but it also shows how, with a certain amount of help, that
person is again able to regain her balance.

As has been pointed out by Meyer, however, the individual
who tends to develop dementia praecox is not a well-balanced
person, but on the other hand is usually one who throughout
life has been in the habit of meeting his difficulties in an
inadequate way, “ and often enough has given evidence of being
habitually dreamy, dependent in his adjustment to the situa¬
tions of the world rather on shirking than on an active aggres¬
sive management, scattered and distracted either in all the
spheres of habits, or at least in some of the essential domains
of adjustment which must depend more or less on instinct or
habit.”

Following Meyer’s lead, Hoch made an analysis of the per¬
sonality of a large series of cases of dementia praecox, and
found that certain traits, such as seclusiveness, shyness, sensi¬
tiveness, lack of adaptability, etc., occurred with great regularity,
and constituted what he aptly termed the shut-in personality.
Such a type of personality was present in about 66 per cent, of
his cases, and in only 8 per cent, did he find a normal per¬
sonality. In manic-depressive cases, on the other hand, he
found that we have usually to do with individuals who are
subject to swings in mood, who are either vivacious, over-active,
enthusiastic, easily excited, or else are subject to blue spells,
worry over trifles, borrow trouble, blame themselves unduly, etc.

The point, then, which I want to emphasise is that these
studies of Meyer and Hoch seem to clearly show that it is not
anyone who can develop dementia praecox or manic-depressive
insanity, but that the psychosis is essentially determined by the
mental characteristics of the individual.

I submit that if we approach our cases in this way we will
soon get away from cut-and-dry formal diagnostic methods,
and, on the other hand, will come to study our cases as indi¬
vidual problems, to be treated on their merits in relation to the
whole life-history of the individual.

To illustrate some of the above points still further, I wish in
the first place to discuss a case of catatonia analagous to those
reported by Kirby, and then in contrast several cases of catatonia

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will be briefly discussed, all of whom, despite certain defects in
their mental make-up, have been gradually able to readjust
themselves, and have made a good recovery, even although it
may be only a transitory one.

(i) A young man, a student, set. 20, was admitted to the
Psychiatric Clinic in a stuporous, terror-stricken condition,
beads of perspiration stood on his forehead and face, his shirt
and underclothes were soaked in perspiration, and his pupils
were widely dilated. His lips and fingers were cold, clammy,
and cyanosed. He had to be assisted to undress, and when put
to bed lay stiffly stretched out, and paid not the slightest atten¬
tion to anyone or anything around him. For the most part it
was quite impossible to get him to answer any questions, but
on one occasion, when asked his name, he gave instead the
name of his father’s chauffeur, and on another occasion mentioned
the name of the hospital. He did not respond to painful
stimuli, and had to be attended to in every way. During his
residence in the hospital he maintained a mute, resistive attitude,
could not be roused to take any interest in anything, and fre¬
quently wet and soiled himself. Once he wrote a word or two,
such as “ going to be shot,” but he never could be got to reply
relevantly. At another time he apparently thought that he
was on a train, and motioned to the nurse to be quiet lest she
would waken the person in the next berth. He was removed
to another hospital, where for many weeks he remained in the
condition described above, and then gradually made a good
recovery, but still later became somewhat hypo-manic.

On studying the life-history of the patient we find that his
mother and a maternal aunt had been mentally affected. The
patient himself had been a healthy child, had developed
normally, and in disposition had been open, jolly, and frank.
He was a general favourite, a splendid athlete, but despite his
physical prowess he had been reckoned modest and well-
balanced. Intellectually he had in everything, except in mathe¬
matics, in which he was backward, been up to the average.

Six months previous to his admission he had taken up some
office-work, but soon he began to behave in -an elated, excited
way, insisted on dancing the tango with the lady typist, and
generally so disorganised the office staff that at the end of
three weeks he was discharged. During the next few months
he continued in a highly excitable, elated, restless, over-talkative

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state. A fortnight previous to admission he became depressed
and downhearted, would not read, refused to take an interest
in social affairs, said that he could not think, that he was going
crazy, and, in addition expressed some vague ideas of persecu¬
tion, saying that one of the maids in the house was a detective,
and that his father had better get rid of her.

To sum the case up, we may say that here we had a per¬
fectly characteristic catatonic stupor, preceded and followed by
definite manic-depressive symptoms. According to Kraepe-
linian teaching we would have been justified from the sym¬
ptomatic picture in looking upon the case as one of dementia
praecox with a very grave prognosis. When, however, we come
to consider the type of personality in whom the psychosis
developed, and the evolution of the disorder, we immediately
come upon features which show the close relationship of such a
case with the manic-depressive psychoses, and warn us that the
prognosis may be not nearly so bad as the catatonic state
might lead us to think. It is just in such a case where catatonic
and manic-depressive phases are present that Kirby believes
that the manic-depressive symptoms are of greater prognostic
significance.

The cases which I am now going to discuss are much more
closely allied to the catatonias seen in cases of dementia
praecox.

(2) A single woman, aet. 45, on admission was in a dull,
stuporous, resistive, mute condition. Her facial expression was
one of grim, determined antagonism, and she strongly opposed
any attempt to help her in any way. She lay in bed with her
arms pressed firmly against her chest, her hands were kept
tightly clenched, but she kept constantly flexing and extending
her legs so that the skin over her heels and knees had become
abraded. On account of her refusal of food she had to be
tube-fed ; she frequently wet and soiled herself.

Ten days after admission she was noted as showing well-
marked flexibilitas cerea and catalepsy, showed no reaction to
painful stimuli, and still did not respond to questions ; she
looked dull, her tongue was thickly coated, and her breath was
foul. About this time, however, as if in response to auditory
hallucinations, she started to make a remark or two, and would
say such things as : “ Oh, Henry, Henry, don’t bring them in
here,” or “ Every man has a right—it was not the baby—why,

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that man is crazy, I’ll have him sued.” She continued to be
tube-fed, at times would steal food from the other patients
which she would devour in a ravenous way, but always refused
to eat anything from her own tray. On one occasion, about
five weeks after her admission, she suddenly behaved in an
extraordinary way ; she smirked, gesticulated, shrugged her
shoulders affectedly, and reminded one of a young girl trying
to play the part of a grand lady ; these actions were repeated
over and over again. During the next few weeks she exposed
herself in a shameless, unconcerned way, chewed thread and
hair, and made many violent, impulsive, fantastic attempts to
commit suicide, eg, by standing on her head and trying to
screw her neck, by trying to smother herself in the bedclothes,
by throwing herself from her bed, etc. Occasionally she would
get out of bed and walk round and round the ward in a dull,
blank way, knocking against anyone or anything that happened
to get in her way.

Then, quite suddenly, seven weeks after admission, one day
when visited by her mother she responded to a question, and
began to talk rationally. Following this she gradually got
clearer and better, and finally started to occupy and interest
herself in a healthy, natural way.

Her history showed that when aet. 29 she had had a
previous attack of mental disorder, similar in character to the
present one, which had persisted for a period of five months.
The present attack had been of about three weeks’ duration.
At first she was quiet and thoughtful, studied her Bible con¬
stantly, and then a few days previous to admission she became
very agitated, paced up and down her room, and when asked
what the matter was replied : “ It is because of my sinful
nature.” It was following this that she lapsed into a catatonic
state, and had to be brought to the hospital for treatment.

A maternal grandmother and a maternal uncle had been
mentally affected. The patient herself had spent a healthy
childhood, had developed normally, but apparently had been
brought up in a narrow, sanctimonious atmosphere, as her
mother with pride asserted that the patient had never been
allowed to associate with ordinary people, that she was allowed
to mix only with girls of the highest moral standing, and that
she had always been most closely guarded against knowing
anything pertaining to her instinctive life. She had been an

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exceptionally conscientious, secretive, obstinate, prim girl, who
never had made many friends, had never cared for games, social
gatherings, etc., but had always occupied her mind with the
serious, religious side of life.

Following this patient’s return to her normal condition,
several attempts were made to get her to review the pyschosis
so as to try to give her a better realisation and understanding
of her disorder, but at all times the patient was exceedingly
averse to a discussion of her case.

Although she was discharged as recovered the reservation
was made that she had very poor insight into her condition.
However, a letter received from her mother one year after her
discharge in part said : “ I would say that she is, and has been,
perfectly well ever since leaving the hospital.”

Here, then, we had to do with an individual whose instinc¬
tive life had been almost entirely suppressed, who on the
surface was prim, secretive, obstinate, and shut-in, and who, in
response to certain difficulties, showed her poor balance by
reacting to the situation with an acute catatonia, characterised
both by stupor and impulsive excitement. In contrast with
this surface picture in her pyschosis repressed trends, as evi¬
denced by her shameless erotic conduct and the expression of
such remarks as “ It is because of my sinful nature,” show
themselves, and indicate clearly enough that underneath the
surface a certain disharmony must have existed. It seems
reasonable to suppose that just such a conflict, occurring in a
person who never had been able to meet her difficulties in a
healthy way, could be responsible for the pyschosis.

(3) A young man, aet. 31, a minister, on admission was in a
dull, mute state, kept his eyes tightly closed, and had to be led
into the ward. He accepted everything done for him quietly
and without resistance. When put to bed he lay flat on his
back with his head thrown back, his eyes tightly closed, and
his mouth wide open. He refused to answer any questions,
had to be raised when necessary, had to be spoon-fed, and did
not react to painful stimuli. He did not show any catalepsy;
occasionally, in response to some joking remark, he would
smile, but he did not seem to take any interest in anything
going on around him. For five weeks the above condition
remained entirely unchanged, and then one day he suddenly
seemed to wake up, and said : “ My mind is all right.” A few

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days later he entered into a discussion of his case, and stated that
during the whole period of his stupor his mind had been quite
clear.

The patient had come from a healthy stock, had developed
normally, and at the age of 21 years had taken his degree of
Master of Arts at Glasgow University. In disposition he was
thoughtful, quiet, industrious, one who shunned company, and
who, from his earliest years, had been religiously inclined ; one
of his teachers had called him “a sphinx.” In 1906, after
attending some revival meetings, he decided that it was his
duty to go out into the world and “ preach Christ,” and make
converts. Two years later he emigrated to Canada, and then
gradually preached his way down through the States of New
York, New Jersey, and Pennsylvania, until he reached Mary¬
land. In July, 1913, while on a holiday, he started to review
his year’s work, and felt discouraged at the poor results
attained. Gradually he became introspective, blamed himself
for his inefficiency, and, as he saw the great gulf that existed
between his ideals and the actual results achieved, he felt that
his only hope lay in prayer. He told, too, of a conflict which
for long had existed between his human and divine nature, and
how it was only with difficulty that he had forced himself to
believe that the secret of Christian growth was the subjection
of man’s desires.

He explained how, during his stupor, he had attempted to
work out how he might become more efficient, how he might
better reach souls, how he could put something into man to
make him live up to the example and teachings of the Master.

A letter received from him one year after his discharge stated
that he was in excellent health, and that he was actively engaged
in his work in the north of Ireland.

In this case, again, we see how a man with the shut-in type
of make-up, instead of meeting his difficulties in a healthy,
aggressive way, tended to brood over them, and eventually
showed an abnormal type of reaction by relapsing into a cata¬
tonic state.

Gradually, however, his resistance was built up, he was again
able to readjust himself to the situation, although He left one
with the feeling that he had very little real insight into the
actual nature of his difficulties.

(4) A single woman, aet. 42, on the night previous to her

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admission to the Glasgow Royal Mental Hospital had attended
a religious meeting, the special topic under discussion being the
Millennium. On returning home she seemed rather excited,
but her conduct did not give rise to any special comment.
The following morning when called she did not respond, her
room door was found to be locked, and access to her room had
to be gained through the window. She was seen to be sitting
up in bed in a trance-like state with her eyes tightly closed.
She adopted peculiar attitudes, sang snatches of hymns, refused
food, and for the most part refused to answer any questions.
When asked her name she replied by saying “ Jesus,” and
repeated that word over and over again.

On admission she was in a state of stupor, lay with her eyes
closed, would not speak, and did not react to painful stimuli.
She showed a well-marked state of flexibilitas cerea and cata¬
lepsy, and gave no indication of appreciating anything going on
around her. This stuporous state was punctuated from time to
time by sudden impulsive acts, during which she was destructive
and homicidal, and had to be given hyoscine. Frequently she
tried to injure herself by throwing herself out of bed, by banging
her head, and then at other times she screamed out loudly,
grimaced, was dirty in her habits, and had to be tube-fed.

During the course of a few weeks she began to interest herself
in others, was most kindly, and most helpful in very many ways.

This patient since the age of 21 years had had six previous
attacks of mental disorder, each of which had been acute in
onset and had been characterised by a state of stupor with
impulsive self-destructive, and frequently very marked erotic
tendencies. An interval of eight years had elapsed between
the present attack and the immediately preceding one. Her
history showed that a maternal aunt had had an attack of
mental disorder from which she had recovered ; a sister had .
died from hydrocephalus. The patient had been a nervous
dhild whose mind had always been more or less filled with
religious questionings, constantly wondering whether she was a
Christian and really belonged to Christ. Throughout her life
she interested herself almost entirely in sociological and religious
work, and, as she expressed it: “ At the age of twenty years I
accepted salvation in Christ, and since that time I have been at
rest in God.” All her life, however, she had been extremely
sensitive, had been dependent for her comfort on the opinion

LXII. 36

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held of her, had no interest in the lighter side of life, had never
been quite able to meet her difficulties frankly, but had always
taken refuge in the Divine.

When any attempt was made to review her psychosis with
her she adopted the attitude that her attacks were due essen¬
tially to a dispensation of Providence, and that therefore it was
not meet for her to discuss them. Even after she had regained
her normal condition she did not bring up the question of her
discharge, apparently rationalising her stay by believing that it
was God’s will.

Such a case speaks so plainly for itself that it is hardly
necessary for me to emphasise it. So far as the symptomatic
picture goes the case is a typical one of catatonia, but the
important fact is that here we are dealing with an individual
who never had really tried to know herself, but who ever since
her earliest days had been in the habit of justifying everything
by taking refuge in simple religious beliefs. It seems quite
clear from her self-destructive and erotic tendencies cropping
out in her psychosis that this patient, underneath the surface,
had very much the same conflicts to deal with as any of the
rest of us. Her beliefs, however, were sufficiently strong to
enable her, after a period of rest and building up, to adjust her
balance. No doubt if not exposed to any special strain that
balance may be maintained for a considerable period of time,
but the probability is that she will be subject to subsequent
attacks.

(5) A young woman, aet. 27, was brought to the Psychiatric
Clinic with a history of having been in a mute, stuporous state
for 17 months, during which time she had twice, impulsively,
tried to commit suicide ; the above state had been preceded by
the expression of vague persecutory ideas. On admission she
was in a dull, stuporous, mute state, had an immobile expres¬
sion, and except for an occasional rather forlorn smile, could
not be made to respond in any way. She showed a condition
of flexibilitas cerea and catalepsy, she did not react to painful
stimuli anywhere over her body, and when commanded she
readily protruded her tongue to be pricked. She did not take
any particular interest in her surroundings, but seemed to under¬
stand what was said to her, readily obeyed commands, and was
cleanly in her personal habits. Physically she was under¬
nourished, but there was no disease of her organs.

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567

Following her admission she continued in the mute, rather
dull state described above, but gradually was induced to take
her food well, and to interest herself in various forms of games
and occupation. She was also given a series of injections of
nucleic acid, which seemed to have a certain stimulating and
beneficial effect. Gradually her condition cleared up more and
more, she became interested, talkative and cheerful, and even¬
tually made a most excellent recovery.

This patient’s father and mother had been first cousins ; a
younger sister, probably suffering from dementia praecox, had
been in a State Hospital for four years : a maternal first cousin
was probably suffering from dementia praecox ; a maternal
uncle had epilepsy. The patient herself had been a frail,
delicate child, studious at school, always seclusive, shy, timid,
and religiously inclined. She was, however, a most competent
housewife, and in many ways was the mainstay of the family.
Following her recovery an attempt was made to review the
patient’s psychosis, but she was quite content to allow things to
remain at a surface level, and adopted the point of view of
leaving well alone.

This case, too, like the preceding one, shows clearly how an
individual with rather narrow general interests, whose resistance
no doubt had been somewhat undermined by a poor state of
health, reacted in a faulty way by developing a mute, stuporous
condition, which in all persisted for a period of twenty months.
Again, however, apparently as a result of her inherently good
stuff, a good readjustment was made.

(6) A young married woman, aet. 29, one month previous
to admission, while suffering from a severe cold heard that a
man living in the next apartment had developed pneumonia.
She immediately came to the unfounded conclusion that she
must be the source of infection, and in consequence of this
fear started to worry. During the next few weeks she was
nervous and excitable, “ did not seem to know what she was
doing,” “ talked out of her head.” She sang and prayed, said
that God had told her to do those things, and stated that she
had seen angels and spirits. She made several attempts to
leave the house in a nude condition, spoke less and less, became
dull, but always recognised everyone around her.

On admission she was noticed to keep her mouth covered
by the bedclothes, and frequently put her hand over her eyes<

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She answered a few formal questions, but could not be induced
to give any description of her illness. She allowed her limbs
to be passively moved, and indefinitely maintained them in
awkward positions, saying, “ God tells me not to move.” At
other times she would behave impulsively, would suddenly get
out of bed and run up the ward, explaining that the voice told
her to behave in such a way. She likened the sound of God's
voice to thunder, and she was told that she was going to
destruction, that this was not the proper place for her, and that
the second coming of Christ was at hand. In addition to her
auditory hallucinations she had had the vision of a spirit’s
flight upwards—“just something white, not exactly in the
form of a bird.”

Her head felt perfectly clear, she was correctly oriented for
time, place, and person, and her memory both for remote and
recent events was quite good.

On the day following admission she had a feeling that her
brain had changed, and said, “ I heard voices of the Heavenly
King, and voices of earth—I had imaginations that people did
not like or want me—I disobeyed God’s voice and He is angry
with me, and said I should destroy myself.” When asked if
anything in her life troubled her she replied by saying, “ I
have been remiss in my habits.” The same morning she
became exceedingly resistive to all attention, refused her meals,
and showed a well-marked echo-praxia, following the nurse
around everywhere, walking where she walked, and stopping
where she stopped. She told how “ spirits of heaven and
earth ” inside her had been destroyed by her swallowing
poisonous substances. Gradually she became more and more
secretive and inaccessible, her expression was staring and
immobile, she allowed saliva to accumulate in her mouth, and
breathed deeply with movement of the alae nasi. For the next
two weeks she continued to behave in the same dull, more or
less stuporous way, took no interest in anything, had to be
urged to eat, and to attend to herself in every way.

Gradually a state of betterment came about, her interest in
things was redeveloped, but when asked to discuss her psychosis
she replied by saying that her difficulties were between God
and herself, and that in addition she had always been in the
habit of keeping things to herself. She made a good readjust¬
ment, and a letter received from her husband six months

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19 1 6.] BY DAVID K. HENDERSON, M.D. 569

after her discharge stated that she was in splendid health both
mentally and physically.

Her history showed that she had come from a healthy stock,
that she had always been of a quiet, retiring, seclusive disposi¬
tion, had been brought up in a strictly religious atmosphere,
her chief outlet and amusement being church sociables.
She was reticent, never a good mixer, always exceedingly
sensitive.

(7) A young woman, set. 19, one month previous to her
admission complained of not feeling well, said that her heart
hurt her, and became listless, uninterested, and drowsy. On
one occasion she dramatically exclaimed to her mother, “ This
is our last walk together ; I am going to die.” On admission
she was in a dull, mute, stuporous condition, took no interest
in her surroundings, and paid no attention to painful stimuli.
She allowed her limbs to be moulded into any position (flexibilitas
cerea), but there was no catalepsy. She had to be spoon-fed,
wet and soiled herself, and masturbated in an open, unconcerned,
shameless way.

For several weeks following her admission no special change
was noted in her condition ; at times she would reply to a
question or two, but a nihilistic trend was prominent, eg.:

Please take your supper . “ I can’t pay for it—I can’t

stay here.”

What do you mean ? . “ I can’t—I am too poor.”

Get into bed . . . “ I can’t—I have no money.”

On one occasion she misidentified one of the nurses, calling
her “ Aunt May.” On another occasion she had a peculiar,
impulsive spell, suddenly jumped out of bed, fell face down¬
wards on the floor, and made a loud noise like the barking of
a dog. For the most part she continued to be very resistive,
untidy in her habits, showed perseveration, at one time would
eat ravenously, and at another time would refuse all food, saying
that it stank. She smeared herself with her excreta, and in
every way was most degraded.

Two months after admission some improvement gradually
began to take place, and eventually she became cheerful, active,
and industrious, and was discharged as recovered. She would
talk quite pleasantly on immaterial topics, but as soon as her
psychosis was touched on she took refuge in an absolute
silence.

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Her history showed that she had come from a neuropathic
stock ; a maternal and paternal grandfather, her father, and a
sister had all suffered from nervous troubles.

The patient herself had always been strong and healthy
enough, but she had always been timid and seclusive ; had not
cared for entertainment or amusement, and had been very
keenly interested in Sunday-school work. Up till the age of
18 years she had been a bed-wetter.

The two last cases reported also show so clearly the conflicts
and reactions already referred to that they need no further
comment.

In general then it may be stated that a series of cases of
catatonia have been presented which, from the purely sympto¬
matic point of view, could not be readily differentiated or
understood. Devine, it is true, has attempted to differentiate
between deteriorating and non-deteriorating psychoses according
to the presence or absence of confusion, except when of toxic
origin. He agrees with Shaw Bolton in asserting “ that mental
confusion exists to a lesser or greater degree in all cases which
are about to develop dementia, and that cases in which this
symptom-complex are absent belong to relapsing or recurrent
forms of insanity.”

There is no doubt that a state of mental confusion—not of
toxic origin—is, in a great many cases; of very ominous
significance, but when the symptoms presented by the group of
cases just recorded are analysed the fallacy of such a dogmatic
statement as Shaw Bolton’s is readily apparent, as in five out of
the seven cases a certain degree of confusion was present.
Other symptoms which have been used in differential diagnosis
have been the patient’s response or lack of response to painful
stimuli, the presence or absence of hallucinations, the cleanli¬
ness of habits, etc. In certain cases, doubtless, some or all of
these symptoms may be of very great importance, but the point
which needs emphasis is that the only safe way of using them
is in relation to the setting of the psychosis. For instance, the
symptomatic picture in the first case of the series corresponded
very closely to that seen in the other cases, but when one comes
to study the setting in which the picture occurs two entirely
different types of individual are found to be involved. In the
first case we have a history of a frank, jolly, open, rather
aggressive type of individual, the period of whose stupor was

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BY DAVID K. HENDERSON, M.D.

571

both preceded and followed by manic episodes. On the other
hand, although in the other cases the onset was acute, still we
have to remember that we were dealing with individuals who
had always been inclined to keep their difficulties to themselves,
who showed in fact the shut-in tendencies so well described by
Hoch, and whose psychosis was simply the culmination of a
long period of mental conflict In such individuals the cata¬
tonic state may be looked upon as a further crawling within
the shell, as a period of defence during which the degree of
resistance may gradually be built up, and a readjustment made.
The completeness of this readjustment must depend to a very
large extent on the amount of insight which the patient is able
to gain into the nature of the psychosis. It stands to reason
that a person who attempts to see how it arose, and what it
signified, must necessarily come to a much better understanding
of his actual difficulties and how to deal with them than the
person who, once he gets over his illness, attempts to forget it.
It is in this respect that our cases have fallen short. One and
all of them refused to review the psychoses in any detail, and
although to all intents and purposes the recoveries have been
excellent, yet one cannot help feeling that their shut-in
dispositions are going to render them highly susceptible to
future attacks.

In this formulation undue stress may seem to have been
laid on the mental factors, and although it is believed that in
the majority of such cases they play the most significant role,
yet at the same time it is readily admitted that in certain cases
physical conditions are also of very great importance.
Personally, I hold the opinion that the vast majority of the
physical anomalies described, for instance, in dementia praecox
are secondary phenomena ; but, whatever one’s views in regard
to that may be, this more or less individual way of approaching
one’s cases allows one to take both the mental and non-mental
factors into consideration, and instead of divorcing them one
from another, attempts to closely harmonise them into relation
with the personality as a whole. Furthermore, the sooner we
get out of the habit of ascribing this, that, or the other mental
disorder to hypothetical toxins of which we have no evidence
in the urine, blood, or general metabolism of our cases, and are
content to study each case on its merits, the better it will be
for the progress of our specialty. As far as pathology is con r

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572 CATATONIA AS A TYPE OF MENTAL REACTION. [July,

cemed, the investigations of Alzheimer, and the more recent
studies of Southard, are of great interest ; but so far not
enough facts have been forthcoming to allow us in any way to
talk about the pathology of dementia praecox.

In the meantime, do not let us worry too much about pigeon¬
holing our cases, but let us study each case from the point of view
of the reaction type ; let us try to bring the symptoms and
evolution of the disorder into relation with the personality, and
let us wait until all the facts have been obtained before we
attempt to draw any differential conclusions. By so doing a
live, stimulating, investigative spirit of work will be engendered
which should enable us to pick out those types of individual
who are most prone to develop psychoses, and, just as prophy¬
lactic measures have been adopted to protect those with a
phthisical diathesis, so also attempts should be made to develop
other prophylactic measures whereby those burdened with a
neuropathic diathesis may be safeguarded.

I am greatly indebted to Dr. Adolf Meyer, Director of the
Henry Phipps Psychiatric Clinic, Johns Hopkins Hospital,
Baltimore, and to Dr. L. R. Oswald, Physician Superintendent,
Glasgow Royal Mental Hospital, for permission to publish the
cases reported.

References.

Campbell, C. Macfie.—“ A Modern Conception of Dementia
Praecox,” Rev. Neur. and Psych., 1909, October, p. 623.

Devine, H.—“The Clinical Significance of Katatonic Symptoms,”
Journ. Ment. Sci., 1914, April, p. 278.

Kirby, G. H.—“The Catatonic Syndrome and its Relation to Manic-
Depressive Insanity,” Journ. Nero, and Ment. Dis., 1913, November,
p. 694.

Kirby, G. H.—“ Prognostic Principles in the Biogenetic Psychoses,
with Special Reference to the Catatonic Syndrome,” Am. Journ. Jnsan.,
Special Number, 1913, p. 1035.

Hoch, August.—“ Constitutional Factors in the Dementia Praecox
Group,” Trans. Am. Med.-Psychol. Sss., 1910.

Hoch, August.—“ Personality and Psychosis,” Am. Journ. Insan.,
Special Number, 1913, p. 887.

Meyer, Adolf.—“ Fundamental Conceptions of Dementia Praecox,”
Brit. Med. Journ., 1906, September 29th.

Meyer, Adolf.—“ The Dynamic Interpretation of Dementia Praecox,”
Amer. Journ. Psychol., 1910, xxi, July, p. 385.

Meyer, Adolf.—“ The Problems of Mental Reaction Types, Mental
Causes and Diseases,” Psychol., 1908, August.

(*) Read at a meeting of the Scottish Division of the Medico-Psychological
Association, March 17th, 1916.

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EXTRACTS FROM AN ADDRESS.

573

Extracts from an Address delivered April 12th, 1916 ,
before the Zoological Department of the University
of Chicago. By Casper L. Redfield.

The first thing I wish to call to your attention is the dis¬
tinction between the foot-pound and the cubic foot. The foot¬
pound is used to measure work, and when work is stored it is
called energy. The cubic foot is used to measure material
substances, or the space in which bodies are contained.
What I have to say relates to things measured by the foot¬
pound or corresponding unit, and not to things measured by
the cubic foot.

If a man is sick he does not hire his doctor by the cubic
foot. He hires him for the foot-pounds of intelligence he has.
Not that we are in the habit of measuring intelligence by the
foot-pound, but what I wish to direct your attention to is the
fact that intelligence belongs in that class of things measured
by the foot-pound and not in that class of things measured by
the cubic foot.

The verb to acquire means to obtain by effort, by the
performance of work, and work is measured in foot-pounds.
If a man goes into a gymnasium he acquires strength by the
exercise he takes, and the amount he acquires is measured by
the foot-pounds of work he does. He will acquire more
strength (muscular energy) by doing a million foot-pounds of
work than by doing a thousand foot-pounds. Acquirements
are also measured by time. A man who exercises regularly
will acquire more dynamic development in a month thanjn a
week, more in a year than in a month, and so on.

If an offspring is to inherit ah acquirement made by the
parent, the parent must make the acquirement first and get the
offspring afterwards, not get the offspring first and make
the acquirement afterwards. Among animals which work
regularly the greatest acquirement exists in later life, hence, if
acquirements are inherited, the better progeny should come
from the older parents. On the other hand, if the better
offspring do come from the older parents, that fact would mean
the inheritance of acquirements, and mean nothing else. The
reason is that age of parents represents time, and time is a
factor in the measurement of work performed, and not a factor
in the measurement of anything else.

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574

EXTRACTS FROM AN ADDRESS,

[July,

It is commonly said that Weismann knocked out the
doctrine of inheritance of acquirements and Lamarck’s theory
at the same time. Weismann did nothing of the kind, either
directly or indirectly. He attacked Lamarck on the inheritance
of mutilations, but if he had known anything whatever of the
subject about which he pretended to give information he would
have known that the assumed inheritance of mutilations had
nothing to do with Lamarck’s theory. He also would have
known that Lamarck had distinctly stated that mutilations
were not inherited.

We are told that Lamarck’s theory is that the offspring
inherit the effects of the action of the environment upon the
parent. It is nothing of the kind. Lamarck took particular
pains to caution his readers against putting such an interpreta¬
tion upon anything he said.

Your text-books tell you that Lamarck’s theory is “ a
species-forming theory.” It is nothing of the kind. Lamarck
says species are an artificial classification by man for con¬
venience, but that they have no existence in nature, and have
nothing to do with his theory. Lamarck’s theory is a theory
of the evolution of structural types by the action of habits
formed in the struggle for existence, the kind of struggle being
determined by the environment. Thus, animals living in
water will struggle in certain ways ; animals living in trees will
struggle in other ways ; animals living in the ground will
struggle in still other ways; and so on. (See Packard’s
Translations.)

I am telling you these things for the purpose of pointing
out to you that the doctrine which denies the inheritance of
acquirements is based on an amazing amount of misinformation.
It is also based on a total lack of scientific investigation of the
subject. Acquirements arc obtained by work, and work is
measured in foot-pounds or some unit convertible into foot¬
pounds. No investigation of this subject can have scientific
merit unless it makes some attempt to measure acquirements
quantitatively, and compare such measurements with subse¬
quently produced offspring.

A parent cannot transmit what he docs not have. If he can
transmit no more than he inherited, how can there be an
evolution of animal powers, either mental or physical ?
Perhaps you think that such an increase might come by muta r

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tion or advantageous variation. But stop a moment to think
what that means. A child is born with something it did not
inherit from its parents! That would mean that special
creation had taken place somewhere in connection with the
reproductive process.

But some persons say that there has been no evolution of
mental power, and they point to the men of ancient Greece as
being equal to anything which has since existed. I might
dispute that claim, but there is a better answer. We are not
descended from Aristotle, Plato, Socrates, et al. Our ancestors
were savages two or three thousand years ago. The fact that
there were great men in ancient Greece is not evidence that
we are no improvement over the savages from whom we are
descended.

But it is even said that we are not inherently superior to
those savages, and that the apparent superiority comes from
education and accumulated information sometimes designated
as social heredity. But how about another three thousand
years, ten thousand years, a hundred thousand years, and so
on back ? If you deny all evolution of mental and physical
powers, then you return immediately to the Garden of Eden
story, with each kind of animal originally created equal to
anything which has since existed. If you attempt to dodge
the Garden of Eden story, then you admit that a parent may
transmit more than he inherited. That “ more ” must be some¬
thing acquired, or it must be some special creation associated
with reproduction. Something from nothing is just as wonderful
at one place as another. The issue is not dodged by removing
special creation from the Garden of Eden to the germ and
dividing it into small fractions so as to spread it over many
generations.

If you wind up a spring you store work in it. You can get
out as much work as you put in, and that work may be used
to drive a clock, pump water, compress air, or do any one of
many other things. If used to pump water the energy (stored
work) is taken out of the spring and stored in the water. It
may then be taken out of the water and stored in some other
place, and so on in endless succession. There are laws
relating to energy, which laws govern it in all of its trans¬
formations. But the energy which went into that spring came
out of your muscles, and you may be certain that those laws

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governed that energy while it was in your muscles, and on its
way to and from that place.

You may concede that fact, yet think that human intelli¬
gence stands on a different footing. A mathematical calcula¬
tion performed by either the human intelligence or a calculating
machine is the same thing, and things which are equal to the
same things are equal to each other. The energy employed to
drive the calculating machine is measured in foot-pounds, and
the difference between the energy going through the machine
and that going through the brain is a difference in the efficiency
of the apparatus, and not a difference in the essence of the
energy involved.

Energy is transformable into many forms, yet it is always
the same energy, and is always measurable in foot-pounds or
some unit which may be transformed into foot-pounds. Heat,
light, electricity, physical strength, and human intelligence are
different species of the genus energy. There are specific
laws for each species, and generic laws for the genus. What
I am driving at is to point out to you that the evolution of
physical strength and human intelligence is and must be in
accordance with certain generic laws which are definite and
precise things in science.

The first of these laws is to the effect that you cannot get
something out of nothing. If, in the process of evolution
from monad to man, we get successive generations of animals
having greater and greater physical and mental power, the
energy involved must necessarily have a source. That source
can only be some existing form of energy. One trouble with
the biological teaching of the present day is that it assumes
conditions which involve a contradiction of this fundamental
law known to science as the Conservation of Energy.

The second law relates to the behaviour of energy, and the
only possible conditions under which it may be conveyed from
its source to an available condition in man or mechanics.
This law says that energy left to itself always dissipates, and
can be raised to an available condition only by the perform¬
ance of work. This means that if there has been an evolution
of mental and physical powers at any time in the past, that
evolution was necessarily the product of work performed.
Unless you are prepared to denounce as unsound the funda¬
mental laws of another science, this is a conclusion you must

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accept. This second law is known to science as the Dissipation
of Energy, and a large amount of the scientific progress during
the past half century is based on a recognition of the soundness
of this law.

The eugenists are telling us that the superior part of the
population is producing an average of about a child and a half
to the .family, while the inferior part is producing some six or
eight children to the family. That is a partial truth which
may be a new discovery to the eugenists, but it is not a new
phenomenon in the history of man. The same thing existed
fifty and a hundred years ago ; five hundred and a thousand
years ago. It existed in ancient Greece, and there are
indications that it existed in China at the time of Confucius.

The eugenists tell us that from the feeble-minded we get
only feeble-minded, but if we are not all descended from
feeble-minded ancestors, then evolution is false. Evolution
tells us that we are descended from a common ancestor with
the ape, and we cannot assume that common ancestor to have
been mentally superior to those members of our community
which we now designate as feeble-minded. Go back only
twenty generations (about 600 years), and each one of us has
more than a million ancestors taken from the common stock.
In a population of a million there are many feeble-minded
persons. But, on the test of family size, we can find them
much nearer. None of us can go back far in our pedigrees
without coming to large families. Under the Binet test, our
eugenists would condemn their own ancestors as unfit to
reproduce, and they would find those “ unfit ” ancestors much
nearer than most of us suppose.

There is, and always has been, improvement in power capa¬
bilities from generation to generation. The most clearly
defined and best recorded case is the American trotter which
was developed from the three-minute trotter to the two-minute
trotter in a hundred years. I have published full details of
the process by which this improvement has been brought
about, yet those who deny the inheritance of acquirements
have deliberately shut their eyes to this definite and positive
evidence, and have gone on repeating their unfounded state¬
ments.

But you need not take the evidence I have collected. You
can see the same thing from the animals with which you deal.

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Acquirements are obtained by the performance of work.
With that in mind it can be seen that the amount of work
performed per generation before reproducing by the different
kinds of animals, is an accurate representation of their advance¬
ment in power capabilities. This is true for all kinds of
animals, but is most easily seen in the higher animals. Man
is intellectually superior to other animals simply and solely -
because he is mentally active more hours a day for more years
before reproducing than any other animal. Increase the
amount of work per generation and the race will advance.
Decrease it and the race will degenerate.

Presidential Address ( ] ).* Our Work as Psychiatrists , and
its Opportunities. By Edward N. Brush, M.D.,
Physician-in-Chief and Superintendent, Sheppard and
Enoch Pratt Hospital ; Professor of Psychiatry, University
of Maryland, Baltimore, Md.; President of the American
Medico-Psychological Association.

[We have received the following Address from Dr. Brush,
who, knowing that We have had some difficulty in obtaining
sufficient material for the Journal since the war began, kindly
offered it for publication in our pages, while it will appear
simultaneously in the July issue of the American Journal
of Insanity , of which Dr. Brush is the Managing Editor.
He is also the President of the American Medico-Psychological
Association for the current year, and his views will no doubt be
full of interest for his colleagues in the specialty on this side of
the Atlantic.— Editor, Journal of Mental Science.\

Fellow-Members of the American Medico-Psycho¬
logical Association, Ladies and Gentlemen, —The
Constitution of the Association requires that the President shall
prepare an inaugural address, which he shall deliver at the
opening session of the meeting. Beyond that requirement it
does not go. It gives to the anxious President during the term
of his office no hint either as to subject, matter, or manner of
that address. The necessity of its preparation haunts his
waking hours and troubles his sleep—and there are betwixt his

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induction into office and the delivery of that dread address
“ more pangs and fears than war or women have.” The con¬
sciousness is always with him of the greatness of the occasion
and his own insignificance.

Permit me primarily to welcome you to the deliberations of
the Seventy-second Annual Session of this Association. I
esteem it, as I have already attempted to tell you, the highest
honour of my professional career that I have been called to this
high office through your generous partiality. Your selection
is to me, at this time, particularly gratifying because it
marks a quarter of a century since I was called to the
superintendency of a hospital, and thereby became entitled to
membership in the “ Association of Medical Superintendents of
American Institutions for the Insane,” by which name this
organisation was formerly known. That Association, of which
this is but a continuation, under a new and more appropriate *
name, was organised in 1844, and has been in continuous and
active existence ever since. It is, therefore, the oldest national
medical association on this continent.

One is tempted on an occasion like this to review its history,
but that has been done by more than one of my predecessors,
and you will have an opportunity to read that history in the
opening chapter of the first volume of a monumental work
undertaken by Dr. Hurd and his associates, The Institutional
Care of the Insane in the United States and Canada , which has
just been issued.

Far be it from my purpose to criticise the body over which
I am chosen to preside. It is not in any spirit of criticism that
I propose to point out the fact that this Association has not
been as assertive as it might have been ; that while its delibera¬
tions have been of great and lasting value to humanity, and to
the advancement of the improved care and treatment of the
insane, it has contented itself too often in registering its opinions
or findings, without following up those findings by attempting
to impress them upon public and professional opinion.

In short, while moulding the opinion and practice of its
members, it has too often, except in purely local matters,
neglected to use the weight of its influence in matters relating
to the entire body politic.

The admirable address upon “ Publicity and the Public
Mind,” to which we listened last year from a gentleman whose

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profession it is to mould public opinion through the press,
must have brought home to your minds, as it did to mine, the
question, How much are we doing to train and inform the
public mind ?

Our predecessors in the early days of the history of this
Association were confronted by certain problems which were of
paramount importance at that time. These had reference
largely to matters relating to providing suitable accommodation
for the insane who were languishing in jails and almshouses, or
wandering at large, and were local problems to be solved in
accordance with local conditions. The problems which con¬
fronted different communities were, with rare exceptions, taken
before legislative bodies rather than, by a campaign of education,
brought before the whole community.

For obvious reasons this was necessary. Not only must
the legislature make appropriations out of the public treasury
for construction and maintenance of hospitals, but laws had to
be enacted governing the commitment and detention of patients
and the administration of the new institutions.

As the country developed, as new States were settled, and
new demands made for provision for the mentally disordered,
these new States took advantage of the experience of older com¬
munities, and this Association formed a general clearing-house
for the exchange of such experiences.

In the matter of hospital construction and general manage¬
ment few things were imported from abroad, and those mainly
related to architectural detail; and there grew up a distinctly
American system of hospital construction and management,
modified as to the latter by the varying views of different
bodies of law-makers, but in the main receiving its directing
and effective force from the membership of this body.

This work, great and valuable as it was, and lasting as its
influence will be, did little toward educating the public mind,
and came but little in contact with the minds of medical men
working in general or special fields of practice.

Absorbed by the intensity of their own labours and the
factors of their own problems, our predecessors took little
pains to interest others in their labours, and as a consequence
were looked upon as isolated from the great mass of the pro¬
fession, and as having no interest in the work and aspirations
of its members.

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In the same degree the members of the general profession
took little or no interest in the work of the psychiatrists, and
either ignored it altogether, or had very warped and distorted
views concerning it.

Gradually, partially as the result of influences within our own
organisation, partially by reason of pressure from without, a
rapprochement between the psychiatrist as a hospital doctor
and the doctor in general practice is being brought about, to
the manifest benefit of each. Much, however, remains to be
done in this direction. We need to see more of what the extra¬
mural workers are doing, and we should give them more
frequent and larger opportunity to observe our work and
methods.

It may not, therefore, be Considered out of place, though I
confess I enter upon the task with much hesitancy and a very
lively appreciation of my inadequacy to the occasion and of my
own short-comings in some of the very matters to which I shall
refer, that I ask your consideration of, and attention to, some
details in which both the Association as an organisation for
public good and its individual constituents can make their force
more effective. Not only can this be done to the benefit of
the members of the Association, but to the advancement of the
science of psychiatry and to the general weal.

This is the age of workmen’s insurance, pensions for
widows and the aged. It is proper, I think, that a body such
as this, composed of workers in a special field of endeavour,
where often the workmen are poorly compensated when their
stipend is measured by the income of professional men in
general or special practice, should consider whether some steps
ought not to be taken to secure for physicians who devote their
best years to the care of the mentally disordered and defective
a more secure tenure of office than is now found in many
localities, and at the end of a certain period of service the right
to retire upon an allowance, sufficiently liberal to secure them
from the danger of want at a period of life when active and
remunerative labour is no longer possible. I have before me
as I write a letter from a physician who has given more than
half a century of his life to public service, whose labours for the
insane and for their better care have given him an international
reputation, and have reflected credit upon his profession and
particularly upon this Association, one whose name adds lustre
lxii. • 37

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to our roll of members. He says : “ Please do not from any
motive of delicacy, or any other reason, fail to consider the
subject of a retiring pension to Superintendents after certain,
years of service. I am not a sufferer under the present system,
fortunately having some income (a modest one), yet the prin¬
ciple is almighty and right and just.” He then refers to the
work of one of the pioneers in psychiatry in the West, who was
deposed by reason of political preference after years of service
to his State and country, and left with little or no means to
comfort his declining years. “ No one,” he goes on to say,
“saves from a salary a competence.” He urges, therefore,
some provision for a “ retiring allowance,” a term which he
prefers to the word “ pension,” in which preference all will, I
think, concur.

I believe you will all admit that the subject is an important
one, and one which deserves your careful consideration. It is
difficult, however, to point out how, except in incorporated and
endowed institutions and in public hospitals in a few States, a
system could be inaugurated by which medical officers—for I
would include in the list assistant physicians as well as
medical superintendents—can be assured after a definite time of
service and reaching a certain age, that they may retire upon
an allowance sufficient in amount to materially assist in their
maintenance for their remaining years of life.

At the McLean Hospital in Massachusetts there is a rule
retiring the Medical Superintendent and the first and second
assistant physicians at the age of sixty-four years with a salary,
after serving not less than fourteen years, equal to 60 per cent.
of the salary received at the time of retirement, to be continued
“ so long as the Trustees vote yearly to so pay.”

The Board of Governors of the Society of the New York
Hospital in May, 1914, adopted a pension system. The
employees of the hospital are divided into two classes. In the
first class is the Medical Superintendent of Bloomingdale
Hospital, which is a department of the New York Hospital,
together with certain other officials of the New York Hospital
and of Bloomingdale. In the second class are all other
employees of the hospital. All employees in the second class
are retired on attaining the age of sixty-five years, and, if they
have been for fifteen years preceding such retirement in the
continuous service of the hospital, are eligible for pension.

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All employees in the first class who have been for fifteen
years or more in continuous service of the hospital at such time,
may, at their own request or at discretion of the retirement
committee, be retired and are eligible for pension.

There are certain other regulations and stipulations contained
in the system adopted, which I do not think necessary to quote.
I know of no other institutions in this country which have a
pension system.

In Great Britain, or at least in England, medical officers
have a retiring allowance after a certain period of service. I
recall a visit to one institution near London several years ago
where there were three Superintendents on the pay-roll—one
active and two superannuated.

In the Presidential Address before the Medico-Psychological
Association of Great Britain and Ireland, July, 1878, Dr.
James Crichton-Browne said : “ Independence of action, fixity
of tenure, and security of pension, are what asylum medical
officers are entitled to ask, not only with a view to their own
comfort, but with an eye to the welfare of their patients and the
claims of science. And the latter consideration, the claims of
science, ought not certainly to be lost sight of in any advocacy
of the interests of our specialty that may hereafter be necessary,
for it is tolerably certain that the title of our specialty to public
deference and acknowledgment must be founded henceforth
mainly on its scientific character” (1).

What the President of our sister Association said thirty-eight
years ago is to-day true of this Association.

If we expect the recognition of the public and its support in
our just demands for adequate remuneration, and the assurance
of a support for the years which remain to us after active duty
is no longer possible or advisable, we must be able to show the
fruits of our labours.

How is this possible, however, under the conditions, which
obtain in many States, and how are “ fixity of tenure ” or
“ independence of action ” to be expected ?

Some years ago I looked over the annual report of a hospital
for the insane in a State, where from the general intelligence of
its people better things would be expected, and found that in
thirteen years nine Superintendents had been appointed to
direct the destinities of the institution, and supervise the medical
care of its patients.

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In other States, Governors have asked and received the
resignations of Superintendents of State hospitals, and have
appointed or directed the appointment of men to their positions
who had, as far as I can learn, no previous training in psychiatry
—no experience in hospital management of any kind, and
presumably no previous medical experience sufficient to obtain
for them a private practice large enough to deter them from
yielding to the tempting political plum held out for their accept¬
ance. What independence of action could men holding such
positions be expected to have ? Is it not the rule of the
political game that such appointees must give a quid pro quo ?
Can you imagine their ability to resist the appeals, or more often
direct orders, to make minor appointments not because of
fitness, but to help the party in power ?

Under such conditions considerations of retiring allowances
are useless and a waste of time. No officer remains long
enough in office to earn one. I had almost said no officer
taking position under such circumstances deserves one.

I have known men appointed through political influence who
rose to the situation which confronted them through painful
and painstaking effort, who, realising their limitations, set
resolutely about the matter of correcting their deficiencies, and
who, in the end, became an honour to their State and their
specialty. These men possessed a force of character which
compelled a recognition of their work and merit, and deterred
future political interference. But even they were handicapped
by the manner in which they obtained office, and much of their
time which could have been given to more useful work was
spent in convincing political hangers-on that the care of the
insane, the nursing of the sick, the conduct of a hospital were
matters above the grasp of the spoilman, and that there was
no political “open sesame" to positions within their appointing
power.

Such exceptions, and they are few, but prove the rule that
appointments to positions requiring scientific ability, medical
skill and judgment, and looking to the best interests of the
hospital, its patients, and of the community at large, the tax¬
payers, should be made by reason of fitness and merit, and for
no other reason under Heaven.

“ There is no political alchemy,” says Herbert Spencer, “ by-
means of which you can get golden conduct out of leaden

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instinct.” What, therefore, is the remedy to the conditions
which exist in too many communities in this land, conditions
which stand squarely in the way of progress, which make some
of our institutions a byword and a reproach ?

The Association has again and again in one way or another
put itself upon record as opposed to political control or
interference through appointments to positions or purchase
of supplies, in institutions for the insane. The history,
The Institutional Care of the Insane in the United States and
Canada , just issued, will be found to refer to many instances of
flagrant abuse in this direction. Instances are given of
Superintendents who, after years of faithful and most valuable
service to the State, have been summarily removed because they
were not supposed to be in “ harmony ” with the political
dogma of the party in power.

There is no one acquainted with our political system but will
admit that the evil is deep-seated and difficult to eradicate.
The shibboleth “ to the victors belong the spoils ” would be
expected from the mouths of bands of marauding bandits, but
not from the lips of men who are supposed to be interested
in working out the destinies of a people whose aspirations are
for a “ government of the people, for the people, and by the
people,” and not an exploitation of the people by the politician
for his own interests and that of his supporters.

By slow educational development, by a steady and gratifying
growth of a class who are independent of political affiliations,
by the introduction of civil sendee laws in some States, the
powers of the spoilsmen are being curbed, and their control
over the destinies of public hospitals weakened. The good
work can only be carried on by the education of public
opinion, by teaching the people and their representatives the
absurdity, to call it by no worse name, of selecting men for
scientific work because of party loyalty and political influence.

Not until such education begins to show the development of
more intelligent methods may we expect to meet with any
success in an attempt to secure continuing tenure of office
based upon good work, and after a reasonable period of such
service the right to retire upon an allowance.

The President of the British Medico-Psychological Associa¬
tion, from whom I have quoted, said of our specialty in Great
Britain : “ With its past history science mingles, perhaps less

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than we could wish. It is not implied that science has ever
been ignored in lunatic asylums since they passed under medical
care, nor that fruitful, scientific researches have not been pursued
in them ; but it is argued that more engrossing occupations
have hustled science into a subordinate place, and that non-
scientific methods of studying insanity have prevailed.” The
speaker goes on to say : “In the literature of insanity to-day
(referring to Great Britain) there is no attempt at mental
analysis, and only the most perfunctory attempt at a classi¬
fication of the expressions and products of the disordered
mind. Half a dozen phrases such as ‘ excitement,’ ‘ inco¬
herence,’ and ‘ depression ’ comprise our whole psychology,
and even these are sometimes employed in a slip-shod
fashion ” (2).

The address from which I quote was made thirty-eight years
ago. During the entire period which has since passed my work
has been in hospitals for the insane. I have endeavoured to
keep myself posted as to what was being done, the methods
pursued, and the results, as related to real contributions to
psychiatry, which came from American hospitals, and while in
many localities there has been a manifest and gratifying
evidence of real advance, this has been in distinct and some¬
what isolated institutions. There has been no general and
marked improvement in all of our hospitals, such as has been
seen in the same time in general hospital work. We are not
alone in this respect ; our English brethren have recently been
taking stock of their position in the psychiatric world. In
1911a Committee of the British Medico-Psychological Asso¬
ciation was appointed to consider the “ status of psychiatry as
a profession in Great Britain and Ireland, and the reforms
necessary in the education and conditions of service of assistant
medical officers.”

This Committee made a preliminary report in 1913, and its
final report was presented in July, 1914.

I do not propose to go into the details of this report, but
some of the findings so well apply to American psychiatry that
I am forced to refer to them. The defects in Great Britain and
Ireland in the status of psychiatric medicine are divided into
three groups :

“(1) Absence of proper provision for the early treatment of
incipient and undeveloped cases of mental disorder.

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“(2) Few facilities for the study of psychiatry and for research.

“(3) The unsatisfactory position of assistant medical officers
in respect of professional status, the prospects of a career, and
the conditions of asylum service ”(3).

To meet the first and second conditions it is proposed to
establish at teaching centres clinics equipped for research work,
and to bring into closer co-operation the general practitioner
as represented by the teaching force in the general clinic, and
the psychiatrist in the special clinic. In these clinics post¬
graduate work would be afforded to the assistant medical
officers from the hospitals for mental disorders. To supple¬
ment the training in the special clinic better means and better
methods of clinical work are suggested in these hospitals, with
properly equipped laboratories and trained laboratory workers.

Various methods are proposed to improve the status of
assistant physicians, to enlarge their professional horizon, and
to attract a better class of men to the service.

Among the suggestions is one which is worthy of note : That
assistants should be appointed on probation, and should not
become established officers until they had passed an examina¬
tion in psychiatry, the law as related to the insane, and in
hospital administration ; with, at the same time, on the part of
the authorities, a larger use of the power of retiring medical
officers who have shown themselves unsatisfactory.

How often, I wonder, are unsatisfactory assistants continued
in office—men who have shown no ambition or no fitness for
the work, or who have grown indifferent and stale—because of
the disinclination on the part of their superiors to perform an
unpleasant duty, or because a successor is difficult to find.

What American psychiatry needs to-day is that the institu¬
tions for mental disorders shall be, in function as well as in name,
hospitals. The same pains in the study of all the aspects of
each case should, and can, with an adequate and trained staff, be
taken in our hospitals as in the better class of general hospitals.
More pains, greater minuteness of study, indeed, are required in
cases which come under our care than is the case in physical
disorders, because we deal commonly with a physical disorder
plus a mental disturbance, each often making and rendering
difficult of elucidation the essential details of the other.

To accomplish this we need an influx of well-trained,
enthusiastic, ambitious young men into our wards.

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We need in all our large cities in connection with our medical
schools, clinics of psychiatry for both teaching and research
work ; for laboratory and ward work which cannot be under¬
taken in the isolated hospitals, but in which men from these
hospitals can participate, as post-graduate workers, carrying
back to their own work the ideals and the methods of the
clinics. These clinics must be controlled by a power independent
of State or municipal authority, otherwise there can be no
certainty of proper appointments or of secure tenure of office.

Our hospitals should be centres of social service, especially in
the way of instruction in mental hygiene. In the matter of
prevention hospital medical officers have a large and inviting
field of labour. They should take a lively interest in the matter
of public education, because, to my mind, that lies very' near to
preventive work. I am in accord with Dr. Chambers in the
Presidential Address before the British Medico-Psychological
Association in 1913 : “ When the prophylaxis of the psychoses
is in question, it is necessary to insist on the cultivation of
mental life and expansion ; on the creation of a mental atmo¬
sphere no less above suspicion than the physical; on pure food
for the mind as w r ell as for the body ” (4). Not only is this true
and necessary as regards prevention of mental disorder, but we
must remember the words of Huxley spoken at the opening of the
Johns Hopkins University in 1876 : “ Your sole safeguard is the
moral worth and intellectual clearnessof the individual citizen ”(5).

Pauperism, crime, the alcohol question, all come within the
purview of the physician to the hospital for mental disorders,
and he should prepare himself by study', not only of his patients,
but of their antecedents and surroundings, their work and their
recreations and habits, to speak with authority. How many of
us to-day can give the reasons for the opinions which we hold,
more or less tenaciously, upon the influence of alcohol in the
aetiology' of the psychoses, and yet it is a question daily asked,
and a question w'hose solution is in our hands.

The after-care of discharged patients is happily being under¬
taken by hospitals through their medical officers or special
agents, trained social workers, trained in the needs of the mental
patient. This work should be widely extended. We can take
lesson from Timon of Athens, who taught that

“ Tis not enough to help the feeble up,

But to support him after.”

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BY EDWARD N. BRUSH, M.D.

589

The hospital which is so situated that an out-patient service
can be maintained will find here a rich mine for exploitation,
and one which will aid materially in bringing cases promptly
under care. If the hospital physician can fortunately engage
in clinical teaching by reason of proximity to a medical school,
he should take advantage of the opportunity. Nothing
sharpens a man’s wits so much as contact with a critical
audience such as is found in a senior medical class. The
hospital which is doing its full duty is itself a place of educa¬
tion, for the training of physicians in psychiatry as applied to
medical science, and in medical science as applied to psychiatry ;
a place for the training of nurses, and a laboratory of psychology
as well as of clinical medicine. The medical director who does
not see opportunities for work beyond the restricted horizon of
his hospital inclosure is short-sighted and misses his oppor¬
tunities for the best work, and the Board of Directors which
does not encourage him in making the best use of such oppor¬
tunities does not appreciate the full value possible to the
community in the institution which it supervises, nor the
opportunity for making the institution do its full duty.

This is the day when efficiency in all departmerlts of human
endeavour is preached. The man, the machine, the institution
which is not working to its full efficiency is a losing proposition.

It may be difficult sometimes to make those who hold the
control, who govern the expenditures, see that some of the best
returns from institutional activities can often be found in fields
which at the first glance do not appear worth cultivating, or
which appear to lie too remote.

No better method could, in my opinion, be devised for
awakening public interest in, and public support and sympathy
for the work of hospitals of our special kind, than showing the
public that the medical officers of these hospitals have not only
an interest in the welfare of the patients in the wards, but also
in that of the people of the community, in their health, in their
work, in their environment, in their cares and perplexities,
in their social problems.

In the words of Lugaro, “ All progress in knowledge and
civilisation is a contribution to the solution of the problems
which psychiatry brings forward and elucidates, but which it
cannot resolve unaided. If the work which has to be done is
gigantic, we can encourage ourselves with the thought that it

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is to a certain extent the task of all good citizens. It is no
mere medical work, but rather one of social regeneration ” (6).

The annual report of a member and former President of
this Association, for the year 1915, to the trustees of the
hospital of which he is Superintendent, opens with this sen¬
tence : “ The besetting weakness of a hospital superintendent
is the complacency with which, when rendering the annual
account of his stewardship, he reviews the operations of his
particular institution ” (7).

Is it not possible that too often that complacency is not only
shown at the time of making our annual reports, but is a
continuing condition of mind with many of us throughout the
entire year ? Are we sufficiently “ alert with noble discontent ” ?
Are we not too frequently satisfied if our patients are comfort¬
ably housed, our wards not too crowded, the routine of the day’s
work not interrupted by untoward accidents, and our statistical
table up to the general average as to the percentage of
recoveries, and possibly a little below as to the percentage of
deaths ? Are we content with keeping up with the procession,
or are we ambitious to lead the van ? Do we indeed keep up
with the procession when we compare our work and results
with what is being done in general hospitals all over the land ?

I know that such queries are not always well received. I
pray you, however, to remember, if anything I may say or have
said appears to be in the line of criticism, that “faithful are the
wounds of a friend.”

A. C. Benson ( The Silent Isle ) has this to say of the critic
who helps him : “ I would welcome (him) even if he knew but
little more than myself; while if my guide is infallible and
disdainful, if he denies what he cannot see, and derides what he
has never felt, then I feel that I have but one enemy the more,
in a place where I am beset with foes.”

I do not place myself in the category of those who know a
little more than you, but, on the contrary, much less than many.
Neither do I propose to deny what I cannot see nor deride
what I have never felt, but for more years than I care to
remember I have watched the progress of general medicine and
surgery and that of psychiatry, and have longed for the time
when, as a field of work for ambitious young men, psychiatry
should come into its own. I believe the time is coming ; it
remains for us to hasten or hinder the day.

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PRESIDENTIAL ADDRESS,

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light upon the aetiology and treatment of mental disorders.
You will recall, however, that Solomon, having found the vanity
of the things which he had constructed with such pride, said :
“ I applied mine heart to know and to search, and to seek out
wisdom and the reason of things . . . even of foolishness

and madness.”

At the meeting last year, in the discussion of certain papers
many complimentary things were said of the work of the young
men. One gentleman, one who but recently most acceptably
filled the position in which I to-day find myself, made use of
the following expression : “ We must encourage these young
men ; the future life of this Association depends upon it, and the
future of psychiatry depends upon it." Another member said,
and I wish to emphasise his statements because I consider them
pregnant with ideas of the utmost importance in the develop¬
ment of psychiatry : “ In the better managed hospitals of the
present time there is an infinitely broader field for the ambitious
young man than was the rule twenty years ago. State hospitals
of to-day, which have developed a reasonable degree of
medical activity, furnish a field for the better type of recent
graduates that can be made as attractive as any other branch
of medical activity. In order that this type of young physicians
can be induced to take up hospital work seriously there must
be some inducement offered other than board and salary.
There must be added the promise of professional advancement.

“ The development of medical work in our various state
institutions depends solely upon the type of men that can be
interested in the work as a permanent vocation. The better
the organisation, the greater the medical activity in any
hospital, the better it will be for all concerned, but especially
for the raising of medical standards. In the development of
our medical work, and especially in the spreading of fuller
knowledge concerning the prevention of insanity, there is a
fertile field for the full expression of the best type of medical
work.”

“ To accomplish the desired results in our medical work it
must be so organised that men can enter the junior grades with
the expectation that their experience will be such as to aid in
their medical development, and that they can leave the service
with an addition to their mental equipment if the work does
not prove permanently satisfactory. The development of a

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BY EDWARD N. BRUSH, M.D.

593

medical service that will make this possible assures to each
patient the best possible protection against medical in¬
efficiency ” (8).

It is to the younger men, therefore, of this Association that
we must turn for hope for the future. Let us see to it that
nothing stands in the way of their work, let us encourage them
by greater freedom of action, by increased privileges, by a more
assured tenure of office, by such opportunities for study and
investigation as shall broaden their medical knowledge, and be
of sound value in any future field of work.

Osier urges the clinician to look well to his companions to
see that they are not of his own age and generation. “ He
must walk with the ‘ boys ’ or else he is lost, irrevocably lost;
not all at once, but by easy grades. . . . To keep his
mind plastic and impressionable he must travel with men who
are doing the work of the world, the men between the ages of
twenty-five and forty ” (9).

And so, my younger associates, you see what the task is,
how we choose you as best fitted to undertake it. You will
dream dreams and have visions, and if they are of your work,
well. We, too, who have preceded you, have also had our
visions ; we, too, have caught glimpses, or at least thought we
did, of results which should reward our labours, and redound to
the benefit of the race, but sometimes, alas ! the fruits of our
labours, like the Dead Sea apples, have turned to ashes as we
thought to pluck them. Such may, at times, be your experience ;
let it not dishearten you. For a time, perhaps, a mere sense
of duty will keep your interest alive in your work. “ Presently
the quick, curious, restless spirit of science enlivens it, and then
it becomes an excitement, and then a pleasure, and then the
deliberate choice of the mind ” (10).

Let me beg of you, however, to take for your motto, “festina
lente .” Remember the words of Pasteur at the opening of the
Institute named in his honour : “ For the investigator, it is the
hardest ordeal which he can be asked to face—to believe that
he has discovered a great scientific truth, to be possessed with
a feverish desire to make it known, and yet to impose silence
upon himself for days, for weeks, sometimes for years, whilst
striving to destroy those very conclusions, and only permitting
himself to proclaim his discovery when all the adverse hypotheses
have been exhausted.”

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594 PRESIDENTIAL ADDRESS. [July,

Do not, moreover, sink your humanity in the calm investi¬
gator, the silent looker-on in life’s phenomena, which are also,
too often, life’s tragedies, which cry aloud as often for your
sympathy as for your skill.

We are not, however, leaving the work to your hands alone.
We beg to come now and again to light our torches anew at
the fires which you have kindled, and to still hold them aloft
until that inevitable time arrives when we must turn them over
to you to bear alone along the course.

My Fellow-Members,—To all there come occasions in life
which are great or important, which afford great opportunities.
On such an occasion, and I view this as one, it is an unhappy
circumstance which makes one fear that he shall not satisfac¬
torily meet the occasion or worthily treat his subject; feeling,
moreover, while he is speaking, how easily he may fail in
explaining what have been the aspirations very close to one’s
self, and growing out of one’s life-work. Much that I have said
badly and haltingly and with poor grace you will forgive.
Much that I would have said you will understand better than I
could have expressed it. We are banded together in a good
cause, and our hopes and prayers are to see :

“ The good cause, despite venal friends
And base expedients, move to noble ends.”

References.

(1) Journ. Ment. Sci., October, 1878, vol. xxiv, p. 352.

(2) Loc. cit., pp. 353, 354.

(3) Loc. cit., October, 1914, vol. lx, p. 667.

(4) Loc. cit., October, 1913, vol. lix, p. 375.

(5) Science and Education, Essays by Thomas H. Huxley, N.Y.,
Appleton & Co., 1896, p. 261.

(6) Modern Problems in Psychiatry, by Ernesto Lugaro, second ed.,
Manchester, 1913, p. 294.

(7) G. Alder Blumer, M.D., Report of Superintendent Butler Hospital,
January, 1916.

(8) Trans. Amer. Med.-Psych. Assoc., vol. xxii, 1915, pp. 224-226.

(9) sEquanimitas and other Essays, by William Osier, M.D., F.R.S.,
etc., p. 151.

(10) The Collected Works of Dr. P. M. Latham, London : The New
Sydenham Society, vol. ii, p. 23.

( l ) Delivered at the Seventy-second Annual Meeting of the American Medico-
Psychological Association, New Orleans, La., April 4th~7th, 1916.

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595

Clinical Notes and Cases.

‘ ‘ Pseudologia Phantastica, or Pathological Lying , in
a Case of Hysteria with Moral Defect By
Williamina Shaw Dunn, M.D., D.Sc.

So little has been written in this country on Pseudologia
Phantastica, or Pathological Lying, that Dr. George Robertson,
Physician Superintendent of the Royal Asylum, Edinburgh, has
urged me to report the following case of this disorder associated
with hysteria and a certain degree of moral defect.

The patient, J. M—, was brought to West House, Royal Edinburgh
Asylum, on February 27th, 1916, from the Victoria Hospital, Edin¬
burgh. He was certified as insane on the grounds that he had
attempted suicide on two occasions—once by attempting to strangle
himself with his pyjama strings, once by attempting to drown himself—
and that he was hysterical, and had difficulty in answering simple
questions.

On admission patient w'as quiet and polite in manner, but seemed
somewhat dazed. He was put to bed in a ward where there were male
attendants, and although he gave no trouble it was evident that he was
very unhappy. He wept copiously, and refused to take his food. He
was only too ready to talk, and within an hour of his arrival had con¬
fided to a sympathetic attendant that it was all a terrible mistake
bringing him to such a place, as his people were very wealthy, that his
father was a director of Lloyds Bank, and was at present on his way to
Scotland in a Rolls Royce car. The fact that the patient was a sltmly-
built fellow of some twenty years, coupled with his evident distress, led
to the experiment being tried of putting him with female nurses. He
brightened up considerably, ate and slept well, and became very talka¬
tive. He now told us his “ full history.”

He said he was the only remaining son of wealthy parents, and that
he was born in the south of England. At the age of thirteen he and
some comrades had a misadventure with his father’s motor launch and,
fearing the consequences, ran off. He explained that there was no
difficulty in getting money to run away with, as he was on an allowance
and had money in the bank. With the money so provided the four
boys crossed to Canada, where they went to a farm belonging to a rela¬
tive of one of the boys. After spending some time on the farm, patient
went into the city and took a job as a clerk. He then enlisted in one
of the Canadian regiments and was sent to England, and from there to
France. While in France he was “gassed,” and had to be sent to
London ; later on he was sent to Aberdeen. He told wonderful tales
of a small ape he carried as a mascot of his regiment, but seemed a little
hazy regarding the ultimate fate of this pet.

While in Aberdeen he met with several wonderful adventures. He
related that one day, while walking in a street in Aberdeen near the

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Dee, he was set on by some roughs and robbed of his coat, wrist watch,
and other valuables. At this time he also began to take fits”—these
he considers are the outcome of the gas in France. He said that
because of these “ fits ” he was discharged from the Canadians, but as
he pined for military service he came to England, and succeeded in
joining the Gordons. He again developed “ fits,” and because of these
he was sent to the Victoria Hospital, Edinburgh.

In the Victoria Hospital he was under the charge of a nurse to
whom he was very attached. The nurse was off duty for some little
time, and pranks were evidently tried upon her substitute. As an
example, J. M— said to the man in the next bed that he would tie his
pyjama strings round his neck, and the other man would give the alarm
that he, J. M—, was strangling himself. At this point of the tale
patient always became sad and said, “ The joke worked too well, and
here am I as a result.” This was, of course, patient’s explanation of one
of the attempts at suicide.

In addition to the foregoing history he added a few artistic touches,
such as the death of his only brother, who was a captain in an English
regiment, the sudden death of his dearly beloved mother, and the
brilliant marriage of his only sister.

The wild improbability of some parts, at least, of this tale was quite
evident, and so inquiries were at once instituted, with the result that the
true story patched from several sources was worked out. It is as follows :

He was born in 1S96, and is the illegitimate son of a girl who was a
maidservant of the humbler class. Her mistress herself adopted the
patient from birth, and has treated him with great kindness, as even
the patient attests. He left school at the age of fourteen, and was put
to work at porcelain works ; he left this on his own initiative, and
went for four months to a large commercial house. From there he
became a grocer’s errand boy, and next a hotel servant, and so on.
He never stuck at any job, and led an idle, unsatisfactory life. He
next enlisted in the King’s Royal Rifles, but was discharged after
sixty-three days’ service as medically unfit. He joined the 8th
Worcesters twi^e, each time being discharged as medically unfit. This
took him on to June, 1915. He is reported to have joined the Royal
Fusiliers, but he certainly enlisted in the 3rd Gordon Highlanders in the
autumn of 1915, and was sent to West House as a private in this
regiment. While in this regiment he was stationed in Aberdeen, and
was in hospital for some little time. He evidently had a rather
unhappy time with his comrades, who teased him, and he seems to have
meditated suicide, and got as far as to walk into the Dee up to his knees,
possibly with intention to drown himself. While in Aberdeen he
began to take hysterical fits, probably in self-defence. When the other
men “ragged’*him he tried first to brave it out, then he wept; this
only provoked ridicule; then he found if he held himself rigid, and
simulated unconsciousness, his tormentors were genuinely alarmed, and
he became the centre of sympathetic attention. He got into trouble
with his sergeant because of insubordination, and was sent to Perth for
punishment. While there it became evident that he required medical
treatment, and he was sent on to Edinburgh to the Victoria Hospital.
There is no truth in the statements that he has been in Canada or in

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597

France. His conduct while in the Victoria Hospital was distinctly
peculiar. On one occasion he went out very lightly clad and sat with his
feet in the snow. He was always eager to elicit sympathy, and very
probably his final indiscretion of tying the pyjama strings round his
neck was done to call attention to himself as much as to play a trick on
the sister.

After his admission to West House his behaviour at first was very
good, but it speedily became evident that unless he got his own way he
could be extremely sullen, impertinent, and insubordinate. After a
short stay in hospital he was transferred to a ward with male attendants.
This change upset him greatly, and he tried hard to get back to hospital
by appealing for sympathy, and later by sullen insubordination; finally
he tried a series of hysterical seizures, and was brought down to hospital
and threatened with a cold bath. He thereupon recovered completely.
He was sent back to the ward, where, under a regime of wholesome
neglect, he speedily improved. The least individual attention on the
part of the officials resulted in the patient either bursting into tears or
embarking on a long account of fictitious happenings. After several
weeks of inattention the patient was spoken to, and persuaded to give a
truthful account of his doings. As the facts of the case were known it
was an easy matter to check the patient when he deviated from the
paths of truth. It was extraordinary the facility shown by the patient
for romancing, and the difficulty he had in telling the plain truth. The
slightest suggestion made by the interlocutor was picked up, and if not
actually interwoven into the tale on hand appeared in a subsequent
effort; for example—When speaking to him very shortly after admission,
he mentioned that he had a sister, and a brother a captain. I slightly
misunderstood him, and thought that he meant that he had a sister who
had married a captain. I betrayed this mistake to him in course of
conversation; he corrected me at the time, but next day gave me a
full account of this sister’s brilliant marriage to a captain in the army—
he was even able to furnish details of the function down to the brides¬
maids’ dresses and bouquets. Although this was pointed out to the
patient he was not at all ashamed, but admitted his tendency to romance.
After the confidence of the patient was gained he began to be more
truthful, but the habit of lying or romancing was so firmly established
that only with one or two persons could he be relied on to be honest,
and those persons had to be very watchful. Apart from this chronic
habit of lying he manifested certain other evidences of moral obliquity.
He seemed absolutely lacking in any sense of honour, and attempted
on several occasions to get loans of money from persons who were mani¬
festly unfit to lend money, with no hopes of repayment. He was utterly
unscrupulous in taking advantage of any indulgence or kindness shown
him, but had a superficial suavity and politeness of manner which served
him in good stead. On the impulse he was quite capable of doing an
unselfish deed, which he thoroughly appreciated and recounted to all and
sundry for the next twenty-four hours, but systematically he was ex¬
tremely selfish and inordinately vain. This vanity was, of course, mani¬
fested in his constant desire to call attention to himself, either by
romancing wildly about his own antecedents, or by announcing that he
was to commit suicide. When it was demonstrated that he was lying,
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598 rSEUDOLOGIA PHANTASTICA. [July,

and that we knew that he was lying, when his “ fits ” and talk about
suicide failed to elicit sympathy or interest, he was clever enough to pull
himself together. After some weeks in West House he announced that
he was to behave, but the improvement seemed to be due to the fact
that his moral vagaries were unremunerative, and not to any improve¬
ment in his moral tone.

Physical examination .—Before describing the symptoms as they ap¬
peared when the patient was examined at West House, I should say
that he was examined by Dr. Ninian Bruce at the Victoria Hospital,
who found all the reflexes to be normal.

The physical examination did not reveal much. There was no sign
of disease in the chest or abdomen, while the evidence from repeated
examinations of his nervous system was very conflicting. When he was
first examined it was found that the lcnee reflex on the right side was
sluggish, while that on the left was normal. The same was found for
the supinator, triceps, and adductor reflexes. There was no ankle or
patellar clonus. The sensory reflexes followed the same rule, as the
plantar, abdominal, epigastric, gluteal, scapular, and cremasteric were
all slightly sluggish on the right side, and extremely active on the left.

The organic reflexes were all normal.

The sensory functions at the first examination showed great disturb¬
ance on the right side ; the sense of touch, temperature, and sensibility
to pain all being apparently diminished. The senses of weight, pressure,
and position were normal on both sides. The diminution of the senses
of touch, temperature, and sensibility to pain was so accurately limited
to the right half of the body that hysteria was instantly suspected.
Further experiments, in which it was strongly suggested to the patient
that feeling was diminished on the left side, led to great confusion of
symptoms. No weakness could be detected in any of the motor func¬
tions, neither was there any abnormality in the special senses except
sight, which was defective. The customary tests applied to the cranial
nerves gave normal results. The only physical symptoms, therefore,
presented by the patient were the sluggishness of the deep reflexes of
the right side, and the upset of certain of the sensory functions. As
regards the first the sluggishness of the deep reflexes passed off, and at
the end of three weeks the reflexes of both sides were equal and normal.
The sensory symptoms, on the other hand, could be made to vary by
persistent suggestion. As the patient improved the fact was demonstrated
to him, and when examined by the physician in charge he gradually
realised it was no use pretending, but with a newcomer he never failed
to demonstrate some abnormality. This abnormality grew in degree
according to the interest or sympathy displayed by the examiner. When
challenged on this point he clung desperately to the theory that his
feelings did change with different doctors ; indeed it was found almost
impossible to get him to own up in this matter. With so hysterical a
patient it was extremely difficult to decide whether he really wilfully
simulated symptoms, or whether he did not catch some suggestion from
the examiner which so dominated him that he was practically hypnotised
into presenting the symptoms.

The mental recovery of the patient, as indicated by a more stable
emotional condition and by greater control over his conduct, coincided

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with the disappearance, or partial disappearance, of his somewhat
anomalous physical symptoms. The moral defect of the patient was, of
course, a serious and unsurmountable difficulty in his complete recovery
to a normal mental condition. Indeed so deficient was the moral sense
that his apparent recovery seemed to be largely due to a realisation that
being ill and troublesome did not pay in this institution, and not to any
greater development of his moral sense.

My best thanks are due to Dr. George Robertson for kindly
criticism and guidance in the preparation of this article.

Part II—Reviews.

The First Annual Report of the Board of Control, for the year 1914.

The First Annual Report of the Board of Control for the year 1914
is a surprise from the fact that it contains nothing surprising. Its late
appearance gave rise to some expectation that it might contain important
new departures, but those who know the overwhelming amount of work
that has fallen on the Board of Control can only wonder that any
report has been forthcoming. Under such circumstances there can be
no astonishment at this being almost a stereotype of its predecessors,
containing little that can be called new.

Statistics, etc. —The number of notified insane persons in England
• and Wales on January 1st, 1915, after adjustment in regard to the
Mental Deficiency Act, was 140,466, an increase of 2,411 on the
previous year.

The increase was 563 on 1913, but was only 21 above the last
quinquennial and 160 above the decennial average. The bulk of the
increase went to the County and Borough Asylums, but 514 were in
Workhouses and 132 in the Metropolitan District Asylums. The number
in Criminal Asylums decreased by 42, and those living in the care of
friends receiving Poor Law relief diminished by 139.

The patients in provincial licensed houses increased by 66, and
private single patients by 16, but those in Metropolitan licensed
houses decreased by 4, and in registered hospitals by 19.

The private patients in County and Borough Asylums are now 38 8
per cent, of the whole number. The Report points out that many patients
classed as paupers are not so in a strict sense, many of them being
maintained by their relatives, who refund the whole of their maintenance,
and in some cases in addition a proportion of the construction and up¬
keep of the asylum. Although some of these are said to be classed as
“ private,” it appears that they are treated as paupers. This does not
stimulate effort on the part of the relatives to contribute to their mainten¬
ance, and it is surely desirable that some encouragement should be given,
by transfer to the private annexes of the asylums, a portion of the

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profits from which might be employed to make up any balance of cost
(if the repayments did not amount to the actual expenditure in the
annexe).

The proportion of males to females per 1,000 amongst pauper
patients (January 1st, 1915), was 465'2 to S34'8, showing by com¬
parison with the statistics of the private insane that-there were 76 per
1,000 more pauper, than private male patients. This is probably
proof that many men of the private class become paupers because
they have not wage-earners to support them as the women have, and
is an added reason for extending all possible relief to the educated
men who are inmates of pauper asylums. The diminished admissions
and the number of vacant beds in the registered hospitals suggest that
these might relieve the County Asylums of some of these unfortunately
placed persons.

First admissions .—The statistics relating to the increase in the
occurrence of insanity are yearly growing in interest since the “ first
admissions ” were separately dealt with in 1898. The ratio of these to
the population, which rose to 4^92 per 10,000 in that year, has averaged
5-13 in the last decade, and was 5 2 in 1914.

The accumulating records of the ages at the time of attack, and of the
form of disease, ought soon to enable conclusions to be drawn in regard
to the gravity of the diseased conditions leading to admission.

The diminution of the recovered discharges from 8,170 in 1905 to
7,457 in 1914, with a mean average for the ten years of 7,699, is not of
very hopeful augury, but this may be of less weight if a majority of the
admissions are at an advanced age or suffering from more unhopeful
forms of disease.

The fact that the readmissions in the past year were 1 per cent, above
the average of the last ten years, on a reduced discharge rate, may be
indicative of greater instability, but might also be due to discharges of
less completely recovered cases. In either case the desirability of the
extension of “ after-care ” is indicated, and it is satisfactory to note that
the Commissioners commend the discharge of patients on trial ” in
some asylums.

New tables .—The two tables (na and 11b) included this year in the
Appendix of the Report, giving the population in age periods in each
area from which'asylums draw their patients, should be of great value in
aiding the solution of the problems relating to the gravity of the mental
disorders now and hereafter being admitted.

Effects of the 'war .—The Report draws attention to the withdrawing
from the asylum service of medical officers and attendants owing to the
war, and expresses regret at the death (being killed in action) of Mr.
Crowther, who had been appointed to succeed Dr. Gayton on his
resignation. This subject, however, will loom so much more largely
in the next report that it may be left without comment at present.
The occupation of asylums as military hospitals, etc., will be a striking
feature in the 1915 report. The weekly cost per head has risen by
3 \d., mainly as the result of the war, and a still larger increase must be
anticipated.

The estimated expenditure for erection of new asylums, alterations,
additions and improvements of those already existing, is ,£414,488, but

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this will probably be greatly reduced under the stringent necessity of
war economy.

The additions include the purchase, of a house for the accommodation
of nurses in connection with the “ Maudsley Hospital.”

Registered hospitals .—The registered hospitals are again admonished
that, “ As these institutions were originally founded upon a charitable
basis, as large a proportion of cases upon unremunerative terms should
be received as is consistent with the reasonable financial stability of
the hospitals, and that the latter should not degenerate into luxurious
homes for wealthy patients only, or principally for them.” It is
certainly very desirable that the managers of these institutions should
consider whether they cannot perform more charitable work. The
examples of the County Asylum annexes have shown that patients can
be maintained on a pound a week as private patients at a profit, so
that patients paying from ior. to ios. per week may fairly be considered
as practically self-supporting under suitable conditions.

The Report gives statistics of the rates of payment in the case of the
principal hospitals, classifying them into (a) those paying nothing ;
(fi) those paying under ior .; (c) from ior. to 21 s. ; ( d ) 21 s. to 42 s. and
(f) 42 s. and upwards per week. From an examination of the statistics
it appears that in the six hospitals whose weekly rate of maintenance
ranges from ^3 7 s. 7 d. to £1 i8r. 4 d., there are close on 12 per cent.
of patients paying less than 21 s.

The total income of these asylums is little short of ,£300,000.

In the four hospitals whose weekly expenditure ranges from j£ 1 15*. i,d.
to yfix 6 s. 7 d., the number of patients received under 21s. is about
44 per cent., on an income of less than one-sixth of the previous class.
So that considerably more patients are assisted in the latter class than
in the former. It would seem indeed that the actual charitable out¬
come is in an inverse proportion to the rate of maintenance and to
the number of highly paying patients, although one hospital shows that
this is not an absolute rule.

No one would wish to detract from the valuable examples in treat¬
ment and administration which these institutions have given, but
admiration and commendaton of their good qualities should not be a
bar to the duty of suggesting the means of making them still more
valuable to the country, and worthy of still higher admiration and praise.

The Mental Deficiency Act, 1913.—This Act came into force on
April 1st, 1914, and on that day the hospitals, institutions, and licensed
houses which had been registered under the Idiots Act of 1886 became
certified institutions or certified houses for mental defectives. A list of
these, with other houses and homes certified or approved up to
September, 1914, is given in the Appendix.

At the end of the year there were 2,959 cases thus accommodated,
a’ very small proportion of the large number that will ultimately have to
be cared for. The outbreak of the war, with the consequent increase of
work and stringency of finance, the Report states, has greatly interfered
with the development of activity in this respect.

Scientific research work .—Scientific research work suffered con¬
siderably from the outbreak of the war, contributions being reported
only from the pathological laboratory of the London County Asylums

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and eight others. Many asylums have no pathological laboratory
or staff to work therein, but combinations of groups of asylums
might yield valuable clinical observations, if working on a systematic
basis. When the medical staff of the Board of Control overtakes
its routine work and has any spare energy, this might be well employed
in considering the numerous clinical problems which demand solution,
and in suggesting the methods by which they could be attacked.

Information concerning all that affects the health of the nation will
probably be greatly in demand when the war is over, and such questions
may come to occupy popular and Parliamentary attention in place of
the squabbles of party politics, which have so long led to the neglect
of these and many other important national needs.

An Introduction to Social Psychology. By William McDougall,

F.R.S.Lond. Methuen & Co. Ninth edition, 1915. Pp. 431.

8vo. Price 5*. net.

The interest aroused by this volume is sufficiently shown by the fact
that it is now in its ninth edition. It was originally published in 1908,
and several of the subsequent editions have been revised, the present
one containing an additional chapter on the sex instinct. The work is
that of an original thinker, and it has been successful in stimulating a
good deal of discussion, and it has undoubtedly exerted a considerable
influence upon contemporary psychological thought.

The aim of the author is indicated in the introduction. He wishes to
present psychology—in a living and practical form—from a standpoint
which may serve as a firm foundation for the study of the various social
sciences. It is obvious that for these latter to be of any value, they
must be based upon an adequate knowledge of the working of the
human mind. Unfortunately, however, in some instances elaborate
systems of philosophy have been erected upon entirely false psycho¬
logical assumptions, and in others the writers have made the frank
avowal that no knowledge of psychology is necessary for an under¬
standing of these subjects. This indifference towards, or ignorance of,
psychology has been undoubtedly in some measure due to the academic
and lifeless treatment of the subject in the past, so that the current
literature has been of but little assistance to students of the allied
sciences. The mere classification of conscious states throws but little
light on those social sciences which deal with human conduct, in so far
as such a method largely ignores the ultimate motives by which such
conduct is determined. Dr. McDougall urges that for psychology to
attain the position of a positive science it should not be purely intro¬
spective and descriptive, but it must be an “ evolutionary natural
history of the mind,” and it must, above all, deal with those innate
fundamental tendencies of the mind which regulate human activities.

The main thesis of the author, a thesis vigorously and convincingly
maintained throughout the book, is that human conduct is determined
by innate conative dispositions (instincts), and that the intellect acts
only in the service of these instincts as a means of attaining the ends
to which they are directed. Such a thesis is, of course, directly opposed

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to that intellectualism which regards man as an essentially reasoning
and logical animal. This school would maintain that the intellect is an
active tendency, an innate independent impulse in man, and practically
an instinct itself. It is hardly the function of the reviewer to discuss
the merits of these opposing schools of thought, but certainly those who
are acquainted with modern developments in the sphere of morbid
psychology would find considerable difficulty in the following teaching of
intellectualism. It is interesting to note how morbid psychologists,
approaching the subject from a different angle to Dr. McDougall, have
been able to demonstrate to what a great extent thought, judgment,
conduct, and belief, in both normal and abnormal persons, are con¬
trolled by primitive undercurrents of feeling of which they are entirely
unconscious.

The chapters devoted to a consideration of the nature of instincts,
and their classification, are particularly clear, and the author presents
the subject from an original point of view, which is a marked advance
on that found in most discussions upon it. Instinct is regarded by
most writers as an innate tendency to certain kinds of action. Dr.
McDougall, however, thinks that instincts are more than this; he
regards every instinctive action as the outcome of a distinctly mental
process which includes, like every other mental process, cognitive,
conative, and affective elements. An emotion is no more than the
affective side of the instinctive process, and each instinct has a specific
emotion—primary emotion—as, for instance, the instinct of flight and
the emotion of fear. This threefold treatment of instincts renders the
subject free from confusion and ambiguity. The relation between
instinct and emotion had not previously been stated in this explicit
manner. Even James, who recognises the intimate relation between
the two conditions, is somewhat perplexing as to the exact connection
between the two. He says : “ Emotions, however, fall short of instincts,
in that the emotional reaction terminates in the subject’s own body,
whilst the instinctive reaction is apt to go farther, and enter into
practical relations with the existing object.” Thus the student gains a
vague opinion that an emotion is almost an instinct, but not quite.
This clear definition of the nucleus which determines conduct is
important, as it enables the reader to follow its development without
difficulty. The cognitive aspect expands into the developed intellect,
the primitive conative impulse exhibits itself in increasing complexities
of conduct, and the emotions develop into organised systems or senti¬
ments.

Having defined and enumerated the various instincts, consideration
is given to certain innate tendencies which, though of great importance
for social life, cannot properly be classed as instincts, as their modes of
action are of a varied character and are not directed towards any
specific ends. The most important of these non-specific tendencies
are sympathy, suggestion, and imitation,—processes of special import¬
ance to social life as they contribute so largely to the formation of the
collective mind of organised society. This question of collective
mental processes is discussed more fully in the second part of the book.
The theme is difficult and elusive, but one of great interest and import¬
ance. The present epoch should afford abundant material for a detailed

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study of this question. The notion of a national consciousness, imply¬
ing the existence of a national will to pursue common ideals, has now
presented itself, as never before, in a particularly clear-cut manner. One
may, perhaps, hope that Dr. McDougall,who is so prominently associated
with the theory of the “ Collective Mind,” may at some future date
enlarge on this notion with special reference to antagonisms of national
minds.

The remaining chapters of Part I are devoted to a study of the
development of these primitive instincts into more complex forms. The
author traces the organisation of emotional dispositions into sentiments,
and demonstrates the importance of these for the character and cpnduct
of individuals and societies. He next passes to a consideration of the
growth of self-consciousness, tracing the effect of the social environment
upon instinctive conduct, how it becomes modified into conduct regu¬
lated by notions of rewards and punishments, then conduct controlled
by anticipation of social praise and blame, and lastly conduct based on
a personal ideal of right and wrong. Finally he presents the question of
volition in an original and striking form.

The second part is devoted to a consideration of the principal ways
in which the instincts play their part in shaping the social life, and in
determining the forms of institutions and of social organisations.
These chapters deal with problems of vital importance to social life of
the present day. As an instance, the section devoted to the reproduc¬
tive and parental instincts may be mentioned, in which the writer deals
with the weakening of these instincts by increased culture and the
habit of independent thought and action. This and other questions
are dealt with in an illuminating and instructive manner which merits
the attention of all those interested in social sciences, either from a
practical or an academic standpoint.

In the first supplementary chapter the author expresses in a more
explicit form the theory of action which underlies his exposition of
instincts and their development, and he combats the theory of psycho¬
logical hedonism upon which the Utilitarian system of ethics has been
founded. He thus develops his main thesis that conduct is not deter¬
mined by the motive of avoiding pain and increasing pleasure, but,
rather, springs from primary tendencies rooted in man, and in the remote
ancestry of the race.

The chapter on the sex instinct will be read with interest in view
of the prominence which has recently been given to this subject. It
contains a criticism of Freud’s sexual theory.

Altogether this book is the work of an acute and original thinker.
The subject is one of considerable interest and importance to the
psychiatrist, and its treatment in this volume might well form the ground¬
work for a study of the problems of mental disorder. Instances, indeed,
might actually be cited in which the application of Dr. McDougall’s
conceptions have been productive of interesting studies in individual
cases of insanity. - H. D.

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The Sex Complex. By W. Blair Bell, B.S., M.D. London:

Baillikre, 1916. Pp. 233, with 50 Plates. Demy 8vo. Price

12s. 6 d. net.

In the sub-title this volume is described as “A Study of the Relation¬
ships of the Internal Secretions to the Female Characteristics and
Functions in Health and Disease.” Professor Blair Bell has here sought
to bring together, in a more or less coherent form, those investigations
of himself and other workers bearing on the same point, which seem to
demonstrate that the reproductive functions are controlled by all the
organs of internal secretion acting in conjunction, in such a way that
the existence is indicated of a genital system, or, as the author terms it,
a “sex complex.” In the past the ovaries have been regarded as the
plastic agents of femininity. We must now regard them, the author
insists, as part of a system to which most, if not all, the other endocritic
glands belong, these latter being of equal reproductive importance with
the ovaries themselves. We also have to realise that the genital
influence of the endocritic glands is not only on the anatomical and
physiological integrity of the uterus, but also on the general metabolism,
and so ultimately on the psychology, of the individual. The same
principles apply also to masculinity, although in this field they are only
incidentally discussed in the present volume.

The volume is divided into two parts, the first mainly physiological
and morphological, and the second pathological. In the first are
considered in order the ovaries, the thyroid, the parathyroids, the
pineal, the pituitary, the thymus, the suprarenals, the pancreas, and the
mammary glands. The last, indeed, are dismissed as not true organs
of internal secretion, except in the sense that “ every cell in the body
should be considered to be an organ of internal secretion,” and some¬
thing is done to clear up the puzzling and contradictory theories
which have been put forward to explain the secretion of milk by the
simple suggestion that we are in the presence merely of a redirection of
maternal elements from the placenta to the breasts, which have been
previously “sensitised” by a variety of stimulating' agents, hormonic
and other.

As regards the correlation of the internal secretions in their genital
functions, the author concludes that the secretions of the ovaries have
no direct influence on the general metabolism, but that they have a
highly important function in keeping the other members of the
endocritic system in touch with the necessities of the reproductive
situation. The rest of the endocritic system is related to the genital
function in various ways, some glands (thyroid, pituitary and supra¬
renals) influencing the development, integrity, and activity of the
genitalia, others (thymus and possibly pineal) appearing to prevent
sexual precocity. Further, all the endocritic organs, acting in harmony,
control the metabolism in response to the necessities of the genital
functions, and in addition adapt the whole organism to the situation,
and regulate the secondary characteristics, physical and psychic, to the
needs of the individual. But if the reproductive organs are removed
or atrophy, the rest of the endocritic system loses its genital functions,
and, contrariwise, insufficiency of the thyroid, pituitary or suprarenals
may cause the genital functions to cease.

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After the summing up at the end of Part I, a chapter on “ Psycholo¬
gical Characteristics ” is inserted. This has somewhat the appearance
of a “ foreign body ” in the volume. No doubt the internal secretions
have a highly important bearing on the psychic condition, but know¬
ledge is still very imperfect and fragmentary. There are, indeed, a few
points to bring forward, such as the influence of the thyroid in increasing
mental energy, and the action of excessive secretion of calcium salts in
lessening mental equanimity ; but for the most part the author is here
reduced to 'vague generalities, and many of these doubtful. He
abandons, indeed, the judicially scientific attitude of his earlier chapters,
and his confidence grows in this unfamiliar field as his knowledge
diminishes ; such generalisations as that modern women, in contrast to
men, are more altruistic than primitive, are altogether hazardous.
Finding that he has so little to say about women’s psychology, the
author takes a further leap and discusses their social sphere. He
scarcely seems to realise the importance of the paragraph in which he
effects this transfer. It is a somewhat illogical and incoherent passage
(p. 114), which begins by stating that “competitive work”—evidently
meaning industry—being “strictly speaking an evolutionary form of the
hunter’s craft,” is injurious to women’s finer psychical functions, goes
on to assert that genius cannot possibly occur in women, and ends by
stating that more latitude is required in the definition of sex. It would
need some pages to deal with all the erroneous and misleading assertions
in this paragraph, but it may suffice to remark that (1) so far from the
industries being a form of hunting and pertaining to men, the most
usual primitive rule is in very diverse parts of the globe that, while the
men fight and hunt, the women alone are concerned with the industries,
even agriculture and house-building ; (2) since it is generally accepted
that genius may sometimes occur in women it is idle to make an
arbitrary statement to the contrary without an analysis of genius, and a
careful investigation of the alleged cases; and that (3) if we accept the
author’s wider latitude in defining sex, if even the gonads are not
essential, if the most various masculine traits may appear in a “ true
woman,” it would be very suprising, even ex hypothesi , if genius were
not sometimes to appear in women. The author has failed to realise
that the social and psychic sphere of women is determined by a number
of biological factors, and not exclusively by the very imperfectly known
endocritic glands.

Part II deals mainly with derangements of development of the repro¬
ductive organs, and with the various disturbances of the internal
secretions in their effects on characteristics and functions. In discussing
hermaphroditism it is pointed out that so-called “ true hermaphroditism ”
in man (with the occurrence of ovo-testes) is better termed “ glandular
partial hermaphroditism,” and the author fully describes a case of his
own, one of the three or four definite cases so far known. The different
balance of the internal secretions in the sexes is well illustrated by the
fact, to which the author calls attention, that in boys sexual precocity
may be produced by neoplasms and hyperplasia in the suprarenal cortex,
testes, pineal, and possibly pituitary bodies, while in girls such precocity is
nearly always produced by ovarian tumours and hyperplasia; changes in
the suprarenal cortex, pineal, and pituitary bodies, which in boys pro-

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duce precocity, in girls producing masculinity. The author reasonably
protests against the operation of oophorectomy before some attempt has
been made “to gauge the degrees of femininity and ovarian activity ” in
the woman, as it is probably only in the cases in which these are below
the average standard that the operation is little likely to produce serious
metabolic disturbance.

The second part of the book concludes with a short section on
“ Sexual Psychoses,” which the author begins with a reproof to
alienists for failing to grasp the fact, “ that has always been staring them
in the face,” that insanity may depend on the state of the internal
secretions. It is unpleasant to be stared at by hypothetical secretions,
and it is to be hoped that Professor Blair Bell may soon be able to
isolate the ovarian secretion to which he attributes so much influence.
In the meanwhile the assumptions here made may suggest various
considerations to the hesitating alienist. The author takes for
granted that excessive or defective sexual feeling, leading to various
psychic anomalies, is entirely a matter of excess or lack of “ ovarian
secretion.” But clinical evidence in all countries shows that oophorec¬
tomy in a large proportion of cases leaves the sexual feelings intact, or
even increases them, and as our author insists that the ovaries are
only one member of the sex complex, that seems to be the natural
result which we should expect to flow from his own premises, even when
we put aside all that may be said for a cerebro-nervous factor.

The psychological and psychiatric sections form but a subsidiary
portion of this interesting work. It embodies the investigations of a
recognised authority in his own field, and will be found full of help and
suggestion by the workers in many other fields.

Havelock Ellis.

The Theory of Psychoanalysis. By C. S. Jung. New York : Nervous
and Mental Diseases Publishing Co., 1915. Pp. 135.

To a number of the readers of this Journal the writings of Freud are
for many reasons distasteful. Their scientific training causes them to
refuse to accept theories stated with little proof, and, even if the attempt
be made to keep as open a mind as possible, their common sense rebels
against some of the sexual doctrines he promulgates. But when they
turn from the literature of the master to that of his disciples there is
disgust. These out-Herod Herod, no doubt seeking a cheap notoriety
by their unbridled licence.

The work under review is, however, in a different class, and it is
interesting to psychiatrists for several reasons. First, Jung has studied
the insane; secondly, he does not dogmatise, but condescends to give
the reader a closely reasoned argument; and thirdly, though he acknow¬
ledges the inspiration received from Freud he is no blind follower of his.
In fact, in regard to some of the most important doctrines of psycho¬
analysis he is unorthodox. In the opening chapters time after time he
praises several of the wonderful discoveries of the master (Freud), then
discusses them, and finally winds up by proving how untenable they are.
It makes one think irresistibly of setting up a ninepin only to knock it
down shortly afterwards. Then, again, the “ censor ” or “ censure ” is

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not once mentioned. There is a sense of loss in the absence of this old
friend from Freudian literature.

In the first chapter the theory that hysteria has its roots in the
so-called traumata or shocks of earliest childhood is discussed, and it
is stated that this conception was given up fifteen years ago and replaced
by the hypothesis of “ repression.”

By the word “ repression ” is understood the psychic mechanism of
the re-transportation of a conscious thought into the unconscious sphere.
Chapter II deals with infantile sexuality, and Jung gives the reasons
which compel him to disagree with Freud’s statement that the sucking
of an infant is a sexual act.

In Chapter III Jung discusses his theory of the “libido.” He con¬
ceives of the libido as vital energy, and compares his views with the theory
of conservation of energy in the physical world. He does not agree with
Freud in restricting the libido to sexual matters. Those who have not
followed elsewhere Jung’s writings on the libido may be interested in
the following quotations : “ I maintain that the conception of libido
with which we are working is not only not concrete or known, but is an
unknown X, a conceptual image, a token, and no more real than the
energy in the conceptual world of the physicist." . . . “ We con¬

ceive libido now simply as energy, so we are in the position to figure
the manifold processes as forms of energy.” “ We term libido that
energy which manifests itself by vital processes, which is subjectively per¬
ceived as aspiration, longing and striving.” . . . “ In early childhood

we find libido at first wholly in the form of the instinct of nutrition
providing for the development of the body. As the body develops
there open up successively new spheres of influence for the libido. The
last, and, from its functional significance, most overpowering sphere
of influence is sexuality, which at first seems very closely connected
with the function of nutrition.”

The next chapter states that in many cases of neurosis the libido
lingers while the individual develops. “ In this way the foundation is
laid for the dissociation of the personality, and thereby to that conflict
which is the real basis of the neuroses.”

The conclusion of this chapter treats of unconscious phantasy, which
leads to a digression on the unconscious which is dealt with in the next
chapter. This is followed by a review of dream analysis, and the asso¬
ciation experiment originally introduced into psychoanalysis by Jung.
Descriptions of theCEdipus and Electra complexes are then given. The
author next discusses the regression of the libido, a subject upon which
he lays considerable stress. “ The utilisation of reminiscences to put
on the stage any illness or apparent aetiology is called a regression of
the libido.” He borrows from Freud the illustration that when a stream
is dammed in its course the rising waters make use of old channels
long disused. Similarly the libido, when it meets an obstacle, may
regress into infantile paths. The aetiology of the neuroses is to be
found in the actual present. Failure qf adaptation and primary sensitive¬
ness also play a part.

The therapeusis consists in freeing the patient from his phantasies,
thus bringing him back to reality. This can be done only by raising the
phantasies and the accompanying libido into daylight.

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1916.] PSYCHOLOGY AND PSYCHOPATHOLOGY. 609

A case of neurosis in a girl, set. n, and the psychoanalysis which
resulted in recovery, is given as an example.

Such, then, are the brief outlines of the Theory of Psychoanalysis.
Literature of this kind is difficult to epitomise, as the manner in which
most Freudians express themselves is diffuse, and the meaning is not
always quite clear. It would assist comprehension if authors were to
deign to summarise their conclusions at the end of each chapter. More
cases by way of illustration would also be helpful. Three cases are given
in this book, for which thanks must be recorded, but more would be
acceptable. It would also be a relief if the unbeliever were to be left
severely alone. Jung deems it his duty to deal faithfully with him, but
such diversions are apt to draw the attention from the main argument.
These, after all, are minor matters, and the Theory of Psychoanalysis
will confirm the high place Jung has taken in the new school of
thought. R. H. Steen.

Part III—Epitome of Current Literature.

1. Psychology and Psychopathology.

The Study of History from a Psycho-pathological Point of View \La
Psycho-pathologie Historique\. (.Revue Philosophique , February ,

1916.) Louis Proal.

In this erudite article the author points out that Brunetiere is
wrong, when, in his study of La Pathologie Mentale des Rois de France ,
he states that Auguste Brachet invented a new science, having for its
object the explaining of historical facts by biology and pathology.
This method of studying history is almost as old as history itself, and
the author supports this view by a formidable array of facts.

Les Regicides , the work of Dr. Regis, the learned professor of the
Bordeaux School of Medicine, is comparatively recent; so is that of
Dr. Laborde on the Commune of 1871. Between 1836 and 1859,
I.elut, Littre, and Moreau de Tours published books on historical
psychology. The historian, Michelet, in his writings, particularly in
La Sorciere and in L'Histoire de la Revolution , has indicated the
influence which physiological and pathological causes exercise on the
course of events. The pathology of the French Revolution has been
especially studied by Taine, who was a member of La Sociite de
Psychologie Physiologique, and had been initiated into the study of
psychiatry by his uncle, the eminent alienist, Dr. Baillargar.

After having referred to the writings of Montesquieu and Voltaire,
the author proceeds to demonstrate that the ancients also studied
history from a psychological point of view. He shows that Plutarch
and Tacitus analyse the passions of crowds and assemblies as thoroughly
as Taine has done, and that both these classical authors acknowledge
the species of intoxication which follows the acquirement of supreme
power. Further, Plutarch realises the evil effect of fear upon the

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judgment and even on the memory ; and he sees as clearly as modem
writers that anger is a feebleness of the mind.

The author is fully alive to the value of this method of studying
history, but he sees that it is beset with many pitfalls. He says : “This
application of psychology and mental pathology to history presents many
difficulties, for it requires various methods and extensive knowledge, the
criticism of texts, and the clinical study of mental diseases. So the
essays on historical pathology which have been attempted are not all
free from exaggerations and errors.”

The psychological historian must be versed in the laws of evidence,
and adroit in their application to given cases, for imagination plays a
part in the account which even an honest witness gives of an event,
leading him “ to enlarge, embellish, or diminish it.”

The point of view changes with the nationality of the chronicler. It
changes also with the flight of time, for, as Voltaire says, “ the same
nation at the end of twenty years has no longer the same ideas that it
had on the same event or on the same person.”

Another cause of uncertainty is the historian’s state of mind. “ Not
only the contemporary witnesses, who relate the facts, do not all see
them with the same eyes, and consequently they interpret them in
different ways, according to their mental bias, their education, their
profession, and their political and religious opinions ; but the historians
themselves study the past with their preoccupations of the present. The
freethinker and the religious man, the democrat and the conservative
cannot arrive at the same judgment on the events of the past.” Voltaire’s
blind hatred of Christianity deducts from the value of his criticism;
Taine's dislike of the Anciett Rigime distorts his views on the causes of
the French Revolution.

But the greatest difficulty of all’ is that the would-be psychological
historians allow themselves to be carried away by their own theories.
For example, Moreau de Tours has accepted almost any fable which
fitted in with his hypotheses. “ Believing that he had discovered an
explanation of genius in a pathological state of the nervous system, he
mixes with his clinical observations doubtful anecdotes and unproved or
badly interpreted little stories, which he has borrowed from historical
novels.” The evil of such a method is far reaching. Lombroso, with¬
out proper examination, accepts the stories which he finds in the works
of Moreau de Tours, and proceeds to argue from them that genius is a
form of epilepsy.

Louis Proal’s paper is not only interesting but useful. It strikes a
note of warning, which was never more needed than at the present day,
when we are so much under the influence of German thought, for it
is characteristic of the Teutonic mind to care little about the truth of
the premises so long as the deductions appear to be logical.

J. Barfield Adams.

Do Psychological Phenomena exist in the Vegetable World ? [Existe-t-il
des Phinomlnes Psychologies dans les Vtgitaux /]. {Revue Philo-
sophique , February^ 1916.). C. Acqua.

This question, the author says, cannot be treated from a theoretic or
metaphysical point of view ; it ought to be dealt with, on the contrary,

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by the positive method of observation and experience. One has been
taught that psychological life is bound up with the presence of a nervous
system. As we descend the zoological scale the nervous system gradu¬
ally simplifies its structure and finally disappears. No one has demon¬
strated with certainty the presence of nervous substance in the protozoa.
Are we, therefore, to conclude that there is no psychological life in these
simple animals ? The author considers that the continuity, which in
zoology binds the most simple phenomena to the most complex, leads
us to think that even among the infusoria there may be rudimentary
psychological phenomena.

But there is no trace of a nervous system in vegetables. Are we to
conclude, therefore, that they have no psychological life ? It is admitted
that certain agents, such as weight, light, etc., provoke the reaction of
movement among vegetables. Without being able to admit the existence
of an organ which accomplishes, even embryonically, a function analogous
to that of a central (nervous) organ among the animals, one can dis¬
tinguish the zones of the reception of the exciting cause, the zones of
conduction, and the zones where the reaction takes place. At the
extremity of the root there is an excitable zone, the geotropism and
hydrotropism of which are the proof of its existence. At the extremity
of the steih there is another excitable zone with its characteristic helio-
tropism.

The compound leaves of certain plants (one presumes that the author
considers the parts of the flower as being morphologically analogous to
leaves, and speaks accordingly) open during the day, and close during
the night, these movements being provoked by light. But when these
plants are kept in the dark, these movements continue at the same
hours for a certain time, and after a while cease completely. This the
author deems to be a phenomenon of memory, the plant recollecting
the stimulus of light and performing the movements even when the
stimulus is no longer felt.

Thus the author demonstrates in the vegetable world the existence of
differentiation (geotropism, heliotropism, etc.) and memory, the two
primary attributes of intellect.

He further points out that the mobile ciliated spore of the alga,
reacts in the same fashion to external agents as the ciliated cell in the
animal kingdom. But while in the case of the animal there is evolu¬
tion and a growing complication of the functions of psychic life, the
vegetable world presents neither this evolution nor this complication.
An inferior sensibility or irritability is common to animals and vege¬
tables, and irritability may be regarded as a function, though a very
inferior one it is true, of psychological life. From this point of view,
one may admit with the author that psychological phenomena exist in
the vegetable world. J. Barfield Adams.

The Results of a Questionary on Antipathy [1 Resultati del Question-
ario sull Antipatid], ( Psiche , October-December , 1915.) De
Sarlo and Fanciulli.

Questions were circulated by an Italian psychological society among
psychologists, professors, and others concerning antipathy, its relation
to other antagonistic states, its description and analysis, its various

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forms, its course and transformations. Something over a hundred
replies were received, and many are here reproduced. They are often
interesting and suggestive, but, as might be expected, sometimes
contradictory. Gambara and others consider antipathy fundamental
and instinctive. Stepanoff, on the other hand, who regards antipathy
as chronic opposition, argues that acute opposition arises earlier than
the chronic form, which is not known in young children, and pre¬
supposes so considerable a social education that it is not one of the
first even of chronic psychic states. Assagioli regards it as a reaction
of defence, derived from the instinct of conservation, and not easily
distinguished from other states of opposition. Fok, however, believes
that the oppositional states are easily determined, and are aversion,
hate, repugnance, and antipathy; he regards antipathy as fundamental
and primitive. Boncinelli and others believe that antipathy is simply
a complex result of many mental states, and that it has no special function,
while Vacca regards it as a purely artificial conception, and mainly
negative.

The authors of the report discuss the question of justified and
unjustified antipathies, and suggest that, while the apparent motives and
causes are not always justified, there may be a form of repulsion having
its ultimate foundation in inherent physico-chemical differences
between individuals, with attractions and repulsions which may have
their reflex in consciousness and psychic conduct.

Havelock Ellis.

A Contribution to the Study of Epilepsia tarda , or Senile Epilepsy, and
of Arteriosclerotic Dementia [Contributo alio studio della epilessia
tarda e della demenza arteriosclerotica\ (Rivista di Patologia

nervosa e men/ale, December , 1914.) Alberto Ziveri.

The term, epilepsia tarda , is applied to the epileptic phenomena
occurring in advanced age. A few authors distinguish between
epilepsia tarda and senile epilepsy, understanding by the first that form
of the disease which is said to appear about the thirtieth year, and by
the second that which occurs after 60 years of age.

Epilepsy occurring in later life is almost always due to primary
affections of the nervous system, as neoplasms, syphilis, parasites,
alcoholism, arteriosclerosis, etc.—arteriosclerosis being the most common
cause. Some writers, without absolutely denying the possibility of the
late appearance of essential epilepsy, point out that the disease may
have been previously present without causing noticeable disturbances,
or the symptoms from their slightness, or from occurring at night, may
have been overlooked.

The author, Dr. Ziveri, records the following case as illustrating
both arteriosclerotic epilepsy and arteriosclerotic dementia.

Teresa, peasant woman, aet. 73, married, four children, three of
whom are living, has suffered from much destitution, and appears to
have had symptoms of pellagra. No signs of mental disease until two
years ago, when she began to have epileptiform convulsions (two a
month), which were followed by psychic disturbances. Afterwards
patient suffered from deafness, confusion, disorder of ideas, and possibly

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613

from delusions. Later, there were impulses to wandering about, and
attempts at suicide. Admitted March 6th, 1914. Physically: Arthritis
deformans of fingers; peripheral arteries hard and tortuous; cardiac
sounds accentuated, especially the first; blood-pressure (Riva-Rocci)
145 mm.; pupils myotic, react feebly; knee-jerks well marked.
Mentally : Is not restless, but only a little irritable and talkative ;
replies to questions, but does not pay much attention; knows her own
name and country, but says that her age is 25 years, and that she
has a son who is either 20 or 25 years old.

March 7th: Completely confused; fell out of bed; walks about
without any object; when questioned replies with a string of words
without any sense.

March 19th : Three attacks of epilepsy. Afterwards very confused.

Patient gradually became mentally weaker, until on April 26th
it was noted that dementia was complete. Bed-sores had now
appeared.

May 14th: One epileptic attack.

May 29th : Two epileptic attacks.

June 6th: Bed-sores very extensive. State of progressive marasmus.
The patient has been unable to swallow for the last two days. Died
at 4.45.

Post-mortem examination of body six hours after death. Weight of
brain and meninges gr. 1,150. On section of brain, several moderate¬
sized haemorrhagic foci were found, one in the second left frontal con¬
volution, another in the left orbital, two others in the right ascending
parietal, and one in the left ascending parietal. These were all in the
white substance of the convolutions.

Everywhere in the cortex there were punctiform and miliary haemor¬
rhages, varying in size from the point to the head of a pin.

The basal arteries and the smaller branches of those of the cerebrum
showed signs of atheromatous degeneration.

Heart. —Slight hypertrophy of left ventricle. Mitral valve with
nodules of retraction. Aorta and aortic valves show slight signs of
atheroma. Coronary arteries tortuous.

Liver. —Commencing cirrhosis.

Lungs. —Right, slight pleuritic adhesions of an ancient date. Left,
two superficial abscesses at base of inferior lobe.

Kidneys. —Left, small urinary cysts. Right, numerous confluent
abscesses occupying two-thirds of kidney substance.

Microscopic examination : Liver. —Slight pigmentary infiltration of
hepatic cells. Commencing perivascular cirrhosis.

Kidneys. —Left, slight fatty degeneration in a few of the tubules.
Right, intense fatty degeneration of all the tubules around the abscesses.
Fatty degeneration of the glomerular epithelium.

Cerebrum. —Degeneration of all the cortical cells (method of Nissl).
Around the punctiform haemorrhages the nerve cells have assumed
elongated and curved forms—the concavity being towards the haemor-
rhage—evidently due to the pressure of the extravasated blood. At a
little distance from the haemorrhage the cells preserve their normal
form. It is observed (method of Bielschowski) that in places the nerve-
fibres are in fragments.

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614 EPITOME. [July.

The fibrillary alteration of Alzheimer was only found in the pyramidal
cells of the cornu ammonis, and there very rarely.

There was proliferation of the cells of the neuroglia.

Many of the smaller vessels presented aneurismal dilations.

A few Redlich-Fischer placques {piastres ), in an initial state, were
found in the cornu ammonis and in the frontal convolutions.

Summing up the clinical and histological points of the case, the
author points out that on admission the patient presented a rather
advanced state of dementia—defective orientation, loss of memory and
of the power of fixing attention, and a reduction of the mental field.
Neither before nor after admission were there any apoplectic symptoms.
Both before (but only during two years) and after admission there were
epileptiform attacks. These were general, with complete loss of con¬
sciousness. They did not last long, but were followed by a marked
state of confusion. There was a certain degree of arterial hypertension,
the arteries were slightly hardened, but there were no important urinary
symptoms (the abscesses in the right kidney and at the base of the
left lung were assumed to be due to purulent infection from the bed¬
sores).

( From the age and the progressive mental enfeeblement, the diagnosis,
during life, was senile dementia, complicated by cerebral arteriosclerosis,
as evidenced by the slight degree of peripheral arteriosclerosis and the
epileptiform attacks. The past history negatived the idea of essential
epilepsy, and there were no signs of alcoholism, syphilis, or endocranial
neoplasms. The absence of apoplectic attacks led to the conclusion
that the cerebral arteriosclerosis was slight.

Pure senile dementia, the author points out, is very rare. It is so
constantly complicated with cerebral arteriosclerosis that the majority of
authors regard them as one and the same disease. Alzheimer and his
school, however, distinguish between the two forms. In pure senile
dementia there is the presence and the great diffusion of the placques
( piastres ) of Redlich-Fischer, andj the fibrillary alteration of the nerve
cells described by Alzheimer, while the vascular lesions are either
absent or very limited. In arteriosclerotic dementia, on the other hand,
the vascular lesions, with all their clinical consequences, are much in
evidence, while the formation of the piastres of Redlich-Fischer and the
fibrillary lesions of Alzheimer are absent or only commencing.

Histological researches, the author says, have urged on the clinical
study of these diseases, and to-day we seem to have made some progress
in this chapter of mental pathology. Arteriosclerotic dementia may be
divided into two principal types. To the first belong those cases with
well-marked symptoms of cerebral haemorrhage; to the second those
characterised by small emboli and small but numerous haemorrhages.
Whilst the first type is easy to diagnose, the second presents a picture
very analogous to that of pure senile dementia; indeed, it seems
impossible in some cases to distinguish between the two forms of
disease during life, and only histological examination can give the
answer to the question.

Perhaps the most important part of Dr. Ziveri’s paper is the report of
the microscopical examination of the brain tissues. A very accurate
account is given of the technique which has been employed, and the

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illustrations, both in black and white and in colour, especially the latter,
are clear.

The most interesting point about the case is the absence of apoplectic
symptoms, in spite of the post-mortem evidence of hremorrhage into the
brain substance. One could have wished that the author had referred to
the part played possibly by the numerous punctiform and miliary haemor¬
rhages in the cortex in the production of the epileptiform symptoms.

J. Barfield Adams.

Nomadism, or the Wandering Impulse , with Special Reference to
Heredity. (Carnegie Institution of Washington, 1915.) Davon-
port , C. B.

This is the second of the author’s studies on the “ feebly inhibited,’
and in the preface he justifies the use of that term, on the ground that,
while the term “mind” could doubtless be stretched to cover the
emotional phenomena he is dealing with, it seems best to consider the
hereditary basis of the emotions separately. “ The chief problem in
administering society is that of disordered conduct; conduct is con¬
trolled by emotions, and the quality of the emotions is strongly
tinged by the hereditary constitution.”

There are numerous varieties of the phenomena here dealt with, from
racial nomadism, through the professional tramp, to the pathological
fugue. The author selects “nomadism” as the best general term,
largely because it has a racial connotation, for “ from a racial point of
view all hereditary characters are racial.” That is to say that the
author regards a tendency to wander as in some degree a normal
tendency of man. In this connection he briefly discusses (1) the
wandering instincts of the anthropoid apes ; (2) the migratory tendencies
of most primitive peoples; (3) the frequency of running away among
children ; and (4) the “ love of adventure ” in adolescence.

The study is based, like other studies in the same series, on family
histories deposited in the Eugenics Record Office. They are of diverse
origin, from some forty contributors, mostly trained workers. In no
case was it expected that the pedigrees would be used to investigate
nomadism, so that bias may be eliminated. In nearly a third of the
cases there is no knowledge of the parents. All the histories, 100 in
number, are here reproduced, and the results are also presented in a
tabular form.

The most obvious fact revealed by the tables is that nomadism is
chiefly found in the male sex; in the principal fraternities there are
168 male nomadics to 15 females. It is therefore argued that
nomadism is a sex-linked trait, and that it follows the hereditary
conditions prevailing in such cases. By hypothesis, therefore, the
tendency should be traced through the maternal side, though the mother
may not show the trait somatically, while it is usually shown in her
father or her mother’s father. Half the sons and none of the daughters
of such a mother (if she married a normal man) show the nomadic
tendency. If the mother is somatically nomadic, and the father not, all
the sons are nomadic. If both parents are nomadic, then all the
children , of either sex are nomadic. If the father is nomadic, then
.half the sons and half the daughters are nomadic. When these hypo-

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thetical results are compared to the actual results revealed by the tables
it is found that there is a fair degree of concordance. There is,
especially, no clear case of a nomadic daughter whose father is known
to be non-nomadic.

It has been argued that nomadism may be regarded as an essentially
male secondary sexual character, like the beard. The author seems
justified in putting aside this hyphothesis since nomadism is by no
means confined to males. In certain matings daughters as well as
sons are nomadic, so that the distribution of nomadic traits among the
offspring may be regarded as a function of the particular mating.

Nomadism is frequently associated in the same family, and even the
same individual, with abnormal mental and nervous states. Davenport
finds “ extraordinarily common ” periodic psychoses with depression
and frequently suicide, fits of temper, migraine, epilepsy, hysteria, sprees,
and sexual outbreaks. All these states are marked by periodicity, and
lead to the conclusion that nomadism is a trait that belongs especially
to families subject to periodic emotional disturbances. Nomadism is
not therefore lo be regarded as a “symptom” or “equivalent” of
epilepsy, hysteria, etc .; the relation is one of concomitancy.
“ The nomadic impulse is, in all the cases, one and the same unit
character.” Nomadism is associated with other sorts of periodic
• behaviour because we are concerned with an individual who belongs to
a “race of periodics” whose inhibitions are from time to time paralysed.
Nomads showing feeble-mindedness and dementia belong to a special
class. They lack the inhibitory mechanism, so that their nomadism is
no longer explosive but chronic, like that of the child or the chimpanzee.

Havelock Ellis.

2 . Clinical Neurology and Psychiatry.

Inheritance of Temperament. (Publication 236 of the Carnegie

Institution of Washington, 1915.) Davenport , C. B.

The author here seeks to analyse the distribution in families of
temperament, as expressed in mood, and to test the hypothesis that it
is dependent on heredity. Mood is divided into two main classes (as
seen in manic depressive states): the hyperkinetic or exalted, and the
hypokinetic or depressed. The hyperkinetic temperament is divided
into two grades: a less developed called nervous (and sometimes
sanguine), and a more developed called choleric. The hypokinetic tem¬
perament is likewise divided into two grades : a less developed called
phlegmatic, and a more developed called melancholic. In some
families there is a prevailing tendency to the first class of conditions,
and in other families for the second class, while yet other families show
a mixed state. How can we bring under one general scheme the
inheritance of these various types of mood ? After several trials the
following hypothesis was selected to test. There is in the germplasm
a factor E , which induces the more or less periodic occurrence of an
excited condition (or an exceptionally strong reactibility to exciting
conditions), and its absence e, which results in an absence of extreme
excitability. There are also the factor C, which makes for normal

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cheerfulness of mood, and its absence c , which permits a more or less
periodic depression. Moreover, these factors behave as though in
different chromosomes, so that they are inherited independently of
each other and may occur in any combination.

To test the hypothesis 89 family histories (with 146 sufficiently
described matings and 629 offspring) were available, and the pedigree
charts of all these families are reproduced. They were obtained
independently of any hypothesis, and none were rejected as opposed
to the hypothesis. The various kinds of matings and their inheritance
are elaborately tabulated and discussed. It was found that the
proportion of non-conformable cases is only C95 per cent. Of 135
offspring of a manic parent all were excitable but six. With neither
parent excitable none of the children are excitable. With neither
parent depresssed the children rarely are. The children of one
depressed and one not depressed parent are not depressed. Davenport
holds that his tables strongly support the conclusion that there is a
marriage selection against similar temperament, and a preference in
mating for a dissimilar temperament.

A special investigation of suicide was made in this connection.
Suicides mostly fall into the hyperkinetic or the hypokinetic group, to
the former at least as often as to the latter. In the hyperkinetic cases
a vivid idea appears, often of hallucinatory nature, and in the absence
of inhibitions is reacted to. Most threats of suicide belong to this
class; the strong emotion is present, there is violent action and violent
language, but the inhibitions remain too strong. The hypokinetic are
over-inhibited, but in them also suicide occurs, the mental anguish of
insufficiency and unworthiness seeking relief in death. Many arterio¬
sclerotic cases ending in suicide belong here. The examination of
forty mainly hyperkinetic families showed that the hyperkinetic disposi¬
tion rarely skips a generation ; it could frequently be traced through
three generations, which is about as far as human memory extends. Out
of the forty families, in eighteen parent and child both committed suicide.
In hypokinetic cases the inheritance of the suicidal tendency is less
clear because less easy to trace, and it is probable that arterio-sclerotic
suicide, like arterio sclerosis itself, tends to run in families. While
hyperkinetics tend to use any method near at hand and often
inadequate, like jumping out of a window or choking with string,
hypokinetics adopt more deliberate and more effectual methods like
shooting and hanging.

The .author has some remarks on the bearing of his investigation on
psychiatrical doctrines. He is opposed to the tendency to regard
mental troubles, whether organic or more especially functional, as
“ disease,” and he deprecates the importance attached to diagnosis.
Records show that a large proportion of cases do not fit into any main
functional types, and it is not uncommon for a patient to be admitted
three times in succession with a different diagnosis every time. “ Now,
where there is so much doubt as to how the ‘diseases’ are to be
differentiated, it is fair to doubt if they are entities. The conclusion is
forced upon one that we are dealing with complexes of behaviour,
with syndromes.” These so-called “ diseases ” may indicate an
incompatibility with the highest requirements of society. “But these

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requirements are, alter all, rather narrow and rigid, and it would he
strange if, amid the vast range of human characteristics, many combina¬
tions did not occur that are far from ideal.” The classical dementia
pnecox shows a complex of traits that are separably not unknown in
some degree among persons who pass for normal. Studies of inherit¬
ance point to the conclusion that “ the functionally insane are mosaics
of chance, accidental associations of socially undesirable hereditary
traits. As a corollary it seems probable that the Kraepelinian or any
other classification of the functionally insane is rather harmful than
otherwise, since it distracts attention from the principal points, such as
periodicity, temperament, inhibition, the destruction of neurones in the
cerebrum, and the specific control of behaviour by internal secretions.”

Havelock Ellis.

The Neurasthenic Element in Disease. (Glasgow Med. Journ., February ,

1916.) Craig , James.

The author’s object in this paper is to emphasise afresh the fact that
neurasthenic symptoms are in some cases the result of underlying disease,
organic or other. Half a dozen cases are narrated in illustration of the
thesis. The author summarises his conclusions under four heads :
(1) Since the early symptoms of disease are often remote from the
organ really affected, it is necessary always to make observations away
from the point to which the patient calls atttention ; (2) it is even
yet more important to enter sympathetically into the patient’s emotional
attitude, in order to gain the knowledge that can only be acquired
by tracing its multiform ramifications; (3) the acuteness of the neuras¬
thenic symptoms is parallel to the gravity of the disease and on a
different level from, for instance, the spes phthisica ; (4) a very wide
and broad view must be taken of the treatment.

Havelock Ellis.

l'he Pathogeny of Essential and Cerebral Epilepsy [Pathogenic de
quelques formes d'Epilepsie dites Epilepsie Essentielle et Epilepsie
Ceribrale\ (Nouvelle Iconographie de la Salpctriere, December ,
1915 ) G. C. Boltcn.

After an extensive series of observations, of which he gives par¬
ticulars, the author concludes that essential epilepsy is neither caused
by intestinal putrefactions (abnormal fermentations, etc.) nor by intoxi¬
cation by purins, nor by retention of, hypersensibility to, or intoxication
from chloride of sodium.

His experiments with the extracts of the ductless glands in the
treatment of epilepsy give the following results. Extracts of the
thymus, adrenals, pituitary body, liver, pancreas, testicles, and ovaries,
separate or combined, have no effect, or very little, on the course of the
disease. On the other hand, magnificent results were obtained by the
administration of the combined extracts of the thyroid and parathyroid
glands.

Seeing the probability that in the action of the secretions of the
ductless glands the ferments play an important role , and that in the dry
state these ferments may lose the whole or part of their activity, the
author always employed fresh extracts in his experiments with the whole

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series of glands mentioned above. Presuming also that the hydro¬
chloric acid of the stomach exercised a similarly deleterious action on
the ferments, he administered the extracts by the rectum.

A considerable number both of recent and chronic cases of epilepsy
were cured by the administration by the rectum of the freshly prepared,
combined extracts of the thyroid and parathyroid glands. In every
case the bromide of potassium, which had been given previously, some¬
times in large doses, was immediately stopped.

Among the epileptic patients subjected to this treatment a certain
number were not benefited. These fell into two groups.

(1) Those suffering from primitive cerebral disease—internal hydro¬
cephalus, tumour of brain, infantile cerebral paralysis, tumour of the
pituitary gland, solitary tubercle, etc.—which was accompanied by
epileptiform attacks.

(2) Those which presented no characteristics of primitive cerebral
disease, and in which the clinical symptoms did not allow one to
diagnose any other malady than epilepsy.

In this latter group it was possible almost always to prove that the
patients had in their childhood suffered from convulsions, either spon¬
taneous and accompanied by fever, or following upon infectious diseases
such as typhus, pneumonia, scarlet fever, or even whooping cough or
measles. The author considers that the epilepsy in these cases is con¬
secutive to a diffuse inflammation of the brain (cortex), or of the dura
mater, or both (chronic infantile meningo-encephalitis). To this form
of epilepsy he applies the term cerebral epilepsy, confining the term,
essential epilepsy, to cases in which there is no history of any past
brain mischief, nor any post-mortem evidence of disease.

After reviewing at considerable length the various symptoms and
physical signs, which a priori seem likely to aid in the differential
diagnosis between cerebral and essential epilepsy as thus defined, the
author comes to the conclusion that the two forms of the disease clini¬
cally resemble each other so closely that (excepting the action of the
combined extracts of the thyroid and parathyroid glands) the only
thing that during life can distinguish them is the past history.

The author then proceeds to review the evidence, which has been
accumulated on the action of the interior secretion of the thyroid and
parathyroid glands on the toxic products of metabolism, and he argues
that when from any cause the influence of these glands is defective,
the toxic products accumulate, and that epileptic attacks or explosions
are efforts of the system to free itself from them. This is essential
epilepsy.

In the case of cerebral epilepsy the thyroid and parathyroid glands
may functionate normally, but the chronic meningitis or encephalitis so
interferes with the circulation in the affected portions of the brain that
the waste products accumulate locally and cause the epileptic attack,
in the same way as in the essential form, in order to obtain relief from
the toxic products.

The author sums up as follows :

(1) In the present state of science, essential epilepsy and cerebral
epilepsy cannot, in the majority of cases, be clinically distinguished the
one from the other.

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(2) Cerebral epilepsy is produced by any disease of the meninges or
of the cortex or deeper parts of the brain which, either by a general
increase of the intra-cranial pressure, or by local processes of sclerosis,
provokes troubles of the circulation in the cerebral cortex (venous
hyperaemia).

(3) Essential epilepsy is a chronic auto-intoxication caused by the
toxic products of alimentary decomposition and by the toxins proceeding
from cellular metabolism, which, in consequence of the hypo-function
of the thyroid and parathyroid glands, are insufficiently neutralised.
As a consequence of hypo-thyroidism and hypo-parathyroidism, the
secretion of the ferments of the intestinal tract and of the intermediary
metabolism is very much diminished.

(4) In both cerebral and essential epilepsy the cerebral cortex, with
its great affinity for numberless poisons of different origins, is slowly
saturated with toxins. In essential epilepsy these toxins proceed from
the metabolism of the whole organism and from the alimentation ; in
the cerebral form of the disease they come from the cerebral cortex
itself, in which, consequent to the troubles of the (local) circulation, a
lymphatic and venous back-wash is produced with an accumulation of
the products of defective metabolism in the affected region.

(5) In all forms of epilepsy one must regard the attack as a reaction
of the organism with the object of relieving itself of the toxins. The
blood relieves itself of these toxins through the kidneys, lungs, and
skin ; later the cerebral cortex evacuates its share into the blood, which
at that moment is deprived of toxins.

(6) In essential epilepsy the administration by the rectum of the
fresh extracts of the thyroid and parathyroid glands, they being the
organs with defective function, is sufficient to make the morbid
phenomena of the disease disappear for ever.

This paper touches upon several points of great interest, but its
principal value appears to be in the explanation that it offers of the
disappointment which has been experienced in the administration of
the dry thyroid extract by the mouth in cases of epilepsy.

I. Barfield Adams.

Nervous Debility (Dibilite Nerveuse). (Nouvelle Iconographie de la
Salpetriere, December , 1915.) A. Austregesilo.

The author defines Nervous Debility as a diathesis, a constitutional
state, or congenital predisposition, which is characterised by

(1) The early onset of fatigue.

(2) Irritability and instability.

(3) Exaggerated emotionalism.

(4) Suggestibility.

(5) Rhythm and periodicity.

(6) Prompt reaction to toxic agents.

(7) Hereditary susceptibility to the action of toxic agents.

(8) Vaso-motor and secretory reactions.

(9) Debility of the gastro-intestinal apparatus.

The precocious onset of fatigue is the symptom most commonly met
with among sufferers from nervous debility. It reveals itself in all
spheres of work—mental, bodily, or visceral.

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If the nerve cell be fatigued, two reactions manifest themselves,
instability and irritability. The instability may be psychic, motor, or
visceral, the first being the most common. As illustrating the psychic
instability, the author points out that such patients have difficulty in
fixing their attention, and can only do so for a short time. Motor
instability shows itself in the muscles of the face—tendency to tics and
other co-ordinated movements—and in the constant movements of the
limbs and of the positions of the body.

Irritability is the constant result of the intoxication and fatigue of
the nerve cells of the cerebral cortex, of the spinal cord, and of the
sympathetic system. It manifests itself in outbursts of passion, ideas or
emotions, in partesthesias, neuralgias, or in frequent secretory troubles.

Exaggerated emotionalism is so constant a symptom among these
patients that many authors regard it as the basis of neurasthenia. The
phobias are a proof of this emotionalism. They generally appear to be
a deviation of the natural instinct of self-preservation.

Having touched upon the vaso-motor reactions, and having dwelt at
some length on the importance of the exaggerated sensibility of the
digestive apparatus among these patients, the author passes on to
the susceptibility which they manifest to the action of toxic agents.

Germs and poisons, he says, of no matter what origin, always seek
the nervous system as the place where they can the most easily effect
bio-chemical changes. The nerve cells of the sufferers from nervous
debility have a hereditary susceptibility to the action of these agents.
The son of an alcoholic is easily made drunk, delirious, or is thrown
into convulsions, by a comparatively small dose of alcohol. The son
of a syphilitic, who has escaped hereditary syphilis, has an accentuated
tendency to nervous maladies, if he chances to contract the disease in
question.

This remark of the author suggests a possible explanation of the
fact that syphilis is not always followed by general paralysis. The son
of parents untainted with syphilis may contract the disease, and yet
escape general paralysis. The son of syphilitic parents, who becomes
inoculated with the disease, will probably develop general paralysis,
because, although he has never manifested the symptoms of hereditary
syphilis, his tainted heredity has endowed him with “an accentuated
tendency to nervous maladies.”

In conclusion the author groups together three functional syndromes
in his picture of nervous debility.

(1) Neurasthenic reactions. (Neurasthenia.)

(2) Hysterical or hysteroid reactions. (Hysteria.)

(3) Convulsive or various motor reactions. (Epilepsy.)

In the first group the intoxicated nerve cell works lazily or abnormally,
and the result is seen in irritability and precocious fatigue, and possibly
in various anaesthesias, headaches, insomnia, etc.

In the second group the nervous disturbance is greater. Its essential
character is suggestibility, and consequently the easy disintegration of
the psychic personality of the sensitive, sensorial, motor, or visceral
elements of the organism.

In the third group the reaction is stronger and affects the psycho-
motor sphere, manifesting itself by loss of consciousness and convulsions.

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The nerve cell of the neurasthenic receives the toxin and works
badly; that of the hysteric is further disturbed in its function, but con¬
sciousness still commands psychic unity; that of the epileptic receives
the toxin, and its explosive reaction, with loss of consciousness, indi¬
cates the greater degree of the disturbance, and the easy disintegration
of motor and psychic functions.

Alcohol, for example, according to the degree of its toxicity on the
organism (I presume that the author means or includes the susceptibility
of the nervous system to the action of the toxin), and according to the
quantity, may cause alcoholic neurasthenia, alcoholic hysteria, or
alcoholic epilepsy. Mutatis mutandis one may observe the same effects
in the case of other exogenous or endogenous infections.

J. Barfield Adams.

On the Differential Diagnosis of Manic - Depressive Insanity and
Dementia Prcecox. ( Glasg . Med.fourn., vol. Ixxx., Sept. 1913, pp.
185-192.) R. M. Marshall , M.D ., Senior Assistant, Royal Asylum ,
Gartnavel, Glasgow.

“The terms manic-depressive insanity and dementia praecox were
used by Kraepelin to designate two disease entities, which he considered
were between them responsible for most of the states of mental dis¬
order usually gathered together under the title, the psychoses.” The
psychoses are something more than states of mental disorder, and some¬
thing less than disease entities; they lie between them. Excitement,
depression, delirium, and stupor are states of mental disorder which
may arise during the course of many diseases, general paralysis,
hysteria, epilepsy, the cerebropathies, constitutional and infectious
diseases; but acute mania, acute melancholia, anergic stupor, delirious
mania, are psychoses. They differ from a state of mental disorder in
so far as they are self-sufficient, and are not the expression of an under¬
lying disease; moreover, they run a fairly definite course, ending either
in recovery or in dementia. The classifications of the psychoses have
been unsatisfactory, and none of them has met with general acceptance.
The most satisfactory method is that formulated by Kraepelin: and, in
the opinion of Dr. Marshall, he “ has done for the psychoses what Erb
did for the amyotrophies.” He emphasised the importance of dementia
as a termination of the psychoses, and gathered those which ended in
dementia into one disease category, dementia praecox, and those which
did not so end into another category, manic-depressive insanity. The
fact that dementia occurred predicated an organic change in the brain,
so that dementia praecox was an organic and manic-depressive a
functional disease of the brain. Certain states of mental disorder are
common to both conditions : yet there are symptoms which render it
possible to distinguish between them. In dementia praecox there is
“ inco-ordination of the individual psychical processes ”: manic-
depressive insanity depends on “a change in the mutability of the
individual psychical processes.” Normal mentality results from the
co-ordinated action of the emotional, intellectual, and volitional
processes, and is characterised by a certain congruity of thought and
conduct. If there is inco-ordination of these fundamental processes,

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incongruity of thought and 1 conduct results. The nature of the incon¬
gruity depends on the mental process mainly responsible for the inco¬
ordination. The symptoms may be for a time emotional, intellectual,
or volitional.

Emotionally the change may be manifested by disordered response to
ordinary stimuli: the response may be absent or perverted. When
absent there is a “general numbing of the emotions”—indifference,
apathy. When perverted there is produced an emotion opposite to the
one which should be aroused. The reaction may be paradoxical; or
two conflicting emotions may be aroused. Transitory and evanescent
emotional outbursts may occur which may pass off harmlessly or may
lead to serious assaults.

Intellectually the disturbance is shown by disorganisation of thought.
There is a general failure of the ideational responses, resulting in
poverty of ideas. Patients lack initiative and spontaneity. Their
conversational powers are limited. There may be incoherence. Those
nfluenced by hallucinations or delusions “ may manifest the dis¬
organisation of their thought only when speaking about them.”

Volition.—The numbing of thought and feeling renders conduct
stolid and stereotyped. The failure of the succession of thought and
the perversion of the emotions lead to anti social conduct, to echo¬
speaking, and echo-acting. There may be fantastic, affected, or
capricious behaviour, grotesque antics and grimaces, coining new
words, or negativism. Negativism is defined as a state wherein the
patient “persistently shows an opposite response to excitants from his
environment.”

In manic-depressive insanity the cardinal symptoms depend on modi¬
fication of the mutability of the individual psychical processes. In the
maniacal state their mutability is increased ; in the depressive state
decreased. But “ however greatly the mutability of the emotional,
intellectual, and volitional processes is modified, they are perfectly co¬
ordinated, and the mental life as a whole shows a normal congruity.”

There is greatly increased excitability, violent outbursts readily occur.
Underlying all these is a constant emotion of self-appreciation, and this
colours all the products of thought. There is flight of ideas. Voli¬
tional activity tends to be displaced by automatic freedom of action.
The patient is constantly employed but never finishes any task he takes
in hand.

In the depressed phase there is diminished response. Volition and
cognition are impeded. Instead of self-appreciation there is self-abase¬
ment. Depression fades gradually into depressive stupor, in which the
impediment of thought and volition is nearly absolute.

If hallucinations and delusions complicate the excitement and de¬
pression, states of confusion result, the maniacal origin of which may
be revealed by the presence of impediment of will and cognition, or
automatic freedom of action and the flight of ideas.

Dr. Marshall is of opinion that dementia prtecox runs a fairly acute
course, terminating in a permanent dementia, which may to a certain
extent be made good by a process of compensation. There may be
remissions during the course of the disease, the patient enjoying fairly
normal mental life. Second attacks, although rare, undoubtedly occur

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Manic-depressive insanity is characterised by recurrence, interchange,
or intermingling of the essential features of the maniacal and the depres¬
sive states. The statement that dementia does not supervene must
be qualified. Mental weakness is sometimes seen where the disease
came on early in life, and where the periodic attacks were severe.

If there is unequivocal evidence of “ intrapsychic ataxia " during a
state of excitement, it denotes dementia praecox. Defect in the con-
gruity of thought is pathognomonic of a dementing process. Conversely,
the presence, in an unequivocal state, of automatic freedom of action
and the flight of ideas, supported by the history of several previous
attacks completely recovered from, are equally sure signs of the excite¬
ment being maniacal. But maniacal states may usher in dementia
praecox and obscure the evidence of psychic ataxia ; arid only a pre¬
sumptive diagnosis of manic-depressive can be made without a history
of previous attacks. A further complication is that in dementia praecox
there are also remissions. Negativism may also be simulated in certain
cases of manic-depressive insanity.

Although extended observation is often requisite before a diagnosis
can be made, Dr. Marshall is of opinion that by psycho-analysis the
early dissociation in thought, premonitory of ultimate dementia, may be
detected ; and that another important diagnostic method is that which
depends on a due appreciation of the somatic changes in dementia
praecox. Hubert J. Norman.

3. Treatment of Insanity.

The Treatment of Cases of Mental Disorder in General Hospitals
(.Reprhited from the Boston Medical and Surgical Journal , vol. c/a w,
Ho. 17, pp. 637-642, April 2T ) rd, 1914.) Philip Coombs Knapp ,
A.M., M.D.

The author maintains the thesis that acute and borderland cases of
mental disease can be received and temporarily cared for in general
hospitals. He admits that mental patients are not looked upon with
favour by the nursing staff or by the other patients, on account of—in
many cases—their restless, noisy conduct. Yet almost all general
hospitals must include at times among their inmates some patients who,
in the course of treatment for such conditions as acute infections,
accidents, etc., become turbulent and violent.

He reviews his experience, extending over four years, in dealing with
patients who manifested some mental disturbance during their stay in
the Boston City Hospital. Twenty beds were allotted for these
patients. There was not, however, a special ward, but the patients
were distributed in several wards. Excited patients were put in
an open ward of eight beds, or in double rooms opening on a corridor.
The doors were not locked, and access was free. About four hundred
patients were admitted annually, chiefly adults. Patients exhibiting a
variety of mental symptoms were thus treated; there were cases of
alcoholism, epilepsy, general paresis, dementia praecox, manic-depressive
insanity, senile dementia, etc. A considerable proportion of the
patients were certifiably insane, and a number of them were eventually

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certified. It was seldom found necessary to resort to any form of
mechanical restraint; occasionally this was applied in the shape of a
sheet tied across the bed, or, very rarely, the camisole was used.
Dr. Knapp believes that much of the restraint used in general
hospitals is due to an inefficient and insufficient nursing staff. Restless
patients often did well when side-pieces were put on the beds. The
absence of mechanical restraint was not brought about by the excessive
use of sedative drugs. Bromide and veronal were used in moderate
doses in a good many cases, especially in alcoholism, but hyoscine,
morphine, or chloral were seldom used. The occasional use of the
wet pack, “ forced feeding, absolute avoidance of alcohol in the
alcoholic cases, a few moderate doses of bromide, and more or less
persuasion ” usually sufficed.

In his four years’ experience there was no suicide, no patient escaped
from the hospital, only very rarely from the ward, no patient seriously
injured himself or others. The patients seldom claimed discharge
because of illegal detention ; if anyone did so, and he was unfit to be
sent out on account of his mental state, the matter was delayed until
certification took place—if that procedure was deemed necessary.

Dr. Knapp is convinced that even without a special psychiatric
pavilion or psychiatric wards, insane patients can be received and
temporarily cared for in the open wards of a general hospital. In
answer to the question as to what good can arise from dealing with
mental cases by this method, he maintains that patients in whom the
symptoms have appeared suddenly, or those who have fallen into the
hands of the police, may be treated expeditiously, without legal
formalities and without waiting to find the patient’s friends; or the
patient may present obscure mental symptoms which make the mental
state a fit object of inquiry, and he may be subjected to observation
until a definite diagnosis can be made, and suitable provision for his
future care arranged without any disturbing legal procedure. Again,
it gives the relatives time to become gradually reconciled to the idea of
certification. Finally, it allows of cases of short duration being treated
in the general hospital until they are able to return home and can then
obtain treatment as out-patients until recovery is complete, thus avoiding
an official recognition of the stigma of having been insane. Dr. Knapp
realises that much injustice is done to the patient in the matter of this
stigma, while he admits that the fact of a previous attack of insanity
renders it allowable for an employer, for example, to look with some
suspicion upon an applicant who has been confined as a lunatic. “ The
employer is justified in doubting his efficiency as he would be in doubting
the efficiency as a look-out man of the applicant who wore ten dioptre
glasses.” Yet the disability implied is often out of proportion to what
in reality exists, and the patient is to that extent unduly hampered. The
same question arises in regard to marriage : some will doubt whether a
person, if once adjudged insane, “ is a fit person to be joined in holy
matrimony.” If this person, who has suffered from some acute mental
disease which does not impair his mentality afterwards or influence his
future offspring, can be treated “ without an official, legal recognition of
his trouble, it may be of great advantage, a positive benefit to the patient
and the community.”

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A general hospital is not adapted for the permanent treatment of the
insane. “ It lacks the opportunities for work, entertainment, exercise,
out-of-door life, and recreation.” On the other hand it has advantages.
Rest in bed is one of the most important. There is also, unless he is
very demented or confused, the atmosphere of physical sickness which
should tend to convince the patient that he, too, is ill and give him
insight into his own condition; and, though in sofne cases this may do
harm, in others it may do good.

It is the duty of every large general hospital to provide accommoda¬
tion for such cases. The mental patient has a claim to treatment therein
just as have those suffering from other morbid conditions. The recep¬
tion of such cases means some extra trouble, more nurses, and more
anxjety for the staff. There are certain risks, but they are not very
great. Every hospital for the insane has its escapes, its suicides, its
acts of violence. The general hospital may expect them as well; but
the benefits to the community outweigh them.

In conclusion Dr. Knapp remarks that it is not practicable to receive
and care for such patients unless there is a special staff under the charge
of a visiting neurologist familiar with mental diseases and their treatment
Something more is requisite than restraint while in the hospital and
commitment at the earliest opportunity. The visiting physician must
“ have control of his patients and their treatment without interference
from administrative officers, and must be alone responsible for the treat¬
ment, the stay in the hospital, restraint, and commitment. Only under
such conditions can the reception and treatment of cases of mental
disorder be of full benefit to the patient and the community.”

Hubert J. Norman.

4. Sociology.

The Dualism of Human Nature and its Social Conditions [Le Dualisme
de la Nature Humaine et ses Conditions Sociales ]. {Revue Phiio-
sof/iique, Febmary, 1916.) Durkhcim.

This article has for its object the more clearly defining one of the
theses sustained by the author in his work, Formes Alementaires dc la
Vie Religieuse , namely, the possibility of explaining scientifically the
constitutional dualism of man. Religions have always recognised this
quality, regarding man as formed of two beings radically different—the
soul on the one side, the body on the other. Psychological analysis,
in a sense, confirms this belief. There are sensations and sensual
tendencies on the one side, thought and moral activity on the other.

After touching on the explanation of this dualism offered by empirical
and idealistic monism respectively, and referring to the ontological
explanation of Plato, whom he practically charges with begging the
question, the author passes on to elaborate his own theory. Moral life
is a constant antagonism between egoism and altruism, and conse¬
quently our psychic life has a double centre of gravity. Our sensations
(and I suppose the author means our ideas of sensations) are individual,
concern us alone, and are incommunicable; our thoughts (concepts)
are social, and are the means by which we communicate with one

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another. These thoughts (concepts), being collective, or rather
being collective in origin, are invested from this fact with an
enormous authority, individuals representing them to themselves
under the form of moral forces, which dominate and sustain them.
The author, therefore, considers that the dualism of man is a struggle
between his individual appetites (egoism) and his social desires
(altruism).

In spite of his criticism of Plato, the author appears to have himself
drifted towards idealism. Something of his theory finds itself fore¬
shadowed in the writings of Marsilio Ficino, one of the principal
members of the Accademia Platonica of Florence in the days of I/orenzo
de’ Medici.

It must be admitted, however, that in demonstrating his theory, the
author assists one to understand the emotion of sympathy, an emotion
which has always been difficult of explanation.

J. Barfield Adams.

4. Asylum Reports.

London County Council , 1914.

The production of this report, without any decrease in particulars
and details, is in itself a matter for some congratulation to Mr. Keene
and those who help him. His office has been much depleted by the
war, perhaps not more so than others relatively, but the huge bulk of
returns and figures, for all of which his office is responsible, cannot be
matched elsewhere.

There is but little increase in the bulk of the insanity of the area, any
increase noted being chiefly in the asylum patients, those in the Metro¬
politan Asylums Board’s care being nearly stationary.

Nearly 1,000 cases have to be provided for outside the Council’s
Asylums, and the Council finds great difficulty in arranging contracts
now } the more so as the class of patients from whom selection has to be
made do not come up to sample as required. The finishing of the
eleventh asylum will therefore be a great easement, but labour troubles
and the war have done much to hinder the realisation of the plans.
The new house at Mistley, however, works very well and economically.
Fifty male patients are housed at a cost for adaptation of ^800, or ^16
a bed, while the annual cost for rent, etc., is about ^130.

The readmissions of those discharged as recovered still bear a heavy
proportion to the discharges, 30 per cent, of those discharged in the
previous nineteen years having returned. Nearly 12 per cent, of those
discharged recovered in the same period have returned within twelve
months of their discharge.

The Banstead Asylum, which was erected in 1877 to accommodate
chronic patients only, is to be remodelled at a cost of ^47,000 so as to
allow of proper supervision and classification.

With regard to the Maudsley Hospital a curious administrative diffi¬
culty has arisen. The Council was of the opinion that the Medical
Superintendent should not live on the estate but should be required to

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find his own residence in the neighbourhood, but Section 276 of the
Lunacy Act requires that the resident medical officer shall reside in the
asylum. There is no room on the estate for his house and no imme¬
diately contiguous house can be leased, so the matter is hung up for
Parliamentary emendation. When will this come ? In the meantime
Section 276 does offer a pis aller, in itself hateful but possibly justifiable
as a temporary measure. It is lawful for the Secretary of State to
authorise the Committee to appoint some other person than a medical
officer to be Superintendent. The duties of a lay Superintendent are
not nearly so extensive as those of a Medical Superintendent. But one
doubts whether the original opinion of the Council is of sufficient im¬
portance to cause delay that must come from waiting on legislation,
though we entirely support the contention that the medical officer
should not be pinned down to residence on the estate.

The cost to maintenance for the year in respect of annuities amounted
to jQ 7,878, while the contributions of the staff came to ,£8,344. The
relative figures for last year were ,£6,000 and ,£8,200. The credit
margin seems to be disappearing rather more rapidly than was
expected at the time the principle of pensions was being contended for.

The war has, as stated, made great calls on the staff. On March
31st, 1915, 538 members were serving with the forces, namely, 13
medical officers, 29 clerks, 496 attendants, workmen, and other
employes. At the time of the report going to press the total had
increased to 661, the casualties to date being 15 killed, 6 dead from
wounds, 4 dead from other causes, 54 wounded, and 4 missing.

The usual liberality is shown in respect to these volunteers. Full
pay, including value of emoluments, less separation allowance (if any),
is accorded.

We note the following matters in the reports of the Medical Super¬
intendents.

At Banstead lobar pneumonia towards the end of the year assumed
an epidemic form, it being present at death in 17 male cases and 19
female. This was continued in the new year, 19 men and 23 women
dying of a virulent form of this disorder in the first three months.
Dysentery has also given much trouble, and caused the death of 10 men
and 11 women, nearly 30 per cent, of the cases attacked dying from
it.

At Bexley Dr. Stansfield notes that in 26‘7 of the male first attack
admissions acquired syphilis was assigned as the exciting cause, while
it figured either as principal or contributory factor in 38 per cent. We
are glad to see that the recovered cases with alcoholic aetiology are
systematically visited by members of the British Women’s Temperance
Association.

One man who escaped joined the Army, and after a few weeks of
turbulent behaviour was dismissed and recertified.

At Cane Hill Sir James Moody, who has since fallen out, notes the
help that is given to probationary cases by the After-care Association,
now that its rules have been altered. We wonder whether this change
is universally known.

At Claybury Dr. Armstrong-Jones records the death of a male
patient in a curious method. He fell forward in a syncopal attack at

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meal-time and in spite of treatment died. Post-mortem a small piece
of meat was found situated laterally near the glottis, but not causing
complete obstruction. It was held that the meat caused a reflex spasm,
which threw an extra and fatal strain on a weak heart; there were
none of the usual symptoms of asphyxia, and no venous engorgement
was present. This case is parallel with the deaths attributed un¬
warrantably to strangulation, where perhaps there is but little mark of
tie, string, or cord used in making the attempt. Dr. Armstrong-Jones
seems to have had a bad time with typhoid fever, which seems to have
pursued a fitful course. Much trouble was taken in examination for
Widal reaction with a view to disinfection, but the source was not
discovered.

At the Epileptic Colony, in every admission the blood-serum
was examined by the Wassermann test, and in no case of uncom¬
plicated epilepsy has a positive reaction been obtained. In the case of
a boy who was non-epileptic and who was suffering from a gumma, the
reaction was negative, but he had been treated a few months previously
in Paris with “606.” Among thje 37 direct admissions near relatives
suffered from epilepsy in 3 cases, from alcohol in 4 cases, and from
insanity in 4 cases. In 8 of the 14 deaths epilepsy was the cause,
in 2 death resulted from a fit, in 3 from the status epilepticus , and
in the other 3 from exhaustion following an increased number of fits.
In 4 cases improvement justified discharge to the care of the parents,
and in all these cases the fits had been controlled by intensive bromide
treatment.

In the report of the Directors of the Pathological Laboratory Dr.
Mott continues his account of the work done regarding the incidence
of mental deficiency among the offspring of the London insane.

The investigations regarding the incidence of mental deficiency among the off¬
spring of the insane in the London County Asylums has been continued during the
year 1914. The Asylum authorities have ascertained the names and ages of the
children under 16, with the school attended, of all the married admissions during
the year. Copies of these notes have been forwarded to the Education autho¬
rities who have reported those children regarded as mentally defective.

Altogether the families of 588 insane parents have been investigated, and accord¬
ing to the reports received from the Education authorities only 15 (2 to 3 per cent.)
of these had mentally defective children.

The reports show that these parents had 1,003 children of school age, 6-16, of
whom 16 (1 to 2 per cent.) were reported as mentally defective. Two of these
children belonged to the same family; a family which I have often used as an
illustration of a remarkable transmission of blindness, insanity, and pauperism
through many generations.

Statistics regarding families (children under 16 years of age) of insane admis¬
sions to the London County Asylums during 1914, in which no mental deficiency
is reported amongst offspring—573 families investigated.

Number of insane parents. —Male, 275; female, 298; total, 573.

Number of children of school age, 6-16 years of age. —Male, 472; female, 489 ;
total, 961.

Number of children under school age, 5 and under. —Male, 222; female, 185;
total, 407.

Number o? children of unknown age. —Male, 18; female, 13; total, 31.

First attack of insanity in parent. —Male, 214; female, 214; total, 428.

Not first attack of insanity in parent. —Male, 48 ; female, 79 ; total, 127.

Unknown whether first attack of insanity. —Male, 12; female, 6; total, 18.

VOL. LXII. 40

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From the information furnished by the reports, an attempt has been made to
approximate the number of children born after the first attack of insanity in the
parent.

Mothers.

Number of children born after first attack, 6-16 years of age. —Male 14; female,
17; total, 31. .

N umber of children born after first attack under school age, 5 and under. —Male,
18; female, 18; total, 36.

Fathers.

Number of children born after first attack, 6-16 years of age. —Male, 10; female,
7; total, 17.

Number of children born after first attack under school age, 5 and under. —Male,
14 : female, 11 ; total, 25.

The reports show that only 56 out of 573 parents had children after their first
attack of insanity, and that 106 children were born after the onset of insanity in
the parent, whereas the remaining 1,259 children were born before the parent
became insane.

These figures show that the majority of the children are born before the patient
becomes insane, and this agrees with the age periods of the onset of insanity in the
great majority of the parents. Voluntary restriction of birth may partially account
for the small number of children born after first attack. Again, there is evidence
to show that in certain types of insanity the reproductive organs may suffer in their
genetic function, and, lastly, a residence in the asylum for a time during the period
when propagation can occur would tend to limit the birth of children.

Age at Onset ok Insanity in Parents—First Attack Cases.

Insanity occurring Insanity occurring
within 3 months within 3 months
after birth of child, to 1 yearaftcr birth Total
Puerperal. of child.

Male.

Female.

Female.

Male.

Female.

Male.

Female.

20-24 •

I

2

2

—

I

I

5

25-29 .

IO

8

7

—

5

IO

20

30-34 .

32

3 1

7

8

7

40

45

35-39 •

3 1

40

3

7

11

38

54

40-44 •

44

35

—

3

3

47

38

45 49 •

34

36

1

3

—

37

37

50-54 •

21

«3

—

1

—

22

13

55-59 •

17

1

—

—

—

17

1

60-64 .

2

1

—

—

—

2

1

192

•67

20

22

27

214

214

Considering the above table it appears that in

the

females 20

out of

214 first

attacks occurred within three months of childbirth, and were therefore probably
puerperal; a further 27 occurred within three months to one year following child¬
birth, and some of these may have a direct or indirect connection with the re¬
productive function. The table also shows a large incidence in the climacteric
period in women, and it will be noticed that the involutional period in males
occurs later, the comparatively high incidence between 40 and 50 being largely due
to the greater frequency of general paralysis.

The foregoing work started from the asylum. Miss Agnes Kelly, on
the other hand, starts from the special schools with an investigation
into histories and environment of 60 mentally defective children. This
work has not advanced far enough to afford material for report. But
we again express our strong conviction that only by such patient
spade-work as is thus carried on in combination can a safe foundation
for sound theory be laid.

The Wassermann reaction, and the relation of insanity to the ductless

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631

glands and reproductive organs, have been the suujects of much work
undertaken by Mr. Mann and Dr. Kojima (Tokio) respectively, under
the direction of Dr. Mott.

The report of Mr. Clifford Smith, the engineer of the asylum, shows,
like those of other departments, difficulties caused by the war—shorten¬
ing of his staff. On the other hand, the war has brought about
considerable postponement of necessary work. The comparative
statement of consumption of coal, gas, water, and electricity also shows
the influence of the war, the reduction in the use of each being appre¬
ciable, while the number of inmates has slightly increased.

At Bexley the steam-engines used in generating current have
hitherto had their cylinders lubricated with oil. Now this is done
with a preparation of graphite, with the result that 140 tons of water
evaporated weekly, which were run to waste formerly as being tainted
with oil, are now saved and used over again in the boilers. This
improvement has made its mark on the coal-bill.

Mr. Keene continues his most valuable analysis of the statistical
information supplied by the ten institutions containing London’s insane.
Though the facts forming the basis of those statistics were gathered and
recorded before the war affected the staff, the actual collation and
valuation of them have been carried out when many of his colleagues
have been taken away. The greater is the debt, therefore, which is
owed to him for keeping alive systematic work which sooner or later
must be of the first service in sorting out and attacking the various
problems connected with the study of insanity. It is much to be
feared that, however willing he may be, he will not be supplied with a
full quantum of material during the continuance of the war. But,
happily, many of his tables deal with those figures which must, in the
nature of things, be recorded, and these go some way towards evi¬
dencing the movements of the insane in masses, though they stop
short of yielding information about the purely medical aspects.

In the table which shows the happenings to patients, in series of ten
years, it is seen that in spite of an increased exit by death on the male
side in the last decennium the total exit is lower than that of the pre¬
ceding decennium, the exit by recovery having dwindled enormously,
viz., from 22'53 per cent, of the total under treatment to i7'85 per cent.
The female recovery rate has decreased nearly as much, but the total
exit is not affected, since the death-rate has increased sufficiently to
meet the difference. The average exit for both sexes combined is
lower for the decennium 1905-14 by r per cent, than for 1895-1904;
but when the question is attacked on a basis of percentage of average
numbers on the register and by series of four years the check on
former exit is still more marked. The average exit for the four years
i9ir-t4 is i'28 lower than the average of 1907-1910, 3'i2 lower
than that of 1903-1906, and 8 03 lower than that of ^91-1894.

These facts go far to account for the increase in the asylum population
of the area, and must augur very unfavourably for the future generations
of ratepayers. While the death-rate in the last twenty-four years has,
thanks to medical and sanitary endeavour, moved down from 9*81 to
8'64, the recovery-rate, in spite of the best medical and sanitary
endeavour, receded from 1156 to 470 on average residence. Really

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EPITOME.

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it would seem lha'. when most have come to the conclusion that there
is no appreciable increase of insanity, another question, almost more'
serious, arises as to the increasing incurability of the disease when it
does occur. Perhaps it may be urged that those who have to decide
on the fitness for discharge on recovery are becoming more critical;
but that, of course, cannot account for such a vast disproportion. Mr.
Keene has some evidence of that increased criticism of recovery in
the fact that the proportion of readmissions occurring among admissions
is lessening.

The proportion of first-attack cases among the admissions increases
slowly.

It is somewhat serious to find that the number of direct admissions
of patients under 30 years of age tends to increase after showing a fall
over previous years, but the over-70 proportion has not altered materially
in the last few years.

The table showing the proportions in which the principal various
forms of insanity occur among the admissions is always interesting.
Recent mania and recent melancholia dwindle year by year, the former
having continuously dropped in the last six years from 14’19 to 9 - 6o,
while a similar fall has occurred in the latter from 23 07 to i7’6i.
This falling off will, of course, suggest a valid explanation of the fall in
recovery-rates. The only other form that shows any marked change is
non-systematised delusional insanity, which has grown by regular
stages from 8-36 to n’33- This, too, is not in favour of a good
recovery-rate.

The most satisfactory History Table is continued. This shows what
has happened in the way of recovery or death to patients when arranged
according to the form of mental disease on admission. Also one finds a
subsidiary table, in which the form of mental disease is replaced by the
assigned cause. These tables must cause much trouble in elaboration,
but, in our opinion, are now indispensable, and will become of more value
each year as the field of inquiry broadens, and possible errors are
minimised by the increasing bulk of contributory figures. Of course
any conclusions drawn from these tables regarding the chance of
recovery in a given case must be affected by the condition of the
individual, his age, his environment, and so on. But it must be of great
assistance to be able to rely on the experience afforded by the tables,
when a patient is found to have no decided departure from the average
and in the influence of such factors.

Regarding aetiology, the various factors do not show any sensible
departure from the usual. Mr. Keene usefully ranges the principal
factors in two tables side by side, the one dealing with all cases, the
other with first attacks only. In both the factors are enumerated as
principal and contributory combined. Several of the figures supply
material for thought. Why should alcohol always appear as a factor in
far greater proportion in all cases than in first-attack cases only? With
syphilis the proportion is the other way. It is somewhat alarming to
find that syphilis enters into 15 per cent, of the first-attack histories, and
to this proportion must be added the findings on subsequent medical
examination and tests.

Certain facts connected with the recoveries need comment. In

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8 years 8,559 recoveries took place. Of these the number of recoveries
under 20 years of age was 4x0; between 20 and 40, 3,980; between
40 and 60, 3,400; over 60, 769; 658 patients recovered who were over
60 at commencement of the attack. The duration of the attack is
stated thus : Less than 6 months, 349 ; 6-12 months, 2,674 > over 1 and
less than 5 years, 2,286; over 5 years, 413.

In connection with the death table Mr. Keene quotes the death rate
from tuberculosis, which, as usual, is lightest at Cane Hill, on the chalk,
while Claybury, which certainly is not on chalk, has the highest rate,
closely followed by Colney Hatch. The average death-rate, calculated
on the average residence in the last four years, is still lowest at Cane
Hill and highest at Colney Hatch, Claybury being close on the latter.
In this relation Mr. Keene usefully points out a possible source of
fallacy. The average number of residents includes both recent and
long-standing cases. The mortality of the former is notoriously higher
than that of the latter, and therefore the relative number of admissions
should be brought under consideration when comparison is made.
Claybury and Colney Hatch admissions are considerably in excess of
those at other asylums. This is a point which is quite worth following
up, as doubtless it will be when Mr. Keene has more opportunity
and help.

Regarding the form of mental disease in those resident at the end of
the year, the bulk consists of dementia and chronic mania and delu¬
sional insanity. The rapidly fatal character of general piralysis is
demonstrated by the fact that while 9 per cent, of the admissions are
due to it, only 2 per cent, of these cases are found at the end of the
year. Of the whole 20,500 patients only 2T3 presented a favourable
chance of recovery.

This being the first report of the new bodies governing institutions
for mental disease, viz., the Asylums and Mental Deficiency Committee,
there is at the end of the volume a short notice of what has been done
for mental defectives. It will be remembered that the London County
Council has decided to alter the character of its Asylum Committee,
by seeking Parliamentary authority for reducing the status of the
Committee to that of its other Committees. Thus the “statutory”
character would be taken away, and much of the policy of the
Statutory Committee would be determined and carried into effect by
the County Council itself. We have before this expressed our strong
opinion that this is a step which will not prove to be in the best interests
of the insane, unless indeed the whole Council becomes the Committee,
and thus its members are one and all individually brought into contact
with the patients. The ordinary committee-man’s lines of thought do
not apply to the care of the insane. But of course Parliament is not
as yet able to give the London County Council the time required to
satisfy its wishes. But the Council is determined to keep matters
as much as possible in its own hands pending legislation. In appointing
the Mental Deficiency Committee the delegation was much the same
as that in the case of its Education Committee. All general principles
are to be determined by the Council, and all questions of importance
are to be reported to the Council for its decision. Thus, apparently,
nothing but spade work is left to the Committee itself. The Council

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634 NOTES AND NEWS. [July,

procured an order from the Home Secretary under Section 66 of the
Mental Deficiency Act, whereby the Mental Deficiency Committee
is appointed to be the Asylums Committee. It will, of course, be bound
in the latter functions by the Lunacy Acts until Parliament assents to
the Council’s proposal, but much of the statutory powers of managing
the asylum will be shown from it. Mr. H. F. Keene, being the Clerk
to the Visiting Committee, has been appointed to the same office under
the Mental Deficiency Committee. The County Medical Officer, who is
also the School Medical Officer, is appointed to office under the latter
Committee; this is a step which is certainly wise. An elaborate
memorandum has been drawn up defining the duties of each of these
two executive officers, so that neither overlapping nor friction should
lessen that ease of administration which is so much called for by the
extent of the work to be done.

Mr. Keene, who, we suppose, has drawn up this portion of the
report, details some of the difficulties connected with the administration
of the Mental Deficiency Act. Among others is that coming under
the second series of tests which must be passed before a person can be
dealt with under the Act. It is only a few who can, in all conscience,
satisfy requirements. He instances the common case of a defective
child (i.e., not an idiot or imbecile) who needs after a time more special
care or education than the fondest of parents can give. Can such a
child be deemed to be neglected, abandoned, without visible means of
support, or cruelly treated ? The difficulty is partly solved by concluding
that the word “ neglected ” must cover cases where, without any wilful
omission, the care and accommodation provided, which might be
adequate for a normal person, are inadequate for one who is defective ;
in other words, that neglect may be constructive as well as positive.
This has enabled action to be taken in many cases. Some negotiation,
which indeed must be delicate, is passing between the Council and
the Metropolitan Asylums Board, whose institutions are obviously most
suitable for the mental defectives belonging to the Council.

Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly General Meeting of the Association was held at the
Medical Society’s Rooms, No. 11, Chandos Street, Cavendish Square, London, on
Tuesday, May 16th, 1916, Lieut.-Colonel David G. Thomson, M.D., President,
in the chair.

There •were present: Drs. T. S. Adair, H. T. S. Aveline, Fletcher Beach, D.
Bower, J. Chambers, R. H. Cole, M. Craig, J. F. Dixon, A.C. Dove, T. Drapes,
R. Eager, J. H. Earls, C. F. Fothergill, A. H. Griffith, H. E. Haynes, T. B.
Hyslop, J. Keay, N. T. Kerr, R. L. Langdon-Down, N. Lavers, H. J. Mackenzie,
A. Miller, J. M. Murray, A. W. Neill, W. F. Nelis, H. H. Newington, D. Orr,
J. G. P. Phillips, W. A. Potts, R. G. Rows, Sir G. H. Savage, J. N. Sergeant,
G. E. Shuttleworth, R. P. Smith, J. G. Soutar, T. E. K. Stansfield, H. F. Stephens,

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635

J. Stewart, F. R. P. Taylor, H. Wolseley-Lewis, and R. H. Steen (Acting Hon.
Gen. Sec.).

Present at the Council Meeting: Lieut.-Colonel D. G. Thomson, M.D. (Presi¬
dent) in the chair, Drs. T. S. Adair, H. T. S. Aveline, J. Chambers, R. H. Cole,
T. Drapes, J. Keay, N. T. Kerr, N. Lavers, H. J. Mackenzie, A. Miller, H. H.
Newington, j. G. Porter Phillips, J. N. Sergeant, J. G. Soutar.T. E. K. Stansfield,
H. Wolseley-Lewis, and R. H. Steen (Acting Hon. Gen. Sec.).

Apologies for absence -were received from: Drs. R. B. Campbell, C. C. Easter-
brook, R. R. Leeper, G. D. McRae, Bedford Pierce, and W. R. Watson.

Minutes.

The minutes of the previous meeting, having been published in the Journal oj
Mental Science for April, were taken as read, confirmed, and duly signed.

The President said that the only business arising out of the previous Council
meeting was that the Council wished members to know that they had had under
consideration the serious depletion of the male staffs of asylums. The Council
had held a special meeting on the matter, and were at present in correspondence
with the Board of Control thereon. A perusal of the Journal for April would show
the length to which the question had been taken.

The late Mr. Hine, F.R.I.B.A.

The President said he was sure every member would be sorry to hear that a
gentleman who had been an Honorary Member of the Association since 1898, Mr.
Hine, F.R.I.B.A., the Architect, had passed away. He died in April. As was
known to members, Mr. Hine designed and altered a great many public asylums,
and had done a great deal in connection with that part of the work which they of
the specialty deemed so important, namely, the comfortable and suitable housing
of the insane. He moved, from the chair, that a vote of condolence be sent to his
family.

The resolution was confirmed by members rising in their places.

The late Dr. Morrison and Dr. O’Neill.

The President also announced that a letter had been received from Mrs.
Morrison, the widow of Dr. Morrison, thanking the Association for its message of
condolence. A similar communication was received from Miss O’Neill.

Papers.

Dr. David Orr and Major Rows, R.A.M.C., M.D.: "Experimental Toxic
Lesions in the Rabbit's Brain, and their bearing on the Genesis of Acquired Idiocy
and Imbecility in Man.” (With lantern demonstration.)

The President, receiving no response to his invitation to members to discuss
the contributions, said it was as he feared, namely, that such learned and advanced
views on these recondite problems prevented anything being said upon them which
might be termed a discussion. But he was sure that the members present would
at least join with him in thanking Dr. Orr and Major Rows for having brought
such extremely interesting matters before them. PersonalIy.it was a great relief
to him to hear pure medicine again, after the routine which they, administrators,
were at present steeped in. He had been much interested in the narration of the
case of psychic vomiting. There was at the present time, in the hospital of which
he had charge, a man who appeared physically sound, to all the ordinary methods
of physical examination. The surgeons had done various things for him, and
finally he had been handed over to the physician. The case was, originally, one
of shell shock, and the most striking stimulus which caused vomiting was the entry
of a new case or convoy of cases into the ward, the vomiting being more violent if
a convoy appeared than if only one case were admitted. Various expedients to
reduce the vomiting had been tried, such as removing the patient to a place a little
removed from the ward during the actual process of admission of the new cases,

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but there was no success from that manoeuvre. Nor had the use of screens any
effect. Members would agree that the theses of the authors had been admirably
presented, with their usual methodical precision.

The resolution of thanks was carried with acclamation.

The 1916 Annual Meeting. .

The President said it was the business of this meeting to fix the date and place
of the Annual Meeting for the summer. The meeting this year would not be of
the usual character, in regard to either length, quality, or quantity ; it would be a
one-day meeting, and it was proposed to hold it in these rooms, on July 27th.
which was the day before the annual representative meeting of the British
Medical Association, so that members attending both functions would be
convenienced. The purpose of the meeting would be mainly to transact
business. Papers would be welcomed, but there would be no social side to the
meeting.

The following further correspondence has taken place between the Board of
Control, and the Secretary of the Association :

City of London Mental Hospital,

Near Dartford, Kent,

May 17 th, 1916.

Medico-Psychological Association of Great Britain and Ireland.

Sir, —At a meeting of the Council of this Association held on May 16th, the
letter received from the Board of Control dated April 4th, 1916, was considered,
and I was directed to thank the Board for their courtesy in so promptly replying
to the letter from the Association dated March 26th, 1916.

1 was further directed to state that the Council were fully cognisant of the fact
that the artisan and other staff did not form the subject of recommendations by the
Board of Control. The Tribunals, unfettered by recommendations, and on the
consideration of each case on its merits, have generally exempted a sufficient
number of men in divisions 3, 4, 5 and 6 to carry on efficiently the work of the
departments in which they are employed. It is only in the staff of male attendants
that depletion in the numbers has been so excessive as to seriously threaten the
main purpose of asylum management, via., the care and treatment of the insane.
Asylum authorities and their Medical Officers have hitherto decided what staff is
necessary for the proper care of the patients for whom they are responsible. The
view of the Council is that no other body is really competent in the absence of
local knowledge to express a valid opinion on this matter. A sound decision
thereon involves a fuller knowledge of facts than can possibly be obtained by a
central board from even the most elaborate tabulated particulars. This being so,
a very serious situation must arise wherever Local Tribunals consider themselves
limited by the recommendations of the Board, who are, necessarily, only imperfectly
acquainted with the requirements of individual asylums.

A conflict of opinion, which the Council regret, has thus arisen in many instances
between the Board and asylum authorities as to what men are indispensable. On
their record Asylum Medical Officers and the Committees whom they advise are to
be trusted to encourage, not to hinder, recruiting, and had they been left free to
prove to Local Tribunals that each man applied for is indispensable the result
would have been more satisfactory.

The opinion of the Board that the circumstances of the time justify “ risks being
faced, amenities being curtailed which would not be permissible under ordinary
circumstances, and a reduction in the high standard of comfort and efficiency which
has very properly characterised asylum management for so many years,” is not
one to which the Council of the Medico-Psychological Association can subscribe.
It is feared that such an admission would make easy a relapse to the extensive
resort to seclusion and mechanical and chemical restraint which prevailed in the
days when attendants were few and inefficient.

While the Council recognise the generous motive which prompted the last para¬
graph of the Board’s letter, they feel that Asylum Visiting Committees and Medical

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637

Officers cannot and would not desire to shift to the Board of Control a respon¬
sibility which is morally and legally their own.

To save the already dangerously depleted asylums from the almost complete
denudation of a skilled and physically fit staff of male attendants, the Council
suggest that steps should be taken (1) to obtain total exemption for those men to
whom temporary exemption has been granted, and (2) to secure that attendants
who have already been rejected as being medically unfit shall not be accepted on
re-examination unless they be found fit for service in the fighting forces abroad,
and that in the event of their being so accepted it shall be competent for the
asylum authorities to appeal to the Local Tribunals for the total exemption of
such of these men as they may deem to be indispensable.

In this way only does it now seem possible to retain a remnant of reliable men
as attendants, and the Council of the Medico-Psychological Association will be
thankful and relieved of some anxiety if the Board of Control can see their way to
support and further these proposals.

I am, Sir, your obedient servant,

The Secretary, ' R. H. Steen,

The Board of Control. Acting Hon. General Secretary.

66, Victoria Street, Westminster,

London, S.W.

The Board of Control,

66, Victoria Street, S.W.

1st July, 1916.

Sir, —I am directed by the Board of Control to advert to your letter of the 17th
May on behalf of the Council of the Medico-Psychological Association of Great
Britain and Ireland, and relating to the recommendation for exemption of Asylum
Attendants from Military Service, and to reply as follows :

As foreshadowed in the Board’s letter accompanying the first set of recommen¬
dations, a considerable number of attendants, for whom temporary exemption was
originally recommended, have now on further recommendations been granted full
conditional exemption. In the cases of many other attendants additional temporary
exemption has been granted, which may be still further extended should this prove
necessary.

As the Board continue to have this power to renew recommendations for exemp¬
tion, they do not consider it necessary that they should take steps to procure
forthwith the total conditional exemption of attendants now temporarily exempted,
nor of the men now employed in asylums who have been rejected as being medically
unfit, but who, it is thought, may possibly, as time goes on, be considered after
further examination fit for service in one or other of the military branches, but not
in the fighting forces abroad. The Board will, however, be pleased at once to
consider any particular case if submitted to them by the Asylum Authority.

The arguments adduced and the opinions expressed by the Council in the earlier
part of the letter have been read with some surprise, and while the Board do not
propose to enter into them at length, I am to mention the following facts.

The policy of withholding from the Asylum Visiting Committees the power of
final decision, as to how many and which of their male staff shall be exempted
from military service, is in harmony with that in force throughout the country
under the Military Service Acts, namely, that employers are not to be the final
judges of their own cases.

The suggestions contained in the Council’s letter that the Board of Control are
without knowledge of local circumstances; that they are imperfectly acquainted
with the requirements of individual asylums; and that they are dependent for their
decisions upon tabulated particulars, are not in accordance with facts. I am to
express the Board’s surprise that such a view should emanate from the Council of
the Medico-Psychological Association. The Board, as they thought the Council
were aware, have ample facilities for supplementing their knowledge of particular
circumstances, and they freely avail themselves thereof when necessary.

The duty which has been imposed upon the Board was not of their own seeking.
That some differences of opinion would occur between the Board and some of the
Visiting Committees and their Medical Superintendents was inevitable ; but in
most instances after personal interviews the Board’s views have been accepted.

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The justification, if one were needed, for invoking the assistance of the Board in
the matter is the fact that, as the result of their action, a considerable number of
men have been set free for the Army, admittedly not without somewhat increasing
the anxieties of the Visiting Committees and their Medical Officers, but so far
without untoward events.

The Council of the Association are in error in thinking (as is suggested by your
letter) that the Local Tribunals have any power of exercising discretion outside
the recommendations of the Board in dealing with asylum attendants as persons
in a certified occupation, and, wherever it has come to the knowledge of the Board
that any Tribunal has attempted to exercise any such discretion, the fact has not
been allowed to pass unnoticed.

The inability of the Council to concur in the Board’s opinion as to the principles
of asylum management which should be followed in the present national crisis is,
the Board think, to be regretted. It will be the duty of the Board, as well as of
asylum authorities, firmly to exert their influence at the conclusion of the War to
bring about a return to a proper standard, and in this they feel sure the co¬
operation of the Medico-Psychological Association may be counted upon.

I am to add that the Board of Control cannot accept the position which the
Council of the Association take up, in attempting to express an opinion as regards
the ability or willingness of Asylum Visiting Committees to place responsibility
upon the Board in this matter. As a matter of fact, the Board are in possession
of letters from a considerable number of Committees, in which the latter either
invite the Board to assume such responsibility or express their satisfaction at the
offer of the Board to do so.

I am, Sir, your obedient servant,

O. E. Dickinson,

« Secretary.

The Acting Hon. General Secretary,

Medico-Psychological Association
of Great Britain and Ireland.

SOUTH-EASTERN DIVISION.

The Spring Meeting of the South Eastern Division was held at 11, Chandos
Street, Cavendish Square, London, W., at 2.30 p.m. on Friday, April 28th, 1916
Among those present were Drs. Baird, Bower, Ralph Brown, Earls, Haynes, J. M.
Murray, Norman, Stewart, Watson, and J. N. Sergeant (Hon. Sec.).

The minutes of the last meeting, having been published in the Journal, were taken
as read and confirmed.

Drs. R. Armstrong-Jones, Hubert J. Norman, T. E. K. Stansfield, and W. H. B.
Stoddart were elected Representative Members of the Council, and Dr. J. Noel
Sergeant Hon. Divisional Secretary for the year 1916-1917. Drs. Fuller, Higson,
and F. Watson were elected members of the Divisional Committee of Manage¬
ment.

It was decided to hold the Autumn Meeting at 11, Chandos Street, Cavendish
Square, London, W., on Wednesday, October 4th, 1916.

Dr. Hubert J. Norman then read his paper on “The Cerebral Complications
of Raynaud’s Disease.”

After a brief discussion a vote of thanks to Dr. Norman for his interesting paper
was carried by acclamation.

SOUTH-WESTERN DIVISION.

The Spring Meeting of the above Division was held, by kind permission of
Dr. MacBryan, at 17, Belmont, Bath, on Friday, April 28th, 1916.

The following Members were present: Drs. Bartlett, Norman Lavers, Legge,
MacBryan, and Aveline, who acted as Hon. Divisional Secretary.

Dr. MacBryan was voted to the Chair.

Letters of apology for non-attendance were received from Drs. Eager, Mac¬
donald, and Soutar.

The minutes of the last meeting were read and confirmed.

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Dr. G. N. Bartlett was appointed Hon. Divisional Secretary.

Drs. Norman Lavers and G. S. Pope were elected as Representative Members of
Council.

Drs. Aveline and J. M. Rutherford were elected as Members of the Committee
of Management.

The Autumn Meeting was fixed for Friday, October 27th, 1916, the place of
meeting being left to the Hon. Secretary, and the Spring Meeting for Friday,
April 27th, 1917.

The members present alluded to the loss sustained by the Division in the recent
death of Dr. C. S. Morrison, and it was proposed that the Hon. Secretary be
requested to convey their sympathies to Mrs. Morrison.

NORTHERN AND MIDLAND DIVISION.

The Spring Meeting of the Northern and Midland Division was held, at the
kind invitation of Dr. Hamilton Grills, at the County Asylum, Chester, on
Thursday, April 27th, 1916. Dr. Hamilton Grills presided.

The following seven members were present: Drs. H. Dove Cormac, Graeme
Dickson. G. Hamilton Grills, C. H. Gwynn, R. W. Dale Hewson, S. Rutherford
Macphail, T. Stewart Adair.

Apologies were received from various members who were unable to be present.

The minutes of the last meeting were read and confirmed.

Dr. T. Stewart Adair was unanimously re-elected Secretary for the ensuing
twelve months.

Owing to the membership of the Division having fallen below 150, two Repre¬
sentative Members only can be elected to the Council. Dr. J. R. Gilmour and Dr.
D. Hunter were unanimously re-elected, Dr. J. W. Geddes having withdrawn his
name.

The kind invitations of Col. Vincent, to hold the Autumn Meeting, 1916, at the
Wharncliffe War Hospital (Wadsley Asylum), Sheffield, and of Dr. H. Dove
Cormac, to hold the Spring Meeting, 1917, at the Cheshire County Asylum,
Macclesfield, were cordially accepted. The dates were left to the Secretary to
arrange.

Dr. Power, Senior Medical Officer, County Asylum, Chester, was proposed by
Dr. Cormac as a Member, and duly seconded. The Secretary stated that this
would be put through the Association in the usual way.

An interesting display of various articles of restraint used in the asylum,
apparently prior to 1840, was made by Dr. Grills, who gave a short description of
them. They included leather appliances for securing various parts of the body,
leather gloves with and without handcuffs, iron belts, etc. An informal chat
followed on the present difficulty of obtaining male staff, on the employment of
female staff in male wards, and other subjects of administrative interest.

A cordial vote of thanks was accorded Dr. Grills for his kind hospitality.

ASYLUM WORKERS’ ASSOCIATION.

Annual Meeting.

The Annual Meeting of the Asylum Workers' Association was held on May 17th
at the rooms of the Medjfal Society of London, 11, Chandos Street, Cavendish
Square, the President (Sir John Jardine, Bart., M.P.) in the chair.

Annual Report, 1915 (Abridged).

The Central Executive Committee, in submitting their Annual Report for 1915,
are proud to be able to record the fact that the response of members of asylum
staffs to the call of King and Country has been such as to have been unexcelled in
numerical proportion by that of bodies of workers in any other professions or
occupations. It was estimated in Mav last that considerably more than 2,000
attendants in asylums in England and Wales had joined the colours, as well as
numerous clerks, artisans, etc. Since that time the numbers have been added to
continually, and in many instances practically all the remaining workers of military

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age under the various Asylum Authorities have presented themselves for attesta¬
tion under Lord Derby’s ’ scheme. This regular and systematic denudation of
staffs since the outbreak of the war has, of necessity, thrown a considerable burden
on those remaining in charge of the patients, which has only in part been relieved
by the provision of temporary attendants of over military age or otherwise ineligible
for service. Numerous nurses have joined the Red Cross, but, speaking generally,
the female sides of asylums have not been affected to anything like the same
extent as the male sides. Nevertheless, the Central Executive Committee feel
that they cannot speak too highly of the self-sacrifice and devotion to duty which
on all hands have been displayed by asylum nurses during the present times of
stress and anxiety. Several asylums in Great Britain have been converted into
war hospitals, and many of the attendants and nurses have been retained for
military service ; the former enlisting as orderlies in the R.A.M.C., and the latter
becoming nurse probationers. The admirable manner in which these have
acquitted themselves in their various spheres of work, and the rapidity with which
they adapted themselves to the novel conditions, are striking evidences of the
efficiency of the training of modern asylum staffs.

The distribution of the former inmates of these war hospitals amongst neigh¬
bouring asylums has in many instances added considerably to the already heavy
burden imposed upon the officers and staffs responsible for their care and general
welfare.

The matter of the position of asylum officers on active service with relation to
the Superannuation Act, which was fully discussed in the Annual Report for 1914,
continued to engage the attention of the Central Executive Committee during the
early months of the year under review, and it gives them much satisfaction to be
able to report that Asylum Authorities in England and Wales have, as far as it
has been possible to ascertain, made satisfactory provision for the safeguarding of
members of their staffs serving with the forces, in this important respect. Twenty
of these authorities have passed resolutions in accordance with the suggestions
contained in the Association’s circular letter of November, 1914, vie., “ That for
purposes of pensions years be added to the period of service of such officers,
corresponding to the time spent on active service with H.M. forces, under
Section 2 (3) of the Superannuation Act.” In the majority of cases it appears
that the alternative course agreed to by the Home Secretary (that of treating
active service during the present war as part of their officers’ asylum service, and
pensionable under the Act) has been adopted. It is possible that after the war
certain unforeseen difficulties may become apparent, and for these a solution may¬
be found by the insertion of a special section into the Asylum Officers' Super¬
annuation Act (Amendment) Bill.

The question of the employment of female nurses in the male wards of asylums
has on more than one occasion engaged the attention of the Central Executive
Committee, who did not consider that the matter was one calling for any resolution
or definite expression of opinion on their part. They have, however, encouraged
discussion on the subject in the columns of the Asylum News.

The Central Executive Committe cannot conclude this report without expressing
their indebtedness to Dr. J. Farquharson Powell for his most efficient conduct of
the business of the Association as Hon. Secretary. Notwithstanding the
increasingly onerous duties of his official position consequent on the war, he has
found time not only to act as Secretary but to carry out, with marked ability, the
editing of the Asylum News, and in both capacities he has earned the grateful
appreciation of the Association.

The President, in moving the adoption of the report, said : We have a smaller
attendance to-day than we have been used to at these annual gatherings, but I
think that the letters of apology for the absence of many distinguished, capable,
experienced, and sympathetic men show that if it were not for the extra labour
that the war has cast upon nearly everybody we should probably have had a large
and distinguished meeting this afternoon. All who know the high purposes of this
Association will be pleased to learn that while this country is being assailed by
powerful kings and their armies our small population of asylum workers had given
more than 2,000 men to the forces last May, and since then a great many more
have gone. In many asylums, therefore, the work is being carried on with new
staffs. Moreover, many of the medical officers have accepted commissions, and,

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like the asylum workers, are now serving the Crown in a way that very few people
are able to do—by the application of their own special medical knowledge and
experience. The next point has reference to the Superannuation Act. You will
see from the report that arrangements have been made to prevent the Superannua¬
tion Act from being in any way worked to the injury of those who have gone to
the Army or Navy. As for the finance of our Association, it is in a better condi¬
tion than might have been expected when so many people have gone to the war,
and so many calls are being made upon everybody. Taking the report altogether
I think we may adopt it with satisfaction. Much is due to the exertions of our
officers. (Hear, hear.) We may congratulate them on the way in which the
Asylum News has been kept going, and on the fact that to a certain extent we have
got Dr. Shuttleworth into harness again. (Hear, hear.) There are things that we
cannot do without his help.

Lieut.-Colonel Thomson, R.A.M.C., in seconding the motion, said it was very
deplorable that the Executive Committee had found it necessary to limit the
Asylum News to quarterly instead of monthly issues. The membership of the
Association was not quite satisfactory. Compared with that of other organisations
it might be regarded as fair, but he thought it could be improved. The people at
headquarters had done admirably, but more interest and energy put forth locally
might produce good results. (Hear, hear.) Perhaps he might offer a useful hint.
The Norfolk County Asylum, of which he had charge, had been converted into a
military hospital. Frequent entertainments for all kinds of objects were got up
there, and it occurred to him that the asylum people themselves were not unworthy ,
objects. He got the new-comers interested in the subject, and he was glad to say
that two little entertainments yielded without the least difficulty £10. He did not
think it was laid down clearly enough that the phrase “ asylum workers” in con¬
nection with the Association included artisans and everybody else, and that all were
invited to become members. (Hear, hear.)

Sir James Crichton-Browne, in the course of his remarks when proposing the
re-election of Sir John Jardine as President, after paying a fitting and well-merited
tribute to the valuable services Sir John had rendered to the Association, made the
following reference to German ideas and methods : It is too soon to speculate what
may be the ultimate effects of this war on medical psychology in this country, but
there is one effect that is already certain, and that is that it will explode and utterly
demolish the spurious deference and respect hitherto bestowed on German teachings
and methods. Our young medical psychologists have been wont to hurry off to
Berlin, Leipzig, or Vienna, to sit at the feet of some supposed pundit in mental
and nervous pathology. Our journals have been full of translations from the
German, and we have been plied with adulations of German wisdom. There will
be no more of that. I say deliberately that in our department we have nothing to
learn from the Hun, that in his treatment of the insane are to be seen traces of the
inherent brutality of his nature, and that what has been extolled as German psycho¬
logical wisdom has been like German sausage, a confused mass of very dubious
and indigestible ingredients. (Laughter.) As regards the modern humane treat¬
ment of the insane, there is absolutely nothing for which we have to thank Germany.

It is France, beginning with Pinel.and England, beginning with Conolly, that have
led the way in that matter, and introduced every amelioration. Germany has
lagged shamefully behind. As late as 1855 that most cruel invention, the circular
swing, by which unhappy patients were whirled round with enormous velocity,
until they were seized with sickness and vomiting, and often fainted away in a state
of terror—an invention discarded in this country one hundred years ago—was in
constant use; and as late as 1871—that is to say, less than fifty years ago—in
most German asylums was to be seen the high collar round the throat, used
to prevent the patient moving his head, heavy chairs in which patients
were securely tied down, stocks in which their feet were held fast, the
cuirasse, or leather jacket of stout ox-hide, with sleeves and gloves of the same
material, and leather buckles and masks that were strapped over the face and
gagged the mouth to prevent screaming. At that time brutality reigned supreme
in the so-called lunatic hospitals of Germany ; and only a few years ago I saw the
strait-waistcoat in free use in a German asylum, and other devices which I could
not but condemn. Those who have read the accounts of what took place at the
camp at Wittenberg, that den of cowardice and cruelty—(hear, hear)—will not

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642 NOTES AND NEWS. [July,

doubt that inhumanity still lingers in German asylums. There is a vein of hard¬
ness and cruelty in the German character that has vitiated their treatment of the
mentally afflicted. 1 have heard of deputations of governors of asylums in this
country going to visit asylums in Germany in order to pick up new and useful ideas
in the treatment of the insane. They might just as well have stayed at home,
except that they might obtain hints as to what to avoid. The arrangements for
clinical teaching and scientific investigation in German asylums are superior, and
the organisation of the lunacy system is good, for it is in organisation that the
Germans excel, but in all that concerns the humane treatment of the patients
German asylums are behind the age. One feels in them at once an atmosphere
that is different from what prevails in our asylums—a coldness^ a severity, an
indifference to human suffering that is revolting; and as regards German asylum
officers, I would say that they show a coarseness and callousness that painfully
contrast with the urbanity and sympathy we are accustomed to here. They largely
regard their patients as more or less interesting specimens, but lose sight of their
sentiency and sorrows. It would be inappropriate that I should discuss here the
recent additions to medico-psychological science in this country derived from
Germany. Psycho-analysis the most notable of these is called—*' prurio-analysis,"

I should be inclined to call it—a slimy, useless, and offensive agitation of human
sludge. I confess I turn with disgust from the German text-books, such as those
of Kraft-Ebbing and Freud—the former was a favourite study of Oscar Wilde—
and thank God for the clarity, the directness, the practical cleanness, and common-
sense of our nature-grown medical psychology. (Cheers.)

Dr. G. E. Shuttlevvorth, seconding the motion, said that nobody knew better
than himself the many excellent qualities which had made Sir John Jardine a tower
of strength to the Association. As he (Dr. Shuttleworth) was Hon. Secretary when
the President accepted office, he could testify that in season and out of season he
was always accessible for advice and assistance about anything likely to benefit
asylum workers. Sir John Jardine had a greater part than was generally known
in the passing of the Asylums Officers’ Superannuation Act of 1909. He was
what might be called chief lieutenant to Sir William Collins, President of the
Association at the time, who successfully passed the Bill, which Sir John backed.
Indeed, priority in desiring such a measure might perhaps be given to Sir John,
for he had actually brought in a Scottish Bill on the subject, but he was good
enough to hand over his position to Sir William Collins, and amalgamate his pro¬
posals with those of the latter in a comprehensive Bill for the whole kingdom.
People were apt to think the Act of 1909 was the end of legislation in connection
with superannuation, but it was nothing of the kind. Sir John Jardine had intro¬
duced into the House of Commons an amending Bill to establish desirable points
which in 1909 were dropped in order to secure the passage of that year's measure.
(Hear, hear.) These points related to the age qualification for superannuation and
other matters. They held that twenty-five years’ service should be enough to
qualify for superannuation in the case of women, whatever their age. They would
like to have the same thing for men, but were told that in this case they were sure
to be refused superannuation, on grounds of precedence, before the age of fifty. If
Sir John Jardine could secure these two points for them—not to mention others—
they would think themselves lucky to have retained him as their President. (Hear,
hear.) He (Dr. Shuttleworth) had that morning come across an original pro¬
spectus of the Association. He was not the first Secretary, though some people
thought he was. Dr. Harding, of Northampton Asylum, and afterwards Dr.
Walmsley, of Darenth, preceded him. The founders were Miss Honnor Morten
(now deceased), of nursing fame, and Miss Laura Evans, then Matron of the
Northampton Asylum. The Association had ever been lucky in its personnel. It
was attaining its majority this year, and during the twenty-one years had had five
eminent Presidents. The first was Sir Benjamin Ward Richardson. Then came
Sir James Crichton-Browne (whom they were proud to see with them to-day).
After him the presidency was held successively by Sir John Batty Tuke and by Sir
William Collins. Now they had Sir John Jardine, and he did not know that any
society could have been more fortunate in securing a succession of such able and
distinguished Presidents. (Hear, hear.) The Association’s first circular calculated
that there ought to be at least 5,000 members, in order to secure satisfactory
working. Something like that number was obtained while the work of promoting

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the Superannuation Act of 1909 was going on, but as soon as the measure became
law the membership fell. People thought they had got what they wanted, and
they probably asked why, in that case, they should continue to pay subscriptions.
That looked rather like proverbially short-lived gratitude, but he hoped asylum
workers would realise the necessity for renewed effort, and that the membership
would again increase in view of the need of still further improving the position of
asylum employees of all classes in relation to superannuation by vigorously pressing
on Sir John’s new Bill as soon as opportunity occurred. There was a new
direction in which he hoped to see the members of the Association multiplying.
Under the Mental Deficiency Act, 1913, many new institutions were being organised
and brought under the supervision of the Board of Control, and there would be
more still when at length peace arrived. It would be incumbent on people
employed in the care of the mentally deficient to be as well equipped as those in
the service of the insane. The Board of Control had issued a circular stating that
they intended to take account of the qualifications of persons employed in connec¬
tion with mental deficiency cases. Some who belonged to the Asylum Workers’
Association had practical knowledge of the care of the mentally deficient, and
would be glad to enrol in the Association persons engaged in that work and to
look after their interests, which were akin to those of asylum workers generally.
He hoped that the Medico-Psychological Association would be willing to lend a
hand in the special training necessary for this class of workers, (Hear, hear.) At
present between eighty and ninety institutions, large and small, were recognised by
the Board of Control, but the number would probably be doubled eventually, and
then there would be a considerable recruiting ground for the Association. (Hear,
hear.) He wished to say, before sitting down, how fortunate he had been person¬
ally in finding so able a successor in the- hon. secretaryship as Dr. Farquharson
Powell, whose proved tact, ability, and industry had ensured success in the work
he had so generously undertaken both as Secretary and Editor. The Association
possessed another able official (with the advantage of lengthened experience) in
Mr. Wilson, who assisted Dr. Powell, and if anything were needed to make the
satisfactory condition of the secretaryship complete it would be found in the fact
that these two worked most admirably and efficiently together. (Cheers.)

The re-election of the President was carried by acclamation.

The following appeared in the April number of The American Journal of
Insanity :

"HOSPITAL 'PREPAREDNESS' IN ENGLAND.

" Not the least of the many lessons taught by the European war is the importance
of taking stock of the provision for sick and wounded soldiers and sailors in pre¬
paring for a sudden emergency. This feature of preparedness is brought out in
striking and most interesting fashion by the address of Lieut.-Col. D. G. Thomson,
M.D., President of the British Medico-Psychological Association, who, as officer-
in-charge of the Norfolk War Hospital, took this year as his theme * The Conver¬
sion of a County Asylum into a War Hospital for Sick and Wounded.’(*)

“ At the outbreak of the war it was thought, not unnaturally, that in a maritime
nation like Great Britain there would be great naval engagements involving the
landing on the North Sea coast of a vast number of sick and wounded men,
whereas the naval hospitals were situated far away on the south coast. With this
idea in mind, Norfolk, being the nearest point to German naval bases, offered as
early as August 5th, 1914, to furnish the Admiralty 100 beds and to erect tents for
150 more 4 n the Norfolk and Norwich Hospital. This offer not having been
accepted, it was transferred later to the War Office, and on October 17th the first
convoy of 100 sick and wounded men arrived. In the same month occurred the
battles of the Marne and Aisne, which, in view of probable requirements, suggested
inquiry as to facilities for treating the wounded in asylums. Thereupon, on
November 23rd, the Norfolk County Asylum offered 100 beds. Towards the end
of January, 1915, the War Office, when the impression obtained that the Allies
contemplated an advance against the enemy in spring, invoked provision for
50,000 beds, of which number the Board of Control requisitioned for 15,000 in

(*) Journal of Mental Science, January, 1916.

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asylums. The plan was that certain county and borough asylums near large
towns should be handed over to the War Office. Dr. Thomson describes how this
herculean task was accomplished, and, despite his great modesty, one cannot fail
to see with how great patriotism and efficiency the upheaval was met, and the
extraordinary service rendered. It would carry us too far to go into the details of
conversion in the twelve hospitals upon which the War Office levied. Briefly, the
scheme involved the division of the whole asylum system into groups, and when
one of the institutions had been selected for war purposes, its patients were distri¬
buted among the other members of the group, or otherwise provided for. At first
there was an unreasoning outcry of prejudice and ignorance in the press about the
‘ outrage 1 of turning over the sick and wounded to ‘ lunatic asylums,’ which was
soon stilled, however, when the propriety and potential adequateness of the
provision were appreciated. The readaptation of the buildings themselves
presented no serious difficulties. Contrary to expectation, there was very little
friction between the former mental nurses and the hospital-trained newcomers.
The men who had been trained as asylum attendants won great praise as orderlies.
The conduct of the patients was excellent on the whole, and there was no trouble
as to discipline. Dr. Thomson attributes the general contentment to the ample
and well-cooked food, the careful planning of occupation and amusements, and
the reduction to the minimum of all unnecessary restrictions on their liberty. In
the discussion which followed the address it appeared that minor changes in
structural arrangements and in method have been effected such as will endure to
the permanent benefit of the insane. Mention was made, for instance, of better
ventilation by departing from the ‘asylum’ type of window, of handles on the
room doors, and of other like modern innovations which the converted war
hospital has brought in its wake. No one can read the address without being
greatly impressed with the magnificent spirit and thoroughness with which the
work was carried through. Dr. Thomson pays a high tribute to Dr. Marriott
Cooke and Dr. Hubert Bond, Lunacy Commissioners, but it is easy enough to
read between the lines that the President of the British Medico-Psychological
Association has himself been magna pars in the performance of a great work of
reorganisation. The Journal salutes the Lieutenant-Colonel.”

[While thoroughly endorsing the generous appreciation of the President's work
by our Transatlantic friends, as conveyed in the above, we feel that it would be
unfair (and Colonel Thomson would probably be the first to deprecate the
omission) to make no mention of the Medical Superintendents of other asylums
who have been called upon to perform a similar task, and who have carried it out
with equally signal success. The country owes them an enormous debt for their
skilful and untiring efforts towards providing cheery and comfortable homes for
the temporary residence of our wounded, where their prospects of recovery are
probably brighter than they would be in almost any other surroundings. We
salute them, one and all.—E d. J.M.S .]

Examination for Nursing Certificate, May, 1916.

Preliminary Examination, May, 1916.

List of Questions.

1. What is the position of the heart? Describe shortly its structure and the
course of the blood through it.

2. What are the chief symptoms of carbolic acid poisoning? If a patient
drinks a quantity of carbolic lotion, what would you do ?

3. What is the difference between fracture and dislocation ? What signs would
make you think a patient had a dislocated shoulder joint? How would you
render aid in such a case to enable the patient to get home ?

4. What is the composition of the blood ? What are the differences between
arterial and venous blood ? How would you distinguish between bleeding from an
artery and from a vein ?

5. What are the functions of the kidneys? State generally the composition of
the urine.

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6 . To what danger is a patient exposed who sustains an open wound ? How
can these dangers be counteracted ?

7. What are the uses of.respiration ? Explain its mechanism.

8. What are the varieties of bones ? Give an example of each.

Final Examination.

List of Questions.

1. Describe a case of Acute Delirious Mania which has come under your own
observation. What are the general lines of management of such an illness?

2. Give a short description of a Neurone.

3. What do you understand by an Emotion ? What disorders of the Emotions
are met with in Mental Diseases ?

4. Describe fully the nursing of a case of Phthisis (Consumption).

5. A person is found unconscious. What causes might produce this condition,
and how would you distinguish between these?

6. Describe minutely the steps you would take to clean and sterilise the various
types of catheters immediately before and after use.

7. What is Dropsy? How would you recognise it, and in what parts of the
body is it usually found ?

8. What are “ Stigmata of Degeneration" ? Describe some examples you
may have seen.

EXAMINATION FOR NURSING CERTIFICATE.

Final Examination.

Abergavenny. —Sidney Barton, Thomas Jenkins.

Chester, Upton. —Mary C. Roberts,* Alice Knowles, Ivy B. Wyndc, Elizabeth A.
Cadwell.*

Denbigh. —Thomas Hughes, Myfanwy Lloyd,* Lizzie J. Williams, Lizzie B.
Jones.

Essex, Brentwood. —Lily Morrell, Martha Crowe.

Glamorgan. —Bessie James, Beatrice M. Evans,* Albert G. Lang, Ernest R.
Salisbury, George W. Bryant, Mary Williams,* Sarah A. Rees, Hugh E. Parry,
Percy Parry, Edith Hopkin.

Isle of Wight. — Ella H. Yielder,* Margaret M. Jones, Eleanor Barratt.

Kent County, Maidstone. —Mona Jarrett,* Millicent V. Platt, Amy E. Smith,
Evan M. Vinehill, Ada Chambers, Edith M. Nuttall, Ethel Webb, Emily J.
Hursell.

Hanwell. —Constance E. Stephenson, Minnie J. Mallion.

Long Grove. —Catherine M. Erskine, Augustus F. Waylan, David I. Duke.
Colney Hatch. —Dorothy M. Bettridge, Emma Marshall, Charlotte M. Corfield,
Margaret Stephenson,* Julia Scanlan.

Claybury. —Susan Harkin, Mary Hughes, Jenny Edwards, Mary Griffin, Nellie
Williams, Florence R. Jordan,* Eliza E. Dungate, Laura L. Reeve.

Cane Hill. —Laura Pollard, Constance Stainer, Rossannah Marsh, Kate L.
Robinson, Emily E. Illman, Adaline F. Wing, Florence E. Rogers, Florence E.
Couchman.

Banstead. —Jane Barrow, Dorothy A. Fox, Edith M. Mallion, Ethel M. Wright,
Nellie Hill, Margaret M. Dalton, Agnes A. Anderson, Mabel E. Bywater. .
Caterham. —Mary A. Williams, Ethel F. Hobbs, Dinah F. Williams.

Leavesden. —Thomas H. Grundy, Ethel M. Webb, Kate Yelverton, Cecilia E.
Mayes.

Shrewsbury. —Mary A. C. Harrison, Charlotte Evans.

Staffs., Cheddleton. —Bridgid Farrelly, Joanna J. Fitzgerald.

Burntwood. —Percy Nutt.

West Sussex. —Adeline Spiegelhalter, Frank Mayo, Harriet Arnold, Annie
Stubbs.

Hayward's Heath. —Madge Hunter,* Maud C. V. K. Martin, Annie G. E.
Hoxey.

VOL. LXII. 41

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646 NOTES AND NEWS. [July,

Hellingly.- —Rebecca M. Collins, Alice E. Lucas, Dorothy A. Steer, Josephine
Dwyer, Agnes Brumbill, John W. Russell.

Barnsley Hall. —Sidney T. Phillips, Ellen A. Mathers.

Winson Green. —Sarah Brassington, Katherine H. Kendrick, Lilian M. Knox,*
Nellie E. Fisher.

Derby Borough .—Ethel Boddington, Kate E. Jennings, Catherine A. Froggatt.
Gateshead. —Lily Lund.

Hull City .—Louise Brackenbury, Annie R. Allison.

Leicester Borough.— Maud M. Kellam, Maud M. Collier, Ethel M. Hickling, Ellen
E Ingram.

Camberwell House .—Lucy E. S. Rowdon, Daisy B. Bates, Dorothy S. Breem.
Bethlem .—Albert H. Joslin, Catherine R. Brown, Emily M. Burt, Maud Page,
Grace R. Lowman, Dorothy Henley.

Coton Hill .— Elsie M. Ledger, Edith Davies.

St. Andrews, Northampton. —Henry J. Battrick, William H. Thistlethwaite,
William S. Brown, Florence Woodford, Ruth Garnett,* Rose Clarke, Daisy
Porter.

Fenstanton .—Elizabeth Mitchell, Louie Palmer, Emmie Dommett.

Holloway Sanatorium. —Violet A. B. Gresswell, Ellen D. Rea, John Meldrum.
Bootham Bark. —Katie E. Taylor, John H. Darley.*

The Retreat, York. —Annie Jarvis, Christina McLauchlan, Mary E. H. Watson.*
Aberdeen District. —Jeannie Mackie, Margaret P. Robertson.

Aberdeen Royal. —Mary Ross, Helen J. Smith, Jeannie Clark.

Ayr. —Annie C. Soutar, Mary C. Watson, Selina McBryde, Jane W. Beaddie,
Wilhelmina McBride.

Banff. —Jeannie Peters, Williamina L. Wilson, Davidina Denoon, Helen D.
Stuart.

Crichton Royal. —Majorie Sidey, Jean Welsh, Christian S. Davidson, Isabella
V. Watt, Mary H. Petrie, Joan B. Duncan.

Dundee Royal. — Helen Buist, Bessie M. Blyth.

Craig House. —Mary Irvine, Mary C. Hamilton, Agnes B. Ritchie, Maggie 0 .
Elder, Janet Kinghorn, Jenny Stirling, Jeanne W. McDonald, Emma A. Glass.
Elgin .—Beatrice A. Browse, Jessie Craib.

Edinburgh Royal .—Jean M. Whitson, Jessie York, Jane M. Gardiner, Elizabeth
Scott, Annie J. Lee.

Edinburgh District .—Annie E. Macdonald.

Gartloch .—Elizabeth P. Rae, Charlotte Currer, Christina B. Crosbie, Peter J.
Clark.

Gartnavel .—Helen F. M. Duncan, Dolina Morrison, Agnes F. McKay, Catherine
Maclean.

Woodilee .—Sophia McD. Smith, Margaret McEwan, William MacFadyen.
Ilawkhead .—Joan Millar, Frances Lyon.

Inverness .—Margaret Mutch, Jessie McG. Campbell, Mary McDonald.

Lanark .—Marion Fitzsimons, Sophia Gibson.*

Melrose .—Agnes M. Macdonald.

Montrose .—Jessie Spalding, Annie P. Black.*

Murray .—Christina F. Stewart, Margaret L. Walker.

Riccartsbar, Paisley .—Mary T. Paul, Jeannie F. Emslie, Isabella Currie.
Stirling .—Nora Don, Katherine McLeod, Maureen Nangle, Janet D. Main.
Larbert Institution .—Mary B. Fraser, Alice L. Ormerod, Sarah W. Miller,
May Shepherd, John Ferguson, Margaret Thompson.

Enniscorthy .—Lucinda A. Pierce, William Delaney.

Mullingar .—Matthew Murtagh, Bridget Maher, Joseph Rabbit, James Lyster,
Agnes Murtagh, Patrick Creamer.

Londonderry .—Edward McGinty, Ailsa M. Brennan.

Omagh .— Mary E. Gallagher, Annie M. Brogan.

I’ortrane.—T Hugh Kirwan, Mary E. Clarkin, Richard Breen, Kate A. Scully,
Christina Nicholls, Annie Bourke.

Richmond .—Bridget Cummins, Nicholas Meehan, Thomas Fagin, Thomas P.
Smyth, Eleanor Furlong, Mary Dempsey, Mary O’Connor.

Palmerston House .—James Maguire.

Bloomfield. —Sarie F. Gilbert.

Warwick County .—Evelyn Flaherty.

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NOTES AND NEWS.

647

Preliminary Examination.

Berks County. —Violet Ellen Wakeling, Ellen Ethel Hiatt, Beatrice Holliday,
Edith Rust, Lucie Sara Darby, Gertrude Fanny Gregory.

Cumberland and Westmorland. —Ebenezer Johnstone Barton, Edith Esther
Lancaster, Lena Hardy.

Essex, Brentwood. —Ethel Rose Pickett, Alice Feeney, Beatrice Alice Bleyard,
Alice Porter.

Essex, Severalls. —Dorothy Rose Whilbourn, Elizabeth Ann Robinson, Ethel A.
Kent, Kathleen Veronica Murphy, Alice Russell, Florence Annie Pitt, Henrietta
Elizabeth Hood, Grace L. Mihill, Bertha Jone*, Ethel Beakhurst, Dora Pearson,
Winifred V. Taylor, Rosa Fisher, Mary Ellen Smith, Alfred Radley.

Glamorgan County. —Elizabeth M. Williams, Henry A. Murphy, Maggie Jones,
Clara Ann Prew, Lizzie Myfanwy Davies, Elizabeth M. Harries, David Thomas,
Thomas Ardwyn Lewis, Edith Gertrude Burroughes, Gertrude A. Price, Winifred
E. Preece, Elizabeth Reynolds, Grace Love Griffiths, Elizabeth E. Jones, Thomas
G. Hand, Jeremiah Daly, Tom Griffiths, Edward Byrne, Charles Winteringham.

Isle of Wight. —Vida Webber, Ivy Baker, Elsie E. Glew, Beatrice M. Message,
Helena A. Bayliss.

Kent, Maidstone. —Annie Barnett, Ellen Cotter, Marjorie Leaver, Mabel Taylor,
Nellie Jones, Lillian May Leverett, Robina Blair Kilgour, Eva Gladys Wood,
Aziel M. Endacott, Clara Hawkes, Bessie Lowe, Mildred C. Tiver.

City of Loudon. —Marion Johnston, Dorothy Clapham.

Cane /////—Florence M. Jarvis, Ethel F. Tucker. Rosa G. E. Brentnall, Caroline
E. Taylor, Emily E. A. Amos, Laura L. Payne, Sarah M. Shepherd, Emily M.
Woods, Maud A. M. Voller.

Epileptic Colony, Ewell. —Mildred Henley.

Hanwell. —E. E. Plumridge, Emily C. Manley, Frances G. Turner, Amy O.
Gardner, Amy M. Brocksopp, Winifred M. Toms, Mary E. Dickens, Elizabeth
Langston, Edith L. Knight, Alice Wilden, Mildred A. Rust, Esther G. Mason,
Maggie Wright, Irene M. Earp, Edith Rowell.

lxmg Grove. —Laura M. Dyson, Evelyn V. Wolfe, Annie Rosena Keys, Annie
I. Gould, Rose E. Dealey, Edith Clarke, Albert J. King.

Manor. — Gladys G. Smith, Alice M. de Mont, Lydia V. Hook, Florence M.
Lake, Kate Louisa Longlev, Dorothy M. E. Cross, Ellen R. Lynch, Rachel
Vaughan, Amy Sallis, Winifred M. Donnellan, Lilian M. Thomas,

Colney Hatch. —Mabel E. Foster, Amy E. Janes, Alice N. Fenn, Emily Bodington,
Yvonne R. Colin, Edith M. Tarr, Kathleen M. E. Shaw, Alice Taylor, Marjorie
A. Watkins, Lois Root, Kate Green, Beatrice L. Dawe, Emily Ashton, Catherine
Turner.

Fountains Temporary Asylum. —Edith Morrison, Edith H. Wright, Violet M.
Hills, Beatrice M. Chapman, Clara Brighton.

Banstead. —Violet M. Taylor, Elizabeth A. Williams, Elsie E. Gill, Daisy M. A.
White. Olive White, Charlotte Hooper, Naomi R. L. Langley, Ethel M. Sperring,
Edith Wilkinson, Dulcibel Jeffery, Elsie M. Quick, Emily R. Hempsted.

Caterham. —Florence Ewer, Jean Young, Mary H. Bellingham, Mabel Williams,
Lena A. G. Yeoman.

Leavesden. —Florence E. Murray, Laura Winifred Sanders, Grace E. Maurice,
May G. Hickman, Rachel Gribbon, Winifred Cox, Evelyn M. Oliver, Mildred E.
Neate, Lottie Hoath, Lucy Holmes, Eva A. Whittaker, Margaret Blew, Nellie E.
Phair, Adelaide Rockliffe, Sarah Hill, Mary B. Protheroe, Elizabeth Marchant,
Edith M. Coles.

Shropshire County. —Myfanwy Lloyd, HildaS. Davies, Mary C. Rees.

Staffs., Cheddleron. —Lilian E. M. King, Florence A. Ledbury, Lily Noble,
Gwladys Jones, Helen A. Findlay, Hilda A. Owen, Jessie M. Macdonald, Elsie
Pollard.

Hayward's Heath. —Gladys Robson, Ellen M. Haysey, Amy Cox, Alice E.
Harbord.

Hellingley. —Jessie Baker, Kate E. Dobinson, Marion Costigan, Winifred M.
Keep, Mary M. Partland, Annie Riddle, Olive Baker, Doris M. G. Welford,
Elizabeth Gibney, May Tindall, Annie E. Netley, Marion H. Burgess, Nora
Powell.

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648 NOTES AND NEWS. [July,

West Sussex. —Arthur W. Riley, William H. Berry, Kate A. Charles, Olive A.
Tribe.

Worcestershire, Barnsley Hall. —Annie Young, Pamela E. Baugh, Elsie M.
Colley, Hilda W. Lucas, John Duflill, Harry M. Storr.

Canterbury Borough. —William Filmer, Bessie Newing. Alice I. Tumber.

Derby Borough. —Mildred A. Coulson, Jane Crook, Kate A. Devine, Lilian
Goodall, Annie Hall.

Gateshead. —Jessie McK. Kennedy, Annie Murray.

Hull City. —Alice Marshall, Frances Clayton, Annie Ellison, Muriel Devereux,
Clara L. Pearson, Floris E. Lloyd, Blanche Froggett.

Leicester Borough. —Miriam Hills, Elizabeth Stanley, Ethel M. Richardson,
Alice E. Whomsley.

Sunderland Borough.— Barbara Laybourn, Jane Curry, Violet Lockey, Beatrice
M. Selbey, Ronald W. G. Dean, Kathleen Cassidy.

Bailbrook House. —Mildred A. Crocker.

Bootham Park. —Emily H. Lambert, Isabel K. Young, Amy Walker, Ida Earless,
Florence E. Willey, William A. Hopwood.

Camberwell House.— Ellen M. Froud, Dorothy K. Wood, Beatrice'Richards,
Edith C. Jordan, Grace E. Luckhurst, Margaret Stephens, Adelaide G. F. Hart,
Emma M. Harden.

Coton Hill. —Salome Price, Elinor Annie Owen, Elizabeth M. Jones.

Hunstanton. —Hilda E. Parr, Georgina Longman, Edith M. Wooldridge, Edith
Earls.

Holloway Sanatorium. —Ethel C. Holdawav, Catherine Tjebbes, Dorothy A.
Brewerton, Maria Leonie Boussier, Brenda H. Peters.

St. Andrew’s. — Ida M. Wade, Hilda M. Pears, Katie M. Potter, Florence R.
BifTen, Louis Botterill, Phyllis R. L. Brown, Ethel Cosford, Alice Webb.

St. Luke's. —Violet A. Birks, Edith M. Tugwell, Ethel R. Smith, Ellen M. Ash¬
bury, Myfanwy Jenkins, Ada F. Jones, Martha A. Morse.

Warneford, Oxford. — Marion G. Green, Emma L. Allard, Nettie Noble.

York, Retreat. —Ada Margaret Ellis, Minna A. S. Samuel, Isabella M. Huggard,
Nina M. Weighed.

Aberdeen Royal. —Jemima Craig, Helen Forbes, Dorothy McHardy, Mary
McRobbie, Elsie M. Minty, Minnie Taylor.

Argyll and Bute. —Grace C. B. Garrow, Margaret F. Campbell, Malcolm
Turner.

Ayr. —Grace Mitchell, Agnes Wilson, Rachel Macmillan, Margaret O. McGill,
Margaret Y. Chalmers.

Crichton Royal. —Francis W. J. Anderson, Lawrence Watts, Robert Neill,
William M. Fraser, Elizabeth Black, Mary F. Edgar, Margaret D. Eadie, Sarah E.
Johnston, Mary Macdonald, Annie Wilkie Smith, Annie Wright, Annie Browne,
Victoria Shelborne, Agnes Liddle MofTatt, Elizabeth Bruce, Janet D. G. McDowall,
Barbara McMorran, Ethel McLennan, Mary S. McCartney, Mary H. Currie,
Margaret Cameron, Agnes W. L. Ednie, Jessie Sidney, Jessie A. Bowie, Mary
Munro, Janet R. Murray, Jean A. S. MacLeod.

Dundee Royal .—Jean A. Smith, Victoria C. Knowles, Annabella Simpson,
Margaret B. Penman, Margaret Harper, Jeannie Car, Mary Duffie, Mina Lovie.

Craig House. —Annie H. H. Lawrence, Isabella Campbell, Jean Davidson, Mary
T. Brady, Margaret H. Shaw, Elsie C. Gentil, Davina Hepburn, Mary R. Robertson,
Edith W. Clelland, Mary E. Shearer, Suzanne G. Crilley.

Edinburgh Royal. —Mary Fraser, Christina B. Donaldson, Sarah M. Richmond,
Muriel M. Pond.

Edinburgh District. —Caroline C. Watson, Kathleen A. Kane, Catherine Mclnnes,
Isabella Mackenzie.

Gartloch. — Agnes E. Anderson, Agnes R. Scott, Allison R. Russell, Mary
Taylor.

Gartnavel. —Isabella Eadie, Annabella Finlayson, Annie Marshall, Annie N.
McGuire, Catherine McKerchar, Williamina Seggie, Rachel W. Stein.

Woodilee. —Patrick McGlynn, Mary McFatter, Marion Lithgow, Isabella Hughes,
Mary Denny, Margaret B. McLean, Elizabeth McNeilage, Annie J. Mack. Macpher-
son, Ellen Devins, Rose A. McLaughlan, Jeanette McLennan.

Haddington. —Catherine Graham, Jeannie McBain.

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NOTES AND NEWS.

649

Hawkhead, Paisley. —Jane Mackinnon, Margaret G. Brown.

Inverness. —MariaS. Sutherland, Sarah McNab, Johan Fraser, Margaret Camp¬
bell, Jessie MacLachlan, Margaret Nowery.

Lanark. —Mary Singer, Georgina Campbell, Mary McCulloch Aitken, Dorothy
Cooper, Mary Ketchen, Flora McDougal Baillie, Annie Davis Clifford, Thomas
Prentice.

Melrose. —Alexander Bruce, Charles Cowie, William J. Ingram, Peter Sinclair,
Elizabeth McIntosh Forbes, Agnes Neil Mitchell, Janet McGlashan McKinnan,
Ethel Palleser, Ann Sinclair, Lizzie W. C. P. Webster.

Midlothian. —Maimie F. Low, Charlotte Manson, Jean Martin White.

Montrose. —Agnes S. S. Smith, Margaret Potter, Julia Brown, Margaret C.
Munro, Elizabeth D. Gibson.

Paisley, Riccartsbar. —Mary Coburn Douglas, Isabella Duff.

Perth District. —Mary Taylor, Elizabeth L. Alexander, Jessie A. Fraser, John
Fraser.

Murray, Perth. — Jean McDonald, Lizzie A. Wilson, Mina de H. Estcourt,
Elizabeth McLean.

Larbert Sterling. —Agnes McG. McLaren, Isabella P. Dixon, Mary Noonan,
Annie Talbot, Mary Flannelly, Elsie Green, Mary McNally, Delia T. Kearney,
Kathleen C. Mawn.

New Saughtan Hall. — Isobelle Black, Mary Jane Brown, Mary A. Mclnnes.

Ballinasloe. —Kate Reilly, Margaret Egan, Katie Treacy, Mary Dooley, Ada
Connelly, Mary T. Manning, Maria Fallon, Agnes Hicks, Katie Goode, Elbe
Concannon, Julia Coyne, Patrick Kelly, John Hanniffy, Michael Kelly.

Londonderry. —Isabella Baird, Susanna Collins, Joseph Millar.

Monaghan. —Thomas Farrelly, Joseph Cochrane, Charles Coleman, Michael
McManus, John McEntee, Maggie McCaffrey, Maggie I. Hanna, Maud Lynch,
Maggie Mulligan, Annie McEneary, Mary Murtha, Bridget Hughes, Annie Daley,
Annie Cully.

Mullingar. —Christopher Fox, Annie Jeanlan, Brigid Ledwidge, Mary Brady,
Mary Anne King, Kate Keogh.

Omagh. —Mary McAleer, Mary McGonigle, Katie Jackson, Brigid Donaghey,
Rosanna Doherty, Rebecca Morrow, Isabella M. Guy, Mary T. McLaughlin,
Martha Lowe, Catherine McNulty, Robert Porter, Andrew Stevenson, Edward
McCormack, Thomas Gavin, Mary Gray.

Portrane. —Caroline S. Noble, Thomas McDonnell, Patrick Glennon, John
Cullen, Bartholomew Dowdall, William Brady.

Richmond. —Patrick Coogan, Denis Lacey, Rose Kiernan, Kate Cass, Christina
Fegan, Jane McNally, Elizabeth J. Gavin, Margaret McGloin, Elizabeth Gore
Elizabeth Doyle, Jane Keogh, Margaret O'Foole.

St. Patricks. —Eva Marcella Smyth, Stasia O’Loughlin.

Waterford. —Catherine Neary, Anastasia Flynn, Hanna Carroll, James Maher,
William Gallagher, Richard Barry.

Bethlem Hospital. —Fred Ernest Wallen, Gladys F. M. King, Eveline M. Hinds,
Sybil E. Burleigh.

Warwick. —Eva Florence Stroud, Mabel Tompkins, Katie Fleming, Annie E.
Dimond, Kathleen Carlos, Elsie Jones.

OBITUARY.

G. T. Hine, F.R.I.B.A.

The list of Honorary Members of the Association has suffered a sensible loss
by the death of Mr. G. T. Hine, F.R.I.B.A. That list has been designedly
restricted to our medical colleagues, and has been almost entirely barred against
laymen. The laymen admitted since the institution of the Association can be
reckoned on one hand. The sole essential condition on which this exclusiveness
has been waived is successful endeavour in pursuing one of the three cardinal
objects of the Association—“ the improvement in the treatment of the insane." In
Mr. Hine’s case it would be impossible for anyone, however critical, to deny that
the lot of the insane is a good deal happier since he devoted his marked talent to
their better housing.

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650 NOTES AND NEWS. [July,

When one speaks of an architect’s ability the mind naturally exercises itself first
about his power to give an imposing and artistic cachet to a pre-ordained structure.
In this direction Mr. Hine was entirely circumscribed by forced economy on the
part of his employers. He had no chance of designing masses of buildings for
the insane in the magnificant style sometimes adopted outside his own sphere of
action. Nevertheless he was very successful in producing satisfactory piles,
which were always neat and never offensive to the eye ; some indeed are striking.
When one thinks of the huge masses, necessarily plain and often much redu¬
plicated, which he had to throw together in such fashion as to avoid unwieldy
ugliness, it may be rightly claimed that his work in the artistic direction was as
excellent as it could be. In another direction, that of securing fair pleasingness
combined with appropriate usefulness, Mr. Hine was equally successful. He
adopted a very safe course in framing estimates, placing his calculations, if any¬
thing, a trifle above expectation, with the result that those estimates were very
rarely exceeded, apart from unavoidable variation in prices brought about by
external agencies. If the committee liked to increase their requirements, the
excess in cost rested with them.

With regard to that duty of an architect—the production of a building that
would answer its purpose to the full—Mr. Hine was abundantly successful. He
had the good fortune to take up his work just at the time when the care of the
insane was commencing to take on a scientific aspect. We can see, in the costly
rebuilding of the lightless, airless barracks which did duty for asylums before that
time, the effects of the want of science. When it became evident that the require¬
ments of hygiene and scientific treatment called for special provision, the building
of the asylum became a special study, and the way was open for anyone who chose
to devote himself to the specialty. If Mr. Hine cannot be deemed the originator
of the art in the form in which it now is, and as far as we know there is no one
to deny this credit to him, he was at least a most competent exponent. The
principal features which can be traced in his chief w’ork may be given as follows :
First, the arrangement of the wards or blocks round a common administrative
centre, so as to secure a minimum distance between centre and periphery. This
resolved itself naturally into the shape of a bow or half-wheel. The disposition of
the component blocks offers a variety of treatment, whether in echelon or con¬
tinuous, all requiring a certain amount of partitioning off from one another,
combined with means of ready access from each to its neighbour. Much in¬
genuity was required in securing these objects. Then followed the designing of
detached “ hospital blocks,” the demand for which was, of course, created by
medical thought. Mr. Hine also designed in happy usefulness some novel houses
or villas for low-grade children and idiots. Another medical suggestion found
ingenious and successful treatment at his hands. We refer to the arrangements
by which male wards can be nursed by females to a greater or less extent, as
might be found desirable. His art in these directions did not come all at once,
it had been built up by degrees, mostly on experience renovated by experience, and
here arose the mutual benefit which came from Mr. Hine's intimate association
with our body and its members. Both sides benefited, for, while he listened with
advantage to private or public conversation on medical requirements, the medical
element was encouraged to evolve useful betterment by the knowledge that there
was one at hand who could put them into being. Mr. Hine was most sympathetic
in such matters, and always ready to take any amount of trouble to work out a
suggestion, if possible.

We think that it would not be unreasonable to claim that Mr. Hine has founded
a distinct school of asylum architecture. Below will be found a list, possibly not
exhaustive, of those asylums for the building of which he was responsible. If
asylums built by other hands can be found which by their dispositions might seem
to invalidate such a claim, one can but say that the plans of any asylum have been
easily obtainable, and further, that the similarity of design is but a compliment to
Mr. Hine.

Personally Mr. Hine was something more than an Honorary Member to many
of us. He was a rare companion, full of information, always ready for a jest, but
possessing that modest quasi-deferential manner in asylum conversation belonging
to the strong and industrious mind which is perpetually waiting on the wisdom
of fools.

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!9l6.]

Mr. Hine’s name and memory, as part of the Association, are preserved to us in
the person of his son, who is with the R.A.M.C. on bacterial work. Mr. T. G. M.
Hine has been a member for ten years.

Asylums built by Mr. Hine : London County—Claybury, Bexley, Horton, Long
Grove ; Gateshead, Hampshire (second asylum), Hertfordshire, Kesteven, Merthyr,
Sunderland, Surrey (Netherne), Sussex Cent. (Hellingly), Swansea, Worcester¬
shire (Barnsley):

Several other asylums were added to or altered by Mr. Hine, e.g., Dorset,
Cotford, Moulsford, St. Albans, Wilts, Leicester.

BALLINASLOE ASYLUM.

The Inspectors’ report on certain occurrences which took place in the above
asylum, as published in the April number of the Journal, has led to a rather
anomalous condition of things, as will be seen from the following extract from the
pages of the daily Press :

Ballinasloe Asylum Inquiry.

Dr. T. J. Considine and Dr. Wm. Dawson, Lunacy Inspectors, attended at
Ballinasloe Asylum to hold an inquiry as the result of a report which they had
made as to the treatment of some patients in the institution.

Dr. Comyn, solicitor, said he had advised his clients, the Matron and the staff,
to decline to give evidence. The Court of Inquiry should be an independent
tribunal.

Dr. Considine said the inquiry was called for by the Asylum Committee, and
they had power to hold it. Those who declined to be examined did so at their
peril.

Dr. Kirwan, R.M.S., was first called, and said on the advice of his solicitor he
declined to give evidence.

The Matron and the other members of the staff did likewise.

Dr. Ada English, Acting R.M.S., said she was told when taking up the position
that it was not her duty to visit the female side. She agreed with the Inspectors’
report. She did not remember giving permission to put the patients to sleep on
straw.

Dr. Murnane said he saw the patients lying on straw, but he gave no permission
for its use. He never knew that the patients were naked.

This concluded the inquiry.

CORRESPONDENCE.

Royal Medical Benevolent Fund.

To the Editor of The Journal of Mental Science.

Dear Sir, —The Royal Medical Benevolent Fund, the great Benevolent Society
of the medical profession, is sorely in want of money now.

Though in ordinary times the medical profession supports its own poor, in
these war times this is no longer possible. At the May meeting the Committee
had a balance of only .£17 in hand, and at the June meeting was faced with a
deficit of .£16. The demands were heavy and had to be met, and this could only
be done by withdrawing .£500 from the bank.

As the direct outcome of the war, not only are the ordinary cases of poverty
greatly increased in number, but an entirely new class of case has arisen urgently
requiring relief, in which without actual poverty there is great temporary distress,
distress, however, which it is hoped will relieve itself soon after the war is over
and the doctors serving return to their civil duties.

At the outbreak of war the medical profession responded freely to the Nation's
call. The Territorial Medical Officers were at once called out, and other medical
men volunteered. Both alike had to leave their practice at very short notice, and
often without being able to make adequate provision for its continuance and
maintenance during their absence. Their pay went but little way to supply the
loss which their absence entailed, for the working expenses of the practice could

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652 NOTES AND NEWS. [July, 1916.]

not be materially reduced. The result was that many families found themselves
in very straitened circumstances. Rent, rates, and insurance brook no delay;
but, worst of all, school bills could not be paid, and if help had not been quickly
forthcoming, the children would have suffered for the patriotism of their father.

The following are typical of the cases with which our Fund has had to deal:

A young doctor, who had only been in practice a few years, volunteered for
service, and was killed in action a few days later. He left a widow, ret. 35, with
two young boys, set. 3^ and 1 year, entirely without means. The Fund voted ^25
for her immediate necessities, and put her into communication with the Officers’
Families Association, which gave further help.

A practitioner, aet. 38, earning ^700 to £8oo, volunteered for service, leaving his
practice in the hands of a neighbour, who was not a success. There were two
young children, and another baby was born shortly after the husband left. The
wife contracted pneumonia and nearly died. A resident patient had to leave the
house. Rent and other expenses led to a debt of about ^80. This the doctor
could not meet, and he hurried back from the trenches to save his home from
being sold up. The Fund voted ^25, the Guild gave £15, the Officers’ Families
Association .£25, and the Professional Classes War Relief Council further help,
with the result that he returned to the Front with his immediate anxieties relieved.

A captain in the Territorials was called out and had to leave his practice in the
hands of a locum, who proved a failure. There were seven children, ret. 2 to 14.
Financial difficulties arose, and payment of the school fees became impossible.
Between the Fund and Guild and Officers’ Families Association, the necessary
fees were raised, and clothing, which was greatly required, provided.

These cases show well the way in which the Fund works, not only by giving
relief itself in money and kind, but also by obtaining through co-operation with
other benevolent Societies more substantial assistance than it could afford alone.

But there is another class in which the distress is perhaps even greater, and
adequate relief more difficult. It is that of men who left home and a good practice
in vigorous health and who have come back, crippled by wounds or with health
impaired, to a practice severely damaged by their absence, and without the strength
or energy to regain the practice and position which they sacrificed.

Our Fund has set apart a special sum to meet emergency claims of this kind,
yet the demands are so great that it will soon be exhausted. We cannot now rely
on the profession alone to supplement it largely, for the medical profession, like
all other professions, is hit very hard by the war, and has no longer its old
resources to draw upon.

What is required is an Emergency Fund large enough to deal adequately with
these emergency cases arising directly out of the war, and for this we are driven to
appeal to the public as well as to our own profession.

We trust that our appeal will meet with a liberal response both from the public
and from the medical profession, for unless fresh funds are quickly forthcoming
it will be impossible to continue the relief which is so urgently required.

We are,

Faithfully yours,

John Tweedy, President.

Samuel West, Hon. Treasurer.

G. Newton Pitt, Hon. Secretary.

II, Chandos Street,

Cavendish Square,

London, W.

July 3rd, 1916. _

NOTICE TO CONTRIBUTORS.

Contributors are requested kindly to bear in mind that, according to Bye¬
law 56, " all papers read at the Annual, Quarterly, or Divisional Meetings of the
Association shall be the property of the Association, unless the author shall have
previously obtained the written consent of the President, after consultation with
the Editors, to the contrary.”

Papers read at Association Meetings should, therefore, not be published in other
journals without such sanction having been granted.

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THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Irelandi]

No. 259 [ n ‘ n ™‘ k< ] OCTOBER, 1916. Vol. LXII.

Part I.—Original Articles.

Mental Disabilities for War Service. By Sir George
H. Savage, M.D., F.R.GP.Lond.

Gentlemen, in providing this paper I have felt many
difficulties, for, while wishing in no way to protect shirkers,
I wanted to avoid sending men into the army who were
almost certain to break down under training, or at the
front.

I meet a good many London doctors, who have little
experience of mental disorders, who act on the idea of giving
the man a chance. As you know it is at times worth running
some risk with mental patients : a complete change in mode
of life may turn a hypochondriac into a useful worker. But in
taking risks one must see on whom the risk falls.

I see patients who might serve as subordinates, but on whom
no personal responsibility must rest.

I was first impressed with the importance of the subject
when visiting, with Major Miles, Block “ D ” at Netley, where,
as he pointed out, there were many men who ought never to
have been enlisted. Such men involved considerable trouble
and anxiety as well as cost to the nation. Later, as con¬
sultant to Lord Knutsford’s homes for officers, I saw other
men who were quite unsuited for the positions in which they
had been placed. And, finally, I have had many old patients
and their relations who have consulted me as to their fitness
for military service.

VOL. t.xii. 42

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As a result chiefly of my experience with this last group,
I purpose placing before you my views on the subject.

First, as to men who have already had at least one attack
of insanity. As these are all under middle age, hereditary
predisposition must influence one’s judgment.

I as a rule oppose the enlisting for active service of any
young man with direct insane inheritance, who has had an
attack of well-marked mental disorder within a few years
which required detention.

Some of these men are quite fit for home or munitions
work.

Often another difficulty arises. The previous breakdown
is unknown to companions and employers, and these look upon
the man as a shirker or coward, and may let him know their
opinion. I have seen several such patients who were becoming
unstable because of the idea that people mistrusted them, and
I have even decided to run the risk of enlisting some of these
men, as I felt that there was a real danger of their developing
delusional insanity with auditory hallucinations.

I have seen a very large number of men who have suffered
from previous nervous or mental disorders, in whom the
struggle as to what was their duty has produced various forms
of mental disorder of a functional character.

One strong, hearty fellow came into my room and at once
burst into tears. He was heartily ashamed of this outbreak,
but no sooner did he begin to describe his other symptoms
than he broke down again. He was sleepless, unable to fix
Iris attention, and I judged him unfit for military training.

In another case—and he represents a special group which
I recognise—the patient, who some years before had been
unable to follow any definite training for a profession on
account of instability, was sent to me as a case of adolescent
mental weakness associated with onanism. Out-of-door
occupation restored him, and he was able to earn a living ;
but when the question of enlistment arose, once more all power
of making up his mind failed. He was distracted and depressed.
He could not sleep, and felt his brain in a state of whirl,
so that he could not decide on or start at anything. He was
agitated and threatened suicide, as he felt he should go out
of his mind if he was called upon to perform duties for which
he was unfit.

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BY SIR GEORGE H. SAVAGE, M.D.

6 55

In another case with a similar history, and with a story of
neuropathic heredity, a few years in Canada seemed to have
established his ability, and he joined the Canadian contingent;
but after a few months’ service all the old troubles recurred, and
it was a question whether he could be safely treated out of an
asylum.

Such cases are suffering from folie de doute.

Here I may refer to the recurrence of symptoms of mental
disorder in those so-called shock cases. I have seen so many
of these patients who, having to all appearances recovered,
break down on return to active service. None of these cases
should go back to service under six months.

I have met a certain number of cases of simple mental
defect in which the weakness, which is often masked, has not
been recognised by the examining doctor.

Thus, some years ago I was consulted about a youth who
could not be educated in the ordinary way. To begin with,
he had a total want of understanding numbers and their
relations, he seemed quite unable to remember any abstract
thing, and though he could copy, he could originate nothing.
He enlisted, but was considered wilfully obstinate and stupid ;
but punishment did no good, and I did my best to get him
out of the army.

A more difficult group of defectives has been seen by me,
and as a rule I let them run their risk of enlisting. Thus, in
the case of one man, about whom I had been consulted when
he was at school for his lying and pilfering ways, no treatment
did any good, and perhaps he may make a useful fighter.

Still another difficulty has arisen in relation to homo¬
sexuality. I have met several men who, without being actual
offenders, have caused trouble by their unnatural attachment
to companions. In two cases the friendship grew into an
obsession, and apart from the companion the man was
depressed, suicidal, and professionally ineffective. Now what
could one do with such a one ?

I have met a few cases in men already in the army who
undoubtedly were suspicious almost to madness before the
war, but who later became definite paranoiacs. In the Boer
war I saw such a one who was sent out in command of a
cavalry regiment. From Africa he sent a very mad telegram
to me ordering me to stop the persecutions from which he was

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suffering. He was sent back to England, and for a time was
under control, but again he wants to be sent out to active
service.

I have seen several patients who had suffered from slight
but undoubted attacks of petit mal. Some of these were
anxious to serve, but, of course, I opposed enlistment on
active service.

It is interesting, however, to recognise a form of functional
epilepsy which may follow shock or injury. I have met
several cases of men who, as the result of psychic strain or
shock, lose consciousness for short periods, and yet when
removed from strain they recover, but relapse if sent back
to duty.

There are some cases in which one has to act on one’s
experience even in opposition to appearances, and perhaps in
opposition to the authorities. There is a young man of very-
high eduqation, a public school and university man of con¬
spicuous ability, who at the end of his university career
collapsed mentally, and for over two years was in mental
stagnation. He lived a simple labourer’s life on the land, and
slowly recovered and became physically and intellectually
healthy, yet, knowing his past and guaging his present state,
I decided that he was quite unfit for trench life. I have
opposed the enlistment of confirmed somnambulists.

I should oppose the enlistment of certain men who have
hallucinations, though I recognise that some such manage to
live fairly normal lives out in the world.

I have met with several rather peculiar cases of obsession.

In one a fine, healthy-looking young man of thirty con¬
sulted me under the following conditions. He is a manu¬
facturer, and some years ago he was in a railway accident.
Since that time he has never been in a train, and the very
fear of a train almost distracts him. He was greatly excited
at the fear of having to travel by train. I remembered having
seen his mother, who was in an asylum for some time suffering
• from melancholia. I decided against his serving.

I have seen two men who, from adolescence, have been
unable to micturate except in private, and I have also heard
of others who have had to leave the army because of this
disability. It seems impossible for such men to live cam:)
life. Perhaps hypnotic suggestion might relieve some of

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igi 6 .] THE COMPLUETIC REACTION IN AMENTIA. 657

them, but I have met some who had been thus treated
without any good resulting.

A large and important class may be called the syphilitic
group. In this I place the general paralytic, the ataxic, and
some para-syphilitic cases. Directly one is consulted by a
middle-aged man for vague and uncertain nervous symptoms
nowadays one not only asks if the patient has had any
venereal disease, but one is not satisfied unless there is
negative YVassermann reaction. I have met with several cases
in which the history of syphilis was comparatively recent, and
therefore the symptoms were treated as possibly removable,
and these have done well. Very many cases of early general
paralysis have occurred in the army, and the life of anxiety
was just the one likely to start the more active symptoms.
It is hardly necessary to say that no man with a clear history
of nerve degenerative symptoms related to syphilis should be
allowed to enter the army, but there are some of the patients
whose symptoms are recent, and who after treatment may be
allowed to enter the service.

The Conipluctic Reaction ( Wassermann) in Amentia:
an Original Study of ioo Cases. By Harold
Freize Stephens, M.R.C.S., L.R.C.P.

All the experiments for this investigation were carried out
by me in the Bacteriological Laboratories at Guy’s Hospital,
and my thanks are due to Dr. Eyre, the Director, for having
placed every facility at my disposal, and to Dr. Ryffel, the
Chemical Pathologist, for his advice and assistance. I am
also indebted to my Board of Management and to my Medical
Superintendent, Dr. Caldecott, for their courteous permission
to undertake this investigation in the case of patients resident
under their care at the Royal Earlswood Institution, at Redhill,
in Surrey.

A foreword is, perhaps, necessary in explanation of the title
I have assumed for this paper, a title for which I beg your kind
indulgence. By the “ compluetic reaction ” I mean the
“ Wassermann reaction.” It ought never to have been called
the “ Wassermann reaction,” for, as everybody should know,

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and as our President has placed on record in his communica¬
tion to the late Royal Commission on Venereal Diseases on
this subject, not YVassermann, but the Belgian Professor Bordet
was the first to “ discover,” to study and “ establish ” the
essential principle of the test. As England to-day is at war
for justice and fair play, it is only meet and right and, perhaps,
our bounden duty that the Belgian should come to his own
again ! The proper name for the “ Wassermann reaction ” is
the “ Bordet-Gengou phenomenon in syphilis,” but, although
this is rightly its proper name, such a designation, however
romantic the association of the things discovered with the
names of their discoverers may be, is nevertheless not quite
correct. For it is but a mere truism to maintain that natural
processes exist and are not made ; they always were and will
be, in spite of their discoverers ; and it is with the things
themselves that science is concerned. The more correct
phraseology, therefore, would be “ the complement-fixation or
deviation phenomenon in syphilis.” For this rather cumbrous
expression I have taken the liberty to make the simpler term
the “ compluetic reaction,” coining the word “ compluetic ” from
the two words “ complement ” and “ luetic,” and as such I beg
leave to submit it to your courteous and generous con¬
sideration.

This paper is divided into two sections :

(A) A summary of the technique employed in the experi¬
ments.

(B) An analysis of the results obtained thereby.

(A) The Technique Employed.

1

The technique employed was that in current use at Guy’s
Hospital. It may be briefly summarised under the following
three heads :

(1) The reagents used in the test.

(2) The preliminary preparations for the test.

(3) The test.

The Reagents.

As is well known, the reagents required for this test are :

(1) Antigen.

(2) Reagin (blood serum or cerebro-spinal fluid).

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1916.]

BY HAROLD FREIZE STEPHENS, M.R.C.S.

659

(3) Complement.

(4) Haemolysin.

(5) Erythrocytes.

(6) Saline solution.

The materials used in my experiments were as follows :

(1) For antigeti a 1 in 10 saline solution of an alcoholic
extract of hitman congenital syphilitic liver.

(2) For reagin only the blood sera were used. The sera
were obtained from the peripheral blood of the patients. They
were used undiluted.

(3) For complement a 1 in 10 saline dilution of fresh guinea-
pig’s serum.

(4) For hcsmolysin a 1 in 20 saline dilution of the haemolytic
sera of rabits immunised against human red blood corpuscles.

(5) Vox erythrocytes a saline suspension of fresh human red
blood corpuscles, obtained always independently of the bloods
to be examined, and diluted 100 times (1 in 100).

(6) A o - 9 per cent, saline solution , freshly made and sterile,
was used for all dilutions in the test.

It may not be out of place here to note the following facts
concerning the reagents :

(1) Antigen. —The strength and properties of a good antigen
tend to remain constant. Its characteristics must, however,
be redetermined and confirmed from time to time by testing
the antigen against known syphilitic reagins. This practically
consists in the performance of a test in which all the factors
are known except the strength and properties of the antigen.
The antigen used in my experiments had been used in the
routine performance of many thousands of tests, in all of
which it was proved to be neither haemolytic nor anticomple¬
mentary, but truly antigenic in its properties.

(2) Reagins. —These were always tested against and com¬
pared with known “ positive ” and “ negative ” sera as
“ controls.”

(3) Complement. —As is now fully recognised, the
complement is the most important factor in this reaction, but
unfortunately it tends to degenerate very easily. The strength
of the complement therefore varies, and must be determined
daily immediately before the tests are performed. The
strength of the complement is best expressed in the terms of
what is known as the minimal complementary dose (the

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“ M.C.D.”), the daily determination of which is one of the pre¬
liminary preparations for the test and will be described later.
By means of the M.C.D. a scale of gradations can be obtained
whereby what may be a purely qualitative test can be
converted into a quantitive reaction. At Guy’s Hospital both
the qualitative and quantitative methods are in daily use. In
every one of my cases, however, two minimal doses of
complement were always employed, for by experiment I found
that both from the qualitative and quantitative standpoints
two minimal complementary doses were sufficient for each of
my cases, a greater dosage resulting in the presence of an
excess of complement, and, therefore, in the production of
error. It is necessary to emphasise the amount of complement
employed, as results with this test from the quantitative stand¬
point are only of value when expressed in terms of the M.C.D.,
from which it follows that, in my series of cases, even the
definitely positive reactions are quantitatively very feeble.

(4) Hcemolysin. —The hasmolysin tends to remain constant.
The strength of the haemolysin is also best expressed in terms
of what is known as the minimal haemolytic dose (the “ M.H.D.”).
The M.H.D. for any given brand of haemolysin therefore tends
to remain constant. The M.H.D., however, should be con¬
firmed from time to time in the manner of the method
described later.

The Preliminary Preparations.

The compluetic test, it will be remembered, is an attempt
to ascertain whether a given serum in the presence of syphilitic
antigen is able to “ fix ” complement, that is, to de-ionise it, to
rob it of its oxydases, and so to render it inactive. The test
is not only a means of ascertaining whether a given serum can
“ fix ” complement, but also how much complement it can so
render inactive. The test is therefore both qualitative and
quantitative. It is a means of ascertaining not only the
fixation ability , but also the fixation capacity of the tested
serum.

Now in order to be able to “ fix ” complement, the given
serum must contain syphilitic reagin— i.e. t the syphilitic
“ antibody.” Therefore the test becomes limited to ascertain¬
ing whether a given serum contains syphilitic reagin and if so

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19 1 6.] BY HAROLD FREIZE STEPHENS, M.R.C.S. 66 I

the quantity of syphilitic reagin it contains. Thus, in my
series of cases, I was able to determine that a certain propor¬
tion of the sera examined did contain syphilitic reagin, and
that the reagin so contained was invariably in small quantities,
being always enough to utilise two minimal doses of complement.
To effect these determinations the method employed, as will
be remembered, is :

(1) To free a given serum of any complement it will
naturally contain— i.e., to “ inactivate ” it.

(2) To add to a measured quantity of inactivated serum a
measured quantity of antigen.

(3) To add to this mixture a measured quantity of fresh
complement.

(4) A certain specified time is then allowed for these three
substances to interact, and at the end of this time— i.e.,
usuallyafter one hour in the air incubator at 37 0 C.—the presence
of “ free ” complement is looked for by means of a delicate
“ colour indicator.” If “ free ” complement is then found to be
present, the serum does not contain syphilitic reagin, and is
said to be “ negative.” If, however, “ free ” complement is
found to be absent (the added complement being “ fixed ”),
the serum does contain syphilitic reagin, and is said to be
“ positive ” ; the degree of its “ positivity ” being determined
by the quantity of added complement that has been “ fixed.”

Such is the test. Its practical value depends upon the
delicacy of the “ colour indicator,” whose efficiency, in its turn,
is dependent upon its ability to detect the smallest traces of
complement. Therefore it will be seen the preliminary pre¬
parations for the test are three in number :

(1) The preparation of the reagin.

(2) The preparation of a delicate colour indicator.

(3) The determination of the smallest amount of comple¬
ment that can be detected by means of this “ colour indicator.”

These preliminaries will now be considered.

The Preparation of the Reagin .—In all my cases each speci¬
men of blood for examination was taken from the peripheral
circulation, about 5 c.c. of blood being withdrawn with aseptic
precautions from the median basilic vein. Each specimen was
allowed to clot, and the serum collected. The serum was then
divided into two equal portions. One portion was heated by
being placed in a hot-water bath at 56° C. for half an hour (i.e..

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“ inactivation by heat ”). The other portion was kept at room
temperature for four days before being tested (i.e., “ inactiva¬
tion at room temperature.”) The reason why each serum was
divided into two portions, one being heated, the other not, is as
follows : Every syphilitic serum is supposed to contain two
substances, complement and syphilitic reagin (antibody);
“ inactivation by heat ” eliminates the complement, leaving
reagin for the purposes of the test. But many workers at
Guy’s Hospital in a long experience of many thousands of
cases have found that heat also tends to damage these syphilitic
reagins, some more intensely than others, so that a possibly
positive serum may declare itself as negative. It has there¬
fore been the practice at Guy’s Hospital in all cases of doubt¬
ful reactions to re-test the serum, unheated, and after keeping
for four days at room temperature. In my 100 cases, however,
I have methodically pursued the double purpose, systematically
dividing each serum into two equal portions, and regularly
examining these after “ inactivation by heat,” and after “ inac¬
tivation at room temperature.” The outcome of this procedure
has been that the results differed in fourteen of my 100 cases.
Of these fourteen cases, four were negative heated, weakly
positive unheated ; ten were negative heated, definitely positive
unheated. The results in all the other cases agreed both with
the heated and the unheated portions of the sera. By testing
the unheated sera in every case I was able to confirm the
results obtained with the heated sera, and vice versA. Against
the method of “ inactivation at room temperature ” it might be
urged that normal sera tend to become positive on keeping,
because of the factor of hydrolysis, which will naturally set free
fatty and amino acids in the serum, an excess of such mole¬
cules having a decided anticomplementary action. But such a
tendency would have been present in every one of the 100
sera examined, and yet in only fourteen cases did the results
differ. Moreover, all these fourteen cases did not occur on the
same day, under the same conditions of atmospheric pressure
and temperature ; and a further examination of the records
showed that one occurred in a set of four, two occurred in a
set of five, two occurred in a set of eight, four occurred in a set
of eight, one occurred in a set of twelve, one occurred in a set
of thirteen, and three occurred in a set of fourteen. So that
the factor of hydrolysis does not seem wholly to explain why

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under the same conditions more positive results should not
have occurred. '

The Preparation of the “ Colour Indicator .”—In the prepara¬
tion of a delicate “colour indicator” for this test, advantage is
taken of the well-known fact that in the presence of comple¬
ment and haemolysin red blood corpuscles are destroyed, the
haemoglobin escaping to colour the medium ; but that in the
absence of complement no haemolysis occurs. On the basis of
this fact a mixture of haemolysin and erythrocytes is prepared.
By this mixture the hcemolysin combines with the red cells
and is said to render them “ sensitive ” to complement. The
mixture is therefore called “ a suspension of sensitised erythro¬
cytes.” In the actual making of the “sensitised erythrocytes”
two stages occur : (1) The determination of the minimal dose
of haemolysin that with complement will produce in a definite
period complete haemolysis of the smallest convenient quantity of
red cells; (2) the mixing of the components in these proportions.

The Determination of the Minimal Hcemolytic Dose .—The
reagents required for this determination are: (1) A 1 in 20
saline dilution of haemolysin ; (2) a 1 in 100 saline suspension
of fresh human erythrocytes; (3) a 1 in 10 saline dilution of
fresh guinea-pig’s serum ; (4) saline solution (0’9 per cent.).
The method is as follows : A series of small test-tubes are
taken, marked A, B, C, etc. Into each of these are placed
diminishing quantities of the diluted haemolytic serum, thus :
o - io c.c., o - o8 c.c., co6 c.c., etc. Then 0.50 c.c., the smallest
convenient quantity, of the erythrocyte suspension is added to
each tube, followed by the addition of an excess of complement,
usually four minimal doses. Each tube is then filled with
saline to a total volume of 1 c.c. The following example is
appended as an illustration :

. Test-tube A. Test-tube B. Test-tube C. Test-tube D.

Haemolysin (1 in 20) ... o'io c.c. ... O'oS c.c. ... 0 06 c.c. ... 0^04 c.c.

Erythrocyte suspension

(1 in 100) . . . 0-50 050 „ ... 050 „ ... 0-50 „

Complement (1 in 10),

four doses . . 0'20 „ ... 0'20 „ ... 0'20 „ ... 0’20 „

Saline solution (o'9 per

cent.). . . . 020 022 „ ... 024 „ ... 026 „

roo c.c. roo c.c. 1.00 c.c. roo c.c.

The tubes are placed in the air incubator for one hour at 37 0 C. The minimal
haemolytic dose (the “ M.H.D.”) is the minimal amount of haemolysin giving
•complete haemolysis of 0'5 c.c. of erythrocytes after incubation in the air incubator

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for one hour at 37° C. In the above example the minimal amount of haemolysin
producing complete haemolysis was found to be 0 08 c.c. (in test-tube B). There¬
fore the M.H.D. for the 1 in 20 saline dilution used was taken as o’oS c.c.

The Preparation of “ Sensitised Erythrocytes .”—In the pre¬
paration of the “ sensitised erythrocytes ” used in my test, four
minimal doses of the 1 in 20 saline dilution of hcemolysin
were taken for each 0 5 c.c. of the 1 in 100 suspension of red
cells. These proportions were used because in actual practice
an excess of haemolysin is found to be necessary on account of
the varying numbers of red cells in each o‘5 c.c. of suspension,
the varying capacity of the cells for combining with haemolysin,
etc. Thus if the M.H.D. were o‘o8 c.c., the recipe for the pre¬
paration would be written as follows :

Jjt Erythrocyte suspension (1 in 100) ...... o‘5 c.c.

Haemolysin (1 in 20), four times o'o8 c.c. (the M.H.D.) . . 0.3 „

o S c.c.

Mix as much as is required in these proportions, and let
the suspension stand at room temperature for fifteen minutes
at least. For each dose of “ sensitised erythrocytes ” O’S c.c.
of the above mixture is used.

The Determination of the Minimal Complementary Dose. —The
“ colour indicator ” having been prepared as above, the next
step is to find the smallest quantity of complement that will
produce complete haemolysis in a definite time of the estimated
dose of “ sensitised erythrocytes.” The reagents required for
this determination are : (1) A 1 in 10 saline dilution of the com¬
plement to be tested; (2) “sensitised erythrocytes”; (3)
saline solution (o’9 per cent.). The method is as follows : A
series of small test-tubes is taken, marked A, B, C, etc. Into
each of these tubes diminishing quantities of the diluted com¬
plement are placed, thus : crop c.c., o'oy c.c., o - c>5 c.c., etc.,
and then to each tube the dose of “ sensitised erythrocytes ”
already estimated is added. Each tube is then filled with
saline to a total volume of 1 c.c. The following example is
appended as an illustratien :

Test-tube A. Test-tube B. Test-tube C. Test-tube D.
Complement (1 in 10) . 0 09 c.c. ... 007 c.c. ... 0 05 c.c. ... 0 03 „

“ Sensitised erythroycte" 0 80 „ ... 0 80 „ ... 0 80 . O'8o „

Saline solution (o'9 per

cent.) • • .oil,, im o 13 ,, ... o 13 ,, ... 1 17 >>

1.00 c.c. 1 00 c.c. 1 "co c.c. 1.00 c.c.

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665

The tubes are placed in the air incubator for one hour at 37° C. The minimal
complementary dose (the “ M.C.D.”) is the minimal amount of complement giving
complete haemolysis of 0'8o c.c. of “sensitised erythrocytes’’ after incubation in
the air incubator for one hour at 37 0 C. In the above example the minimal
amount of complement producing complete haemolysis was found to be 0 05 c.c.
(in test-tube C). Therefore the M.C.D. for f’ e 1 in 10 saline dilution used was
taken as 0'05 c.c.

The Test.

The test itself may now be described. As already stated, all
the quantities of the reagents used in my reactions are the same
as those employed at Guy’s Hospital in the routine examination
of cases with the exception of the complementary doses, which
did not vary in my tests, two minimal complementary doses
being always used, as these were found by experiment to
be both necessary and sufficient for each of my cases. The
method employed was as follows :

The Patient's Serum. —(1) For each serum two small test-
tubes marked A and B were taken. (2) In each of these
tubes was placed O'l c.c. of the patient’s serum. (3) To each
tube was then added two minimal doses of complement. (4)
Into tube A, but not into tube B, was finally measured o - 1 c.c.
of the antigen. Tube B was thus used as a “control” against
tube A, for as tube B contained no antigen, one was able to note
whether the patient’s serum was naturally anticomplementary
or not. (5) The volume of fluid in each tube was then brought
to the same level by the addition, when necessary, of saline.
Both tubes were then carefully shaken so that the contents of
each were well mixed, the completest asepsis being observed in
all the measurements.

The “ Control" Sera .—Each patient’s serum was always
tested against and compared with two known sera, a syphilitic
and a non-syphilitic serum, used as “ controls.” For each of
these “ control ” sera two tubes^ were also prepared similar in
every way to the two tubes containing the patient’s serum.

For the testing of each patient’s serum, then, six tubes were
prepared—two for the patient’s serum, two for the syphilitic
serum, and two for the non-syphilitic serum. When these were
ready they were placed in the air incubator for one hour at
37°C. The estimated dose of “ sensitised erythrocytes ” was
then added to each tube, and all the tubes were replaced in the
incubator at 37 0 C. for another sixty minutes. They were
carefully examined at regular intervals, and the results finally
recorded at the end of the hour.

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PRINCETON UNIVERSITY

666

THE COMPLUETIC REACTION IN AMENTIA, [Oct.,

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A note may here be added with reference to the use of
“ control ” sera in my series of cases. All my tests were
performed at the same time and on the same days on which the
routine Wassermann work of Guy’s Hospital was undertaken.
I worked side by side with the hospital serologists, and we used
the same materials for our reagents. Therefore, in addition to
my own “ controls,” I had the advantage of the hospital’s series
of tubes (i.e., of those containing two minimal doses of com¬
plement) to check my reactions, and to confirm the accuracy
of my results.

Schema of the Test.

.

•

Unknown serum.

Syphilitic serum.

Non-syphilitic serum.

Tube A. 1 Tube B.

I

1

Tube A. Tube B.

.

Tube A.

Tube B.

Reagin (undiluted) .
Antigen (1 in 10)
Complement (1 in 10),
two doses

Saline solution (o’9
per cent.)

OTO C.C. I O’IO C.C.

OTO C.C. ; —

0*10 C.C. O '10 C.C.

— | OTO C.C.

1

OTO C.C. OTO C.C.

OTO C.C. —

OTO C.C. OTO C.C.

1

— OTO C.C.

1

O’lO C.C.

O'10 c.c.

o-ioc.c.

1

OTO C.C. |

O IO C.C. I

[

o’10 c.c.!

The tubes are placed in the air incubator for one hour at 37 0 C

1

"Sensitised erythro¬
cytes”

0 80 c.c. i o’8o c.c.

o - So c.c. o’8o c.c.

o'8o c.c.

o’8o c.c. j

I

I TO C.C. I* 10 C.C.

no c.c. no c.c.

no c.c.

no c.c.

The tubes are replaced in the air incubator for thirty minutes at 37“ C. They
are then examined every ten minutes, and the results finally recorded at the end
of another thirty minutes— t.e., one hour after the addition of the " sensitised
erythrocytes.”

Interpretation of the Results .—The results in my series of
cases were recorded as follows: (1) When no haemolysis
occurred the reaction was said to be “ definitely positive ” (2)

When partial haemolysis occurred the reaction was termed
“ weakly positive.” (3) When complete haemolysis occurred
the reaction was called “ negative.”

Summary of the Technique.

In their preliminary report on the methods of carrying out
this test, the Sub-Committee of the Section of Pathology of this
Society defined what is generally understood to be “ the

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PRINCETON UNIVERSITY

1916.] BY HAROLD FREIZE STEPHENS, M.R.C.S. 667

original Wassermann test” by its essential principles as
follows :

“(i)The ingredients of the test (red corpuscles, ‘antigen,’
haemolytic amboceptor, complement) are derived from different
sources.

“ (2) The serum to be tested is inactivated before use. An
independent ‘ haemolytic system ’ is employed, consisting of a
suspension of red corpuscles, an inactivated haemolytic serum, and
a fresh normal serum containing complement. The haemolytic
values of the antiserum and complement are determined by a
separate preliminary experiment.

“ On general scientific grounds the Sub-Committee is unani¬
mously of the opinion that, since the test is a quantitative
reaction, the titre of the reagents ought, within practicable limits,
to be accurately known.”

From the above definition of the “original test” the
technique herein described will be seen to differ, but it is
sincerely hoped that the results so obtained will not therefore
be very greatly impaired. Three points in connection with this
technique must be briefly recalled, inasmuch as these points
are directly concerned with the interpretation of the results
obtained.

First, the serum. Each serum to be tested was always inacti¬
vated before use. Each serum was divided into two equal
portions ; one was subjected to “ inactivation by heat,” the
other to “ inactivation at room temperature.” Each portion
was then tested in exactly the same way and the results carefully
compared, when it was found that in only fourteen cases did
the results differ. In all other cases the results agreed both
with the heated and the unheated portions of the serum. Thus
by testing the unheated sera, in every case the results obtained
with the heated sera were confirmed, and vice versd. As some
observers would maintain that more correct results are obtained
by “ heating ” the sera, and others by testing the sera
“ unheated,” it was hoped to avoid the fallacies arising from
both sources by systematically examining each serum in this
way.

Secondly, the amount of complement used in each test. In
every one of these determinations two minimal doses of com¬
plement were always employed, for by experiment it was found
that two minimal complementary doses were necessary and

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668 THE COMPLUETIC REACTION IN AMENTIA, [Oct.,

sufficient for each of these cases, a greater dosage resulting in
the presence of an excess of complement, and therefore in the
production of error.

Thirdly, the “ controls.” Three sets of “ controls ” were
used, (i) Each serum, whether heated or unheated, was
always tested with and without “antigen,” to determine whether
it was naturally anticomplementary, and so to avoid if possible
an excess of “positive” results. (2) Each serum, whether
heated or unheated, was always tested against and compared
with two known sera, a syphilitic and a non-syphilitic, under
exactly the same conditions. (3) All these tests were per¬
formed at the same time and on the same days and with the
same materials as the routine Wassermann work of Guy’s
Hospital. Therefore, in addition to the above “ controls,” there
was always the hospital’s series of tubes (i.e., of those con¬
taining two minimal doses of complement) by which to check
the reactions, and to confirm the accuracy of the results.

(B) The Results Obtained.

In this section of the paper the results obtained by the above
experiments are analysed as follows :

(1) Total percentage. —Of the 100 cases examined, forty-two
gave positive reactions. None of the fifty-eight “negative”
cases, after a thorough clinical examination, revealed any of
the characteristic lesions of syphilis, so that this group of forty-
two “ positive ” cases would seem to include all the patients
with syphilitic amentia whose blood serums w r ere examined.
Of the forty-two “positive” cases, twenty-two were “definitely
positive,” and twenty were “ weakly positive." To many
workers on this subject these figures would appear to yield a
large percentage of “ positive ” results. The following facts,
determined by a closer analysis, must therefore be stated :

(i) That when the sera were inactivated by heat , the reaction
was found to be present in twenty-eight cases, being—

“ Definitely positive ” in . . 22 — 10 = 12 cases

“ Weakly positive” in . . 20 — 4 = 16 cases

“Negative” in . . . 58 + 14 = 72 cases

(ii) That when the sera were inactivated at room temperature ,
the reaction was found to be present in forty-two cases,
being—

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PRINCETON UNIVERSITY

1916.] BY HAROLD FREIZE STEPHENS, M.R.C.S.

669

“ Definitely positive ” in . . 12 + 10 = 22 cases

“ Weakly positive ” in . . 16 + 4 = 20 cases

'* Negative ” in . . . 72 — 14 = 58 cases

From which it will be seen—

(a) That in eighty-six cases the results agreed both with the
“ heated ” and the “ unheated ” sera, being—

“ Definitely positive ” in . . .12 cases

“ Weakly positive” in . . ... 16 cases

“ Negative ” in . . . -58 cases

( b ) That in fourteen cases the results differed both with the
“ heated ” and the “ unheated ” sera, so that—

In ten cases the reaction was “ negative ” heated, “ definitely
positive ” unheated.

In four cases the reaction was “ negative ” heated, “ weakly
positive ” unheated.

Now those workers who would maintain that heat tends to
damage certain syphilitic reagins, some more intensely than
others, so that a possibly positive serum may declare itself as
negative, would regard the fourteen differing sera as yielding
more correct results when tested after “ inactivation at room
temperature,” and would therefore consider that a “definitely
positive ” reaction was obtained in twenty-two cases, a “ weakly
positive ” reaction in twenty, and a “ negative ” reaction in
fifty-eight, their total percentage of “ positive ” results being 42.

On the other hand, those observers who would urge that
normal sera tend to become positive on keeping because of the
factor of hydrolysis producing strong anticomplementary bodies,
would consider the fourteen differing sera as yielding more
' correct results when tested after “ inactivation by heat,” and
would therefore record them as “ negative,” or at best as being
“doubtfully positive,” and their total percentage would be 28
(16 “weakly positive,” and 12 “definitely positive.”)

Finally, there would be some observers who would hold that
because only two minimal doses of complement were used in
each of these determinations, only those cases in which the
results were noted as “ definitely positive ”— i.e., those cases in
which absolutely no haemolysis was observed—should be
regarded as “ truly positive.” These would therefore discard
the “ weakly positive ” and “ doubtfully positive ” cases as being
“ negative,” and their total percentage of “ positive ” results
would be 1 2, with which I personally am in agreement.

LXII. 43

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670 THE COMPLUETIC REACTION IN AMENTIA, [Oct.,

However the above figures may be interpreted, the point I
wish to emphasise is this : that the results have been very
carefully and accurately recorded ; the “ controls ” have been
numerous, strict, and efficient; and that under the conditions
of the technique employed, as herein described, these results
may be considered to be correct.

(2) Sex .—All the cases examined were males.

( 3 ) Age .—The youngest of these patients was set. I 2, the
five oldest were act. 51, 52, 52, 73 and 78 respectively. There
were fifty-seven patients between 12 and 21 years of age
inclusive, twenty-one between 22 and 30 years inclusive, and
seventeen between 30 and 50 years inclusive, so that the
majority of the patients were boys. This fact is of some
importance, for the compluetic reaction tends to vary with age,
as shown in the following tables :

Table A .—Showing the Incidence of the Reaction at Different

Age-periods.

Age-periods.

Number of
cases
examined.

Number of
positive
reactions
at each
age-period.

Percentage of
positive
reactions to
cases examined
at each
age-period.

Percentage of
positive
reactions
at each
age-period to
total number
of positive
reactions.

Under 12 years

12 to 15 years inclusive
16 to 21 years inclusive
22 to 30 years inclusive
Over 30 years

21

22

8

8

36 8 T 456

50 0 J

3809

36 ' 3 6

45 23 j y

1904

1904

From this table it will be seen :

(i) That of all the positive reactions obtained twenty-six
(or about 62 per cent.) occurred in patients between 12 and 21
years of age inclusive ; while only eight (19 per cent.) occurred
in those between 22 and 30 years inclusive, and eight (19 per
cent.) in those over 30 years.

(ii) That positive reactions occurred in 45 per cent, of the
patients between 12 and 21 years of age inclusive, in 38 per
cent, of those between 22 and 30 years inclusive, and in 36 per
cent, of those over 30 years of age.

Hence it would seem that the incidence of the reaction
tended to diminish as the ages of the patients increased. But

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PRINCETON UNIVERSITY

19 I 6.] BY HAROLD FREIZE STEPHENS, M.R.C.S. 67 I

a closer study of the cases revealed an interesting modification,
which also is indicated in Table A, where it is shown :

(i) That a larger percentage of positive reactions occurred
between the ages of 16 and 21 inclusive than at any other
period— viz., 45 per cent.

(ii) That 50 per cent, of the patients between the ages of 16
and 21 inclusive gave positive reactions, while about 37 per
cent, of those below 16 years, and about 3 7 per cent, of those
above 21 years, gave positive reactions.

From which it appears that the curve of the incidence of
the reaction in aments tends to rise from between the ages of
12 to 15, reaching its maximum height between the ages of 16
to 2 1 and then gradually falling again as the ages increase.

Again, the intensity of the reaction at different age-periods
is shown in Tables B and B 1 :

Table B.— Being an Analysis of the Cases giving “Definitely

Positive ” Reactions.

:

Age-periods.

Total

number

of

positive
reactions
at each
age-period.

Number

of

cases

giving

41 definitely
positive**
reactions.

Percentage of

44 definitely
positive *
reactions
to the total
number of
positive
reactions
at each
age-period.

Percentage of
* 4 definitely
positive **
reactions
at each
age-period
to the total
number of

44 definitely
positive **
reactions.

Under 12 years .

_

_

_

12 to 15 years inclusive

7

6

857

272

16 to 21 years inclusive

19

I I

579

478

22 to 30 years inclusive

8

3

375

13 04

Over 30 years

8

2

25°

87

Table B 1 .— Being an Analysis of the “Weakly Positive” Cases.

Age-periods.

Total

number

of

positive
reactions
at each
age-period.

Number of
cases
giving

44 weaklv
positive”
reactions.

Percentage of
“ weakly
positive *'
reactions
to the total
number of
positive
reactions
at each
age-period.

Percentage of
** weakly
positive *’
reactions
at each
age-period
to the total
number of
“ weakly
positive'"
reactions.

Under 12 years .

12 to 15 years inclusive

7

I

14*2

50

16 to 21 years inclusive

19

8

420

420

22 to 30 years inclusive

8

5

625

263

Over 30 years

8

6

750

3 I - 5

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672

THE COMPLUETIC REACTION IN AMENTIA, [Oct.,

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From these tables it will be seen :

(i) That all the positive reactions, save one, occurring
between the ages of 12 and 15 inclusive were “definitely
positive,” no haemolysis being detected in any of the cases.

(ii) That the percentage of “ definitely positive ” reactions
diminishes with the increasing ages of the patients.

(iii) That while there is only one “ weakly positive ” reaction
between the ages of 12 and 15 inclusive, the percentage
of such reactions increases with the increasing ages of the
patients.

(iv) That if a composite graph were drawn illustrative of
both these tables it would appear that the curve of the intensity
of the reaction is similar to the curve of the incidence.

From this study, then, of the relationship of the incidence
and intensity of the compluetic reaction in aments to the age
of the patient, it becomes manifest that the reaction tends
to be strongest and most frequent in patients between the ages
of 16 and 21, and that it appears to be more frequent and
stronger in those below 16 than in those above 21 years of
age ; but it was not possible to determine exactly how either
the incidence or the intensity curves should be drawn, the
reason for this failure being shown in Table C. Such curves,
however, ought to be realised when a very large number of
reliable results have been tabulated and examined.

Table C.— Showing the Number of Cases Examined, and the
Number of Cases giving Positive Reactions for each Year

of Age from 12 to 25

Years inclusive.

Age.

C.

+

±

T.

Under 12 years

—

. —

—

—

12 years old

2

. -

—

—

»3

2

2

—

2

14

M

9

3

1

4

15

II • *

6

1

—

I

16

II ■ •

7

1

3

4

17

II

8

3

1

4

18

II

6

. 1

1

2

19

II • •

7

2

—

2

20

II *

4

. —

2

2

21

II

6

4

1

5

22

II • •

2

. —

—

—

23

II • •

6

2

—

2

24

II / •

1

. —

—

—

25

II • •

2

. —

1

1

C. = number of cases examined.

+ = number of cases giving definitely positive reactions.
± = number of cases giving weakly positive reactions.

T. = total number of cases giving positive reactions.

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Original from

PRINCETON UNIVERSITY

1916.] BY HAROLD FREIZE STEPHENS, M.R.C.S.

673

(4) Social status .—The fathers of forty-two of the patients
were members of the skilled trades and labourers, thirteen
patients were the sons of members of the professions, and thirty
were born in the mercantile classes. As these cases were
chosen spontaneously and more or less haphazard, it is inter¬
esting to remark that the parents of the smallest number of these
aments are members of the most highly organised occupations,
viz., the professions ; and it is also of importance to note that
precisely those spheres of industry which have shown little or
no manifestations of the social spirit contain the parents of the
majority of these syphilitics (vide Table D).

Table D .—Showing the Social Status of the Patients examined.

Occupation of father.

Skilled trades and labourers
Professions .

Mercantile .

Dead and unknown

Number of patients
examined.

42

«3

30

IS

Number of patients
giving positive
reactions.

21

4

14

3

All the 100 patients were born and bred in England (in her
cities, towns, and villages) except seven. Of these seven, two
were from the Channel Islands, one from the Isle of Wight, one
from India, one from Barbadoes, one from Mauritius and one
from Buenos Aires. The boy from Buenos Aires and the boy
from the Isle of Wight gave “ weakly positive ” reactions ; the
sera of the other five were “ negative.”

(5) Life-history .—The compluetic reaction being an index of
existing syphilitic infection, and not in the nature of an
immunity reaction, the question arises as to whether the
infection in this series of cases was an intra- or an extra-
uterine one— i.e., whether the syphilis was “ congenital ” or
“ acquired.”

The fact that the majority of these patients came under
institutional discipline and observation at a very early age, and
were all of them under due protection when at home or with
friends, together with the absence in them of all the physical
signs and symptoms of “ acquired ” syphilis at any period of
their lives, tends to dispose of the presence of this type of the
disease in any one of these cases, the likelihood of which under
the circumstances would be extremely remote. All the forty-
two positive cases may therefore be said to be, in varying
degrees, the victims of intra-uterine or “ congenital ” syphilis

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674 THE COMPLUETIC REACTION IN AMENTIA, [Oct,

But, save for the ophthalmoscopic and otological conditions,
which unfortunately were not determined because of the obvious
practical difficulties of such inquiries in aments, the most care¬
ful examination of the patients themselves failed to reveal the
presence of any of the characteristic lesions of “ congenital ”
syphilis in any one of them, a fact which has also been noticed
by Dr. Plaut, of Munich, Major Mott, and other observers.( 2 )
Nor did a study of the records of the parental and family
histories adduce evidence of the disease in any of the parents
or their forebears—a fact which is less surprising, for the histories
in such cases are notoriously misleading. The compluetic
reaction, being the only reliable evidence in forty-two of these
cases of their being syphilitic at all, was also the conclusive
testimony to the presence of syphilis in either or both their
parents.

A note may here be introduced on the appearance of the
stigmata of “congenital” syphilis in aments. It will be
remembered that “ congenital ” syphilis is an intra-uterine
affection, and it will also be recollected that the children of
syphilitic parents need not necessarily be aments. So that
apart altogether from the fact that certain central nervous
systems are peculiarly prone to attack by this virus, the mani¬
festations of “ congenital ” syphilis w'ould appear to be depen¬
dent upon the time of onset of the infection in utero, bearing a
direct relation to the structural condition of the developing
organism. That the majority of congenital syphilitics bear
evidences of epiblastic or mesoblastic infection would £eem to
show that the foetus is not attacked till late in its development,
or, perhaps, that the maternal defences are able to protect it
till then. The presence of an earlier neuroblastic infection is
manifested by the cases of juvenile general paralysis of the
insane, a condition to which any of the preceding cases may
succumb, while the earliest embryonic infections would appear
to result either in the death of the organism or in arrested
development. Thus, consider those cases of “ infantilism,” free
from all obvious syphilitic stigmata, in which Major Mott has
seen in both ovary and testis myriad colonies of the Spiroclucla
pallida. Similarly retarded development of the other members
of the endocrinic glands may be found to be due to the same
cause, and how closely the endocrinic system is associated with
the central nervous system is daily becoming more manifest.

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PRINCETON UNIVERSITY

191 6.] BV HAROLD FREIZE STEPHENS, M.R.C.S.

675

Broadly considered, amentia may, perhaps, be interpreted as a
symptom-complex of arrested brain development, such retarda¬
tion being due either to an inherent inability on the part of
the brain cells to grow and evolve, or to the effects of some
factor inimical to their perfect fulfilment, such a factor being
either traumatic, or toxic, or inflammatory in its appearance.
In either case the syphilitic virus may be present as cause or
coincidence— eg., the inherent inability of the brain cells to
develop may be due to some occult influence of the virus, or
the results of its toxicity may be more recent and pronounced.
Our knowledge, therefore, of the “ stigmata ” of congenital
syphilis requires some replenishing. How many, for example,
of the so-called stigmata of degeneracy are in reality the
stigmata of syphilis ? We do not know. Those of the latter,
so frequently described and portrayed, are mainly somatic in
incidence, originating in fully developed structures {eg., nodes,
scars, the syphilitic wig, interstitial keratitis, etc.). What is
seriously needed is a more careful study of the germinal
developmental stigmata (mainly microscopical in character), and
the signs and symptoms with which these are associated, and
by which they are rendered more evident to the naked eye—
eg., as in “ infantilism,” certain cases of cretinism, perhaps also
certain groups of simple aments. In other words, evidences of
arrested or deranged and irregular development, if shown to be
directly due to the effects of the luetic virus, ought to be
regarded as being in themselves “ stigmata ” of congenital
syphilis. Again, what of the bio-chemical stigmata ? One
of these, surely, is that which has been studied in recent
years on such a very extensive scale as “the Wassermann
reaction.”

To continue with this analysis, the next point to be deter¬
mined was whether the syphilitic virus acting alone was respon¬
sible for the mental defect in these forty-two congenital cases,
or whether it attained that end with the assistance of other
factors. An analysis of such factors, based on a consideration
of the so-called “causes ” of amentia, is given in Table E (see
pp. 676 and 677), from which it will be seen :

(i) That in addition to syphilis certain reputed germinal and
somatic defects are together present in seventeen cases ; that
these germinal defects only are present in seven cases ; and
the somatic defects only in eighteen cases,

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PRINCETON UNIVERSITY

■Showing the Factors concerned in the JEtiology of Forty-two Possible Cases of Syphilitic Amentia.

676 THE COMPLUETIC REACTION IN AMENTIA, [Oct.,

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PRINCETON UNIVERSITY

( B) The AEtiological Analysis of the Twenty Cases giving “ Weakly Positive" Reactions.

1916.] BY HAROLD FREIZE STEPHENS, M.R.C.S.

677

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PRINCETON UNIVERSITY

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678 THE COMPLUETIC REACTION IN AMENTIA, [Oct.,

(ii) That in addition to syphilis, fourteen cases have at least
one of these reputed defects, fourteen others at least two such
defects, and eight have three. One case has as many as six
germinal and somatic defects, another has five, and four have
each four of such defects. In no case is the syphilitic virus
unassociated with at least one of these aetiological factors.

Other points to be noted in Table E are :

(i) Of the forty-two positive cases the neuropathic diathesis
occurs in seventeen. (Of the 100 cases examined a neuropathic
inheritance was recorded in only forty-four ; so that syphilis
was detected in seventeen of the forty-four cases with a neuro¬
pathic heredity. Of these seventeen cases the diathesis was
recorded in seven in the parental histories only, in six in the
family histories only, and in four in both family and parental
histories. It appeared in seven cases on the maternal side
only, in six on the paternal side only, and in four on both
sides. Five of these cases gave family histories of amentia,
three of insanity, and two of a “ neurotic heredity.” Eight of
the parents were said to be “ neurotic,” one is insane, one
had a spinal affection and was a cripple, and two died in
apoplectic fits.)

(ii) There appears to he no family or parental history of
alcohol.

(iii) Tuberculosis is seen to occur in the inheritance of six
patients : in the family histories of four, and in the parental
histories of three.

(iv) Consanguinity is present in two cases. (In one the
parents were first cousins ; in the other the parental grand¬
parents.)

(v) One of the patients, a cretin, has a paternal cousin who is
likewise a cretin ; and the mother and sister of another patient,
also a cretin, have suffered from exophthalmic goitre. Each
of these cases also has a neuropathic inheritance, but, being
instances of a metabolic inheritance as well, they are again
noted here under a separate heading.

(vi) Adverse mental states of the mother were said to have
been present during the foetal development of five cases, and
adverse physical conditions of the mother in three. Six others
are the children of aged parents.

(vii) Fifteen are firstborn - children ; ten of these gave
definitely positive reactions, the other five being weakly positive,

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1916.] BY HAROLD FREIZE STEPHENS, M.R.C.S. 679

It is therefore very probable that a series of abortions may
have preceded the birth of most of these patients, although
such a history, unfortunately, was not recorded in any case
either as positive or negative evidence.

(viii) Difficult and protracted labour with instrumental de¬
livery is recorded in seven cases (four of which were firstborn
children).

(ix) One patient was a premature birth, another was a ten
months baby, and a third is the fifteenth child in his family, and
the second of twins.

(x) Infantile illness is cited in seventeen cases, and infantile
head injuries in five.

To what extent must now be considered does the syphilitic
virus play its part in producing the mental deficiency in each ’
of these cases ? Its exact influence is, of course, difficult to
estimate, but from a study of Table E it will be seen:

(a) That the virus is undoubtedly an auxiliary and augmen¬
tary factor in the aetiology of eleven cases— viz., in Nos. I, 2 , 3,
6, 11, 23, 24, 25, 26, 28 ,29.

(b) That it probably is the exciting or determinant factor in
six cases— viz., in Nos. 5, 9, 10, 27, 35, 36.

(c) That it appears to be the essential factor in twenty-five
cases— -viz., in Nos. 4, 7 , 8, 12 , 13, 14, 15, 16, 17 , 18 , 19, 20,
21, 22, 30, 31, 32, 33, 34, 37, 38, 39, 40, 41, and 42.

(d) That in no case is it the only ^etiological factor, for even
on analysing Group C it will be seen :

(a) That though in two cases (viz., 18 and 37) the syphilis
appears to be wholly responsible for the amentia, it in reality
has produced the mental defect J, by acting upon already de¬
generated germ plasm. Thus in No. 37 the boy’s father was
said to have died of phthisis ; and No. 18 , a Mongolian idiot,
was the son of aged parents, being the eleventh child.

(b) In all the other twenty-three cases the syphilis appears
to be associated with damaged nervous tissues. Thus No. 38, a
Mongolian imbecile, and the second in his family, is said to have
come of a healthy stock, being born under normal conditions,
but two months previous to his birth his mother was shipwrecked
and nearly drowned ; while in the remaining twenty-two cases
some adverse adventitious factor, occurring either at birth or
during infancy, was always present. A study of these adven¬
titious factors reveals the following interesting facts :

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1916.] BY HAROLD FREIZE STEPHENS, M.R.C.S. 68 1

infancy, the essential cause of his amentia was probably not
the injury but the syphilis, which, perhaps, was also the
probable aetiological factor in No. 12 , another alleged case of
infantile traumatic amentia.

In conclusion, then, it should again be noted, and perhaps
emphasised, that in none of these forty-two cases giving a
positive compluetic reaction did the syphilitic virus acting
alone appear to produce the amentia. In every instance it
would seem that the virus was associated with and acted
upon inherently defective, diseased and degenerated, or
damaged nervous tissues. And this, perhaps, is only to be
expected, for, as will be recollected, the children of syphilitic
parents need not necessarily be aments, although, as is also
known, a minority of congenital syphilitics, if untreated or ill-
treated, are liable to become the victims of various nervous
lesions under mental or physical strain and stress ; and this is
especially so—in fact, it may even be said to be only so—in
those patients in whom the central nervous system is in
the least way defective. Given a healthy nervous system,
congenital syphilis, as is proved by common medical
experience, will not produce amentia. On the other hand, it
is quite possible, and even reasonable, to suppose that given
an exceedingly virulent neurotoxic type of syphilis in utero
the healthiest nervous system would be likely to fall a victim
to the virus. Between these two extremes, the various grades
of syphilitic amentia may be found.

(6) Classification. —Mr. Tredgold, in his book Mental
Deficiency, maintains that “ there are two fundamentally
different forms of amentia; there are also innumerable
degrees ; and it is convenient to describe certain distinctive
clinical varieties.” The forms of amentia Mr. Tredgold has
called primary and secondary ; the degrees are now jumbled
together into four groups by Act of Parliament; the clinical
varieties are well known. In the following paragraphs the
lines of classification suggested by Mr. Tredgold will be
followed with slight modifications :

(a) The forms of amentia: Of the 100 cases serologically
examined seventy-six were cases of primary amentia, and
twenty-four cases of secondary amentia. Of the forty-two
cases giving a positive compluetic reaction thirty-two were
cases of primary amentia, ten cases of secondary amentia, so

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that of all the cases of primary amentia examined, a little over
42 per cent, were positive, and of all the cases of secondary
amentia examined, nearly 42 per cent, were positive. More¬
over, as to the intensity of the reaction in each group, nine of
the thirty-two cases of primary amentia gave “ definitely
positive ” reactions, thirteen “ weakly positive ” reactions, and
ten “ doubtfully positive ” reactions ; while three of the cases
of secondary amentia gave “ definitely positive ” reactions,
three “ weakly positive ” reactions, and the remaining four
“ doubtfully positive ” reactions.

( b ) The degrees of amentia : By Act of Parliament the
“ innumerable degrees ” of amentia are now legally grouped as
four—idiots, imbeciles, feeble-minded, and moral imbeciles.
All the IOO patients examined were either idiots or imbeciles.
As a matter of fact, seventy of them may be considered to be
imbeciles and thirty are idiots. Half of these thirty idiots
gave positive reactions, in five the reaction being “ definitely
positive,” in five “ weakly positive,” and in five “ doubtfully
positive ” ; while of the seventy imbeciles, twenty-seven gave
a positive reaction, and of these seven were “ definitely
positive,” eleven “ weakly positive,” and nine “ doubtfully
positive."

(c) The clinical varieties of amentia : No distinctive clinical
type of syphilitic amentia has been described. Of the known
clinical varieties the following occurred among the 100 cases
examined :

(I) Primary Amentia.

(1) Microcephalus. Nil.

(2) Mongolianism.11 cases.

(3) Simple amentia.65 cases.

(Ia) Primary Amentia with Complications.

(1) With paralysis only.2 cases.

(One Mongol and one simple primary ament.)

(2) With convulsions only .... 26 cases.

(All simple primary aments.)

(3) With paralysis and convulsions . . . Nil.

Got

(II)

Secondary Amentia.

(1) Hydrocephalus .

• • . . •

3 cases.

(2) Hypertrophicism

.....

1 case.

(3) Cretinism .

4 cases.

(4) Simple amentia .

• • ■ • •

16 cases.

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19 1 6-] BY HAROLD FREiZE STEPHENS, M.R.C.S. 683

(IIa) Secondary Amentia with Complications.

(1) With paralysis only ..... Nil.

(2) With convulsions only .... 10 cases.

(One hydrocephalic, one hypertrophic, and eight simple

' secondary aments.)

(3) With paralysis and convulsions ... 5 cases.

(One cretin, two hydrocephalic, and two simple secondary

aments.)

Each of these varieties will now be considered ( vide also
Table F, p. 686).

(1) Microcephalus. —Unfortunately no case was examined.

(2) Mongolianism. —Of the eleven cases examined only
three were positive. In other words, in over 72 per cent, of
these cases the sera did not react to the test. Of the three
Mongols giving a positive reaction two were doubtfully
positive and the other was weakly positive. Brief records of
the life-histories of these eleven Mongols are appended :

The Negative Cases.

Case i.—I diot, set. 14. (1) Ancestral history, nil. (2) Parental

history, nil. Father a farm labourer. (3) Personal history: The
third of five children ; birth normal; infancy and childhood healthy.

Case 2.—Idiot, set. 25. (1) Nil. (2) Nil. Father a labourer.

(3) The seventh of seven; fright of shipwreck to mother when three
months pregnant \ an eight months child ; birth normal; infancy and
childhood healthy.

Case 3.—Idiot, set. 20. (1) Nil. (2) Father somewhat dull; father

and mother set. about 35 when patient was born ; father a clerk. (3)
The second of three ; fall of mother at seventh month ; birth normal;
infancy and childhood healthy.

Case 4.—Imbecile, set. 26. (1) Nil. (2) Father died of nephritis ;

mother healthy. (3) The fifth of six ; fall of mother just before full
term ; birth normal; infancy and childhood healthy.

Case 5. —Imbecile, set. 20. (1) Paternal grandmother, aunt, and

sister epileptic. (2) Nil. Father manager of brickfields. (3) The
only child ; birth normal; infancy and childhood healthy.

Case 6.—Imbecile, set. 18. (1) Nil. (2) Nil. Father an

engineer fitter. (3) The fifth of eight; birth normal; infancy and
childhood healthy.

Case 7.— Imbecile, set. 22. (1) Nil. (2) Mother always very

delicate; father a policeman. (3) The eighth of nine ; birth normal;
infancy and childhood healthy; has right internal strabismus.

Case 8.—Imbecile, set. 23. (1) Nil. (2) Nil. Father a bank

clerk. (3) The fourth of five; a seven and half months child; birth
normal; infancy and childhood moderately healthy.

The Positive Cases.

Case 9.—Imbecile, set. 21. (1) Nil. (2) Nil. (3) The second of

four \ fright of shipwreck and drowning to mother two months before his

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birth ; birth normal; infancy and childhood healthy; C.R. weakly
positive.

Case io. —Imbecile, set. 17. (1) Nil. (2) Nil. Father a doctor.

(3) The firstborn ; birth normal; infancy and childhood healthy ; C.R.
doubtfully positive.

Case ii.—I mbecile, aet. 27. (1) Nil. (2) Nil. Father a furniture

remover (died from accident). (3) Eleventh of eleven ; birth normal;
infancy and childhood fairly healthy; C.R. doubtfully positive.

(3) Hydrocephalus .—Only three cases were examined, and
one of these gave a doubtfully positive reaction. Their life-
histories are briefly as follows :

Case i.—I mbecile, aet. 15. (1) Nil. (2) Nil. Father a labourer.

(3) The sixth of ten ; protracted labour and instrumental delivery; left
hemiplegia, Jacksonian epilepsy ; C.R. doubtfully positive.

Case 2.—Imbecile, aet. 27. (1) Nil. (2) Mother died of erysipelas;

father a doctor. (3) The second of seven; birth normal; infantile
convulsions; C.R. negative.

Case 3.—Imbecile, aet. 40. (1) Nil. (2) Father died of phthisis;

mother died of “cancer”; father a schoolmaster. (3) The eighth of
ten ; worry to mother during pregnancy ; birth normal; epilepsy when
young ; has left internal strabismus ; C.R. negative.

(4) Hypertrophicism .—One case was examined, giving a
definitely positive reaction. This boy is aet. 1 3, and the fourth
child in a family of four. When he was born his father was
aet. 70, and his mother aet. 40. No consanguinity existed
between his parents ; no phthisis, alcoholism, or insanity was
said to be present in the life-histories. His father died of
general peritonitis ; his mother is alive and healthy.
Instrumental delivery was necessary at his birth, but with the
exception of recurrent convulsive attacks from which he at
present suffers, he has always been in good health. Mentally
he is an imbecile of a cheerful temperament and a happy
disposition.

(5) Cretinistn .—Four cretins were examined, and of these
two gave positive reactions, one being definitely positive and
the other doubtfully positive.

Case i (giving a definitely positive reaction).—A boy, aet. 16, and the
second of a family of six, all of whom are said to be normal. A paternal
cousin is a cretin ; the mother is said to “ neurotic ”; otherwise the
life-histories are normal. Both his parents are healthy, his father being a
fisherman. The mother attributes the patient’s condition to the fright
she sustained on seeing the cretin cousin for the first time while
pregnant with the patient. His birth was normal. He has taken
extracts of the thyroid gland since the age of 18 months. He
was operated on as a child for cerebral abscess. At the present day he

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685

1916.] BY HAROLD FREIZE STEPHENS, M.R.C.S.

is a strong, healthy, robust boy. He suffers occasionally from epistaxis,
and recently he had two attacks of melaena. Mentally he is imbecile.

Case 2 (giving a doubtfully positive reaction).—A boy, set. 16, and
the second of a family of three. No defect is recorded as present in
his ancestral history. Both his parents are “ neurotic,” but physically
in good health. His father is a warehouseman His m other an 1 her
eldest child, his sister, have had exophthalmic goitre. The birth of the
patient was normal. He has had thyroid from an early age. He is and
has always been in good health. Mentally he is imbecile.

Case 3 (giving a negative reaction).—An idiot, set. 16, with a history
of “ neurotic heredity.” His father, a parson, died of “ heart disease ” ;
his mother is alive and healthy. He is the only child, and instrumental
delivery was necessary at his birth. He lias had thyroid from an early
age. He is epileptic. He also has a left otorrhcea, a right ptosis, and
undescended testes.

Case 4 (giving a negative reaction). — An imbecile, ?et. 22, and the
second in a family of five. Recorded in his family history is the fact
that a maternal niece is feeble-minded and subject to epilepsy. His
father died of “ cancer of the kidneys." His mother is in good health
but she says she was unable to speak distinctly till the age of 12. His
eldest sister is a cretin. His birth was normal, but his “ mother used
to think a great deal about a cretin when carrying him.” No infantile
injury or other illness is recorded. He has had thyroid from the age
of 2, and is to-day robust, strong, and in good health. He is very deaf.

(6) Simple Amentia. —In the book aforementioned, Mr.
Tredgold writes: “The majority of persons suffering from
primary amentia present no special distinguishing features other
than the anatomical and physiological anomalies common to
aments in general; they may therefore be termed simple
aments, and they correspond to the * genetous ’ group of
Ireland.” “ This term,” he adds in a note, “ is open to the
objection that all primary aments may in reality be called
‘genetous.’” In this paper both the “genetous” group of
Ireland and the “ simple aments ” of Mr. Tredgold are called
by the more exact name of “ simple primary amentia.” It is
here suggested that the term “ simple amentia ” should include
a larger number of cases than those concerned in Mr. Tredgold’s
definition; that so it should be capable of division into
two classes, corresponding to the two forms of amentia, and
that these two classes of simple amentia should be termed
“ simple primary amentia ” and “ simple secondary amentia ”
respectively. Mr. Tredgold’s definition, in fact, may be
adapted as follows: Persons suffering from simple amentia
present no special distinguishing features other than the ana¬
tomical and physiological anomalies common to aments in

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general; they may be divided into two classes corresponding
to the two forms of amentia and may be termed “ simple
primary aments” and “ simple secondary aments ” respectively.
Hy simple primary amentia would be understood the “ simple
amentia” described by Mr. Tredgold, while simple secondary
amentia would constitute all those cases of secondary amentia
in which the mental defect is due to gross cerebral lesions that
are the results of toxic, inflammatory, or vascular causes, but the
patients themselves are not distinguished by any of the special
characteristics peculiar to the clinical varieties of secondary-
amentia definitely known and described (vis., hydrocephalus,
cretinism, etc.).

Table F. —Showing the Relation of the Reaction to the Clinical
' Varieties of Amentia Examined.

Clinical variety.

Number

of

cases.

Number of
“ definitely
positive*’
reactions.

Number of
“ weakly
positive **
reactions.

Number of
“doubtfully
positive"
reactions.

1

Number ol j
“ negative "
reactions.

(A) Primary Amentia —
(1) Microcephalus

(2) Mongolianism

11

—

I

2

8

(3) Simple amentia

Os

10

11

8

(72 per
cent.)

30

(B) Secondary amentia —
(1) Hydrocephalus

3

(>5'3 per
cent.)

_

(17 per
cent.)

(12 3 per
cent.)

1

(55 4 P er
cent.)

2

(2) Hypertrophicism .

I

1

—

—

—

(3) Cretinism

4

1

—

1

2

(4) Simple amentia

16

—

5

X

IO

(C) Amentia with compli¬
cations —

(1) Amentia with
paralysis

7

2

5 1

(2) Amentia with
convulsions

4 «

s

9

7

20

(12*2 per
cent.)

(22 per
cent.)

(17 per
cent.)

(48 8 per
cent.)

Each of these two groups of simple amentia will now
be considered.

(a) Simple primary amentia : Of the hundred cases examined
sixty-five were cases of simple primary amentia, and of these
twenty-nine (or 44 6 per cent .) gave positive reactions. More¬
over, of the sixty-five cases twenty-seven were cases of amentia
with complications, and thirty-eight were uncomplicated cases.

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687

Of the latter fourteen (or 368 percent.) gave positive reactions,
while of the former fifteen (or 5 5'6 per cent.) gave positive
reactions. Again, of the twenty-nine cases giving positive
reactions ten gave “ definitely positive ” reactions, eleven
“ weakly , positive ” reactions, and eight “ doubtfully positive ”
reactions. Of all the “ definitely positive ” reactions 40 per cent.
were given by the complicated cases, and of all the “ weakly
positive ” reactions 45 per cent, were given by the uncomplicated
cases.

(b) Simple secondary amentia : Sixteen of these cases were
examined. zEtiologically, they may be classified as follows :
Simple secondary amentia due to—(i) “ infantile convulsions,”
seven cases ; (ii) recurrent convulsions in early childhood, three
cases ; (iii) other illnesses in infancy, four cases ; and (iv) head
injuries in infancy, two cases. The first two of these groups
will be considered in the section dealing with “ amentia with
convulsions.” It may here be recollected that the aetiological
group of simple secondary amentia due to “ recurrent convul¬
sions in early childhood ” was known by the older writers as
“ eclampsic amentia.” To-day Mr. Tredgold calls the same
group of cases “ epileptic amentia,” distinguishing them from
“ amentia with epilepsy,” where the convulsions are a complica¬
tion and not the cause of the amentia. Both these terms,
however, tend to confusion and are therefore not employed in
this paper. Of the remaining two aetiological groups of simple
secondary amentia, the sera of the four cases due to “ other
illnesses in infancy” gave negative reactions, the illnesses
recorded being “sunstroke,” “ meningitis,” “illnessat teething,”
and “ mastoiditis.” Both the cases due to head injuries in
infancy gave positive reactions, one being doubtfully positive
and the other weakly positive. In the aetiological Table E
these two cases are shown as Nos. 12 and 42 respectively, and
they are very probably cases in which the syphilitic virus and
not the alleged injury is the primary and essential cause of the
mental defect.

(7) Amentia with Complications. —Of the 100 cases examined
forty-three were cases of amentia with complications. Of these
forty-three cases twenty-one (or 48*8 per cent.) gave positive
reactions, while of the fifty-seven uncomplicated cases twenty-one
(or 36' 8 per cent.) gave positive reactions; so that of all the
positive reactions obtained half were given by the uncomplicated

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cases and half by the complicated cases. Again, of the seventy-
six-cases of primary amentia examined twenty-eight (or 36‘8
per cent.) were cases with complications, while fifteen of the
twenty-four cases of secondary amentia (/.<?., 62 - 5 per cent.) were
complicated cases. Of all the cases of primary amentia with
complications, fifteen (or 53*5 per cent.) gave positive reactions,
while of the uncomplicated cases of primary amentia seventeen
(or 35*4 per cent.) gave positive reactions. Of all the cases
of secondary amentia with complications six (or 40 percent.)
gave positive reactions, while of the uncomplicated cases of
secondary amentia four (or 44^5 percent.) gave positive reactions.

The cases of amentia with complications will now be con¬
sidered under two heads : ( a ) Cases with paralysis ; ( b) cases
with convulsions.

(a) Amentia with paralysis : The physical condition of seven
of the IOO patients was complicated with paralysis, the types of
paralysis being as follows: Hemiplegia, three cases ; strabis¬
mus, three cases ; and ptosis, one case. Of these seven cases,
two gave doubtfully positive reactions, both being hemiplegias
and cases of secondary amentia. One of these two, a hydro¬
cephalic, is also subject to “ Jacksonian epilepsy.”

(fi) Amentia with convulsions : At the present day seventeen
of the 100 cases examined suffer from recurrent convulsive
attacks commonly designated by the convenient group-name of
“epilepsy.” In addition to these, eleven others have suffered
from similar attacks when younger, but are not so affected now;
and twelve others are said to have had “ infantile convulsions.”
Moreover, one other case is subject to “Jacksonian epilepsy.”
In all, then, forty-one of the 100 cases examined have had
convulsive attacks at some period of their lives. These cases
are analysed in Table G.

From this table it will be seen :

(i) That, excluding the “Jacksonian epileptic,” of the forty
remaining cases of amentia with convulsions twenty {i.e., 50
per cent.) gave positive reactions, five being “ definitely positive,”
nine “ weakly positive,” and six “ doubtfully positive.”

(ii) That, excluding also the cases of “infantile convulsions,”
there are twenty-eight patients who are or have been subject
to recurrent convulsive attacks. Of these sixteen (a little
over 57 per cent.) gave positive reactions, five being “definitely
positive,” five “ weakly positive,” and six “ doubtfully positive.”

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689

(iii) That of the seventeen cases suffering at the present day
from recurring convulsive attacks, commonly designated by the
group-name of “epilepsy,” ten, or nearly 59 per cent., gave
positive reactions ; and of these positive reactions 30 per cent.
were “ definitely positive.”

Table G. —Being an Analysis of the Forty one Cases of Amentia

with Convulsions.

Clinical variety.

No.

of

cases.

Number of
“definitely
positive *
reactions.

Number of
“ weaklv
positive*’
reactions.

Number of
“ doubtfully
positive **
rea< tions.

Number of
“ negative”
reactions.

Recurrent convulsions

at present day —

(1) Simple primary aments .

15

2

4

3

6

(2) Hypertrophic

I

(«3 P er
cent.)

1

(27 per
cent.)

(20 per
cent.)

(40 per
cent.)

(3) Cretin (with paralysis) .

I

—

—

—

I

Recurrent convulsions

in childhood —

(1) Simple primary aments .

7

2

I

2

2

(2) Hydrocephalic (with

paralysis) .

I

_

_

_

I

(3) Simple secondary aments

2

—

—

I

I

(4) Simple secondary aments
(with paralysis) .

I

_

_

I

"Infantile convulsions ”

(1) Simple primary aments .

4

.

I

_

3

(2) Hydrocephalic

I

—

—

—

I

(3) Simple secondary aments

6

3

—

3

(4) Simple secondary aments
(with paralysis) .

I

_

_

I

"Jacksonian epilepsy ”—

(1) Hydrocephalic (with

paralysis) .

I

—

J

1

—

Hence it would seem from the above study that of all the
patients who have had convulsive attacks at some period of
their lives over 50 per cent, gave positive reactions ; while of
those who might have been designated “epileptic” at some
period of their lives a little over 57 per cent, gave positive
reactions ; and of those diagnosed as “epileptic” to-day nearly
59 per cent, gave positive reactions.

Again, comparing the figures given in Table G with the
total number of cases giving positive reactions {viz., forty-two
cases), it will be seen that of all the patients giving positive
reactions twenty-one (or 50 per cent.) have had convulsive

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attacks at some period of their lives ; sixteen (or 38 per cent.)
might have been designated “ epileptic ” at some period of their
lives ; and ten (or nearly 24 per cent.) are diagnosed as
“ epileptic ” to-day.

Considering now the non-convulsive cases, it will be remem¬
bered that fifty-nine of the 100 cases examined have never had
a convulsive attack of any kind at any period of their lives.
Of these fifty-nine cases twenty-one gave positive reactions.
In other words, half the total number of positive reactions in
this series occurred in non-convulsive cases, and the other half
in those who have had convulsive attacks at some period of
their lives. To be more exact, 50 per cent, of the positive
reactions occurred in non-“ epileptic ” cases, and 38 per cent, in
those cases which might have been designated “ epileptic ” at
some period of their lives. On the other hand, as already
noted, a little over 57 per cent, of these “ epileptic ” cases gave
positive reactions, while of the non-“ epileptic ” cases only 3 5'5
per cent, gave positive reactions.

Other facts to be noted are as follows :

(а) Seventy-six cases of primary amentia were examined,
and of these twenty-six were cases with convulsions. Of the
convulsive cases, fifteen (or 577 per cent.) gave positive
reactions, while of the fifty non-convulsive cases seventeen (or
34 per cent.) gave positive reactions.

(б) Fifteen of the twenty-four cases of secondary amentia
were cases with convulsions. Of these convulsive cases six (or
40 percent?) gave positive reactions, while of the non-convulsive
cases four (or 44^5 per cent?) gave positive reactions. More¬
over, of the fifteen convulsive cases ten were cases with con¬
vulsions only, and of these five (or 50 per cent?) gave positive
reactions.

( c) Eighty-one cases of simple amentia were examined, and
of these thirty-six were cases with convulsions. Of the convul¬
sive cases nineteen (or 527 per cent?) gave positive reactions,
while of the forty-five non-convulsive cases sixteen (or 3 5'5 per
cent?) gave positive reactions. Moreover, thirty-four of these
cases were cases with convulsions only, and nineteeen (or 55 8
per cent.) gave positive reactions.

Again, of the thirty-six cases of simple amentia with convul¬
sions, twenty-six were cases of primary amentia and ten of
secondary amentia. Of the twenty-six cases of simple primary

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amentia with convulsions, fifteen (or 5 7'6 per cent.) gave positive
reactions, while of the non-convulsive cases of this type fourteen
(or 35*8 per cent.) gave positive reactions. Of the ten cases of
simple secondary amentia with convulsions, four (or 40 per
cent.) gave positive reactions ; of the eight cases of this type
with convulsions only, four (or 50 percent.) gave positive reac¬
tions ; while of the non-convulsive cases two (or 333 per cent.)
gave positive reactions.

The last point to be investigated was the relation of the
intensity of the “ epilepsy ” and the frequency of the convulsive
attacks to the incidence and intensity of the reaction. Unfor¬
tunately, no such relations were obtained. Three of the
“ negative ” cases, for instance, were the severest cases of
“ epilepsy ” examined ; while of the “ positive ” cases the most
severe and the mildest gave “ definitely positive ” reactions, the
serum of the second worst was only “ weakly positive ” and so
on. One slight feature of this series of cases, however, should
be noted. It was found that the convulsive attacks in the
“ positive ” cases tend to be far more frequent during the night
and the early hours of the morning than they are during the
day, while in the “ negative ” cases they are most frequent
during the day. The intensity of the convulsive attacks in
each instance appears to be characterised also in the same way.
This feature of the “ positive ” cases, therefore, tends to bring
them into line with other syphilitic conditions— eg., the
syphilitic headache, which is said to be most intense towards
the early hours of the morning.

Recapitulation.

The main points of this paper may be recapitulated as
follows :

(1) The Incidence of the Compluetic Reaction in the Cases of
Amentia Examined. —The blood sera of 100 aments were
examined, and a “ positive ” reaction was found to be present
in forty-two ; but only twelve of these are to be regarded as
“ truly positive.”

(2) The Intensity of the Reaction in the Cases of Amentia
Examined.

(i) Sera were tested heated and unheated. Sera in which
no haemolysis occurred were recorded as “ definitely positive ”

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those in which partial haemolysis occurred as “ weakly positive.”
Sera in which the results differed when heated and unheated
were recorded as “ doubtfully positive.” Of the forty-two sera
giving a positive reaction in twelve the reaction was found to
be “definitely positive,” in sixteen “weakly positive,” and in
fourteen “doubtfully positive” ; but only the twelve “definitely
positive” reactions are to be regarded as “truly positive.”

(ii) Quantitatively, even the “ definitely positive ” reactions
are to be considered as feeble reactions, for the syphilitic reagin
present in each of these cases was invariably found to be in
small quantities, being always enough to utilise two minimal
doses of complement.

(3) The Relation of the Presence of the Reaction to the Sex of
the Patients Examined .—This was not determined, as all the
aments examined were males.

(4) The Relation of the Presence of the Reaction to the Age oj
the Patients Examined .—The reaction w'as found to vary with
age. Asa rule, it tended to diminishin incidence and intensity
as the ages of the patients increased. It appeared, however, to
be strongest and most frequent in patients between 16 and 21
years of age ; and it tended to be more frequent and stronger
in those below 16 than in those above 21 years of age. In
considering the total percentage of the positive results obtained,
it should be remembered that the majority of the patients
examined were boys, 38 percent, being between 16 and 21,and
57 per cent, under 21 years of age.

(5) The Relation of the Reaction to the Forms of Amentia
Examined .—The reaction was obtained in a little over 42 per
cent, of the cases of primary amentia, and in nearly 42 per cent.
of the cases of secondary amentia. It tended to be a little
stronger in the latter group of cases.

(6) The Relation of the Reaction to the Degrees of Amentia
Examined .—Only idiots and imbeciles were examined. The
reaction appeared to be more frequent and stronger in the
idiots than in the imbeciles; thus, 50 percent, of the idiots
examined gave a positive reaction, and in i6'6 per cent, the
reaction was found to be “ definitely positive,” whereas it was
^present in 3S‘5 per cent, of the imbeciles, being “definitely
positive” in 10 per cent.

(7) The Relation of the Reaction to the Clinical Varieties op
A mentia Examined.

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693

(i) In over 72 per cent, of Mongols the serum did not react
to the test. Of the eleven cases examined, a positive reaction
was obtained in three, being “ weakly positive ” in one and
“ doubtfully positive ” in the other two.

(ii) One of three cases of hydrocephalus gave a “ doubtfully
positive ” reaction.

(iii) Only one case of hypertrophicism was examined, and
this was found to be “ definitely positive.”

(iv) A positive reaction was obtained in two of four cretins,
being “ definitely positive ” in one, and “ doubtfully positive ”
in the other.

(v) Eighty-one cases of simple amentia were examined, and
the reaction was found to be “ definitely positive ” in ten,
“ weakly positive ” in sixteen, and “ doubtfully positive ” in
nine. Excluding the “ doubtfully positive ” cases the reaction
was found to be present in 32 per cent, of simple aments. It
appeared to be more frequent in the cases of simple primary
amentia than in the cases of simple secondary amentia.

(vi) Of the seven cases of amentia with paralysis, two, both
hemiplegias, gave “ doubtfully positive ” reactions.

(vii) Excluding the “ doubtfully positive ” cases, the reaction
was present in 41 - 2 per cent, of patients suffering at the present
day from recurring convulsive attacks, commonly designated by
the group-name of "epilepsy”; in 35*7 per cent, of those
diagnosed as “ epileptic ” at some period of their lives ; and in
237 per cent, of non-" epileptic ” cases. It should also be
noted that of the simple primary aments with recurrent con¬
vulsions to-day, a “definitely positive” reaction was obtained
in only 13 per cent.

(8) The R 5 le of Syphilis in the ^Etiology of the Cases oj
Amentia Examined. —Three points are to be noted :

(i) That as the compluetic reaction is an index of existing
syphilis, all the positive cases are to be regarded as weak
syphilitic infections.

(ii) That these weak infections were intra-uterine or “ con¬
genital ” in origin.

(iii) That the syphilitic virus did not appear to be wholly
responsible for the amentia in each of these cases, but seemed
rather to have been associated with and to have acted upon
inherently defective, diseased and degenerated, or damaged
tissues.

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In conclusion, I should like to state how very grateful I am
to Sir George Savage for his kindly interest in and generous
appreciation of this my work, whereby it was submitted to the
authoritative criticism of Major Mott, who, though he regretted
that the technique employed was not in strict conformity with
that of the “ original” test, yet agreed the results obtained were
of sufficient value to be placed before this meeting.

APPENDIX.

Shoving some of the results published.

Number

of

Number

of

Percentage

of

Names of observers.

“ positive'’

“ positive"

examined.

results

obtained.

results

obtained.

In France.

Raviart, Breton, &c. (1)

In Denmark.

246

76

308

(a) Lippmann (2)

78

7

89

( b ) Idem .....
In Germany.

(?)

(?)

132

Kellner, Clemenz, &c. (3) .

216

8

37

Dean (4^.

380

5 i

154

Thomsen, Boas, &c. (5)

2,061

31

»\5

Krober (6) ....

In Atnerica.

262

56

21'3

Atwood (7). ....

204

30

14^6

W. C. Stoner and E. L. Reiser (8)

1,050

83

79

Dawson (9) ...

—

. —

40

(a) Stevens (10) ....

21

. 2

95

\b) Idem .....
In England.

18

6

333

Muirhead (11)

S

. —

—

Scholbere and Goodall (12)

46

15

326

Chislett (13) ....

22

11

500

Gordon (14) ....

400

66

i 6'5

Fraser and Watson (15)

205

123

6o'o

(a) Rees Thomas (16)

163

8

49

(b) Idem .

—

—

100

Robertson and Findlay (17)

*5

• (?) 9

59 °

F. E. Batten (18)

2

. —

(a) Mott (19)

257

21

81

(b) Idem .....

200

24

12*0

H. F. Stephens ....

100

12

120

References.

(1) Raviart, Breton, Petit, Gayet et Cannae.— Rev. de Mid., Par.,
1909, xxviii, p. 840.

(2) Lippmann.— Munch, med. Wochenschr., 1909, lvi, p. 2417.

(3) Kellner, Clemenz, Biiickner und Rautenburg.— Deutsch. med.
JVochenschr ., Leipz. u. Berl., 1909, p. 1827.

(4) Dean.— Proc. Roy. Soc. Med., 1910, iii (Neurol. Sect.), p. 117.

(5) Thomsen, Boas, Hort, und Leschly.— Berl. klin. Wochenschr.,
1911, xlviii, p. 891.

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695

(6) Krober.— Med. Klin ., Wien, 1911, vii, p. 1239.

(7) Atwood.— Journ. Amer. Med. Assoc., Chicago, lv, p. 464.

(8) Stoner, W. C., and Keiser, E. L. — Cleveland Med. Journ., 1912,
x, p. 251.

(9) Dawson.— Journ. of Psycho - A sthenics, Faribault, Minnesota,
December, 19x2.

(10) Stevens.— (a) Journ. Amer. Med. Assoc., 1915, lxiv, p. 1636;
(h) four. Amer. Med. Assoc., 1916, lxvi, p. 1373.

(11) Muirhead.— Journ. of Ment. Sci., 1910, lvi, p. 651.

(12) Scholberg and Goodall.— Ibid., 1911, lvii, p. 218.

(13) Chislett. — Ibid., 1911, lvii, p. 499.

(14) Gordon.— Lancet, 1913, ii, p. 861.

(15) Fraser and Watson.— Journ. of Ment. Sci., 1913, lix, p. 640.

(16) Rees Thomas.— (a) Report of the Commissioners of Lunacy,
1912, p. no; ( b) Lancet, 1914, i, p. 1001.

(17) Robertson and Findlay.— Glasgow Med. Journ. , 1914, ii, p.

241.

(18) Batten, F. E.— Quart. Journ. of Med., July, 1914, vii. p. 444.

(19) Mott.— (a) Pinal Report of the Royal Commission on Venereal
Diseases, (Cd. 8189, 1916), Appendices, p. 144; (b) Proc. Roy. Soc.
Med., 1916, ix (Sect, of Psychiatry), p. 64.

( l ) A paper read before the Royal Society of Medicine, and reprinted from its
Proceedings, 1916, vol. ix (Section of Psychiatry), pp. 27-63.— (’) Vide the Appen¬
dices to the Reports of the Royal Commission on Venereal Diseases, printed
separately in (Cd. 7475, 1914) and (Cd. 8190, 1916).

Discussion.

Dr. Percy Smith : Before the Wassermann test was discovered the percentage
of definite syphilitic cases in mental defectives (idiots and imbeciles) appeared to
be only 2 or 3 per cent., and the enormous difference in the percentages now shown
by various observers raises doubt as to the real proportion of syphilitic cases. It
is interesting that in the case of " mongol ” idiots the percentage of syphilitics
appears to be low, these cases being commonly the youngest child of a large
family when the mother is approaching the limit of reproductive function.

Dr. Shuttleworth : In reference to the statistics of syphilis and mental defect
quoted by Dr. Percy Smitii, these were published by Dr. Fletcher Beach and
myself in Hack Tuke’s Dictionary of Psychological Medicine so long ago as 1892.
They were based upon clinical signs and family histories of 2,380 cases investi¬
gated at the Darenth and Royal Albert Asylums, and gave a very low estimate
viinder 2 per cent.) of the influence of inherited syphilis as a factor of idiocy, etc.
The late Dr. Langdon-Down also stated that in his large experience of idiots at
Earlswood, as well as from pathological investigations as Physician to the London
Hospital, he was of opinion that not more than 2 per cent, were the subjects of
congenital syphilis. The Spirochata pallida was, however, not discovered till
1905, and the earlier statistics rested solely on personal stigmata and family
history. Subsequently the Wassermann reaction came into vogue as a test, and
very varying reports have been issued by successive observers. In the new
edition (just published) of Mentally Deficient Children, there appears a table
of percentages obtained by fourteen different observers, varying from i'5 to 60, in
which positive reactions to the Wassermann test have been recorded in the blood
of congenital cases of mental defect. Dr. Stephens apparently found such reaction
in 42 per cent, of his 100 cases at Earlswood. Unfortunately I was prevented
from arriving in time to hear the early part of the paper, in which presumably Dr.
Stephens has described the technique he has adopted. But the discrepancies
noted lead to the suspicion that the methods used by the various observers cannot

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have been uniform, and consequently the results must be to some extent dis¬
counted. The inquiry is a most important one, and I trust that Dr. Stephens will
utilise the material at Earlswood to the full. I am especially interested in the
comparison made by Dr. Stephens as to reaction in certain characteristic types.
The mongolian type, for instance, has shown comparatively little “ compluetic "
reaction, and this accords with clinical experience that such cases are “exhaustion
products” rather than of toxic origin, though in exceptional cases a syphilitic
taint may give rise to maternal exhaustion. 1 have always suspected that certain
hydrocephalic cases are of syphilitic origin, and that is a point on which the com¬
pluetic reaction will shed scientific elucidation.

Sir George H. Savagf.: 1 regret the smallness of the meeting, for I think the
paper by Dr. Stephens one of the most important which have been read at the
Section. It will be fully appreciated when it is in print. A very great change has
taken place in the opinion of doctors in relationship to syphilis as a possible or
partial cause of mental deficiency. Recently a paper has been read at the Medico-
Psychological Society on the influence of toxins in producing mental deficiency.
We all allow that syphilis is the most dangerous toxin to the nervous system, and
we are prepared to recognise it as a cause of amentia. The former authorities on
idiocy, such as Langdon-Down and Ireland, did not recognise it as a factor. The
great difference between the percentage of positive Wassermann reactions met
with at Earlswood from , similar observations in Germany makes one feel, with
our President, that the technique should be revised in some way so as to bring it
into line with that of the Germans. It is again interesting to note the number
of patients with a positive reaction yet with no external stigmata pointing to
inherited syphilis. Recently I saw a case of a father who had had syphilis. He
had had two children, one of whom died of epilepsy and the other is a very well-
marked mental defective, yet without external signs of inherited disease. The
paper is suggestive and gives evidence of good work in a field much neglected-in
England.

The President : I congratulate Dr. Stephens upon his paper, which is a
valuable contribution to knowledge at the present time. I wish that it had
appeared before the Report of the Royal Commission had been published. The
high percentage obtained by Dr. Stephens may be due to several causes. It is
necessary first of all to separate cause from coincidence; a positive Wassermann
reaction of the blood, the cerebro-spinal fluid not having been examined, does not
necessarily prove that the idiocy was due to syphilis. In support of this statement,

I may mention that Sir John Collie has shown that g-2 percent, of males apparently
healthy applying for employment in'the various occupations connected with the
administration of the L.C.C.—for example, tramway, fire brigade, etc.—gave a
positive Wassermann reaction. The sera of these men were tested in the
pathological laboratory of the L.C.C. under my direction, and the original
technique (Wassermann’s) was employed. I have tested the bloods from 200
cases of mental defectives, and have found a positive reaction in 12 per cent.

I wish that Dr. Stephens had employed the original Wassermann technique, for
it was laid down by the Royal Commission, strengthened by a report of a
Committee of the Pathological Section of this Society, that short cuts were
undesirable, and that it would be better if the original technique were employed
in all investigations. I would accept the 12 per cent, of marked positive reactions
of Dr. Stephens, for that about corresponded with the results obtained by Dean
and others. I think the remainder of the cases which gave a partial or a weak
reaction should be reinvestigated by the (approved) method of technique I have
alluded to. I presume he considers that these positive cases were due to con¬
genital syphilis, and not acquired. I am therefore surprised to learn that the
larger number of positive cases occurred in adolescent patients. Plaut’s observa¬
tions on the children of general paralytics rather showed that the reaction tended
to disappear with age. Dr. Stephens remarked that few cases showed any signs
of syphilis on the body. Dr. Plaut only found one case out of twenty infants with
a well-marked positive reaction showing any eruption on the body. Infantilism,
imperfect development, or arrest of development of the reproductive organs, is
very common in idiots and low-grade imbeciles; this may be due to syphilitic
infection of the organ. I have found the spirochastcs in the testes of a foetus.
The family history showed a number of pregnancies resulting in defective children,

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697

and children born dead or dying in early infancy. The mother, however, was an
imbecile; the dead children and abortions came after the living, so that probably
the mental deficiency had nothing to do with congenital syphilis. Indeed, the
history tended to show that the mother was syphilised after having given birth to
living children, including the mental defective. The serological test in such a
case would have been most valuable. I should like to ask Dr. Stephens whether
he has made a comparative analysis of the family histories of the positive and
negative cases, especially in regard to the result of pregnancies in the mothers.
When I visited Darenth I found idiots of whom it was said there were no signs of
syphilis, yet examination of the fundi showed choroido-retinitis. The reason why
more mental defectives do not occur as a result of congenital syphilis is due to
the fact that if the spirochmtes enter the central nervous system the child dies.

Dr. Stephens (in reply) : The paper I have written, as you see, is a bulky one.
I have therefore only chosen those sections of it that I thought would be easier to
read, and questions concerning others I hoped to answer as they were raised in
this discussion. I have also purposely omitted all reference to a few important
aspects of the subject, hoping thereby to make certain of being asked about them.
Dr. Percy Smith has raised an important issue, and in answer I should like to say
that the patients have been very carefully examined from the clinical standpoint,
and that in no case could I find any definite syphilitic stigmata, lesions usually
considered to be characteristic of the inherited disease. I must, however, state—
and this will answer the President’s question also—that the ophthalmoscopic and
otological examinations of these patients were unfortunately not undertaken
because of the obvious practical difficulties of such inquiries in aments precluding
one from making any general statements on these points. The family histories
have also been carefully investigated and were “ negative,” from the information
I had at my disposal; but such information is invariably deficient, and in the
majority of cases unreliable. These observations, based on the clinical aspects
and family histories, agree with those obtained by other workers, who may be
divided into two groups—those who recorded their observations before the com-
pluetic reaction was used in the investigation of amentia, and those who have
themselves employed the test in such investigations. Dr. Shuttleworth (1) has
given us his own results, published in collaboration with Dr. Fletcher Beach in
1892, when clear evidence of inherited syphilis was found in only I'lj per cent, of
their cases; while Dr. Langdon-Down (2) detected the stigmata in 2 per cent, of
cases; and Dr. Ireland (3) recorded with some surprise that the disease was not
concerned in the aetiology of amentia. Later, however, Dr. Sherlock (4) obtained
satisfactory evidence of syphilis in one or other parent in 14 4 per cent, of ninety
cases, and Professor Th. Ziehen (5), of Berlin, detected the disease in as many
as 17 per cent, of aments. Therefore, before the advent of the compluetic reaction
the percentage of syphilitic cases, based on clinical evidence alone, was considered
to be small. Since the employment of the test, however, a larger number of
syphilitic cases have been detected, but the same small percentage of clinical
results has been obtained as shown in the writings of Dr. Plaut, Major Mott, and
others. Therefore one of two conclusions is true—either that the reaction is not
associated with syphilis, which in the light of our present knowledge would be
considered absurd, or that the more obvious clinical stigmata of syphilis are not
found in aments, which, with the testimony of the present and past experience of
competent observers to support it, would appear to be correct. With Dr. Percy
Smith’s remarks on the causation of mongolianism most observers would to-day
agree, but it was not so very long ago when this condition was considered to be para-
syphilitic, and that is why 1 have emphasised the point that in the sera of over
72 per cent, of mongols I have found the reaction negative. In answer to the
President I have to say that, with the exception of seven, the patients came from
all parts of England—from villages, towns, and cities ; and they were drawn from
all ranks of society. These points I have mentioned in my paper. Both Major
Mott and Dr. Shuttleworth have referred to the technique employed in these tests.
One of the principles of the “ original method,” as defined by the Society’s Sub-
Committee, is that the ingredients of the test should be derived “ from different
sources.” If this means “ from different individuals,” then the technique I
employed agrees with that of the “ original ” test. But if it is intended to mean
" from individuals of different species ” ( e.g the rabbit, the sheep, the guinea-

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pig), then the technique I employed does not agree with that of the “original ”
test, for I used in my "haemolytic system” human red blood corpuscles (always
obtained, it must be remembered, independently of the bloods to be examined).
Otherwise my technique conformed with the principles of the “ original ” test,
and as shown in my paper eyerything was done to render the determinations as
accurate as possible. Major Mott questions the accuracy of the "unheated”
reactions. 1 agree with him, but I do not think they in any way invalidate the
final interpretation of the results obtained. I should like to emphasise the fact
that 12 and not 42 should be taken as the total percentage of the positive results.
I have recorded the other reactions merely to indicate that they have been
obtained, and in my paper I have given reasons why they should be rejected
as “ negative.”

References.

(1) Hack Tuke’s Dictionary of Psychological Medicine, London, 1892; also
Amer. Journ. of Insanity, 1888, lxiv, p. 381.

(2) Mental Affections of Childhood and Youth, Churchill, London, 1887.

(3) On Idiocy and Imbecility, Churchill, London, 1877.

(4) The Feeble-minded, Macmillan, London, 1911.

( 5 ) Psychiatrie, Leipzig, 1908, p. 613.

Reaction Time in Nervous and Mental Diseases. By
E. W. Scripture, M.D., Ph.D.

I. Introduction.

Our knowledge of whether a person is normal, or suffers from
neuritis, or is a case of dementia prsecox, is derived entirely
from observations of how he reacts to his environment—that is,
to various stimuli. The thought at the basis of these researches
is that an attempt may be made to produce an environment
where the results will be accurately recorded in a simple, direct
way.

The study of the nervous and mental condition of human
beings consists of a study of their reactions—that is, of their
responses to stimuli. By using stimuli of sound or light to
which the person must respond by a voluntary movement, some
degree of simple mental activity is involved. By requiring dis¬
crimination between two stimuli, and choice between two
actions, more complicated mental action is included. These
researches have not gone beyond this rather simple degree of
mental action involving sensation, perception, discrimination,
choice, and volition. They should be extended to higher forms
of reaction to include association of ideas, judgments, emotions,
etc., in fact, to all and more than what is included in a regular
examination.

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699

1916.]

The method here employed differs from other methods of
examination and study by resulting in a measurement. The
simple reaction to a light or a sound, involving sensation and
volition, results in a measurement of time—the “ simple reac¬
tion time.” The more complex response involving discrimina¬
tion and choice results also in a measurement of time—the
“ complex reaction time.” The various higher mental activi¬
ties can be tested by methods of experiment that result in
measurements of time or accuracy or force.

Such a series of self-recording tests may perhaps be developed
and extended to include all the essentials required for a dia¬
gnosis, while the increased precision in certain tests may make
a large part of the ordinary examination unnecessary.

The researches of past years in physiology and psychology
have shown that the time of a reaction changes with the condi¬
tion of the individual, with the complications of the situation,
etc. Hitherto these researches have been confined almost
entirely to normal persons. It is the purpose of this investiga¬
tion to determine how persons with various nervous and mental
diseases respond to certain simple definite problems.

The simplest problem is that of being required to watch for
a signal, and to respond by the movement of a finger when the
signal is perceived. Such a response is termed a “ simple
reaction.” Although a reaction may be studied in many ways,
the time it requires—the “ reaction time ”—is that factor for
which the technique has been most developed.

The ordinary measurements of reaction time involve a fine
clock-work registering in hundredths or thousands of a second.
Each result has to be recorded by the experimenter. The
taking of 100 reaction times can hardly be accomplished in less
than one hour. Such a method is entirely too cumbersome for
clinical use. I have therefore devised a self-recording method
that shows directly to the eye without measurement just how
quick the reaction time is, and just how it varies. The whole
series of experiments in all their details is fixed on paper in a
few minutes in a way that would require hours of work by the
older methods. The diagnosis, in so far as it depends on these
records, is settled on the spot. The actual reaction times can
be obtained with the greatest accuracy by measuring the auto¬
matic record at any convenient time,

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REACTION TIME IN MENTAL DISEASES, [Oct.,

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II. Apparatus.

A recording drum (kymograph) turned by clock-work, carries
a surface of smoked paper (Fig. i). On the axle of the drum
there is a spring that makes contact once every revolution with
an insulated metal point held by a support. Every time the
spring passes the contact point an electric circuit is closed for
an instant. This circuit includes a magnetic signal or minia¬
ture incandescent lamp. The magnetic signal makes a move¬
ment once every revolution. This movement can be used as a
visual signal by making the action noiseless with a piece of
cotton, or the sound itself can be used as an auditory signal.
The little lamp is used as a visual signal.

The record on the smoked paper of the drum is made by a
magnetic marker on a stand. The marker is placed so that its
recording point rests against the drum with no current passing
through, and is pulled away from the drum as soon as the
circuit is closed. A separate circuit with a battery current
interrupted by a telegraph key is connected with this marker.
The closing of the circuit by the key holds the point of the
marker away from the drum.

Before an experiment the drum is turned until the spring
touches the insulated point and the signal is given. Holding
the drum in this position, with the marker circuit broken so
that the point touches the drum, the marker is run up or down
on its support. The vertical white line thus drawn indicates
the point of the drum directly under the marker at the moment
the signal circuit is closed; it is called the “zero line.”

To make a record the patient holds his finger on the key to
keep the circuit closed, and the point of the marker away from
the drum. The drum is set in motion. When the signal, is
given he releases the key, and so lets the marker draw a white
horizontal line on the smoked paper. The rate of revolution
of the drum can be regulated to suit the occasion.

The scheme of a record is shown in Fig. 2. The space from
the zero line to the beginning of the horizontal line represents
the time that elapsed between the moment of the stimulus and
the moment of the reaction ; it is called the “ reaction time.”
The length of the horizontal line represents the “ holding time,”
or the time the patient held his finger off they key.

After the reaction occurs, the recording point is moved down

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Fig. i.— Recording apparatus.

To illustrate paper by Dr. E. W. Scripture.

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BY E. W. SCRIPTURE, M.D.

701

about half a millimeter by a notched wheel. The drum con¬
tinues to turn, and after a short time (four and a half seconds)
the signal is made again, and the patient again reacts. In this
way records are made at small distances apart.

Before or after each record a time line is drawn on the drum
by applying to it a fine point at the end of a tuning fork
vibrating one hundred times a second. Each wave of the time
line represents one-hundredth of a second. After the record has
been varnished a portion of the time line is cut out, and used
as a scale to measure the reaction time and the holding time.

-Head ion

Tim.—#.

i

Holding Time

1

Time Line

Fig. 2. —Scheme of reaction record.

The important advantage of having the successive records
at equal distances apart is gained by placing the marker on a
support that can be lowered by rack-work similar to that of
a microscope. The following arrangement is added. On the
inner side of the small wheel that lowers the support by
connection with the rack-work shallow depressions are drilled
in a series. A dull-pointed steel pin is fixed in a barrel against
a spring so that its point rests in a depression of the wheel.
As the wheel is turned the point is forced out of the notch, but
falls into the next one; this is sufficient to cause the hand to
stop in turning the wheel.

Recording reaction times in this way gives at once a complete
I.XII. 4 5

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REACTION TIME IN MENTAL DISEASES,

[Oct.,

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picture of how the reaction times grow longer or shorter, how
they become more or less irregular, etc. For much clinical
work it is not necessary to make measurements ; the record
sheet presents a sufficiently accurate picture of the condition.

The time required for the marker to touch the drum after
the current is broken—its “ latent time of the break ”—is
registered by passing the current from the battery through
the marker, and then through the contact on the drum. This
arrangement also registers the time required for the point of
the marker to leave the drum after the current is made, that
•is, the “ latent time of the maker.” For the small marker used
here the latent times of the break and of the make averaged less
than o - oo5 sec. These times are very regular, the average
error being 0*002 sec.

The latent time of the magnetic signal was measured in the
same way as that of the marker. It was very small and
regular, averaging o'oi sec.

The time required for the lamp to light up after the contact
is made—its latent time—was measured in the following
manner. The lamp was placed back of the drum, and just
below its lower edge. Exactly opposite it in front of the drum
there was placed a long tube with a vertical slit at one end.
The observer looked through the other end and adjusted the
tube so that he could see the lamp through the slit. On the
bottom of the drum there was placed a strip of cardboard with
a horizontal slit in it; this slit was covered by a paper slide.
The cardboard was so placed that, the moment the contact was
made, the left end of its slit was in a line with the lamp amd
the slit in the tube. The paper was pulled aside so as to leave
a narrow slit in the cardboard. If the lamp had lit up exactly
when the contact was made, it could have been seen through
the narrowest possible slit in the cardboard, but as it took
time for the lamp to light up, the drum had turned a certain
distance in that time, and so a larger slit W'as necessary'. The
slit was enlarged until the observer could just see the light.
Then the time of exposure through the slit was measured. In
this case the latent time of the lamp was found to be approxi¬
mately o'oi sec.

The zero line nominally indicates the moment of* the occur¬
rence of the visual or auditory signal. Actually the signal
occurs afterwards by the amount of the latent time. All the
records are therefore too long by the amount of the latent time

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BY E. W. SCRIPTURE, M.D.

7&3

of the signal, namely, in these researches by approximately
O'Oi sec. To get the true reaction time this amount must be
subtracted. The marker makes its registration too late by the
amount of its latent time. Therefore this amount must be
subtracted from the registered reaction time to get the true
reaction. These two latent times are subtracted in the
computations.

The holding time is not affected by the latent time of the

marker, as the marker touches the drum about o’oi sec. after
the reaction is begun, and leaves it about ooi sec. after the
reaction is ended.

The regularity of the drum is tested by having an electrically
driven tuning fork register continuously for a large number of
revolutions without rewinding the drum. There should be an
equal number of waves for each revolution. A test for forty-one
revolutions showed that the speed did not decrease to any
amount that could be detected, and that the average irregularity
amounted to 2 per cent.

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704 REACTION TIME IN MENTAL DISEASES, [Oct.,

In a complex reaction the person has to discriminate between
two stimuli, and choose between two acts. In one set of
experiments two magnetic signals were used. These consisted
of two electrical bells, with the knobs bent so that they did
not touch the bell. They were thus noiseless and were used
as visual signals. They made contact only once, the self¬
interrupter having been removed. For a movement of the
left hand signal the person was to release the left one of the
two keys; for a movement of the right hand the right key.
The two signals were fastened to a board some distance in
front of the telegraph keys. A triple pole double-throw switch
was so connected with the telegraph keys that in one position
it caused the right hand bell to move, or the white light to
flash ; in the other position the left hand bell to move, or the
green light to flash. An electric buzzer was inserted in each
key circuit so that it acted if the wrong key was used. Thus
with the double-throw switch in one position, the right hand
bell moved, and the right hand key registered a straight line on
the drum, just as in the preceding arrangement for simple
reactions; but if the left hand key was released by mistake the
buzzer interrupted the current, and the magnetic marker
registered a dotted line.

In another set of experiments two lights, a white and a green,
were used, and also two keys, one for each hand. When the
white light was flashed, the person was to release the right
hand key, when the green one was flashed, the left hand key.

III. Interpretation of Results.

The great advantage of this form of experiment is that
it furnishes at once a picture of the quickness with which a
person responds to a stimulus, and also of his variability.
For a quick person the horizontal lines are near to the vertical
line ; for a slow person they are further away. For a
steady person the ends of the horizontal lines are at about
the same distance from the vertical; for an unsteady person
their positions vary more or less greatly. Any lengthening of
the time or increase of variability is presented at once to the
eye without measurement.

When detailed information is desired, the distance from the
vertical line to the beginning of each horizontal line is measured
by means of the waves of the time line. This gives the reac-

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BY E. W. SCRIPTURE, M.D.

705

tion times in hundredths of a second. The average of these
reactions is taken for the whole record, or for any portion that
may be selected.

To obtain the person’s variability for a set of reactions the
difference is found between the average and each individual
measurement, and then these differences-are averaged without
regard to sign. For example, the first fourteen reactions for a
certain normal person are given in the first column below.

Reaction times.

Variations.

0*20

0-007

0 *l6

0-047

0*21

0-003

0’24

0-033

0-23

0-023

o-i8

0*027

0'20

0-007

0 "2I

0-003

o’i8

0-027

0*24

0033

0-24

0-033

0T9

0-017

0-25

0-043

0-17

0-037

0-207

Average . 0-024

rage reaction

is 0-207 sec - The difference between

this and the first reaction (o - 2o sec.) is 0-007 sec. The second
column gives these differences for the entire set of fourteen.
The average of these differences, 0-024 sec., is called the average
variation. The average variation is T *br or 12 per cent, of the
average reaction time. Although computations are made in
thousandths, the results are best stated in hundreths in the
present case. The average reaction is thuso'21 sec. and the
average variation 0-02 sec. The latter value is a good index of
the irregularity of the results. Another value, the mean square
error, is a slightly better one, but in the present case it hardly
repays the additional labour of computations.

IV. Normal Records.

A typical normal record is shown in Fig. 4; it was made by
a physician known for his remarkably equable temperament.

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706 REACTION TIME IN MENTAL DISEASES, [Oct.,

Inspecting the record we notice that the results fall into five
groups. There is first a very irregular group reaching through
the fourteenth record, which represents the period of “ training
in.” Then there is a regular group reaching from the fifteenth
through the forty-fourth, which might be called a period of
“ steady gait.” At the forty-fifth experiment there is a sudden
great lengthening of the reaction. This is undoubtedly due to
a readjustment in the person’s mental condition, which we can
attribute to some “ distraction.” From the forty-fifth through
the fifty-fourth there is a steady gain in rapidity as the person
returns to his condition of steady gait. From the fifty-fifth
through the eighty-first there is a very regular group which
again can be considered a period of steady gait. After that the
reactions become irregular and longer, representing a condition
of “ fatigue.” The average reactions and the average variations
are given in Table I.

Table I (Fig. 4). —Normal Person, A. Simple Reaction.

Average

Average

Average

Average

reaction.

variation.

holding time.

variation.

1st group, 1—14, training in .

0*20

003

Ol 6

003

2nd group, 15-44, steady gait .

016

002

019

002

3rd group, 45-54, distraction .

0'20

003

019

003

4th group, 55-81, steady gait.

O 15

0*01

O' 19

0*02

5th group, 82-95, fatigue

O' 18

003

OI 7

002

Whole average

Ol8

002

O' 18

002

11 %

n%

The shortest average reactions are found in the groups of
“ steady gait,” namely, o‘i6 and 0*15, the small average varia¬
tions being 0'02 and o’oi. “ Training in,” “distraction,” and
“ fatigue ” are marked by long reaction times, and greater
irregularity. The time of holding does not seem to vary much
either in length or in regularity.

The record shown in Fig. 5 is that of a physician of normal
temperament. The period of “ training in ” reaches through
the seventeenth reaction ; it includes one very late or “ de¬
layed ” reaction, and one reaction due to anticipation of the
stimulus, or “anticipated reaction.” The explanation of the
atter case is that since the experiments occurred at regular

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BY E. W. SCRIPTURE, M.D.

707

intervals, the person knew about when to expect them. If he
were nervously excited, he would be liable to react before the
actual stimulus. This is the “anticipation reaction.” The
next following twenty-one reactions belong to the period of
“ steady gait,” a condition of confident expectation and reliant
self-control. There is, then, evidently a third period reaching
through the sixty-third reaction that shows steadily increasing

Training in

Steady cjait

Distraction

Steady gait

Fatigi

ue

Training in

Steady gait

■Incipient fatigue

Adv anced fatigue

Fig. 4. Fig. 5.

Reaction records, simple, normal.

irregularity. Such an increase indicates a change in condition,
which we can term the “ effect of fatigue ”; when the change
is small it can be termed “ incipient fatigue.” In the last
period the reactions are very irregular, showing a high degree
of fatigue. The results are given in ;Table II.

In this case the period of “ training in ” shows itself mainly
in the great irregularity, the"?average variation being 0^04 sec.,
while the 'average reaction, o‘i7, is"scarcely different from that
of the period of^’steady'gait.” Likewise the average holding

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708 REACTION TIME IN MENTAL DISEASES, [Oct.,

time, o‘i7, does not differ. Its quick movements indicate a
condition of strong mental concentration; in spite of this the
lack of adjustment during the training in is shown by the irre¬
gularity. The effect of fatigue on the reaction time is demon¬
strated quite strikingly in the average variation for the last
groups.

Table II (Fig. 5). —Normal Person, D. Simple Reaction.

1st group, 1—17, training in .
2nd group, 18-39, steady gait .
3rd group, 39-63, incipient

fatigue

4th group, 64-85, advanced

fatigue

Average

reaction.

Average

variation.

Average
holding time.

Average

variation.

0‘17

Ol6

Ol8

020

004

O'OI

0.02

005

o' 17

o'i7

016

o'14

003

0 'Q 3

0.02

001 ; c

Whole average

0'l8

0-03

o'16

O'02

17 %

13 %

Table III (Fig. 6). —Normal Person, C.

Simple Reaction.

Average

Average

Average

Average

reaction.

variation.

holding time.

variation.

ist group, 1-6, training in .

O.29

O’ 04

027

005

2nd group, 7-31, steady gait .

023

0 02

0'23

o - o6

3rd group, 32-39, beginning

of fatigue

O '20

003

022

0'02

4th group, 40-58, great mental

fatigue

0-13

O'12

024

0-05

Whole average

0*21

005

023

005

-

33%

22%

The record shown in Fig. 6 is that of a physician of equable
temperament who was somewhat fatigued. We note that the
first six reactions show the usual characteristics of “ training
in.” The reactions that follow through the thirty-first corre¬
spond to the condition of “ steady gait.” We notice that the
reactions steadily become shorter as the person gets more
accustomed to the experiment. Thereafter the reactions begin
to show increasing irregularity, indicating the beginning of

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709

1916.]

fatigue. The following ones show signs of very great mental
fatigue. We note particularly that the first two reactions of
this last group show extra movements of the finger. There are
also three anticipatory reactions, and several more repeated
movements. One reaction anticipates the stimulus by a long
time, and the finger is held down longer than in any other case.
The results are given in Table III.

The record in Fig. 7 is that of a rather highly strung
professor, who had just been lecturing to a large audience ; the
record was made, moreover, in the presence of a number of

Fig. 7.

visitors. The quick reactions and the sudden release of the
key are characteristic of the person’s energetic nervous
temperament; the great irregularity represents the condition
of nervous excitement. The results are given in Table
IV.

In this record the results for the first ten are very irregular,
owing to the factor of “ training in.” The next two tens are
very regular. Thereafter great irregularity exists, showing the
condition of fatigue and excitement.

The preceding records have been those of “simple reaction,”
that is, response to an expected stimulus of known character
by the same movement.

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710 REACTION TIME IN MENTAL DISEASES, [Oct.,

Table IV (Fig. 7). —Normal Person , S. Simple Reaction.

Average

reaction.

Average

variation.

Average
holding time.

A verage
variation.

1st ten .....

O '20

004

0-14

003

2nd ten .....

017

003

O'10

002

3rd ten .

0 21

002

009

o'oi |

4th ten.

0*20

O07

009

003

5th ten .

O' 16

004

010

002

6th ten .....

Ol6

OO7

010

0*02 1

Last eight ....

O 13

004

O'11

002

Whole average

0'l8

004

22 %

O'll

0*02 |
18 %

Table V (Fig. 8). —Normal Person, M.

Average

Average

Average

Average |

reactiou.

variation.

holding time.

variation.

Simple

Reaction.

1st group, 1-23 . . .'

019

003

O'10

002

2nd group, 24-39 •

0*15

OOI

on

O'02

3rd group, 40-56 .

015

002

009

0*01

I

Whole average

Ol6

002

010

,

002

13 %

20 % 1

Complex

Reaction.

Whole average

°39

007

010

0*02

18%

20%

To introduce a more complicated mental condition, two
stimuli were prepared as described above. The person was
told to react with the right hand to one and with the left hand
to the other. The subject was thus obliged to distinguish
between the two objects, and to choose which hand he was to
move. The two mental processes of discrimination and choice
were thus added to the simple reaction. The lower part of
Fig. 8 shows a record of such complex reactions to white and
green lights. We note at once the enormous irregularity,
and the long average. Contrasted with this is the record
of the same person in the upper part of the figure, which shows
the simple reaction time for the same person on the same

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711

occasion. The average simple reaction time is scarcely more
than one-third of the complex reaction time. The average
variation is small. This man’s holding time seems to be
remarkably constant. The results are shown in Table V.

Fig. 8. —Reaction record, simple and Fig. 9. —Reaction, record, simple,

complex, normal. alcoholism, tense type.

V. Records for Alcoholism.

The records for alcoholism show three distinct types, all
differing from the normal.

One type is that of persons who have been long addicted
to alcohol, but who at the present moment are not markedly
under its influence. Fig. 9 shows the simple reaction of a
confirmed alcoholic who had been abstinent for three weeks.
He held his muscles tense and reacted with great vigor; his

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7 12 REACTION TIME IN MENTAL DISEASES, [ Oct .,

eyes and his expression showed fierce attention. For the
eighty-two reactions the results were : average simple reaction,
o - i4 sec., average variation, 0‘02 sec. or 14 per cent. ; average
holding time, o - 22 sec., average variation o - 03 sec. or 14 per cent.
His reactions were as quick and regular as those of the best
normal subjects. This fact has already been observed by

Fig. 10.—Reaction record, simple, Fig. ii. —Reaction record, simple,

alcoholism, sluggish type. alcoholism, disintegration type.

Nadler in the case of alcoholics. ( l ) There is practically no
period of “training in” and no fatigue, although the test
included eighty-two experiments. Such a record shows a state
of abnormal excitement that maybe called “alcoholic tension."

A different type is shown by the record in Fig. 10. The
pat it nt is a chronic loafer who lets his wife support him by
washing. He drinks beer constantly. The sluggish condition
is apparent in the very long reaction times and holding times

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191 6 .] BY E. W. SCRIPTURE, M.D. 713

at the start. He is gradually aroused ; toward the close his
record approaches the normal.

The reactions fall apparently into three groups. The first
group is very long and irregular; it has an average reaction
time of o*47 sec. and an average variation of o # o6 sec. (13 per
cent.). The second group has an average of 0'28 sec. and an
average variation of 0‘04 sec. (15 per cent.). The rest of the
record is evidently the patient’s “ steady gait,” with an average
reaction of o'14 sec. and an average variation of o‘02 sec.
(14 per cent.). The mind in this case is dull and unresponsive,
showing a condition of “ alcoholic sluggishness.”

A very different condition is that of a patient whose record is
shown in Fig. 11. He had been four days on a spree, he could
not sleep, and he felt that he was on the verge of delirium
tremens. His record shows great irregularity. He frequently
forgets to react at all. His average reaction is 0^44 sec.; his
average variation is 0‘ii sec. (25 per cent.). The condition
expressed by this record we might term that of “ alcoholic
disintegration.” The mind has difficulty in fixing its attention.
It acts slowly and irregularly; it often makes mistakes.

A comparison of the results of alcoholics with those of
normal persons indicates some rather striking conclusions. It
may be suggested that the drinking of malt liquors like beers
produces a sluggish condition of mind that is very unfavourable
to clearness of thought and action. Further records may be
expected to show that the habitual beer drinker is a much less
efficient person than the abstainer. On the other hand, many
records have shown that the whiskey drinkers respond with
greater rapidity and precision than the normal person. This,
however, has no bearing on the ultimate effect of whiskey on
the nervous system.

VI. Records for Hysteria.

The mental inhibition characteristic of hysteria shows itself
in the reaction records in great irregularity, unreliability, and
hesitation. The hysterical person is keenly sensitive, and is
quick to perceive, but the disturbed condition of mind prevents
steady, consistent, decisive reactions.

One girl, set. 19, came to the clinic complaining of her
inability to speak above a whisper. Her voice was always like
that of a hoarse, shrill whisper. Other symptoms of hysteria

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714 REACTION TIME IN MENTAL DISEASES, [Oct.,

were present. The diagnosis given was hysterical aphonia. In
attempts to use the Jung association experiments she would sit
motionless ; when asked why she did not respond with a word
she would answer that she w r as only thinking of the word given.
Her voice returned upon an occasion when the physician put
his finger into her larynx. Her reaction records are given in
Figs. 12 and 13. The average simple reaction was 076 sec.
with an average variation of o’o8 sec. or 22 per cent. The
average complex reaction time was o’55 sec., with an average
variation of 0^40 sec., or 73 per cent .; the average complex

Fig. 12. —Reaction record, simple, hysteria.

holding time was 072 sec., with an average variation of o'55
sec., or 76 per cent. Both the simple and the complex reaction
times and the holding times were longer and more variable than
in the case of normal persons. The patient complained of her
eyes troubling her. She sometimes gazed vacantly, and appar¬
ently did not wake up to the light until after an interval; this
reminds us of the vacant waiting condition during the associa¬
tion experiments. These results differ very greatly from those
in the normal records. The intermission of action and the
irregularity are characteristic of hysteria. ( 2 )

A patient, aet. 18, had a peculiar hysterical cry. Her record.
Fig. 14, shows the characteristics of hysteria. The average

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J

r

I

i

i

*

\

:

(

I

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715

simple reaction time was o‘3i sec., with average variation of
0*12 sec., or 39 per cent.; this is much longer than the normal
and very much more irregular. The same is true of the average
holding time, 0^44 sec., with an average variation of 0*15 sec.
or 34 per cent.

A man, ast. 28, had paralysis and tremor which copied the
condition of an old man seen ten years ago by the patient. His
record of simple reaction gives an average reaction of 0’63 sec.,
and an average variation of o - 20 sec. (32 per cent.) ; an average
holding time of 2’oo sec., and an average variation of ri4 sec.
(57 per cent.)

Such records with long average times, great irregularity,
hesitation, and mistakes are what would be expected from a
person preoccupied by some thought. The mental condition in
hysteria consists in mental disturbance by an emotional complex
which has been pushed out of consciousness but which still
makes itself felt: the distraction is by a mental factor that is
not in consciousness. This distraction produces delay and
uncertainty in action.

VII. Records for Epilepsy.

The records of a number of epileptics may be illustrated by
the following three cases:

A patient, set. 25, had been an epileptic for twenty years.
He had just had a fit in the clinic. His voice showed the
typical epileptic speech.( 3 ) His record for a simple reaction is
shown in Fig. 15. The record is characterised by a reaction
time of o'5o sec.; this is long when compared with the normal
reactions which range round 0’20 sec. The holding time,
078 sec., is also much longer than normal.

These facts seem to be connected with the well-known mental
sluggishness of the epileptic. The fact that the holding time
is very much longer at the start, and becomes shorter at the end,
seems to indicate that the mind is gradually aroused from its
sluggishness. The average variation for the reaction time is
o'i6 sec. (32 per cent.) ; this is also very large when compared
with that of normal cases. The average variation of the holding
time, o - 55 sec. (65 per cent.), is likewise very large. There.seems
to be a great difference between the first and last parts of the
record. The first part, with a reaction time 0^44 sec. (average
variation of o'i2 sec. or 27 per cent.), and holding time of i - 26

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716 REACTION TIME IN MENTAL DISEASES, [Oct.,

sec. (average variation of o‘6g sec., or 55 per cent.) shows a
condition of more steady sluggish mentality. The latter part,
which has a reaction time of o - 55 sec. (average variation, 017
sec., or 31 per cent.), and a holding time of 0’28 sec. (average
variation, 0’57 sec., or 49 per cent.), gives evidence of fatigue and
perhaps strain.

A patient, set. 31, had her first fit two and a quarter years
ago, and her last fit one year ago. There was no apparent
mental deterioration. Her record, as shown in Fig. 16, indi-

Fig. 16.—Reaction record, simple, epilepsy.

cates three periods like that of a normal person, namely,
“training in,” “steady gait,” and “fatigue.” There is a
marked difference from the normal in the long time of reaction,
and in the long time of holding; the fatigue is also far more
marked than in any normal patient. The measurements gave
the averages: simple reaction, 0^43 sec. (average variation, o'16
sec., or 37 per cent.).

A patient, set. 43, had had fits for ten years. Two fits had
occurred during the previous week. Her reaction time, Fig. 17,
showed great lengthening and great irregularity as compared

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717

, with those of a normal person. The measurements gave the
averages : simple reaction, 0*47 sec. (average variation, o’io sec.,
or 21 per cent .); holding time, 0*22 sec. (average variation, 0'05
sec., or 23 percent.).

The mental sluggishness and readiness to fatigue of the
epileptic are characteristics strikingly brought out in these

Fig. 17.—Reaction record, simple, epilepsy.

records. The unreliability of the hysterical person, the various
mental states of the alcoholic, all give different types of records
none of which could be due to such slow and deliberate mental
processes as in the case of epilepsy. Even the sluggish alco¬
holic does not show such deliberateness, especially in the
holding time.

The history of the patient often leaves doubt whether the
trouble is epilepsy or hysteria. All the well-known symptoms
of epilepsy have been counterfeited in some cases of hysteria.

LXII. 46

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It is quite probable that no condition of hysteria can give up
its own natural distracted form of reaction, and adopt the
sluggish epileptic form.

VIII. Records for General Paralysis.

General paralysis, or progressive paralysis, is characterised
by gradual deterioration of the mental powers; there is loss of
memory, deficiency of attention, apraxia, etc. Response to a
signal is probably as simple a mental problem as any that could
be presented.

The patient, J. K—, set. 35, first noticed his thickened
speech and mental dulness two years ago. His record (Fig. 18)
gives an average reaction time of 0*47 sec., with average varia¬
tion of o’og sec. (19 per cent.) ; this is about twice the length of
a normal reaction time. The holding time, ro8 sec., with
average variation of o‘46 sec. (43 per cent.) is extremely long
and irregular.

When the disease is in a more advanced stage the character¬
istics become more marked, as is seen in the record of P.,
Fig. 19, whose average reaction is i‘24 sec., with an average
variation of 0'62 sec. (50 per cent.), and an average holding time
of o'gg sec., with average variation of C47 sec. (47 per cent.).
The broken line in the figure is a record of the tremor.

The resemblance between these records and some of those
for epilepsy seems to be an indication of the common factor of
mental deterioration. It would be interesting to know if similar
results are obtained in other conditions of mental degeneracy.

IX. Comparison of Results.

The averages for each of the cases reported above are
given in the table on p. 719.

X. Conclusion.

The life of an organism consists of reactions, or responses to
stimuli. Different organisms, and different conditions of the
same organism, give different responses. Different nervous
and mental conditions show themselves by different responses
to sensations.

The preceding investigation had as its object to develop a
technique for the simplest kind of reaction in such a way that
a result could be obtained quickly and visibly. The ordinary

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719

reaction time technique gives the results in figures; here the
whole reaction picture is presented directly to the eye, with no
necessity for measurements.

Table VI.— Summary.

Reaction Time.

Holding Time.

Type*

Figure.

Kind of
Reaction.

Average

time.

Average

varia¬

tion.

Relative
varia¬
tion .

Average

time.

Average

varia¬

tion.

Relative

varia¬

tion.

Normal

4

Simple .

Ol8

002

Per

cent.

11

018

002

Per

cent.

II

II

5

99

0‘l8

003

17

016

002

•3

99 •

6

99

021

005

23

023

005

22

99 •

7

99

Ol 8

004

22

on

002

18

99 •

8

If

qi 6

002

>3

010

002

20

99 •

8

Complex

039

007

18

010

002

20

Alcholic

9

Simple .

014

002

14

022

0-03

14

99 •

IO

99

0-30

004

14

O25

003

12

99

I I

99

044

011

25

065

009

>4

Hysteria

12

99

036

008

22

062

014

23

99 *

«3

Complex

055

040

-73

O72

055

76

99 •

14

Simple .

031

012

39

044

015

34

Epilepsy

15

99

050

o - i6

32

0-78

o ‘55

65

99 •

16

99

043

016

37

0 26

004

15

99

17

99

047

0*10

21

022

005

23

General Paralysis

18

99

0-47

0 09

19

1 08

046

43

99 99

>9

ff

I '24

0-62

50

O99

047

1

47

The few diseases already studied show marked reaction
types even for simple forms of reaction. It should be quite
possible to develop more complicated forms of reaction whose
' variations will give diagnoses directly in the records. In
other words, it is my belief that the reaction test can be made
so complete and reliable that a diagnosis of epilepsy, hysteria,
general paralysis, etc., can be obtained as surely and accurately
as one of diabetes or chronic nephritis from a urinary analysis.

I may be permitted to say that these researches form part
of a larger scheme for studying the manifestations of nervous
and mental disease in various ways. The variations in speech,
which are studied by means of records, show similar results
to those recorded here.

(*) Nadler, “ Reaction Time in Abnormal Conditions of the Nervous System,”
Studies Yale Psychol. Lab. (Scripture), 1897, vol. iv, p. 1.—( J ) Nadler, as before.—
( 5 ) Clark and Scripture, “ The Epileptic Voice Sign,” New York Med. Record ,
1908.

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Seguin a?id Physiological Education. A Lecture delivered
July 18th, 1916, to the Summer School for Teachers of
Mentally Defective Children, at Bedford College, Univer¬
sity of London. By G. E. SHUTTLEWORTH, B.A.,
M.D., etc. Hon. Consulting Physician (formerly Medical
Superintendent), Royal Albert Institution, Lancaster,
and “ Special Schools ” Medical Officer, Willesden Educa¬
tion Committee.

I MUCH appreciate the honour of being allowed to supple¬
ment your more formal courses of study with regard to mental
defectives by a few biographical particulars and personal
reminiscences of one who may be designated as the pioneer in
their training, and the earliest exponent of the educational
principles essential to their mental development. I may add
that the principles Sdguin laid down some seventy years ago
apply to a far wider range than the instruction of imbeciles,
and I shall hope to show that his master mind anticipated many
of the modern methods which of late years have been accepted
by the educational world as recent discoveries. As Mr. Holman
well puts it in the opening sentence of his admirable book (1)
on Sdguin (to which I would at once express my appreciative
acknowledgments), “ The world has not infrequently had to
^discover its great men after they were dead, though their
works lived after them.” The voice of Sdguin was indeed, in
his own day, at any rate as far as general educational science
was concerned, as of one crying in the wilderness, and was
even derided by the self-satisfied educationalists of the time.
His ideas were indeed in advance of the age in which he
lived ; but what joy would it have been to him to see a
summer school of earnest students of the subject nearest to
his heart!

Edouard Seguin was born in 1812 of a good Burgundian
stock, numbering among his forebears several physicians of
repute. Educated first at the Provincial College of Auxerre,
and subsequently at the Lycde St. Louis in Paris, he studied
medicine at the Sorbonne, where he fell under the inspiring
influence of Itard and Esquirol, both eminent medical professors
with a penchant for psychological investigation. Itard had,
indeed, startled his scientific contemporaries some thirty years
earlier by his attempt to humanise and educate the so-called

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“ Sauvage de l’Aveyron,” a boy, apparently about i 2 years old,
captured in 1798 by sportsmen in the forest of Caune. The
boy had obviously been for a long time running wild in the
woods and had probably subsisted on small game, roots, nuts
and acorns. This creature, more like a beast than a human
being, unclothed and speechless, fiercely resisting with his teeth
and nails—grown into claws—all attempts to clothe or control
him, ultimately found his way to the school for deaf mutes at
Paris, then under the charge of Sicard, the successor of the
famous Abb£ de l’feptte. The case excited much interest
amongst the savants of the day, and Itard inclined at first to
the opinion that the savagery of the boy was simply due to
his solitary life and deprivation of human control and com¬
panionship. Various means used for rehabilitating him having
proved utter failures, Itard by degrees and reluctantly came to
the conclusion that the boy was an idiot. Thereupon he set to
work to formulate a scheme of training which he thought would
be suited to his condition, and the steps of the process proposed
were :

(1) The development of the senses ;

(2) The development of the intellectual faculties ;

(3) The development of the affective functions ;

and thus he unconsciously laid the foundation of the education
of mental defectives.

S^guin’s gifts as a student, especially his analytical powers
and his persevering patience in research, had gained him Itard’s
esteem, and the young physician became the favourite companion
of his old age. At the veteran’s house he would often meet
Esquirol, then the foremost psychologist of France. We can
imagine “ the feast of reason and the flow of soul ” that
would attend the gatherings of so notable a trio. It was
indeed through the influence of Itard (whom he refers to as his
illustrious master) that S^guin determined to devote himself to
the study of idiots, and to think out methods for their improve¬
ment ; and in his efforts in this direction he had the cordial
assistance and encouragement of Esquirol. In 1837, when
only 25, StSguin undertook the treatment and education of a
child (Adrian) “almost dumb and apparently an idiot” (to
quote the guarded description of the case by Esquirol and
Guersant), and these authorities testified by formal certificate in
August, 1839, that after eighteen months’ careful training S^guin

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had taught his pupil “ to make use of his senses, to take care
of himself, to speak, to write, to reckon, etc.” Evidently the
“ apparent idiot ” was of a type superior to that we should call
idiotic nowadays ; but the fact remains that new and special
methods were necessary to initiate progress which had previously
been considered hopeless. There is fortunately preserved in
Seguin’s pamphlet entitled Rtsutni dc ce que nous avons fait
depuis quatorze itiois, originally published in 1839, but
reprinted by Bourneville with other memoirs in 1897 (2), a state¬
ment of the principles and proceedings which led to so happy
a result with this pupil, and this account is also signed by
Esquirol as vouching for its correctness. Encouraged by this
individual success, Sdguin proceeded to open in 1839 a “school
for idiots” in Paris, the first “special school ” on record. This,
though necessarily more or less an experiment, and scrutinised
not always in a friendly spirit, justified its existence as time
went on by excellent results, and attracted numerous visitors
from all civilised countries. It served indeed as a model for
developments which soon arose in Switzerland and Germany,
and later in America and Great Britain.

The success of this “ private adventure school”—for such it
was, as it had been equipped and carried on at Sdguin’s personal
risk and expense—drew the attention of the public authorities of
Paris to the possibilities of amelioration, if not of cure, of
what had been previously deemed the hopeless condition of
defectives, and Sdguin was requested by the Minister of the
Interior to give a probationary course of instruction to the
poor idiot children at the Hospital for Incurables—subsequently
removed to Bic6tre, outside the fortifications—and in 1842 a
Government Commission reported so favourably on his work
that a further year’s trial was recommended, and in consequence
of their final report he was appointed director of the Idiot De¬
partment of the great Bicetre Hospital, with which he remained
connected until the French Revolution of 1848. Meanwhile,
his name as an author was becoming widely known, and
amongst his publications we find his first comprehensive essay
on the “ Theory and Practice of the Education of Children
Mentally Retarded and Idiots,” being of the nature of a
report on his work with those in the public charge, and an
article contributed to Annales dHygiene on the “ Hygiene and
Education of Idiots.” I have here an original copy of his

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great work published in 1846 under the title of—“Traitement
Moral Hygiene et Education des Idiots et des autres enfants
arri^rds ou retardds dans leur ddveloppement, agitds de
mouvements involontaires, ddbiles, muets non-sourds, bdgues,
etc.” I have quoted this title at length because I wish you to
note that Seguin’s studies and methods extended far beyond
the lowest types of defectives. This book was crowned by the
French Academy, and for many years remained the best, if not
the only, guide to the training of defectives on scientific lines.
Sdguin had not altogether a bed of roses in connection with
his public work at the Bicetre, for there he was confronted by
implacable rivalries, and sometimes subjected to unfair mis¬
representation. Still his love for his little patients carried him
through, and he was constantly excogitating fresh plans for
their welfare. So he went on till the political upheaval of
1848 led him to take an active part in the establishment of a
Republic, and when this was supplanted in 1850 by the
ambitious pretensions of the Prince President (soon to declare
himself Emperor), he emigrated, with his wife and young son,
to the great Republic of the West. In the United States,
whither his fame had preceded him, he soon found congenial
friends at the institutions then being organised for the feeble¬
minded (eg, the Massachusetts State Institution, near Boston),
and he subsequently helped Dr. H. B. Wilbur to get into
working order the newly opened New York State Institution at
Syracuse. By request he also undertook for a time the
direction of the Pennsylvania Institution, a post which he
occupied up to 1857. After one or two spells of general
practice (eg., at Cleveland and at Mount Vernon) we find him
attracted to the City of New York by the fact that there
existed close by—at Randall’s Island—a large Municipal
Establishment for Idiots, in which he was instrumental in
procuring needed reforms, and in organising appropriate
teaching. It was in 1866 he published his English work,
entitled “ Idiocy and its Treatment by the Physiological
Method,” of which we shall speak later. I have referred to
Seguin’s occasional spells of private practice ; these were under¬
taken as a means of livelihood, for he had a wife and a young
son to maintain, and, unlike certain founders of new systems
of education of our own times, had never tried to make money
by patenting his inventions, but had generously placed

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724 SEGUIN AND PHYSIOLOGICAL EDUCATION, [Oct.,

them at the free disposal of his colleagues and indeed the
whole educational world. His experiments and apparatus, how¬
ever, cost him time and money, and unfortunately he had an
invalid wife for whose benefit he undertook several expensive
journeys to Europe, and he spared nothing in the education of
his son, Dr. E. C. Seguin, whom he subsequently had the
satisfaction of seeing recognised as one of the leading neuro¬
logical physicans of New York. Sdguin lived and died a poor
man, rich however in his consciousness of self-sacrifice in the
cause of humanity, and of the success of his efforts to improve
the condition of the most piteously afflicted of God’s creatures.
Even in the comparatively uncongenial work of family practice
his acuteness and originality could not be suppressed. The
introduction of the clinical thermometer as a scientific aid to
diagnosis interested him greatly, and he devised a special form
of it for family use. In 1873 he came to England as a
delegate from his medical colleagues to read a paper on
“ Clinical Thermometry ” at the annual meeting of the British
Medical Association, held at King’s College, London, and this
was the occasion of our first meeting. I approached him after
the discussion on his paper, and asked him if he were the
author of the books on Idiocy which I had read with so
much pleasure and profit. “ I am the man,” said he, “ but who
are you ? ” Explanations followed, and I did not leave him
till he had promised to pay me a visit at Lancaster, where I
was then the young and inexperienced superintendent of the
three-year-old Royal Albert Asylum. He came and spent a
week with me, and to the inspiration of this visit much of the
subsequent success of this institution is due. In 1876, when
Dr. Fletcher Beach and I undertook a tour of visits to the
American institutions for the feeble-minded, we met again at
Seguin’s modest residence in New York, where he was leading
a widowed life, and devoting himself to literature in the
intervals of his medical practice. Well do I remember one
evening spent with him—not over walnuts and wine, but the
simple fare of “crackers” and iced water—when he discussed
with us what we had seen at the various institutions, and startled
us by his keen insight into the conditions of each, and his
quaint but good-humoured criticisms. One could not be long
in his presence without being struck by his penetration and
his transparent honesty of character, his ready resource, his

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modesty with regard to his own achievements, and his unselfish
encouragement to his juniors to take advantage of their more
favourable circumstances to surpass them. Seguin has been
accused of undue optimism as to the results he attained, but no
one conversing with him could doubt his entire sincerity, and his
utter detestation of humbug of every kind. In person he was a
dapper little man rather below medium stature, neat in his
dress, and his expression beamed with intelligence, his eyes
piercing you through, and lending force to his quaint precept
in his English work on Idiocy that in dealing with the
wandering eye of the imbecile “ the main instrument in fixing
the regard is the regard.” In his later days he was a victim to
dysenteric troubles, which on October 28th, 1880, brought
his useful life to a close, not, however, before he had married, as
his second wife, one of his most gifted teachers whose work he
had recorded in two of his latest publications, “ The Psycho-
physiological Training of an Idiotic Hand,” and “The Training
of an Idiotic Eye." To her he bequeathed the little school—
the “ Seguin Physiological School ”—which he had established
with her assistance in New York ; and this is now a flourishing
establishment for mentally deficient children of well-to-do
parents in a charming location at Orange, New Jersey, under
the direction of Mrs. Elsie Mead Seguin (whose personal
acquaintance I had the pleasure of making in London a year
or two ago).

We must now turn from the man Seguin to his educational
work. We have already drawn attention to the fact that he claims
that the doctrines which he advanced as indispensable for the
successful training of defectives were applicable also to the
education of ordinary children. I will read two paragraphs
from his great book of 1846 which explain his views in this
regard (see Holman, op. cit., pp. 30—31):

“ From this truly exceptional situation has resulted a work
which I believe to be entirely new, not only upon Idiocy but
even upon Education. For, in taking as my aim the treatment
of young idiots, I was continually led, by the very nature of my
subject, to inquire into methods, to weigh theories, and to
discuss practices of instruction. Though all the methods which
I studied seemed to me to be good for ordinary children, or
rather, though the intellectual development of ordinary children
renders them excellent, they lost their illusory power in propor-

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tion as I attempted to apply them to idiots. None of them was
sufficiently complete; none took sufficient account of the psycho¬
logical and physiological anomalies of which the human being
is capable, to be satisfactory to me.

“Thus proceeding always by the method of elimination, in
proportion as I advanced in my critical examination of methods,
I found myself alone, not only in my attempts at a treatment of
idiots, but equally in the work of general pedagogy, which I
thus saw myself partially compelled to formulate, day by day,
with more and more precision. It followed that instead of the
book which I wished to write upon a single subject, I fear I have

written two : one upon Idiocy, and the other upon Education.
For such is the force of logic that one of these questions cannot
be resolved before the other ; so I have been compelled to resolve
the second in order to reach the solution of the first. More¬
over, so intimate is the connection of the various theories of
anthropology, that, instead of a simple question of idiocy, I
have found myself engaged in questions of hygiene, physiology,
education and morals, which are inevitably connected with the
first.”

Holman well puts the main features of Sdguin’s physiological
method of education in the following paragraph ( op. cii.,p. 5o):

“ Broadly put, the conclusions at which he arrives are : man
is at first predominantly an animal, though always a man in
essence ; and he must, therefore, be educated primarily through

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his activities and his senses. In order that he may finally be
the best sort of man his native capabilities will permit, he must
primarily be the best sort of animal he can be. In other words,
all the physical functions included in his muscles, senses, and
nerves must be educated to their fullest efficiency at the
moment, as the best means of developing his mind ultimately,
since the central brain is dependent for its early development
upon the development of local brains. But in all this the
educator must ever keep in view the fact that man must always
be developed, even from the very first moment, in such a way
as to secure a harmonious growth of his powers of body, mind,
and will.”

Seguin himself, in the course of an address (3) to a New York
Medical Society in 1869, after discussing the causes, anatomical
signs, and medical aspects of the subject, goes on to speak of the
principles of physiological education, which in his view consists
of educating the mind through perceptions instead of by pre¬
arranged reasonings, and on the following axioms :

(1) That if we could take hold of an organ, we would be able
to make it produce its function.

(2) That the organs of sensation being within our reach and
those of thought out of it, the former are the first we can set
in action.

(3) (Consequently) The physiological educatio?i of the senses
must precede the psychical education of the mind.

After illustrating the above propositions by practical instances
{eg., in the history of the Aveyron Savage and of Caspar Hauser

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as contrasted with the results of purely intellectual education,
which he says produces fools and pedants, not true scholars),
he concludes his thesis with the assertion that “ the physiological
education of the senses is the royal road to the education of the
intellect; experience , not memory , the mother ofideas” Elsewhere
he sums up briefly his method with defectives on the following
lines :

(1) To exercise the imperfect organs so as to develop their
functions, and

(2) To train the functions so as to develop the imperfect
organs.

Unfortunately time does not permit us to pursue these prin¬
ciples into their varied educational applications. It must suffice

to remark that the reforms of recent years in the curricula 01
schools, such as the gradual reduction of mere memoristic
learning and parrot-like repetition, and the substitution of syste¬
matic exercises of the muscles, of the hand and of the eye as
well as of the ear, in other words of physical and manual instruc¬
tion, follow from these principles. Of the various devices invented
by Sdguin for finger drill and sensorial gymnastics I can but
briefly speak, but many of them have been incorporated into the
Montessori “ pedagogic material,” not indeed without acknow¬
ledgment by the distinguished foundress of the system (herself
originally instructress of defectives), though I may add that their
source is often insufficiently recognised by her followers. I
show you specimens of Sdguin’s educational appliances intro¬
duced into the Royal Albert Schools after my visit to America
in 1876 (kindly lent for this occasion by my friend and successor

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Dr. Coupland), and I think those familiar with the Montessori
“didactic material” will trace their resemblances. In my
opinion the alterations introduced are not altogether improve¬
ments ; but after all it is not so much the exact form of
apparatus that matters as the intelligent spirit—the Dottoressa
calls it “ Spirituality ”—in which it is used.

Had time allowed I should have liked to refer to Sdguin’s
efforts to obtain for the poor children of the crowded quarters
of New York the benefits of open-air teaching by the establish¬
ment of what he called “ garden schools ” in the public parks
and squares. I have here his plea on this subject published in
1878 (4)—another proof of his pioneer prescience in a cause

which is only just now coming into accomplishment here
through the tardy official approval and advocacy of open-air
schools.

In conclusion let me quote one pregnant sentence from
Sdguin’s English book on Idiocy which shows the spirit in
which he regarded his relations with his pupils : “ To make

the child feel that he is loved ” (he writes), “ and to make him
eager to love in his turn is the end of our teaching as it has been
its beginning.”

List of References.

(1) Holman, H. —Slguin and his Physiological Method of Education,
London, 1914.

(2) Premiers Me moires de Siguin sur Ildiotie, publies par Bourne-
ville, Paris, 1897.

(3) New Facts and Remarks concerning Idiocy , New York, 1870.

(4) Our Parks: to be or not to be. New York, 1878.

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The Cerebral Associations of Raynauds Disease f) By

Hubert J. Norman, M.B., D.P.H. Captain (Temp.),
R.A.M.C., County of Middlesex War Hospital.

It was in 1862 that Maurice Raynaud first made public his
description of the condition with which his name has since
been associated, and his Thesis for the Doctorate in Medicine
has now become a classic in medical literature (1). Although
there may be meticulous critics who will dispute his claim to
priority in the delineation of the disease-complex known as
Raynaud’s disease, there can be no doubt that it was he who
first succinctly and clearly described the condition. To use a
phrase which is apposite in dealing with such a subject—it was
Raynaud who first drew a “ line of demarcation ” between the
symptoms characteristic of his syndrome and those typical of
gangrenes in general. In his own words, he was dealing with
“ a very limited corner of the general history 01 gangrenes.”
In the present paper it is proposed to remain within still stricter
limitations, yet even there the amount of clinical material is
not inconsiderable. There is an additional interest, too, from
the fact that Raynaud, especially in his later researches (2),
became more and more convinced that the explanation of the
peripheral symptoms should be sought in some change in the
central nervous system.

It may be of interest briefly to summarise Raynaud’s
description of the peripheral changes which are to be seen in
this disease. In the mildest degree there is local syncope in
which the toes, fingers, nose, or ears are yellowish-white, cold,
numb, insensitive to touch ; next there is local asphyxia, in
which the fingers, for example, are cyanosed ; and thirdly, the
condition may become more marked and gangrene may result
According to Raynaud these are degrees of one condition.
The point upon which he laid most stress is the symmetrical
nature of the disorder, there is, he said, “ une remarquable
tendance k la symdtrie ” (3).

This tendency to symmetrical involvement is the most
characteristic feature of the condition differentiated by Raynaud.
It is almost needless to say that not all degrees of the disorder
occur in a particular patient, although cases have been recorded
in which they have all been observed.

Such an obvious and intractable condition as gangrene was

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certain to attract the attention of observers. From Hippo¬
crates onwards it has formed the subject of much discussion
and speculation^ 8 ) Raynaud realised this fully, and he
devoted some time to the consideration of the work of his
predecessors, but he came to the conclusion that little work had
been done before his time in regard to the question of gangrene
resulting from disorder in the nervous system. One observer,
Zambaco, he considered, however, as going too far in the
opposite direction (4). Zambaco, whose material was drawn
chiefly from among the insane, believed that if the function of
the nervous system is interfered with, it alone can bring about
gangrene without any lesion in the vessels. Racle, writing in
1849, described a form of gangrene with nervous phenomena (5).
He did not draw attention to the symmetrical nature of the
affection, but he did not complete the writings of the papers in
gangrene. His brother, however, informed Raynaud that he
had been much impressed by the symmetry of the lesions (6).
An interesting case, which Raynaud appears to have over¬
looked, was published in the same Journal as Racle’s memoir.
It is that of a Mulatto in Brazil, recorded by Rapillaud (7).
Monro has given a historical sketch of cases prior to the publi¬
cation of Raynaud’s thesis which approximated to Raynaud’s
disease or were actual examples of it ( ya ). While Raynaud
himself quotes in his thesis cases described by Lachmund
(1676), Hertius (1685), Bocquet and Molin (1808), Rognetta
(1834), Godin and Portal (1836), Topinard (1855), and Bernard
Henry (1856). It is clear, therefore, that even the minor
degrees of this condition had been noted before Raynaud wrote,
but it was left for him to make the generalisation and to
marshal the facts in an orderly way.

In enumerating the predisposing causes, Raynaud notes that
those chiefly affected are persons of a “ nervous or lymphatic ”
temperament, and in the history of the patient he lays stress
upon the influence of neuroses, especially hysteria and epilepsy.
Several cases which I have had the opportunity of observing—
among them, three soldiers who have been in active service—
and a brief survey of the literature of the subject, have served
to strengthen the impression of the importance of the nervous
element in the production of this disorder. To deal with
the condition from all points of view, even in a cursory manner,
would entail the expenditure of much time and energy; it may

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not, however, be without interest to gather together a group
of symptoms illustrating one aspect of Raynaud’s disease,
and to note the cerebral disorders which may be associated
with it.

“ Hysterical ” Symptoms.

Among Raynaud’s cases there are some which exhibited
markedly the “ hysterical ” element. One (Observation 2), a
young woman, aet. 25, who suffered from local syncope, had
“ quelques attaques de nerfs, avec perte de connaissance, sensa¬
tion de boule, pleurs et rires involontaires.” A young soldier
(Observation 3), also with local syncope, when electrical treat¬
ment was tried became hysterical, “ Larmes, cris, ddsespoir, sans
perte de connaissance.” Raynaud notes the predominance of
the nervous element in this instance. In another case (Obser¬
vation 8) which he quotes from Landry (8), that of a young
woman, set. 22, the symptoms were still more marked. With
the local asphyxia there was such intense pain that the slightest
touch produced convulsions. Later in the attack the pains
recurred, and the convulsions became so marked that it was
necessary to restrain her “ on dtait forced d’attacher la malade.”
He notes that there was no globus hystericus. The fits, which
continued for nearly two months, were not apparently epileptic
but hysterical. Nine months later, when she was pregnant and
had improved in health, her husband died, and she had violent
convulsions followed by “ ddlire nerveux ” which passed in three
days. Another interesting symptom—which will be referred
to again—was noticed at this time, namely, “ complete aphonia.”
At times there was analgesia of almost the whole of the body,
without anaesthesia. Later in the attack she attempted suicide
by taking laudanum ; she became comatose but rallied and
recovered from this. She is stated to have had no recollection
of this incident. She improved for a time, but died later of
phthisis. Raynaud, commenting on this case, remarks that “ the
hysterical convulsions always accompanied the paroxysms of
pain in such a way that it is legitimate to place them to the
account of the latter ... in proportion as the malady
developed and became established, the nervous symptoms
became generalised and aggravated, aided by moral emotions
of which the influence was undoubted ” (9).

Observation 9 deals with a female, aet. 30, who had, when a

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child, lived in bad hygienic conditions and been maltreated by
her parents. She gave a history of hysterical symptoms at
about the time of puberty, and since that time she had had
hysterical attacks at times of emotional stress. At the age of
27, as a result of a fright, she had amenorrhcea, dead
fingers, and local asphyxia. Her condition varied, but generally
became worse; in addition to the Raynaud there was profound
cachexia. As a result of hearing of her father’s death she had
a violent “ nervous attack,” and was insensible during a whole
night. There was slow but progressive mental enfeeblement,
cerebration slow, and she was easily fatigued mentally; there
was steadily increasing difficulty in hearing. This case ended
fatally.

Observation 15, a female, jet. 27, had local asphyxia in
hands, feet, and nose: dry gangrene of extremities. After
weeks of acute pain and loss of sleep there were three days in
which she was subject to disorientation for about ten minutes
on waking. This was followed by hysteriform attacks,
throbbing in the head, and a feeling as if she would fall.

In case three of Raynaud’s “New Researches” he notes a
sudden loss of consciousness associated with left hemiplegia.

Hale White considered a case of Raynaud in a girl, jet. 16,
an orphan who had been much neglected, as being “ decidedly
hysterical ” (1 o).

The term “ hysteria ” is generally a rather unsatisfactory
one. Frequently it appears that symptoms which do not fall
into more definite categories are heaped together under the
name of hysteria. Rheumatism and hysteria have more off¬
spring fathered upon them than they can reasonably claim.
Raynaud may have been right in calling the seizures in, for
instance, Observation 8 hysterical: but it is not unreasonable
to suggest that they might have been to a considerable extent
spasmodic, and secondary to the vasomotor condition. Monro
appears to be of this opinion in regard to Observation 15.
The “ hysterical phenomena,” he says, “ seem to have been due to
the exhaustion and pain caused by the vasomotor disorder in one
who had previously been neurotic”(11). It has been said
that “ hysteria may mimic all other maladies ”: but the same
writers remark that the greatest danger arises from failing to
appreciate the limitations of hysteria and allowing its presence
to interrupt careful search for organic disease of which it

LXII. 47

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to come on. The attacks always began with a chilly feeling,
as if cold water were being poured down his back ; this sensation
lasts long enough for him to find a place upon which to lie down;
he then loses consciousness and becomes convulsed. The attack
lasts about half an hour, and after it he feels weak and has head¬
ache.” The local syncope occurred at times in this case without
fits being associated with it. The fits did also take place
during cold wet weather in summer. After three winters the
convulsions ceased but the other symptoms continued ; while
after another three years, when there was asphyxia of nose,
ears and fingers, there were no further convulsions, but abdominal
pain (14). Osier describes an anomalous case, that of a
German girl, aet. 13-5-, who came ot a neurotic family. At
ten years of age she had (?) chorea: “ This was followed

immediately by three groups of symptoms, viz. : painful
swelling of the legs, painful swelling behind the left ear,
and falling attacks. ... At first, and for a year, she would
fall forward, two or three times a day, on her hands and head,
and, unless caught, would roll on the floor. There was no
sound, no convulsion, and probably no loss of consciousness,
but of this she is not sure. For the last two years she tias
always had time to get to a chair or lounge, never loses
consciousness, and it never lasts more than five minutes, and
often only a few seconds. During these attacks she feels
faint and powerless” (15). There is here possibly a condition
less marked than in the definitely convulsive cases already
mentioned : and one analogous to minor epilepsy. In another
case, a little girl who had a condition allied to Raynaud’s
disease—cyanosis of both lower limbs nearly up to the knees
—there were “ some ill-defined epileptoid attacks followed by
some paresis of the lower limbs” (16). Colcott Fox narrates

a case, a woman, aet. 41, “of spare habit and with an

anxious face and intensely nervous temperament.” He said
that she was a “ dreadful sleeper,” especially after the slighest
worry or excitement, and she had had several severe hysterical
attacks on similar provocation. He describes her as “ exces¬
sively nervous, hysterical and emotional ” (1 6a). Levi and
Raymond describe the case of a woman, jet. 43, who had

Raynaud’s disease of hands, feet and forearms. She was

“ undoubtedly hysterical,” and she had convulsions, polyuria,
etc. Another case they describe as hysterical and easily

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hypnotisable (\6b). Solis-Cohen, dealing with an analogous—
if not a similar—condition, acroasphyxia, describes the case of
a woman, aet. 25, who suffered from constant headache for three
or four months and who had occasional attacks of dizziness.
In another case by the same author, a woman, set. 19, who was
“ easily excited,’’ there were mild epileptic attacks. In a third
case, in addition to other symptoms there was on one occasion
a “transient partial obscuration of consciousness” (16c).

In a case of Osier’s he records occasional attacks of
“ dizziness and transient obscuration of consciousness,” paresis
and aphasia.

Epilepsy.

Raynaud’s disease has been noted in several cases in
association with definite epilepsy, and with epileptic insanity.
Here the local symptoms have been subsequent to more or less
prolonged epileptic trouble. Case 19 of Raynaud’s thesis,
which has already been referred to, would probably fail to be
included in this category. In a case of Fdrd’s (17) he was
unable to obtain a definite history as to which condition
preceded the other. It is that of a man, set. 48, who had his
first epileptic fit at 41, and who had had twelve up to the
time when Fdrd saw him. The patient stated that they all
occurred during the winter ; but more frequently he had had
attacks of vertigo with loss of consciousness. He also
exhibited a curious condition, a disseminated asphyxia over
the body. (In a case of symmetrical congestive mottling of
the skin reported by Cavafy there were no cerebral symptoms)

(18) . Fdrd came to the conclusion that as the epileptic
manifestations and the circulatory disorders seemed to have
developed about the same time, and as they both showed marked
predominance during the winter, it was permissible to establish
a relationship between them. If this were so it would, as
Fdrd points out, lend support to the angio-neurotic or
sympathetic theory of epilepsy, a theory attributed to
Schneevogt and also to Charles Bell.

Bland recorded a case, a man, act. 23, who had epileptiform
seizures for ten years previously and who, at the time when he
developed the symptoms of Raynaud, was acutely maniacal

(19) . I am able to add to this the case of a man aet. 35,
who had had epileptic fits for at least seven years. He had

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recurring attacks of epileptic furor; he was at these times
violent, intractable, and destructive ; and, also, during the phase
of excitement, he was much influenced by auditory hallucina¬
tions. During a maniacal phase he developed an inflammatory
condition of the forehead which was suggestive of erysipelas,
but which was not definitely so : this descended downwards to
the face, and passed off in the course of a few days. After it
had lasted two days local asphyxia of both feet was noticed
which subsided, except from the toes, which were gradually
becoming more gangrenous when death resulted. The feet had
been exposed to cold about this time, as the patient tore all his
clothing off and would not allow cotton wool and bandages to
remain on his feet.

Bernstein has reported a case of Raynaud’s disease associated
with epilepsy (20). In YViglesworth’s case, an epileptic and
insane woman who suffered from chronic Bright’s disease
with secondary hypertrophy of the heart, there was gangrene
of fingers and onq great toe. In addition she had peripheral
neuritis in all four limbs (21).

Mania and Melancholia.

The occurrence of the symptoms of Raynaud’s disease have
been noted in association with epilepsy, and with the maniacal
phase in epileptic insanity. They have also occurred fairly
frequently in mania not dependent upon epileptic excitement,
in melancholia, and in the depressed phase of manic-depressive
insanity. In a case of Southey’s, a boy, aet. 9, in whom
gangrene of the right index finger developed, there were
maniacal symptoms. He was nervous, excited, cried donstantly
when examined or spoken to ; and he was noisy, especially in
the evenings (22).

Barlow says that Southey informed him that “ since the
publication of this case he had seen several examples of
Raynaud’s disease in asylum cases ” : the type of case is not
specified (23). Edgerley gives a case, a woman who had been
in an asylum “ for some years,” and who during the early part
of her stay had long periods of comparative sanity. During
the maniacal attacks she was noisy, incoherent, destructive, and
covered herself with dirt. Whenever the mental relapses
occurred, her hands showed characteristic signs of Raynaud’s

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disease. At first local syncope and then local asphyxia. During
remissions of mental symptoms her hands resumed their normal
appearance. (The same author records a case which may be com¬
pared with Fern’s. A woman, aet. 37, who had had three previous
attacks, developed ecchymoses over her body and limbs at the
height of the excited period. Such a case, though not one
which Raynaud would have included in his category, is inter¬
esting from the point of analogy. It might be more properly
associated with the cases of “ stigmata ” upon which much stress
is laid by many of the devout: more especially as she had
delusions that she was being crucified and stoned) (24).
Macpherson relates the case of a girl in whom the vasomotor
symptoms set in four days after her admission with acute
mania. At the outset, however* a week before admission, there
had been depression with suicidal impulses instead of exalta¬
tion (25).

In manic-depressive insanity the symptoms of Raynaud’s
disease may appear either during the maniacal or during the de¬
pressed phase. Ritti noted in his cases that it was during the
stage of depression. Esquirol (26), among others,has called atten¬
tion to the alteration in the peripheral circulation which occurs so
frequently among the insane. In Ritti’s first case, a woman, aet.
28 on admission, there is a history of mania for a number of
years with occasional remissions. Later, definite alternations are
noted, each phase lasting from ten. to fifteen days, and at this
time there were lucid intervals between the attacks. After a
time, however, the attacks of mania and melancholia followed
one another without intermission. Frequently during the
depressed phase she had local syncope and local asphyxia of
the fingers of both hands, but always one hand at a time and
only certain fingers. In his second case, a woman aet. 41,
there had been an attack of acute mania, at the age of 27.
This lasted for three months, and she then became depressed.
After this she was normal for a time, then for several years
there were periodical attacks of boulimia lasting about eight
days. From the age of 35 and onwards excitement and
depression followed one another without any intervals. When
the symptoms of Raynaud appeared it was in the form of local
syncope and local asphyxia of the hands and feet. Ritti
remarks that he never observed them during the maniacal phase
(27). In contradistinction to this I have observed a case of

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manic-depressive insanity in which there was local asphyxia, and
later symmetrical gangrene of the toes and of the tissues for
about an inch and a half above them. This was in a woman,
set 37, who had six months prior to admission been depressed
and had attempted suicide. On admission she was maniacal,
noisy, restless, incoherent in speech, sleepless, unclean in habits.
The symptoms of Raynaud’s disease appeared after about three
weeks of this intense excitement. In another case there was
a history of two previous attacks of mania, but no record of
any pronounced periods of depression. She remained acutely
maniacal for two months after admission. Her left forearm
and hand were first affected with swelling and then dis¬
coloration ; this disappeared and then the right leg and foot
were attacked. Next the left lower limb and side up to the
axilla were affected. Later, symptoms of gangrene appeared in
the feet.

Urquhart recorded a case of Raynaud’s disease in association
with melancholia. The patient was a woman, set. 50. There was
a history of one sister having had puerperal mania, and another
sister was said to have committed suicide. The melancholic
symptoms had lasted for three years : she was restless, deluded,
had ideas of impending ruin and of her unworthiness ; she was
also suicidal. Two years prior to the symptoms of Raynaud’s
disease—local asphyxia in both feet—she developed left
haematoma auris (28). In a case reported by Shaw there
were melancholic symptoms, delusions of poisoning, and suicidal
tendencies (29).

Targowla tells of a man, who, at the age of thirty-six, began
to suffer from melancholia with suicidal impulses and insomnia.
Raynaud’s phenomena began about a year earlier than the
mental symptoms. According to Targowla the attacks of
melancholia and of local asphyxia did not appear to exert any
influence on one another (30).

Another of Urquhart’s cases exhibited symptoms more
suggestive of dementia praecox. It was that of a man, ait. 33,
who had always been “ nervous and flighty.” Seven years
prior to admission he had yellow fever. He became mentally
confused, made mistakes, and was unable to work. He was
obstinate and resistive ; he was depressed and had hypo¬
chondriacal ideas, such as, that he could not straighten his legs,
that he had no feet or stomach. He was at times excited and

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restless. He had a habit of crawling on the floor, squeezing
into corners or underneath furniture, and when thus placed lay
stark and still. He was persistently wet. He developed
ha:matoma auris on both sides, and later local asphyxia of both
feet. Later there was gradual exhaustion and death (31). I
have observed a case of dementia praecox with marked
negativism, restlessness, apathy, and progressive mental enfeeble-
ment, who developed local asphyxia in both feet with patches
of desquamation. He was at that time jet. 25, and
his mental symptoms had lasted for several years. Another
case, a female, aet. 23, was stated to have begun to show
mental symptoms at 21. She gradually became mentally
enfeebled ; she was confused, unable to converse, and childish.
She was at times excited, restless, violent, occasionally thought
that she was going to be burnt. She developed recurring local
asphyxia of both feet.

The following cases I have had the opportunity of observing
at the County of Middlesex War Hospital among soldiers who
have been on active service: Pte. A. B—, aet. 19, went to
France in April, 1915, and was in the trenches and under fire.
In October he was sent into hospital with “ bad circulation.”
It was reported that on parade he did not appear to understand
the orders given, and sometimes wandered from the ranks. He
complained that things were stolen from him. He rambled
about at night, and was much influenced by auditory hallucina¬
tions. He was depressed and wept. He was deluded and
said that “ chloride of lime was being sprinkled over blood in
the next room.” He was dull, stupid, and confused, cerebration
slow, memory defective. He had typical recurring attacks of
local syncope and local asphyxia in the fingers and toes. He
improved steadily and became bright and cheerful. After the
mental improvement had become pronounced the circulatory
troubles still continued, and later he had an attack of aphasia
to which reference will again be made.

Private C. D—, jet. 21, went to France in January', 1916;
he was in the trenches for five days. Whilst there he was
heavily shelled but was not struck or buried. On the last day
which he spent in the trenches his officer was shot beside him.
He was much shaken, and later was not able to recall events
about this time very accurately. He became depressed and was
sent into hospital. He was at that time nervous, emotional,

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and depressed. He stated that when alone he felt as though
someone were following him. He did not hear voices but he
felt as if “ things were put into his mind.” He said that on
the day before his admission to hospital in France, he felt that
he wanted to jump into the water. On his return to England
he was brighter, but still nervous and rather tremulous. The
noises in his head he compared to the ringing of bells. For
some time he had suffered from headaches, at nights he had
“ visions which were not quite dreams.”

He had local syncope and local asphyxia of the first and
second fingers of both hands, and these symptoms recurred from
time to time. He had noticed this condition for years. He
believed that it came on after he had acute rheumatism and
chorea. He said that his mother suffered from a similar con¬
dition. Vision impaired ; he had observed a progressive weak¬
ening of his sight for some years. The right pupil was slightly
larger than the left.

This patient gave an extensive history of nervous instability
in his family, and of a tendency to vascular degeneration. On
the paternal side, his great-grandfather had hemiplegia, grand¬
father very excitable, became “ mad if he took drink,” eventually
had a seizure and died, grandmother suffered from violent
headaches, was of a very nervous temperament, markedly
hypochondriacal ; a cousin is mentally deficient. His mother
is nervous and hysterical. His brother is very excitable, and
at times becomes confused and forgetful. This patient himself
is sallow-complexioned and nervous. He says that he was
troubled by “ voices ” when he was about 1 7 years old, and that
about the same time he attempted suicide. He says that he
was subject to convulsions as a baby.

Private E. F—, set. 40, exhibited a local condition which
approximated to Raynaud’s disease, but which might be more
accurately described in the category of acroasphyxia. Both
hands were from time to time cold and almost syncopal, and
this was succeeded by the asphyxial state ; in the latter phase
the hands looked as if they had been dipped in a solution of
indigo. He gave an interesting history. He had had fifteen
years’ service. In 1906 he was operated on for “tumour” of
the left testicle, and the testicle was removed. Just after this
he had a “ fit,” and another one a year later. During these
fits he lost consciousness. In 1908, while he was in India, he

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had malaria, and it was after this that he first noticed the change
in his hands. In May, 1915, he was in France, and was buried
by a shell explosion. He had a similar experience later in the
year, in September, and he gave a history of gas-poisoning
about the same time. In November he went to Salonika.
Whilst walking with a friend there he fell down suddenly and
was unconscious for about twenty-four hours. He was sent
back to England, and on his return was depressed, nervous, and
tremulous. At times he was incoherent in speech. On two
occasions he attempted suicide in what is described as “ an
ostentatious manner,” and he is reported to have had some fits
of an hysterical nature. Since I have seen him there have been
no further fits or attempts at suicide. He has, however, been
depressed and plaintive. He complained very much about his
digestion, and said that he had been unable to retain any food,
but this was not noticed after his admission. Gradual improve¬
ment took place mentally and physically, but at the time of
writing there is apparently some mental reduction, and he is
facile and more satisfied with his capabilities than his state
warrants.

Mental Enfeeblement.

In certain cases the symptoms of Raynaud’s disease in
insane patients have been noted after mental enfeeblement had
become pronounced, although it does not occur in demented
cases to the extent that one might, d priori , imagine when the
sluggishness of the circulation in such patients is cortsidered.
There is apparently some other factor, it may be the involve¬
ment of certain parts of the nervous system. Iscovesco has
noted the occurrence of local asphyxia in three cases (females)
with confirmed general paralysis of the insane (32) ; Hutchinson
in a case of congenital syphilis with defective mental develop¬
ment (33).

The majority of Zambaco’s cases which exhibited symptoms
of Raynaud’s disease were general paralytics (34). A case
of Barlow’s, a middle-aged woman, during a slight remission
of her attacks of local asphyxia, became the subject of
delusions which were always worse in the evening (34a).
Ibotson relates a case, a woman, set. 40, who suffered from
phthisis, and exhibited progressive mental enfeeblement and
who developed Raynaud’s disease. The mental symptoms

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had lasted six years. She had the delusion that she would find
a fortune in a water-closet, and she was continually putting
both her hands down to pull it up. She was also influenced
by auditory hallucinations (35). Case 16 of the Thesis, though
not a case of dementia, was one of profound physical and
mental enfeeblement. It related to a man, aet. 34, who had
gangrene of fingers and toes. “ Le visage, ainsi que tout le
corps, £tait d’une paleur mortelle : les yeux etaient fix£s ou
roulaient languissamment dans leurs orbites, puis s’arretaient
comme ceux d’un idiot, ou comme si l’esprit affaibli du malade
avait 6t6 frapp£ par quelque objet effrayant ” (36). Pitres
and Vaillard record a case, a young woman of feeble intelli¬
gence from childhood. At 18 years of age she began to suffer
from tremors and stiffness of the limbs until at length walking
became impossible; the lower limbs passed into a state of
extreme contracture, and the patient was bed-ridden and
demented. Gangrene of the feet developed, and eschars on the
body. Post-mortem there were discovered chronic hydrocephalus
of the lateral ventricles, undue adhesion of the pia mater to
the cortex of the hemispheres, and great thickening of the
skull. There was also diffuse sclerosis of the dorso-lumbar
part of the cord (3 6 a).

Aphasia.

The occurrence of aphasia in connection with Raynaud’s
disease is rare. He drew attention to it in his eighth case,
to which reference has already been made. From time to
time there was a complete loss of speech with inflammation,
laryngeal pain, cough, or expectoration. “ Cela lui arrive
souvent, presque tout a coup, et dure quelques heures ou
quelques jours.” He noted that no other nervous symptoms
accompanied this loss of speech : and he appears to have
thought it a part of the hysterical condition : “ La malade
pretend que c’est par faiblesse qu’elle ne peut pas parler, bien
que rien ne denote une faiblesse generale plus considerable
en ces moments” (37). One of the most interesting cases
with this symptom is recorded by Weiss. It occurred in a
woman, aet. 35, of neurotic tendency both personally and by
heredity. The disturbance of speech began suddenly. The
patient became pale at the same time : her lips were pale, and

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the retinal arteries narrowed to a striking degree. She had
difficulty in pronouncing familiar words, and she transposed
words or syllables and used wrong ones. Voluntary movement
not affected. The attack was at an end in fifteen to twenty
minutes, speech being quite restored. A similar attack occurred
four weeks later (38). In Osier’s case, already referred to, a
woman, aet. 47, there were occasional attacks of numbness and
mottling of the fingers for five or six years. Then she began
to have dizziness and transient obscuration of consciousness.
This occurred on three occasions. About a month after the
third attack there was aphasia, paralysis of right hand, and
paresis of right foot. From all these she soon recovered.
Four weeks later she developed complete motor aphasia and
spasm of the right hand. In less than a day these passed off.
Two months after this there was headache, left hemiparesis,
discoloration and tenderness of right hand. This was in
February. In July of the same year she had a third attack of
aphasia with right hemiplegia. At this time there was local
syncope and asphyxia of right hand and fingers, and the
tip of the nose was blue. In July of the following year she
had again the giddiness and vomiting. This was followed by
intense pain in the right hand : the fingers blue and the hand
.anaesthetic. Speech was on this occasion retained. She
gradually became comatose and died (39). Stockman has
described a case of a woman, aet. 26, who had local asphyxia
of both feet and of the left forefinger, and of the nose and ears.
On three occasions she lost the power of the whole of her left
side. She could not move her arms or legs and could not
speak: on one occasion she felt as if her tongue were fixed and
immovable. This lasted about five minutes each time, during
which she remained perfectly conscious. On several occa¬
sions she had temporary loss of memory during conversation.
She expressed it as forgetting what she intended to say. “ It
was not inability to express her thoughts in words, but a lapse
of memory as to what she was going to say. On each occasion
it only lasted a few minutes” (40). In Simpson’s case, a
woman, aet. 60, in whom the symptoms of Raynaud’s disease
had appeared at the age of 48, there were giddiness
and faintness, some paresis of the left arm and of the left leg,
and slight aphasia. She was strange and dazed : she had left¬
sided headache and her sight was dim. The speech defect

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lasted till the following day. There was also hyperaesthesia
for the taste of sugar (41).

In the case of Private A. B—, to which I have already
adverted, aphasia occurred after the symptoms of depression,
the delusions, and the auditory hallucinations had passed. He
was a bright, intelligent youth, and did not seem in the least
hysterical. The aphasic state began on the Saturday morning.
He said that he was trying to say something and could not.
He had “ felt a bit strange in the morning but could speak ” :
and on the day before it seemed to him “ as if things were
muddled up. He felt limp, and as if he was going to be ill.”
He could understand what was being said to him but could not
reply. He played the piano during the aphasic period, and
there were no hemiplegic symptoms. Speech returned suddenly
during the following Wednesday night. He said that “ he sat
up in bed and spoke ” : and he continued able to speak there¬
after. He stated that the muscles of his throat felt stiff and
painful. He thought this was because of the efforts he had
made to speak.

The association of aphasia with Raynaud’s disease is an
interesting and rare one. To look upon it as an hysterical
aphonia is unsatisfactory. We do not know what hysteria is
in spite of elegant explanations—and to explain one incom¬
prehensibility by another advances knowledge little. There
may be a figurative and ironical meaning even in the term
itself: perchance he who coined the word intended to convey
that the true explanation of the condition was hidden in the
womb of time ! If so, parturition does not yet appear to have
taken place.

The explanation given by Weiss seems plausible. He
thought that the aphasia was due to a “ spastic ischaemia in
the region of the third left frontal convolution.” A similar
condition in other regions of the brain might account for
other symptoms. Simpson suggested the varying symptoms
in his case could “ only be accounted for by corresponding
attacks of cerebral anaemia or congestion affecting different
areas of the brain.” “ They are,” he adds, “ compatible with
no single lesion.” A case recently recorded of injury in the
neck which necessitated ligature of the common carotid artery
on the left side is interesting in- this connection. The patient
“ lay in a dull, heavy, stupid condition for twenty-four hours.

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After that he gradually seemed to understand what was said
to him, but was quite unable to put any of his thoughts into
words for several days. . . . The mental dulness rapidly im¬
proved, but recovery from the aphasia was a much more gradual
process.” He was not able to articulate for fourteen days,
and then only a few words. Slow recovery of the power of
speech followed. There was paresis of the right side for two
or three days.( 4 )

Ocular Symptoms..

In his later researches Raynaud paid much attention to
the ocular symptoms. One case, a man, aet. 59, became
subject to local asphyxia of the extremities, and a few weeks
later to paroxysmal impairment of vision. During the
period of asphyxia he could see quite well, but as the digits
were recovering their normal colour the sight, especially of the
left eye, became dim. Vision was restored at the moment when
a new attack of asphyxia supervened. Ophthalmoscopic
examination in the period when the discoloration of the
extremities was at a minimum revealed narrowing of the arteries
and pulsation of the veins. During the period of cyanosis the
arteries did not regain their normal calibre, as might have been
expected, and the venous pulsations persisted. Yet the cyanosis
of the extremities and the visual troubles alternated so regularly
that the diminution of one “ infallibly announced the appear¬
ance of the other, and this many times in the same day.” The
second case, a young man, xt. 22, was admitted for boulimia
and polydipsia, and had cyanosis of hands and face. “ At the
same moment when a paroxysm commenced, he experienced a
notable obscuration of sight, but when the cyanosis passed off,
vision was restored.” There was narrowing of the arteries
during the cyanotic period, with restoration of calibre when
reaction set in. The retinal veins were not observed to
pulsate (42). Bland’s case had for a time dimness of vision
and inability to read, with unusual pallor of the fundus.
Morgan noticed a narrowing of the retinal arteries though vision
was good. After recovery from the Raynaud’s disease and
after three months’ good health, the patient suffered for a time
from severe headaches with simultaneous dimness of vision (43).
Stevenson has reported a case in which there was on one
occasion complete loss of sight for some minutes and at several

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other times dimness of vision (44). In a case of Hutchinson’s
there was iridoplegia. Both pupils were quite immobile, the
left was larger than the right. There was gangrene of the nose
and left ear. Simpson’s patient, it has already been noted,
suffered from dimness of sight. Calmette states that in three
malarious patients who had local asphyxia, there were also
ocular troubles (45). In one of Solis-Cohen’s cases, vision was
at times misty, in another there was sudden dimness of vision,
progressing in the course of a few minutes to total blindness
which lasted about a second. This transient blindness recurred,
but affecting only one eye.

Private C. D—, whose case has already been referred
to, noticed that, in association with the local syncope and local
asphyxia, there was increased dimness of vision, particularly in
the right eye.

Headache.

Headache is a not infrequent concomitant. It has already
been referred to in the cases quoted from Osier and Simpson
(where it was left-sided). Wood speaks of a case, a man,
where there were attacks of localised pain similar in character
to the pain felt in the fingers. It sometimes accompanied and
sometimes alternated with the pain in the extremities (46).
In the case of Private C. D— there were troublesome general¬
ised headaches. Solis-Cohen noticed in one of his cases of
acroasphyxia that there was, associated with visual trouble,
intense headache lasting about ten minutes, and in another
constant headache for three or four months. In a case of
Vulpian’s there was occipital headache.

Paretic ( Hemiplegic ) Symptoms.

These have been noted in several cases. In Raynaud’s third
case (Thesis) there was apparent paresis of the right arm. In
Case 3 of the New Researches there was hemiplegia of the
left side lasting for two hours.

In Simpson’s case, associated with the aphasia, there was
left-sided hemiplegia; a similar condition was recorded by
Stockman. Osier noted at one time affection of the right side
with aphasia ; on the second occasion, of the right hand again
with aphasia ; thirdly of the left side but without aphasia ; and

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at the fourth attack right hemiplegia again associated with
aphasia. In the case recorded by Weiss there was diminution
of motor power.

Raynaud believed that the motor symptoms were due to
defect in the afferent impulses rather than to muscular
weakness.

With the hemiplegic symptoms one may associate the con¬
dition of the intermittent limp where the patient “after a few
steps becomes unable to walk farther, owing to intolerable pain
in the muscles of the leg ” (47).

Erythromelalgia and Raynauds Disease.

There is, at times, some confusion in regard to the two
conditions. Vet Weir Mitchell, who first described erythro¬
melalgia (1872), remarks that it is inconceivable that these two
disorders should ever have been confused, and a glance at his
categories of symptoms certainly supports this statement. In
erythromelalgia, or “ red neuralgia,” there is flushing and local
fever; in Raynaud’s disease the part is either bloodless or
dusky and congested, and there is lowering of temperature. In
the two cases with which he illustrates and contrasts these con¬
ditions there were noticeable nervous symptoms. The case of
Raynaud’s disease was a woman, set. 30, pale, nervous, and
excitable, who, after a long strain and much work, developed
local syncope and local asphyxia in the fingers. The erythro¬
melalgia was in a man. In the course of the disease he became
silent and morose ; there was paresis of leg and arm ; he had
nine attacks of convulsions—“ or rather of rigidity.” He
became “ more or less hysterical,” gradually bed-ridden, had
“ queer, indescribable feelings in the head,” and he disliked all
mental effort (48). Although there is dissimilarity in the
symptoms there may be some relationship in pathological bases.
Weir Mitchell at first inclined to the view that erythromelalgia
was due to “ some form of spinal disorder,” later he considered
peripheral neuritis as a possible cause. In Wiglesworth’s case
of Raynaud’s disease there was neuritis in all four limbs, while
Pitres and Vaillard held that most of Raynaud’s cases of
gangrene were caused by peripheral neuritis. Bramann recorded
some interesting cases which were possibly related to both
Raynaud’s disease and to erythromelalgia. In three brothers,

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jet. 7, io, and 13 respectively, there began in each at the
fourth year of life a condition characterised by violent pains,
great redness and swelling. It attacked almost symmetrical
spots on the extremities, and most of these spots proceeded to
the state of gangrene. Bramann considered that the symptoms
pointed not to vascular but to spinal disease, and he suggested
syringomyelia as the most likely cause (49).

Conclusion.

The time has not yet arrived when it is possible to say what
is the exact condition in the nervous or vascular systems which
give rise to the varied symptoms of Raynaud’s disease. This
being so it is not surprising that various theories have been
promulgated to account for them. Some of the suggestions
are rather of the nature of explaining one symptom by anothei.
For example, when the localised headache in a case of Raynaud’s
disease is said to be due to “ localised meningeal congestions,”
one is still left to discover the cause of these congestions.
Raynaud inclined to the view of the central nervous origin of
the symptoms. “ The marked symmetry of the lesions,” he
wrote, “ ought to suggest that they originate in a discharge
either spontaneous or reflex, starting from the cord and radiating
thence to the vascular nerves of the extremities ” (50). Barlow
sums up as follows: “ The last development of Raynaud’s
doctrine ... is that there is a peripheral excitation, most
commonly consisting in an impression produced by change of
temperature in the cutaneous nerves, and that whilst in a
normal state either very low temperature or exposure for a long
period are necessary for the production of more or less analogous
effects, in these individuals an insignificant difference is suffi¬
cient ; further, that the peripheral stimulus affects that part of
the grey matter of the cord which presides over the vasomotor
innervation, and that a great exaggeration of the irritability of
that part of the cord must be assumed . . . Now given

the initial slight peripheral stimulus there seems no reason
why the central disturbance should not radiate and become
manifest in several different regions successively instead of
simultaneously ”(51). Monro, whose admirable monograph on
this condition has rendered all students of it his debtors, thinks
that “ the phenomena of Raynaud’s disease must be brought

LXII. 48

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about through the agency of the nervous system.” As to the
particular part involved he says : “ Accepting then the theory of
an increased excitability of the vasomotor centres in the
cerebro-spinal axis, allusion must be made to the situation of
the unduly sensitive centres. Raynaud is undoubtedly correct
in saying that the part of the cord varies in different cases.
The varied distribution and the occasional unilateral character
of the symptoms suggest that the disturbance is in the sub¬
ordinate vasomotor centres of the cerebro-spinal axis. This is
doubtless specially true of cases that originate in consequence
of severe exposure. On the other hand, cases that are due to
emotion have their source in cortical disturbances, and these
will, no doubt, operate through the principal centre in the
medulla. If a subordinate centre in a given limited area has
once been rendered over-excitable, through exposure or other¬
wise, cortical discharges, such as those connected with emotion,
may at any time call forth paroxysmal overaction limited to the
over-sensitive region. The theory of a cortical starting-point
for the vasomotor discharge is favoured by the frequent
association with such functional disorders of the cortex as
insanity, epilepsy, etc.” (52). Purves Stewart suggests that
“ profound molecular changes exist ... in the sympa¬
thetic system ”(53). L6vi and Raymond lay stress upon the
emotional factor. They think that the vasomotor phenomena
in Raynaud’s disease and in erythromelalgia have their origin
in certain emotions which give rise to subconscious fixed ideas.
Among their general conclusions are the following: (1) There
is a form of Raynaud’s disease which is purely hysterical. It
may originate or reappear under the influence of a moral
emotion or shock, it may disappear or be improved by hypno¬
tism, but there remains a vasomotor system easily affected.
(2) Acute rheumatism is frequently found in the antecedents
of patients, and may determine the localisation of hysterical
manifestations. (3) The onset is sudden, the origin emotional.
The disease is psychical. (4) The central theory must be
accepted, that is of a neurosis with localisation in the cerebro¬
spinal centres (54).

Those who incline to the so-called “ psychic ” agency in the
production of such symptoms as are seen in Raynaud’s disease
would do well to remember that he looked upon those differing
symptoms as degrees in one condition. So with the exciting

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factors it is a question of the strength of the stimulus, but there
is at the same time the response of the organism. Where the
instability of the nervous system is so marked that it responds
to minimal stimuli the tendency is among certain people to
place the results in a category which is marked off from all
others. Thereafter it is only a question of personal predilection
as to whether they are labelled psychic, spiritualistic, or
miraculous, or by those who, admitting in their very phraseology
their incompetence to see, designate the facts as hidden or
“ occult,” and then quarrel with anyone who endeavours to
illuminate the dark places—and they are many—of their scheme
of things.

Emotion as at least an exciting factor has been frequently
noted. Noyes records a case, a woman of nervous tempera¬
ment, in whom attacks were produced by cold and emotion.
“ Three or four separate attacks have been observed to occur in
rapid succession whilst the patient was under examination

. . owing to emotional excitation” (55). In Stockman’s

•case, “ cold, mental excitement, worry, and slight traumatism ”
brought on the attacks (56). Colcott Fox notes regarding his
case that “ the extremities were affected in a second if she was
startled by a sudden knock at her door or any unusual occur¬
rence” (57). Solis-Cohen thinks that in certain individuals
there is a congenital want of balance in the circulatory appara¬
tus. “ Mental or even physical shock in a subject of congenital
vasomotor ataxia might cause the sudden development of
exophthalmic goitre, and an exposure to cold from which a
normal individual would quickly react may cause local asphyxia,
chilblains, frost-bite, or even gangrene ” (58).

In certain cases the cerebral symptoms are apparently
secondary to the vasomotor changes. The aetiology of manic-
depressive insanity is obscure, and the possibility of periodic
vascular changes cannot be lost sight of. Ritti was strongly of
this opinion. He thought it allowable to surmise that a similar
condition might be taking place in the brain, that there is
spasm of the cerebral capillaries, that the depression may only
be the result of cerebral anaemia consecutive to this spasmodic
contraction, and that finally the mania is due to re-establish¬
ment of the cerebral circulation, which in the phase of reaction
may even be exaggerated (59). This was the opinion of Luys,
who, speaking of this form of insanity, said that the phenomena

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of alternating depression and excitement succeeded one another
by imperceptible degrees ; this is brought about by “ la fatality
des lois de la circulation capillaire.” According to him, excite¬
ment and despression are only “ des variations dynamiques
apparentes de l’etat d’ischemie ou d’hyperhemie successives par
lesquelles passe la trame nerveuse interessee ” (60). It is
probable, however, that the explanation is not quite so simple
as this, and other additional factors will doubtless be found to
underlie these changes. Nevertheless, the mental symptoms
which have been observed in association with Raynaud’s disease
may eventually help to elucidate the subject of the causation of
mental disorder.(*)

In other cases the symptoms of Raynaud’s disease have been
subsequent to long-continued mental disorder. Edgerley remarks,
“ While in certain cases disorder of the circulatory system is a
cause of insanity, much more often mental disorder produces
circulatory disorder ” (61). It seems probable from a survey of
certain of the cases already mentioned that the gradual spread
of disorder in the cerebral cells gradually involved those areas of
the nervous system which preside over the vasomotor and other
mechanisms. Cases of general paralysis of the insane frequently
provide a dramatic illustration of the gradual spread from one
area to another of the nervous system, and one may readily agree
with Urquhart when he remarks of the cases described by him
that they may be “ correlated with cases of general paralysis
where intractable bedsores occur in similar symmetrical disposi¬
tion.” It is not possible, however, to come to any decision on
the matter at the present time. The mechanism of cerebral
processes has yet to so great an extent to be discovered that
the relative value of various factor^, physiological or patho¬
logical, in bringing about disorder in the human economy cannot
be decided. We do know that gross interference with the
cerebral circulation can bring about rapid changes in brain
function. Pressure on the common carotid arteries, such as is
practised by Japanese wrestlers, speedily produces unconscious¬
ness, and Lauder Brunton gives an example of how the same
result used to be brought about before the introduction of
chloroform as an anaesthetic by means of raising a person
rapidly from the recumbent to the standing position (62). In
these cases there is produced almost instantaneously the con¬
dition to which all insanity tends—abolition of cerebral func-

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tion. If in such a condition as Raynaud’s disease there is a
more localised interference with cerebral circulation, it is
legitimate to infer that function may be inhibited pari passu
with the vascular involvement. A further inference would be
that cerebral disorder involving those areas whose function is
more specifically described as mental, may arise from the vaso¬
motor changes. On the other hand, it is necessary to remember
that the cerebral and the vascular changes may be dependent on
other factors such as a toxaemia or a deficiency in glandular
secretions. Nothing but a patient study of all the factors
involved is likely to lead to that stage at which it will be allow¬
able to pass from hypothesis to explanation ; it must suffice us
for the most part to endeavour to gather the materials wherewith
others shall build.

Bibliography.

(1) Raynaud, A. G. Maurice. —“De l’Asphyxie Locale et de la
Gangrene Symetrique des Extremites,” These pour le Doctorat en
Medecine , Paris, 1862.

(2) Idem. —“New Researches on the Nature and Treatment of Local
Asphyxia of the Extremities,” Selected Monographs (New Sydenham
Society), London, 1888, p. 1S2.

(3) Paris Thesis, p. 18.

(4) De la Gangrene Spontance produit par Perturbation Nerveuse,
Paris, 1857.

(5) “Memoire sur des nouveaux caracteres de la gangrene,” etc.
Gazette Medicate de Paris, December, 1849, p. 985. (This reference is
stated wrongly in Raynaud’s Thesis as 1859 ; an error which is repeated
in Barlow’s translation in Selected Monographs, p. 9).

(6) Paris Thesis, p. 19.

(7) Gazette Mcdicale de Paris, July, 1S49, p. 544.

(7 a) Monro, T. K.— Raynaud's Disease, Glasgow, 1889, p. 18.

(8) Landry, O.— Recherches sur les causes et les indications curatives
des maladies netveuses, Paris, 1855.

(9) Selected Monographs, p. 52.

(10) Guy's Hospital Gazette, 1844, pp. 121, 143; Clinical Journal,
1894, vol. iii, pp. 369-375.

(11) Monro.— Op. cit.,\>. 153.

(12) Church and Peterson.— Nervous and Mental Diseases, London,
1901, p. 586.

(13) Brit. Med. Journ., 1S82, vol. ii, p. 1155.

(14) Thomas, H. M.—“Case of Raynaud’s Disease associated with
Convulsions and Hasmoglobinuria,” Johns Hopkins Hospital Reports ,
1890-91, ii, pp. 114-118. (Report of case continued by Osier, Amer.
Journ. Med. Sci. (new series), 1896, vol. cxii, p. 522.)

(15) Osier.—“ Cerebral Complications of Raynaud’s Disease,” Amer.
Journ. Med. Sci. (new series), 1896, vol. cxii, p. 529.

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(16) Barlow.— Trans. Clin. Soc., vol. xviii, 1885, p. 311.

(16a) Fox, T. Colcott.—“On Two Cases of Raynaud’s Disease,”
Ilnd., 1885, vol. xviii, p. 300.

(16 b) Levi, L, and Raymond.— Archives de Neurologie, No. 95;
Journ. Ment. Sci., January, 1896, vol. xlii, p. 193.

(16c) SolisCohen, S.—“Vasomotor Ataxia: a contribution to the
subject of idiosyncrasies,” Amer. Journ. Med. Sci., 1894, vol. cvii,

pp. 132 - 134 .

(17) Fere, Ch.—“Note sur l’Asphyxie Locale des Extermitds, chez
les Epileptiques,” Nouvelle Iconographie de la Salpetri'ere, 1891, vol. iv,
P- 354 -

(18) Cavafy, J.—“Symmetrical Congestive Mottling of the Skin,”
Trans. Clin. Soc., 1883, vol. xvi, p. 43.

(19) Bland.— Lancet, 1889, vol. ii, p. 838.

(20) Bernstein.— London Medical Record, 1883, vol. xiii, p. 337.

(21) Wiglesworth.—“Peripheral Neuritis in Raynaud’s Disease,”
Trans. Path. Soc. Lond., 1887, vol. xxxviii, p. 6r.

(22) Southey.—“Case of Local Asphyxia Symmetrical Gangrene,”
Trans. Clin. Soc., 1883, vol. xvi, p. 167.

(23) Selected Monographs, p. 193.

(24) Edgerley, S.—“Certain Conditions of the Circulatory System
in the Insane," Journ. Ment. Sci, July, 1896, vol. xlii, p. 504^/^.

(25) Macpherson, J.—“Case of Acute Mania with Symmetrical
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(26) Esquirol.— Des Maladies Mentales, t. i, pp. 201-203.

(27) Ritti.—“De l’Asphyxie Locale des Extrdmites dans la Pdriodede
Depression de la Folie a Double Forme,” Annales Medico-Psychologiques
(6th series), Paris, 1882, vol. viii; Traitl Clinique de la Folie a Double
Forme, Paris, 1883, p. 106 et seq.

(28) Urquhart, A. R.—“ Two Cases of Raynaud’s Disease,” Edin.
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(29) Shaw.—“Raynaud’s Disease,” A r c 7 v York Med. Journ., 1886,
vol. xliv, pp. 676-679.

(30) Targowla.—“Un cas d’asphyxie locale symetrique intermittente
des extremites chez un lypemaniaque,” Annales Medico-Psychologiques,
1892, vol. xv, pp. 400-403.

(31) Urquhart.— Loc. cit.

(32) Iscovesco.—“Asphyxie Locale des Extrdmitds,” Comptes rendus
hebdomadaires des stances et me moires de la Socitti de Biologie, 1894,
vol. i, p. 289.

(33) Hutchinson, J. — Arch, of Surg., 1894, vol. v, p. 220.

(34) Zambaco.— Op. cit.: Selected Monographs , p. 8.

(34a) Barlow.— Selected Motiographs, p. 193.

(35) Ibotson, E. C. B.—“Raynaud’s Disease in a Phthisical Dement,”
Guy's Hospital Gazette (new series), 1889, vol. xii, p. 253.

(36) Raynaud.— Thesis, p. 97.

(36a) Pitres et Vaillard.— Archives de Physiologic nor male et patho-
logique, 1885, p. 106 ; Selected Monographs, pp. 196-197.

(37) Raynaud.— Thesis, pp. 58-66.

(38) Weiss.— Wiener Klitiik, 1882; Monro, op. cit., p. 156.

(39) Osier.— Loc. cit., p. 524.

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(40) Stockman, R.— Edin. ALed. Journ., 1903, vol. xiv, p. 252.

(41) Simpson, J. C.—“ Remarks on Raynaud’s Disease, with cases,’'
Edm. Med. Journ., 1892-93, vol. xxxviii, p. 1030.

(410) Madden, F. C.—A Case of Marked Temporary Aphasia after
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Brit. Med. Journ., April, 1916, p. 585.

(42) Monro.— Op. cit., pp. 159-160; Raynaud, “New Researches in
the Nature and Treatment of Local Asphyxia of the Extremities,”
Selected Monographs, pp. 158-167.

(43) Monro.— Op. cit., p. 160.

( 44 ) Steyenson, L. E.—“Case of Raynaud’s Disease,” Lancet, 1890,
vol. ii, p. 917 ; Monro, op. cit., p. 161.

(45) Calmette.— Recueil de mbnoires de medicine, 1877, vol. xxxiii,
p. 24 ; Monro, p. 161.

(46) Wood, H. C.— Trans. Coll, of .Physicians, Philadelphia , 1892,
vol. xiv, p. 166.

(47) Stewart, Purves.— The Diagnosis of Nervous Diseases , 1906,
P-i 5 6 -

(48) Weir Mitchell, S.— Clinical Lessons on Nervous Diseases, 1897,
pp. 180-184.

(49) Monro.— Op. cit., p. 157.

(50) Selected Monographs , p. 155.

(51) Barlow.— Trans. Clin. Soc., 1883, vol. xvi, p. 186.

(52) Monro.— Op. cit., pp. 188, 196.

(53) Stewart.— Op. cit., p. 43 (note).

(54) Levi and Raymond.— Archives de Neurologie, No. 95 ; Journ.
Men/. Sci., January, 1896, vol. xlii, p. 193.

(55) Noyes, A. W. F.—“Raynaud’s Disease,” Austral. ALed. Journ.,
1893, v °l- xv » PP- 265-269.

(56) Stockman.— Loc. cit.

(57) Fox.— Loc. cit.

(58) Solis-Cohen.— Amer. fourn. Med. Sci., 1894, vol. cvii, p. 144.

(59) Ritti.— Annales Medico-Psychologiques (6th series), Paris, 1882,
vol. viii, pp. 36-49.

(60) Traiti clinique et pratique des maladies men/ales, p. 515.

(61) Edgerley.— Loc. cit.

(62) Brunton.— The Action of Medicines, p. 172.

( l ) Read at the Spring Meeting of the South-Western Division, April, 1916, and
awarded a Divisional prize.—(*) Hippocrates, describing the effects of what is
described as epidemic erysipelas, notes that “ in many cases both forearm and arm
dropped off ” ( Epidemics , Bk. iii). Thucydides, in his description of the plague at
Athens, says: “ For the mischief, being first seated in the head, spread over the
whole body, and if one survived the most formidable symptoms, an attack in the
extremities manifested itself; for it was determined to the genital organs and to
the hands and feet, and many escaped with losing them, and some with the loss
of their eyes" (ii, 49). Lucretius, following Thucydides, describes those who were
afflicted with the plague in the following terms : “ The powers of the whole mind
and the whole body grew languid, as if on the very threshold of death . . .
the mind was distracted with anguish and dread ; the brow was gloomy; the look
wild and fierce ; the ears disturbed and filled with noises." He tells us how some
of the sufferers lost their hands and feet, the eyes, and the genital organs. “Upon
some, too, came forgetfulness of all things, so that they knew not even themselves"
(Bk. vi, 1159 et seq .).—( 3 ) Vuipian records a case in which there were symptoms

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apparently of an hysterical nature. Discussing the nervous symptoms he says that
he does not consider them to be hysterical, but due rather to constriction of the
vessels in the heart, the brain, and the medulla. “ L’affaissement general, l’obnubi-
lation de la vue, les vertiges, l'impossibilit^ de parler, etc., s’expliquent par un
trouble cdr^bral" ( Gazette des HCpitaux, 1884, vol. lvii, pp. 65-66). Paget
noted a case where, following cold bathing, there were local syncope and sub¬
sequently flushing and heat. Commenting on the probable condition of parts
which are the seat of pain or other morbid sensations, in cases of spinal irritation
or so-called hysteria, he remarks : 11 When such parts are out of sight, we are apt
to think of them as changed in nothing but their nerve-relations. They are spoken
of as only functionally disturbed, this implying that if we could see them they
would appear in a perfectly normal state. It is more probable that their vasomotor,
as well as their cerebro-spinal, nervous systems are, as in this case, affected; and
that through the vasomotor influence they are in some cases anaemic and in some
hyperaemic, or in both of these conditions at different times” (Sir J. Paget,
St. Bartholomew's Hospital Reports, vol. vii, pp. 67-69).—( 4 ) Targowla hazards the
opinion that the melancholia and the local asphyxia in the case described by him
may be due to the same cause—vasomotor disorder. “ Lorsque ce trouble survient
dans la circulation enc^phalique, il se manifesto par un acces de lypemanie; le
mfme trouble, localise au extr£mit£s, produit l’asphyxie locale intermittente dont
souffre le malade” (Annales Medico-Psychologiques, 1892, vol. xv, p. 403).

On Shame. By James Rae, M.A., M.D.

Here we shall consider the effect of shame; then try to
discover why we feel it at certain times, and whether it can be
represented as the development of any other emotion.

I.

In the first place we must establish the physical signs and
accompaniments of shame: The attitude changes slightly;
there is a movement of withdrawal, a shrinking from notice.
The eyes are averted or downcast, and the head droops. The
face flushes, and the dilatation of the Vessels may extend over
the chest or even further; the pulse-rate is quickened. A
tingling of the skin is next perceived as the vessels Contract and
the face pales. At the same time there is—though perhaps only
momentarily—a confusion of thought.

Here is a physiological state. The vasomotor centre is
actuated by the emotion, and the fibres must therefore have a
connection with the frontal lobe. We know that the vaso¬
motor centre lies in the grey matter of the floor of the fourth
ventricle, and the fibres are believed to pass down the lateral
tracts. The vasomotor fibres to the face are mixed up with the
fibres of the seventh and ninth cranial nerves. It is, however,

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the depressor fibres that are concerned with flushing, and their
exact course is uncertain.

There is evidently a disturbance of the higher control, and it
is interesting to recall the homologous phenomenon of the total
absence of shame in dreams, though its presence might be
expected as an accompaniment of social progress. However
abruptly a person wakes out of a dream of crime or indecency
no shame is felt, even if the course of the dream be deliberately
retraced.

Shame may arise from personal modesty, from fear, from
appearing at a disadvantage, from hearing of or seeing some
untoward behaviour in others, without there being any associa¬
tion with the shamed person.

II.

The shame from infringement of personal modesty is fre¬
quently seen in the operating theatre in women, but the
discussion of this may be postponed for the present. The same
variety is sometimes seen in highly-strung boys, who will refuse
to learn swimming because of the necessary exposure of their
bodies. A most remarkable instance of regard for personal
modesty is the historical one of Philip II of Spain. This King
gave stringent orders that after his death the persons who
tended his corpse were to cover his private parts with a linen
cloth, having their faces veiled the while, under penalty of
execution. In both instances the feeling appears to be due to a
fear of ridicule of personal appearance or detraction. There
are a few cases—not to be too readily believed—of men inordin¬
ately vain of their beauty having recourse to a thick veil after
receiving facial injuries. Was the Man in the Iron Mask the
victim of disfigurement ? To exhibit the extreme of grief the
Greek artist painted a curtain to conceal the face as if from
shame at revealing emotion. Again, we have the sixteenth
century ruff and the wide skirt introduced to hide deformities
of King’s favourites, while the yellow ruff went out of fashion
because a woman poisoner in the first years of the seventeenth
century wore one at her execution. This, however, belongs
more properly to shame at untoward behaviour in others.

To return now to the shame felt by women about to be
operated upon: this is noticeably the case with the hospital
patient. If her chest is uncovered for the anaesthetist her arms

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are at once crossed over it; again, on coming round from the
anaesthetic, if her dress is not adjusted she will invariably repeat
the gesture. With women not of the hospital class this does
not hold true, and the explanation is undoubtedly to be found
in their custom of exposing shoulders and arms in evening
dress. Apparently the shame that a young girl might be
expected to feel at appearing at her first “ grown-up ” dance in
a costume so different from what she has previously worn is.
entirely overcome by her readily understood excitment.

Some may recollect the two-century old story of the young
Spanish princess who was escorted to France to be married. On
her way the mayor of a small town through which she passed
prayed that the community might present her with the silk
stockings the town produced. He received the shocked reply:
“ Fellow, the Princesses of Spain have no legs! ” A curious
survival of this delicacy about women’s possession of lower
extremities is the feminine trick of pushing the skirt down a
trifle when a woman is sitting, and this is still practised even
in these days of skirts which just cover the knee. Women show
no shame in bathing before a crowded beach, and indeed I am
told by a friend that during the hot summer of 1913, women
walked about the piers of south-coast towns with a “ university”
swimming suit and slippers as their sole covering. It is in
fact noticeable that the persons who most quickly cover them¬
selves with a wrap after leaving the water are males.

It is significent that for four hundred years women have
been in the habit of exposing in the most liberal way the
upper part of the thorax. The only exceptions to this are the
period of about thirty years in the seventeeeth century ended
by the Restoration excesses, and that of less than a decade
towards the end of the eighteenth century which was followed
(in France) by the scandalous caricatures of classical attire,
and the Empire and early Victorian fashions.

As this is not an essay on costume we had better leave this
part of the subject. What has been said is intended to show
that the most outrageous lack of peripheral covering is placidly-
accepted by a woman if the fashions of dress so decree, and
that in women personal modesty is but a matter of convention.
Anyone who wishes for further details has only to refer to
“ Studies in Psychology of Sex ” by Havelock Ellis, Part II,
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III.

The preceding section has been simple, but in considering
fear as a cause of shame we come to a matter of great
complexity. Fear is produced by

(а) Physical danger.

(б) Personal loss or inconvenience.

(c) Possible punishment.

(if) Wrong conduct (moral fear).

(e) Anxiety for others.

These causes of fear are, if not faultlessly arranged, at least
comprehensive. Which of them can we delete with reference
to shame ? The last is cancelled at once, since anxiety for
the welfare of others is a virture. It is true that shame may be
due to virtue, but this we shall consider at a later stage of our
analysis. As for the others, it is not they but the fear of them
that causes shame: yet even this statement has to be further
modified.

Fear may be so intense as to abolish all shame (in the
person afraid) at the display of it. If the individual’s higher
centres are sufficiently developed, he will be enabled to confront
the danger though still afraid, and even though his fear be
such as to leave no room for shame, he may nevertheless
remain fully alert and capable. Cowardice is nothing but
physiological weakness of control, and if a man is incapacitated
from performing his task by sole reason of his fear of physical
danger he does not feel shame until the fear and its cause have
passed away.

Fear of personal loss or inconvenience is not strong enough
to produce shame unless the fear has to do with some
unworthy object, in which case the consciousness of the
unworthiness may give rise to shame. One may be “ afraid ”
of missing a train, for example, if the feeling be genuine fear
and not merely discomfort, but the actual missing it does not
cause shame unless it is due to laziness or to carelessness. In
the latter case it is placed more correctly in the group of fear
of wrong action and possible punishment.

The mere contemplation of a wrong action, although the
intent of committing it be entirely absent, is a cause of shame.
It by no means requires such an action to be carried out before
repentance is experienced. An unexpressed distrust of some*

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one which is later found to be baseless, an entirely mental
elaboration of a scheme of revenge, a “ sight of means to do
ill deeds,” are all capable of bringing about a rush of self¬
contempt ending in shame, though it, no more than the origin
of it, may be disclosed. (The true origin is the realisation
that the particular thought is a wrong one; which implies,
first, the evil thought; second, a criticism of it; third, a com¬
parison between it and an abstract moral standard ; and fourth,
the condemnation. Some would add that there must be a
thinker before there can be a thought, but the problem of
whether this should not rather be expressed as “ the coiscious -
ness of thought implies a thinker” would lead us far into the
realms of philosophy.) The shame of possible punishment
powerfully reinforces the influence of the moral standard.
“ Because right is right to follow right ” is a motive less potent
now than it was in the days of the Greek sophists, and the
modern man is more often deterred from wrong-doing by fear
of its consequences than urged to virtue for its own sake.

When a wrong action is committed, it is condemned by an
abstract moral standard, which depends on tradition both reli¬
gious and family, modified by personal habits. The common
practice of swearing is not acquired until the early sense of
shame at using profanity, is lost. Leigh Hunt’s essay describing
his childish self-torture at being “ the boy who said ‘ damn ’ ”
is a good illustration of this. There are many people who
swear almost without realising they do so, and yet avoid the
use of certain expressions, while the Oriental references to the
probable ancestry of the hearer are repugnant to the European
mind. Similarly, a man who after leading a normal life trans¬
gresses the law of the land, may “ feel his position acutely,” to
use the routine phrase of sensational journalism, either in the
dock or when released from prison, but if several times con¬
victed loses all sense of degradation.

IV.

This leads us directly to the next cause of shame, namely,
•appearing at a disadvantage. As civilisation advances certain
conventions are established, and any infringement of these
causes shame. A man tells us of his father’s death, and we
condole with him on the loss; if truthful we might feel bound
to declare that “ such a disreputable and drunken old scoundrel

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is better off the earth,” but we should be ashamed to do so.
We offer amiable congratulations on a badly executed song or
sketch, and feel no shame at our lying praise of it. These
minor hypocrisies seem quite inadequate to arouse a sense of
shame. The person whom the action most nearly concerns
feels no shame at it, and it is the truthful critic who would be
shamed.

Let us return again to the example of the exposed law¬
breaker—be he embezzler, forger, cheat, or liar. It is true that
he may feel shame at the planning of his crime, but it is a self¬
contempt not identical with his emotion when he is publicly
stigmatised as dishonest. In this case he thinks of the loss of
trust, of position, of friends, and of money, and when his mis¬
deeds come to light his first impulse is to save himself. The
disgrace to his business partners and to his family is beyond
his thoughts, which are entirely devoted to his own loss of
public repute.

But we are not driven to such crass examples to illustrate
the shame felt on appearing at a disadvantage; there are many
minor ones we may cite. Tripping on a rug at the entrance
to a crowded room, upsetting a glass, a thoughtless remark
which at the time or later one finds has deeply hurt the feelings
of one’s hearer, all produce shame, and the mere recollection of
them revives the feeling for some time afterwards. Of a similar
nature is the shame experienced at appearing in inappropriate
dress at some public function, or wearing at an unusual time
some costume quite suitable in itself for another occasion.

In an earlier paragraph the statement was made that virtue
may be a cause of shame. It is quite possible to know one is
in the right and yet feel shame. One may be disgusted by an
obscene jest, by an account of astute commercial dishonesty,
and be shamed because one is the only member of the company
who does not admire it. This may be due to one’s own wish
that one had more worldly-wisdom ; there is no surer way to
flatter the boy of nineteen than by treating him as one
acquainted with all forms of evil. The feeling of shame in
such circumstances may be a genuine disgust at whatever has
called it forth, but there is more often that perception of
appearing at a disadvantage. The blush of conscious innocence
may in truth be due to an apprehension of ridicule at ingenuous¬
ness which is discordant. Again, one^may do a generous action
or take some trouble to help another, and at the same time be

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most anxious that one’s kindness should not be known. Why-
shame should be felt for this reason is difficult to explain except
on the ground that bringing oneself into prominence is in a
way appearing at a disadvantage.

V.

Next we have to consider shame caused by untoward
behaviour in others. We have already mentioned an example
in the yellow ruff. Another instance is the avoidance of the
name Stephen by the English Royal Family. The horrible
wickedness of the one King of that name has banished it from
the families of his successors save as a subsidiary. (It must be
stated, however, that the significance of this avoidance is
largely diminished by the many changes in dynasty.) As other
instances of what may be termed national shame are the effects
produced by the news of the fall of Khartoum, and the “ Black
Week ” of the South African War.

Members of a class may be shamed by an opportunist
abandonment of principle by a large body of the class. Then,
too, there is the family shame of owning a disreputable member,
or facing the scandal which is attached to suicide or to marital
infidelity. Of a similar nature is the shame felt at hearing a
relative make a tactless or brutal remark, just as though the
hearer himself were guilty of it. “ Visiting the sins of the
fathers upon the children ” might be interpreted as fixing the
period required for the shame of a family disgrace to pass away.
To this we must add the shame felt by onlookers at the display
of fear by another. All this appears once more to be due to a
sense of depreciation in value of a part which must affect the
whole, and so cause the whole to appear at a disadvantage.

VI.

Such an analysis of shame requires for completion a
distinction between shame and certain other emotions. We
have already mentioned the physical signs of shame: blushing
and shrinking may be due also to diffidence or to shyness;
blushing to anger, but in this case there is no shrinking, and
the blush is less extensive. Shame, as we have attempted to
show, depends on the opinion of others. Both diffidence and
shyness are produced by a sense of unworthiness or inferiority
in the individual, quite irrespective of the estimate of others.

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This statement that shame depends on the opinion of others is
by no means contradicted by the possibility of the individual
feeling shame while alone, for there is always the reference to
a standard other than his own. But the shy or diffident
person notoriously feels sure of himself in solitude. In
imaginary rehearsals of scenes through which he has passed—
actually to his own confusion—he always carries himself with
easy self-possession, and Vesprit d'escalicr is famed for its
brilliancy. He can make plans for his confident behaviour,
but the presence of others disconcerts him totally. Shame, it
may be repeated, is experienced quite irrelevantly to the presence
of other people.

Where all were afraid, or immodest, or brutal, or obscene,
or dishonest, or disgraced, none would feel shame. From what
has been expressed in the foregoing paragraphs it will be seen
that shame is invariably set up by an incongruity between the
shamed person and his associates. If the particular circum¬
stances involved no loss of position—moral or material—it is
doubtful whether shame would ever be felt. And as this
dependence on the opinion of others is the important factor,
it does not seem too far-fetched to define shame as “ the social
expression of self-interest.”

Unfitness to Plead in Criminal Trials. By M. Hamblin
Smith, M.A., M.D., Medical Officer, H.M. Prison,
Portland.

The subject of this paper is the criteria of an accused
person’s fitness to plead to an indictment charging him with
some criminal offence. It is a consideration of the questions
which are involved in the special verdict of “ insane on
arraignment.’’ We shall see, however, that in this connection
the word “ insane ” is used in an extended sense.

There are four stages in the process of any criminal case,
tried on indictment, at which the question of the accused
person’s mental condition may have to be reviewed : (1) Before
the trial. (2) Before he pleads to the indictment at the trial.
(3) During the progress of the trial. (4) After the trial.
The questions raised at the second of these stages are those

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which mainly concern us here ; although, for statistical purposes,,
we must consider the cases found insane before trial. We
shall see that these questions are essentially practical, and that
they differ materially from the fascinating metaphysical question
of a person’s “ responsibility according to law.”

Probably the very controversial character of the points
involved in the verdict of “ guilty but insane ” accounts, to
some extent, for the comparatively small attention which has
been given to the verdict of “ insane on arraignment.” But
the latter verdict is worthy of attention, and is by no means
infrequent.

The author trusts that he may be pardoned for giving a
short historical introduction. He thinks that this is not merely
of antiquarian interest, but that it really serves to throw light
on the question of pleading at trials.

In former times persons accused of felony were not con¬
sidered to be tried properly unless they consented to their trial
by “ pleading and putting themselves on the country.” The
indictment having been read, the prisoner was asked (as he is
at the present day), “ How say you; guilty or non-guilty?”
If he replied, “ Non-guilty,” he was then asked, “ How will
you be tried ? ” He had to reply, “ By God and my country.”
If he refused to answer these questions he was said to “stand
mute ” ; and a jury was sworn (as a jury may be sworn to-day)
to try whether he was “ mute of malice ” or “ mute by the
visitation of God.” If found “mute of malice,” and accused
of treason or misdemeanour, he was taken to have pleaded
guilty, and was dealt with accordingly. But if accused of
felony the trial could not proceed in the absence of a plea, and
the prisoner was condemned to be pressed ( peine forte et dure)
until he pleaded or died. The usual object of a refusal to
plead was to preserve the accused man’s property for his family
by avoiding the forfeiture to the Crown which followed on a
conviction. As there could be no trial, there was no con¬
viction, and hence no forfeiture of goods. In 1659 a Major
Strangways was pressed to death for refusal to plead. The
last case of pressing was in 1726, when a man accused of
murder was pressed for two hours, and then pleaded not
guilty ; he was tried, convicted, and hanged. The law remained
as stated above until 1772, when standing mute in cases of
felony was made equivalent to a conviction. In 1827 it was

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enacted that in such cases a plea of not guilty should be entered,
and the trial be proceeded with in the usual way (1). A part
of old Newgate Prison was known as the “ press-yard,” and the
name survived until the destruction of the building.

The question of “ mute of malice ” need not detain us long.
At the present day such an event is not likely to occur, save in
the case of a prisoner who is attempting to feign insanity.
A curious case may be mentioned, that of a man named Harris
who was tried for murder in 1897. After the murder he had
attempted to cut his own throat, and had inflicted such injuries
on his vocal cords that he was unable to speak. His trial was
postponed to the next sessions, when presumably his vocal
condition had improved, for he was then tried and sentenced to
death. It might, perhaps, be debated whether this man was
mute “ of malice.”

Coming to muteness “ by the visitation of God,” this may
occur in deaf-mutes, or in cases of insanity or mental defect.
As the question of the cause of the muteness is only one of
the questions which may be raised on arraignment, it will be
convenient to return to muteness later.

Having found that the prisoner is “ mute by the visitation of
God,” the jury may next be sworn to try whether the prisoner is
“ fit to plead.” And, further, the jury may again be sworn to try
whether he is “ sane or not.” It seems that, strictly speaking,
the jury should be separately sworn to try each of these three
issues, in the order as stated above. This rule, however, is not
always followed, and the judge may put all or any of these three
issues to the jury.

The prisoner may not be mute, and yet may be unfit to plead
by reason of mental disease or defect. It is a general rule
of English law that a man must be present at his trial. This
is certainly the case in trials for felony, and, except under very
exceptional circumstances, in trials for misdemeanour also. The
prisoner has - a right to be present in body, though he may
forfeit this right by his own misconduct : judges have ordered the
removal of a prisoner who was wilfully and persistently noisy.
And he has also a right to be “ present in mind.” In other
words, he must be sane at the time of his trial ; or, at any rate,
he must be able to understand the proceedings. This right
appears to be part of the English common law. Hale says :
“ If a man in his sound memory commits a capital offence, and

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before arraignment becomes mad, he ought not to be arraigned,
because he cannot advisedly plead to the indictment ”(2). And
Blackstone says : “If a man before arraignment for a capital
offence becomes mad, he ought not to be arraigned, because he
is not able to plead to the indictment with that advice and
caution that he ought” (3).

It will, of course, be remembered that in the days of Hale
and Blackstone capital offences were far more numerous than
they are now. The Statute 33 Hen. VIII, c. 20, made treason
a special exception to this general rule, and provided that if,
after committing an act of treason, the prisoner became insane,
he was still to be tried, and if found guilty was to be dealt
with. But this remarkable statute was repealed by 1 and 2
Phil, and Mary, c. 10. It appears from old authorities that
the question of the prisoner’s sanity at the time of trial might
be inquired into by the jury impanelled to try the indictment (4).
But the law was finally settled by “ The Criminal Lunatics
Act,” 1800. This statute was passed after the trial of Hadfield
(a man who had fired a pistol at George III), and it provided—
“ that if any person indicted for any offence shall be insane,
and shall on arraignment be found so to be, by a jury lawfully
impanelled for that purpose, so that such person cannot be tried
upon such indictment, it shall be lawful for the Court to direct
such finding to be recorded, and thereupon to order such person
to be kept in strict custody until His Majesty’s pleasure shall
be known.” And this remains the law to-day.

So we have to consider what is the degree, and what the
kind of mental disease or defect which justifies this verdict of
“ insane on arraignment.” Pleading to the indictment is not
merely a matter of saying “ guilty ” or “ not guilty.” Much
more is involved than this. The essential point is the state of
the prisoner’s mind at the time of arraignment. And, according
to Russell, the test is “ whether the prisoner is of sufficient
intellect to comprehend the course of the proceedings on the
trial so as to make a proper defence”(5).

The word “ proper ” is clearly the difficulty. Baron Alderson
in the case of R. v. Pritchard directed “ that the jury must be
satisfied that the prisoner was of sufficient intellect to compre¬
hend the course of the proceedings on the trial so as to make a
proper defence, to challenge a juror to whom he might object,
and to understand the details of the evidence.” The author

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has heard it laid down in court that the prisoner must be able .

(if defended by counsel) to give proper instructions for his
defence, or (if undefended) to cross-examine the witnesses for
the prosecution. Presumably all the criteria mentioned by
Baron Alderson must be satisfied in order to establish the
prisoner’s fitness to plead.

If these rules were applied strictly and literally a very large
number of prisoners would have to be declared unfit to plead.

For instance, take the right to object to (technically, to “ chal¬
lenge ”) a juror. How many prisoners are even aware of their
right in this respect? True it is that the Clerk of the Court
repeats a formula which informs the prisoner of his right. But
one may be permitted to wonder how many prisoners find this
information intelligible. And, again, it is a question as to how
many prisoners are capable of making what may reasonably be
called a “ proper defence,” or of cross-examining witnesses, or
(if defended) of giving proper instructions for their defence.

But it is clear that mere ignorance, or lack of education, or
ordinary stupidity, will not be enough to justify a verdict of
unfitness to plead. And cases of this kind, if undefended, are
safe in the hands of the presiding judge, from whom they receive
all possible and proper assistance.

What then is necessary in order that a prisoner may properly
be allowed to plead ? He must clearly understand that he is
on his trial. He must understand for what offence he is being
tried. And he must be able to appreciate the difference between
a plea of “ guilty ” and of “ not guilty ” (see R. v. Wheeler,
1852). If there is any uncertainty on these points he is unfit
to plead. Next, he must have a reasonably clear idea of the
proceedings against him at the trial, and of their meaning and
effect. It must not, of course, be expected, or claimed, that an
ignorant man of the labouring class should have the same ability
to make a defence which would be possessed by a highly
educated man. But it may perhaps be insisted upon that he
should not be markedly below (either by reason of mental defect
or disease) the average mental capacity of a man of his age,
education, station in life, etc. No demur will be taken to the
position that any condition of acute insanity—mania, melan¬
cholia, dementia praecox with stupor, acute confusional insanity,
etc.—would justify a verdict of “ insane on arraignment.” The
real difficulty arises in cases of undeveloped insanity, e.g. } early

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general paralysis or commencing senile dementia, and also ir»
such states as paranoia and some cases of epilepsy.

What, then, are the points which we must consider ? Memory
is an important matter. If the prisoner’s memory for recent
events is markedly affected, so that he is unable to remember
the events at the time of the alleged crime, then surely it is.
impossible for him to make a proper defence to the charge.
Indeed, in some cases of senile dementia the word “trial”
would be a misnomer. Difficulty, in this direction, may arise
in early cases of general paralysis ; and an awkward problem
is presented in cases where an offence has been committed
during an epileptic “ equivalent," or in a post-epileptic condi¬
tion. As a general rule, such a patient will have no recollection,
of events which occurred when he was in this state. And so it
might be urged that he was, to a large extent, incapacitated
from defending himself against the charge. The author is of
opinion that the prisoner should plead, evidence of the epilepsy-
being placed before the court at the proper time. Such a
patient might well be apparently normal in the intervals between
his epileptic attacks. But in a case of epileptic insanity the
situation is altogether different, for here the memory, percep¬
tion, attention, and judgment may be so affected that the
prisoner may be unfit to plead (R. v. Henley, 1912). Memory'
is not, of course, the only point to be considered. If his per¬
ception, attention, reasoning power, and the other elements-
which make up intelligence, are markedly' impaired, then it may
be that the prisoner should be regarded as unfit to plead r
having regard to the conditions of fitness to plead which have
already been laid down. And, besides intelligence, the emo¬
tional reaction and the will power must be taken into account.

The existence of delusions would not be, in itself, a sufficient
ground on which to base inability to plead. Delusions are, of
course, excellent facts on which to base a demonstration of
insanity, and it is impossible to say what part of a man’s
conduct is unaffected by an insane delusion. Yet in cases of
paranoia, where delusions (eg., of persecution) may be the
prominent feature, the patient may be capable of defending
himself with much acumen. It cannot be too clearly pointed
out that a man may be insane, and may be found “ guilty but
insane ” at his trial, and yet may have been rightly considered-
fit to plead.

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A person may have been insane at the time of the crime, and
may be recovering at the time of trial. Such an event is very
likely in cases of puerperal insanity with destruction of the
child. The prisoner should plead, and a verdict of “ guilty but
insane ” will probably be returned. The mental questions on
arraignment are solely concerned with the state of mind at the
time of arraignment.

A prisoner may be aware of the nature of the crime with
which he is charged, may have given himself up for it, and
may know quite well that he is being tried, but yet may be
unable by reason of his mental state to “ take a rational part in
his trial, to understand the evidence against him, and to do his
best to defend himself against the charge ” (Baron Pollock, in
R. v. Mills, 1 884).

So far we have considered what may be called cases of
■“ certifiable insanity.” Surely the principles laid down might
include many cases of “ mental deficiency.” An “ idiot ” or an
“ imbecile ” would naturally be found “ insane on arraignment.”
And it seems that the rule might apply in many cases of
“ feeble-mindedness.” The “Mental Deficiency Act,” 1913,
defines such cases as persons “ who by reason of mental defect,
■existing from birth or from an early age, require care, super¬
vision, and control, for their own protection or that of others.”
Apply the criteria of fitness to plead to such persons. And
apart from what might be called “statutory feeble-mindedness,” in
which a congenital or early origin must be proved, there are
many cases of “ senile ” and of “ alcoholic ” feeble-mindedness.
In 'these, as in the congenital cases, the intelligence, the
emotional reaction, and the will-power are often most markedly
affected. Such persons may often be quite unfit to plead.
And the author would suggest that the criteria of fitness to
plead might often be applied in such cases, and the power of
detention under the “ Criminal Lunatics Act,” 1800, might
often be used. The congenital or early origin of the case need
not be proved ; the question of fitness to plead is all that need
be considered. If it is objected that it is too great an exten¬
sion of terms to call such cases “ criminal lunatics,” the answer
is that it is not so great an extension as we shall see later is
made in some cases of deaf-mutes.

So we have seen that no general rule can be laid down as to
the degree or character of mental disease or defect which.

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renders a person unfit to plead, any more than an absolute rule
can be made as to the degree of mental derangement which
renders a person “ irresponsible for his criminal actions.”
Each case must be considered on its merits. All the circum¬
stances must be weighed with care. And the possibility of
feigning or exaggerating symptoms must not be ignored. All
this will require close and continuous observation of the
prisoner, and often careful inquiry into his history and into the
circumstances of the crime. The process may be of a very
intricate character, and may involve repeated and prolonged
interviews with the prisoner. The author knows that he is
touching on difficult and highly controversial matter. But he
ventures to think that in many cases inquiry will be futile
unless there is discussion of the circumstances of the crime with
the prisoner. And, further, he considers that any information,
bearing on the guilt of the prisoner, which is obtained in this
way, must be regarded as confidential. The author believes,
and it is confirmed by his personal experience, that this privi¬
lege, though perhaps technically unknown to the law, is prac¬
tically allowed by courts at the present day. In epileptic, and
in other cases, where the question of loss of memory may be of
paramount importance, free discussion of the circumstances of
the crime must be an essential feature of the examination. All
this has its bearing on the question of full inquiry into the
mental state of every person before his trial. The author holds
strong views on this subject, but it is not a matter which can
be entered into here.

Many cases may be doubtful. And it must be remembered
that, as Dr. Nicolson says, it is desirable that a prisoner,
although insane, should be allowed to plead if he is at all
capable of doing so (6). It is, for many reasons, well that
whenever possible a verdict should be obtained on the merits
of the case. It may happen that the prisoner is proved
innocent. If he is insane, there are still ways of dealing with him.

Now let us return to deaf-mutes. There may be the possi¬
bility of communicating with such a case either by writing or
by means of the sign language. And the prisoner is then in
the same position as a foreigner, ignorant of English, who has
to be communicated with through an interpreter. His sanity
or insanity would still have to be considered. But a deaf-mute
who is illiterate and is ignorant of the sign language cannot be

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communicated with at all. Such a person is clearly unfit to
plead, and is properly so found. And in the case of R. v.
Emery, 1909, it was held that such a finding is equivalent to a
verdict of “ insane on arraignment.” Exactly similar cases
were R. v. Leese, 1914, and R. v. King, 1908. So, as suggested
at the beginning of this paper, the word “ insane ” has a some¬
what extended meaning. With deaf-mutes the only thing to
be done is to endeavour to prove whether there is any means
of communicating with them. This may involve a difficult
decision. And this difficulty may be much increased when the
deafness, although great, is not absolute, and the inability to
speak is not complete (R. v. Birch, 1914).

The possible combinations of circumstances, and the verdicts,
may be put in a tabular form :

(I) Prisoner may be “ mute by the visitation of God.”

(i) Sane and can be communicated with—Fit to plead.

(ii) Presumably sane, but cannot be communicated with—
Unfit to plead.

(iii) Insane (or mentally defective), but can be communi¬
cated with—Unfit to plead.

(II) Prisoner not mute, but insane (or mentally defective):

(i) Able to make a proper defence—Fit to plead.

(ii) Unable to make a proper defence—Unfit to plead.

How do such cases usually occur in practice ? The author,

of course, writes from the position of a prison medical officer,
upon whom the duty of reporting to the court in all doubtful
mental cases is laid. The jury may form their opinion of the
prisoner’s sanity or insanity from his manner and appear¬
ance (7). But practically there must be some suggestion, how¬
ever informal, of unfitness to plead ; and this may come from
the prosecution, from the defence, or from some other source.
And in most cases the first suggestion comes from the prisoner's
side, in cases which are defended by counsel (an insane man
himself is not likely to put forward a plea of insanity). This
explains the fact that pleas of insanity are most common in
capital and other serious cases. Counsel are unwilling to risk
an indefinite detention for a client, in consequence of an offence
which would normally be punished by a short period of
imprisonment. The modern tendency towards shorter sentences
will increase this reluctance.

Simple uncontroverted cases will give rise to no difficulty.

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But the case may be contested by the prosecution (as in R. v.
Taylor, 1888), or by the prisoner (as in R. v. Mauerberger,
1887). Counsel may wish fora verdict on the facts. In this
event the medical witness will be cross-examined. There is
some difference of opinion as to the manner in which the
medical evidence should be given. Facts must, of course, be
the basis of any opinion which is given. Some judges allow,
and even ask, the medical witness (after he has described the
observed facts) to express his opinion as to the prisoner’s ability
to understand the proceedings, to make a defence, etc. Other
judges appear to have ruled that these latter questions are for
the jury alone, and that the medical witness must confine him¬
self strictly to a description of facts. This latter view, if
pushed to the limit, seems unreasonable. But perhaps the best
plan is to describe the case fully and give a reasoned opinion
in the written report before trial, and in court to answer such
questions as may be asked.

A defended prisoner may persist in pleading in spite of his
counsel’s admission that he is unfit to plead. This occurred in
the case of R. v. Douglas, 1885. He was finally allowed to
plead, and was found guilty but insane.

A peculiar condition of affairs occurs when an insane man,
having been declared fit to plead, persists in pleading guilty.
Further inquiry into his mental state by the court appears to be
barred, and he must be sentenced and then dealt with as an in¬
sane prisoner. Such a case occurred in R. v. Swatman, 1876,
and also in a case in the author’s own experience in 1913.

There is no appeal against the finding of a jury that a prisoner
is fit to plead. Of course it is possible to appeal that a sentence
may be quashed on the grounds of insanity (7).

All persons, deaf-mutes and others, who are ordered to be
detained as insane on arraignment are treated and classed as
“ criminal lunatics.” This seems a peculiar title, for two reasons.
Firstly, such persons have never been convicted of the crime
charged against them. Under the “ Criminal Lunatics Act,” 1884,
if a person detained as “ insane on arraignment ’’becomes sane, the
Secretary of State may order him to be remitted to prison to be
dealt with according to law. And, presumably, a deaf-mute,
detained because it was impossible to communicate with him,
might also be remitted to prison for trial, if, by means of
education, communication became possible. And secondly, it

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BY M. HAMBLIN SMITH, M.A.

773

is doubtful whether even persons found “ guilty but insane ” at
their trial can properly be termed criminal lunatics. For the
judgment of the House of Lords in R. v. Felstead (1914)was that
•a verdict of “ guilty but insane” does not amount to a conviction.

Taking a number of years before the war, the average yearly
number of verdicts of insane on arraignment was 24 male and
6 female cases. This amounted to 3 per 1,000 males and
9 per 1,000 females of cases convicted on indictment. (Strictly
the figures should be reckoned on the numbers tried on indict¬
ment, but the author simply wanted to illustrate the relative
frequency of the verdict in men and women.) To these
numbers should be added such cases as are certified insane
while waiting trial (38 males and 30 females), who were pre¬
sumably so insane that any attempt at a trial would have been
impossible. And there must also be added an uncertain
number who were certified insane on remand and at the police
court, some of whom would have been indicted had their cases
being allowed to proceed. During the same period a yearly
average of 28 men and 12 women were found “guilty but
insane.” From the opening of Broadmoor Criminal Lunatic
Asylum to the end of the year 1912 there were received into
that institution 721 cases certified while awaiting trial or
found insane on arraignment, of which 482 (67 per cent.) were
charged with murder or attempted murder, and 1,282 cases
acquitted on the grounds of insanity, found guilty but insane,
or reprieved on the grounds of insanity, of which 1,115 (87 per
cent.) were for murder or attempted murder. (These numbers
support the suggestion, made earlier in this paper, that the plea
of insanity is far more frequent in murder trials than in any
other class of crime.) And on December 3 1 st, 1912, there were
in Broadmoor 195 men and 74 women certified while waiting
trial or found insane on arraignment; and 346 men and 145
women acquitted on grounds of insanity, found guilty but insane,
or reprieved on grounds of insanity. The marked preponderance
of women will be noted, having regard to the fact that the
number of men tried on indictment to the number of women
so tried is about 11*5 to 1. The great excess of these cases
among women is probably accounted for by the large number
of infanticide cases, in which there is a great reluctance to con¬
vict (a conviction necessarily implyinga sentence which everyone
.knows will not be carried out).

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Conclusions.

(I) The term “ insane on arraignment ” is used in a somewhat
extended sense. And it would be well if some alteration in
the legal phraseology were made {eg., to substitute the words
“ unfit to plead ”).

(II) No absolute standard of insanity or mental defect can be
laid down as unfitting a man to plead. Each case must be
considered on its merits.

(III) That while recognizing that the presumption in all cases
should be that the prisoner is fit to plead, there is some reason
to think that in many cases it would have been well had the
question of the prisoner’s mental state been considered at an
earlier stage.

The author is only too well aware of the defects of this paper.
He has two excuses for publishing it—the comparatively small
attention which seems to have been given to this verdict, and
the fact that he was asked to write it by an eminent alienist
with whom he was associated in a case several years ago. He
has tried to make the legal side of the paper as accurate as
possible.

References.

(1) Stephen.— History of Criminal Law of England.

(2) Hale, Sir Matthew.— Pleas of the Crozvn (circ. 1650).

(3) Blackstone.— Com?nentaries on the Law of England, vol. iv.

(4) Wood-Renton in Hack Tuke’s Dictionary of Psychological
Medicine.

(5) Russell.— Crimes.

(6) Nicolson.—Allbutt’s System of Medicine, vol. viii.

(7) Halsbury.— Laws of England, vol ix, etc.

Other Authorities.

Archbold.— Pleading, Evidence, and Practice in Criminal Cases, 24th
edition.

Orange.—“ Capacity to Plead,” in Hack Tuke’s Dictionary.

Wood-Renton. —Law and Practice of Lunacy.

Pitt-Lewis, Smith, and Hawke. —The Insane and the Law.

Williams, J. W. Hume.— Unsoundness of Mind.

Everest, Lancelot F.— The Defence of Insanity.

Dixon-Mann.— Forensic Medicine.

C h i tty.— Statu tes.

Taylor. —Medical Jurisprudence.

Numerous cases reported in various Law Reports, “State Trials,"and
volumes of Journ. of Mental Science, Lancet, British Medical Journal,
and Medico-Legal Journal (New York).

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REVIEWS.

775

Part II.—Reviews.

Pragmatism and the Problem of the Idea. By the Rev. John T.

Driscoll, S.T.L. Longmans: New York and London. 1915.

Crown 8vo. Pp. xxvii, 274. Imprimatur of Remigius Lafort,

S.T.D., Librorum Censor.

A book which, like this, is avowedly written to support a foregone
conclusion naturally arouses prejudice against it. That a Roman
Catholic priest should condemn any philosophical doctrine that is not
to be found in St. Thomas Aquinas is so much a matter of course that
it is natural to presuppose his condemnation of pragmatism ; and his
Preface admits and proclaims that the book is the result of studies
carried on for some years in an endeavour to show that pragmatism is
erroneous. He embarked on the study of pragmatism in the same
spirit as a predecessor of the same faith embarked on the study of
parallax. This open-minded critic asked Galileo the meaning of
parallax, so that he might write against it, for he had heard that it was
inconsistent with the doctrines of Aristotle. So Father Driscoll inquires
the meaning of pragmatism so that he may write against it, for he has
heard that it is inconsistent with the teaching of Aquinas. It is thus at
least that we interpret his Preface. We are not, therefore, led to expect
a veryaccurate account of pragmatism, nor do we expect to find unbiassed
criticism of the doctrine so called, and in neither respect does the book
surpass our expectation. There is indeed no actual misquotation.
Father Driscoll quotes copiously and correctly, but the student who
should obtain his notion of pragmatism from this book, as it is intended
that Catholic students should, will obtain a notion that is not very clear
and that is a good deal distorted. To say that William James and
Prof. Bergson teach that the end justifies the means ; that they judge
means without reference to the principle of right and wrong; that they
gauge the truth or goodness of an action by personal success alone; are
really shocking distortions of the teaching of these eminent men ; and
to say that the influence of these two teachers is material and sensual is
ludicrous. The doctrine that the end justifies the means has always
been identified in the minds of Protestants, and of a good many Roman
Catholics also, with the teaching of the Jesuits, so that if William James
and Prof. Bergson had taught such an immoral doctrine (they have not)
they would have been following the most illustrious authorities in Father
Driscoll’s own church. Father Driscoll’s acquaintance with science may
be judged from his assertion (p. 263) that the scientific hypothesis of
evolution now rests upon Mendel’s law. I have tried to divest myself
of the prejudice which, as I have said, a book written to support a
foregone conclusion naturally arouses, but I am bound to say that my
prejudice was faint indeed in comparison with my postjudice. The
book is intended for Roman Catholic students, and for them I daresay
it will serve its purpose, but it is not to be commended to anyone who
wishes to obtain a true account of pragmatism.

Chas. A. Mercier.

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Collected Papers on Analytical Psychology. By C. G. Jung, M.D.

LL.D. Authorised translation edited by Dr. Constance E. Long.

London: Baillifere, Tindall & Cox, 1916.

In the author’s preface it is explained that this volume contains a
selection of articles and pamphlets written at intervals during the past
fourteen years. As the papers are arranged in chronological order it is
possible to follow the gradual alteration in Jung’s views with regard to
psychoanalysis.

The differences between the Vienna and the Zurich schools are stated
briefly as follows : The Vienna school is mainly concerned with the
analysis of the symptoms to find the cause. The Zurich school tries to
find out the aim of the disease. To quote from the preface : “For to the
Zurich school the symbol is not merely a sign of something repressed
and concealed, but is at the same time an attempt to comprehend and
to point out the way of the further psychological development of the
individual. Thus we add a prospective import to the retrospective
value of the symbol.”

A volume consisting of selected papers does not lend itself to review
unless each paper receives separate attention. There is a considerable
amount of repetition which is unavoidable, but which, though as a rule
distracting, at other times is helpful, as a point not understood on the
first occasion, when repeated in a different way is clear.

The chapter which will especially interest the readers of the Journal
is number XIII, entitled “ The Content of the Psychoses.” In this
the author contends that most cases of insanity have psychic, not
physical, causes. He deprecates all study of the morphology of the
brain, and states that in three-fourths of the brains examined post-
mortem at Burgholzi nothing abnormal is found. He therefore con¬
cludes that the path of psychiatry in the future must be only by way of
psychology. Of course, definite organic diseases of the brain, eg,
general paralysis, etc., are excepted. This sweeping assertion is not
altogether convincing, especially when it is remembered that the advo¬
cates of a toxic causation of insanity could quote exactly the same
evidence in support of their theory.

In the same chapter examples of psychoanalytic studies in several
insane patients are given, and explained in characteristic manner.
These explanations are clever and are possibly the correct ones, but
equally possible is it that other interpretations may be nearer the truth.
It is impossible to withhold admiration for the amount of work which
Jung and his assistants must undertake in the studies of their cases,
and the ingenuity expended in arriving at the solution of their
problems. Though science must be studied for itself and not for its
practical results, still the question will obtrude itself, “ Is the patient
any better after the psychoanalysis?” So far, in its dealings with the
insane, the therapeutic results of this new method are disappointing.

To those who wish to keep abreast of the literature the present
volume will be most helpful, especially if their knowledge of German is
limited. The translation has been well done, and the book has been
carefully edited.

Several of the chapters have a foot-note giving the place and date in

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777

which it originally appeared. This certainly adds to the interest, and
should be supplied to all. It was stated a short time ago in a corre¬
spondence in the medical journals that no mention had been made of
the names of certain people who had acted as translators of several of
the chapters. These defects will, no doubt, be rectified when a second
edition is called for. R. H. Steen.

Part III—Epitome of Current Literature. '

i. Psychology and Psychopathology.

Tilt Biological Point of View in Psychology and Psychiatry. ( Psycho¬
logical Review, vol. xxiii, March , 1916, pp. 117-128.) Abbott ,

E. Stanley.

It is necessary to consider psychology and psychiatry from the
biological point of view, because only in this way can they be rendered
objective, and as free as possible from metaphysical bias and a priori
theories. By the term biology he connotes the science of living things,
and not merely the study of structures and physiological activities.
The fundamental differences between non-living and living things are
that the latter by internal activities make themselves out of the materials
of their environment, and reproduce their kind. The power of adapta¬
tion to environment in non-living things is very limited, and there are
no self-directive activities. The life of the individual biological unit
consists in the continuous adaptation of itself to its environment as well
as it can. If it stops reacting by internal activities, it dies. If it does
not react as well as it can, it succumbs to external agencies, or does
less well than its neighbour. Man may be looked upon as such a
biological unit. Many of his internal activities are physiological, but
most of those which result in his external behaviour or conduct are
psychological. All of his activities are directed to the great end of his
best self-adjustment to his whole environment, though lesser or nearer
and more concrete ends are usually more immediately prominent to the
individual. Reaction is to a large extent unconscious. Psychical
activities are links in the chain of internal reactions. Each link is a
reaction, effect of preceding links, cause of succeeding ones. Study of
causes leads back to factors of the environment, and to anatomical
structure and physiological process. Study of effects leads forward to
behaviour and to bodily changes and processes. Every psychic event
is a reaction. The nervous system is the structure specially adapted for
the performance of psychic functions or processes. Mind is the abstract
name given to the capacity to react in certain ways, to the organised
whole of any individual’s psychic reactions, or to the content of any
individual’s psychic reactions, especially ideational ones. It is a function
or set of functions, but through misconception it is often used to indi¬
cate some mysterious thing which can act of itself or is opposed to or

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contrasted with body, and it is often referred to as having structure.
“ From a strictly biological point of view it bears the same relation to
brain and to the individual that respiration does to lungs and to the
individual, or that running does to legs and to the individual. It is
the individual , not the brain, that thinks or exercises the other psychic
activities we call mind, just as it is the individual, not the lungs, that
breathes, or the individual that runs, not the legs. But by means of
the brain, the lungs, and the legs, the individual thinks, breathes, runs.”

We do not think of opposing or contrasting respiration or running
with lungs, legs, or body. Neither should we do so with brain or body
in the case of mind. Nor is it less absurd to say that mind is brain,
and brain is tpind.

Some structural knowledge is essential for the proper comprehension
of function, whether it be respiration or mind. So intimately are
structure and function related that it will doubtless be found eventually
that racial, family, and even individual traits are partly dependent on
more or less minute structural differences in brain architecture and
nerve-cell distribution. Such knowledge is a pre-requisite in psychiatry.
The effects of, for instance, toxaemias, fatigue, and brain lesions on
mental processes are of recognised importance; while the effects, in
particular, of the emotions on bodily activities have been emphasised
by Crile, Cannon, and others. In the writer’s opinion the bodily con¬
dition acts to some extent on the ideational processes and content
through the affects, especially in the insane. From the biological point
of view the relations between body and mind are in principle almost as
simple as those between body and any other function.

Environment as a cause of psychic activity has been too much neg¬
lected : it acts upon the unit, which reacts to it. Any given unit will
react to the extent of its capacity for reacting, and this is determined
by its structure. The chief environmental factors are matter and modes
of energy (light, sound, heat, etc.) ; other living creatures ; relations of
various kinds—genetic, social, business; law or necessity; obligations
and rights. Psychology cannot adequately study the mechanism with¬
out a knowledge of the nature of the stimulus any more than physiology
can adequately study the mechanism of digestion without a knowledge
of the composition of foodstuffs.

Every biological unit is not only in an environment, consisting of
these factors, but each one is at the centre of its own environment, and
is itself part of it. It may be regarded as consisting of a set of con¬
centric circles or spheres, each representing a limited situation, the
factors of which act with greater or less force upon the unit at the
centre, and to which the unit responds with more or less activity,
physical and psychical. The inner circles—the immediate surround¬
ings—are constantly changing, and require constant adjustment on the
part of the individual: the remoter ones, as a rule, change less and
require, therefore, less adaptation. In psychiatry, for example, it is
necessary to study the patient’s total reaction to his total environment.

“ The biological point of view—that every psychic event is a reaction
of an individual—if consistently followed and applied will correct a
tendency, prevalent to some extent in most if not all psychologies, very
•common in James’s psychology, and fairly running riot in the writings

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of the Freudian school, to personify, as it were, or to make indepen¬
dently acting entities of the psychical functions. Making all due
allowance for a proper use of analogies and of abstractions to avoid
descriptive phrases and periphrases, and for literary leavening of an
otherwise perhaps heavy dough, there yet remains enough of such
usage to indicate a haziness of conception on the part of the writers,
and to becloud for the reader a subject not too clear at best—not to
mention its scientific inexactitude.”

The unity of the “ego” is determined by the facts that it is the same
organism which reacts at successive times, that each experience is
recorded in the same individual (not in any other), and that the
organism can recall the content of most of these experiences by subse¬
quent psychical activities. Partial or split personalities may be
explained on the hypothesis that the individual cannot recall or make
use of large groups or sets of experiences, and can react in more than
one way at a time.

In answer to the objection that his view may be considered purely
mechanical or fatalistic, the author says that, though the individual
must react to the environment, there are yet many possibilities of re¬
action : and he can, even must, choose which of the possibilities to
carry out. There is a compromise between free-will and determinism.
“The individual must react, but has a measure of choice—freedom of
will—as to how it shall react, i.e., as to what reaction it shall make.”

Hubert J. Norman.

The Religious Problem and Psychical Research (Le Prollcme Religieux
et les Sciences Psychiques.) (Revue Philosophique, April , 1916.)
Boriac , £.

The psychic sciences constitute an attempt to organise the study of
various mysterious mental and moral phenomena which occur in human
life. In so far as the religious life offers numerous examples of these
phenomena, it is natural to ask if those sciences, which have taken such
phenomena for their special study, might not be called upon to furnish
useful or even indispensable elements for the solution of the religious
problem. The whole of these sciences may be resumed under three
headings, often confused though actually quite distinct, viz., hypnotism,
animal magnetism (including telepathy), and spiritualism. Hypnotism
—including suggestion, states of torpor and unconsciousness, and dis¬
sociations of consciousness (Janet)—deals with phenomena which are
reducible to laws and which do not oblige us to assume the existence of
causes or faculties other than those which are already known to exist.
Animal magnetism also, a condition uncertain and contested, does not
imply conceptions which compel us to depart from the sphere of nature,
though it assumes the intervention of a force as yet unknown, more or
less analogous to the physical forces, light, heat, and electricity. Spiri¬
tualism, on the other hand, deals with phenomena—or claims to do so
—outside the sphere of nature altogether, and passing into a plane of
activity habitually separated from normal life and activity.

Having defined and described the phenomena in question under
these three categories, the writer proceeds to the discussion of their

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780 EPITOME. [Oct,

possible value to the religious problem. The subject may be approached
both from the point of view of the scientist or philosopher who surveys
the exterior phenomena of religion, and also from the standpoint of the
believer to whom religion is a matter of inner conviction and faith.
From the first point of view there is no doubt that the religious sciences
find in the psychic sciences a wide field for the advance of their peculiar
researches. Thus a knowledge of hypnotism and the neuropathic
temperament make the various episodes described in the biographies of
the saints much more believable. In such histories almost all psychic
phenomena, clothed in religious form, are to be found, but preserving
under this form evident analogies to those described at the present day
under the categories of hypnotism, dissociated consciousness, animal
magnetism, and spiritualism. When, however, the religious question is
considered from its essential basis the psychic sciences can furnish no
great light. The religious sentiments, the religious idea, seem quite
independent of all these more or less abnormal psychic phenomena.
Religion has its deep and probably indestructible roots in the highest
moral aspirations of human nature. Two interpretations are given to
spiritualistic phenomena—one which explains them as the subconscious
experiences of the medium, and the other which explains them as the
manifestation of intelligence, exterior to this world. The first hypothesis
is the only one in accord with scientific postulates, and even if the latter
were clearly demonstrated, in so far as religion is not solely a matter of
belief in a future life, such certitude would have but little value from a
religious point of view. The writer concludes that religious experience
is independent of objective verification, and, whatever may be the future
progress of psychic science, religion will always be a matter of faith and
intuition. H. Devine.

The Opposition to the Doctrine of Association of Ideas. [ L'Anti -

associationnisme.\ (Revue Philosophique , May, 1916.) Dugas, L.

By the exaggeration of the scope of the law of association of ideas a.
reaction has been provoked which questions not only its scope, but its
sense and value. If, says the author of this article, there is a law
which seems established in psychology, it is that of association. All the
philosophers from Plato to Spencer have recognised it. But the use that
English empiricists have made of it has given umbrage to the rationalists
of our day, and they pretend and charge themselves with proving that
association of ideas, as they understand the doctrine, cannot, and in fact
does not, exist.

Brochard, in his article on the “ Law of Similarity,” which appeared
in the Revue Philosophique in 1880, opened the anti-associationist cam¬
paign. He did not wish to destroy all the laws of association, but only
one—the most important by the way—the law of association by resem¬
blance. “ Ideas of the past,” he says, “ being presented at the same
time as those of the present, we can observe whether they are like or
unlike. But one sees that the perception of the resemblance or contrast
only occurs after the appearance of the ideas. It is not the cause but
the consequence of association. The ideas are already associated by
contiguity at the moment when we notice that they are alike, and their

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resemblance would escape us if the law of contiguity had not already
done its work.”

Association then by similarity comes only in consequence of associa¬
tion by contiguity, or, to put it in another way, there is no association
by resemblance, but only a judgment of resemblance passed on associated
ideas in virtue of the only law of association which exists, namely, that
of contiguity. The association of similar ideas is only apparent; the
mind has not the power of grouping such ideas, of searching for them,
or of discovering them ; it can only wait for them.

But if similar ideas cannot associate together, cannot evoke each
other, cannot recall each other, if they associate only by contiguity, it
may be asked : (1) How is it that contiguity so often causes the meeting
of similarities ? One would say that it searched for them, that it aimed
at causing the encounter, which ought to be, by hypothesis, accidental,
exceptional, and rare.* (2) How does the mind take cognizance of a
resemblance which it cannot discover at once, at which it does not aim
beforehand, which it is not disposed to notice, and which it does not
look for ?

Brochard’s idea of association is a law of reproduction of past
phenomena in their order of succession. The more the reproduction of
the past is perfect, without change, integral, literal, the more it
approaches a pure mechanism, the more it is an automatic unrolling of
images and of acts, which no thought directs, the better it realises the
idea of association which Brochard has conceived.

Others, however, do not take the word in such a rigorous sense.
Plato, for example, remarks that association constitutes a discovery, a
progress of thought, that is to say the passage from an idea present to
the senses to one which has escaped from the senses. “ Recollection,”
says Plato, “ is perceiving a thing in such a manner by the senses or
otherwise as to think of another thing which one does not perceive, and
which one does not recognise in the same manner as the first; thus,
seeing a musical instrument, one thinks of the person who plays it.”
Reminiscence then enters into the association of ideas, which Plato does
not name, but which he designs in a very clear fashion, and of which he
expresses the law in these terms: “ Reminiscence is caused sometimes
by similar things, and sometimes by dissimilar things.”

The writer proceeds to examine in detail the theory of association by
contiguity—the theory of mechanism, as he terms it—and to point out
its fallacies. In the course of his arguments he remarks that the only
real law of association is the law of interest, and that this law is
applied to memory, considered either as a conservation or as an
evocation of the past. For example, I retain from the past only
the facts which I had an interest in considering at the moment; I
evoke from the past only the facts which I am interested in remem¬
bering now.

Although throughout the whole of his article it is evident that the
writer leans to the doctrine of association by resemblance, yet he arrives
at the conclusion that one cannot put forward association of ideas as a
universal and unique law which will be in psychology what the law of
attraction is in astronomy and physics. There is not one but several laws
of association. They are heterogeneous and irreducible, and they

LXII. SO

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express the relations between ideas—not necessary relations, but only
possible—in such a way that the true psychological problem is to define
and class these “possible modes of association.”

These laws of association, then, are simple frames (cadres) of thought,
frames not rigid, into which thought may, not must, enter; or, making
use of another metaphor, they are different ways, which open before the
thought, and which it is invited, not compelled, to follow.

These laws are only different manners, forms, or methods of thinking.
But these methods, which command and direct the course of thought,
are themselves imposed on each mind by its own nature, by its own
mental idiosyncrasy. Association explains itself by idiosyncrasy of
temperament. Besides, this is expressed in common language; a man
is characterised by his turn of mind, his form of thought, or, to put it
in another way, by the nature or kind of his association of ideas,
and one understands by that that if it be his associations which
define his mind, it is his mind which determines the course and
form of his associations. Still it is necessary to add that each mind
has several aspects, several manners or forms of thought; or, to
express it in another way, one can engage one’s self in different ways of
association, and one does not fail to do so. The laws of association,
then, can be considered as different and successive points of view of
the same mind.

This may be explained by examples:

(1) Association by contiguity characterises minds which are fond of
the temporal and spacial order of things, which depend on this order for
recovering their recollections, and which do not take the trouble of
assembling, grouping, or comparing their ideas. This is also the point
of view of minds which are resting themselves, taking a holiday as it
were, and which give themselves up to the accidental associations which
circumstances bring.

(2) Association by resemblance is characteristic of minds which are
occupied and preoccupied by a dominating idea, which bring everything
to this idea, discover it everywhere, and strive to seize or to procure
comparisons with it. It is also a point of view which certain minds may
momentarily take without it being natural or proper to them. Finally,
one may see among those in whom this form of association dominates a
tendency to gather everything to one’s self, to shut one’s self up in an
habitual circle of ideas; in short, an egoistic and conservative turn of
mind.

(3) Association by contrast characterises the minds which receive

every new idea badly, and which, to get aw r ay from it, and to defend
themselves from it, throw themselves at first into the arms of the opposite
notion. This form of mental contradiction is common and natural, for
it is not always and only from vanity and jealousy that one contradicts.
One may do so from an instinct of legitimate mental defence, not
defiance, but of simple prudence with regard to the ideas which present
themselves. One wishes to take time to get used to these new ideas,
so one resists and examines them before surrendering. Association by
contrast is also the mark of minds which love extreme fluctuations and
oscillations of thought. J. Barfield Adams.

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Delay and Precocity in the Development of the Child between Two and
Four Years of Age. \Le developpement de r enfant. Retard simple
essentiel etprecocity de f enfant de deux a quatre ansi] (Revue Philo-
sophique , May , 1916.), Collin, Dr. Andre.

On account of the imperfection of the nervous system at birth, a child
is not only unable to execute certain movements, walking for example,
of which most animals are capable, but it reveals a number of physical
signs, such as exaggerated tendon reflexes, Babinski’s sign, etc., which
Dr. Collin has united under the name syndrome infantile.

Under normal conditions this syndrome breaks up about the age of
two and a half years, each of the symptoms which compose it dis¬
appearing at different epochs. It is on the early or late disappearance
of these symptoms that Dr. Collin believes a prognosis can be founded
of the mental and motor future of the child.

“ Delay and precocity,” says Dr. Collin, “ are branches of the same
trunk.” A slight delay in mental or motor development may be a good
prognostic, but a flattering precocity is suspicious.

Here are two patients : one, suffering now from dementia pnecox,
walked at seven months, and at two years astonished friends and
neighbours by his intelligence; the other, capable only of rough work
on the land, did not walk until he was four years old, did not speak
until five, and suffered from enuresis until he was fifteen years of age.

There are, as has been suggested above, certain cases of delay, which
are not very serious in themselves, and are due rather to ethnological
and family causes than to toxic or infectious conditions, and which
develop normally later on. But backward children often remain more
or less abnormal, and among them Dr. Collin recognises three principal
clinical types.

(1) The weak-minded child with his modalities of intellectual debility,
backwardness at school, moral debility, and debility of will.

(2) The child with motor debility, more or less marked, extending
from confirmed awkwardness and the impossibility of performing
corporal exercises, to slight motor deficiencies, which can hardly be
observed. One may meet with mental and motor debility united in
the same patient.

(3) The child subject to hysterical manifestation, suggestibility in all
its forms being only too likely to produce accidents among children
whose mental and motor development has followed an abnormal course.
More serious consequences may develop in the adult age, and symptoms
of a precocious dementia may manifest themselves. “ The nerve cell,
which has already given evidence of insufficiency and fragility, may, by
forced marches, destroy itself precociously.”

The essential cause of delay or backwardness (and, one presumes, of
precocity) is weakness of the nerve cell, injured in the place of least
resistance by unfavourable circumstances during embryonic develop¬
ment. The nerve cell more evidently than any other embryonic element
bears the impress of heredity. The injuring causes may be neuropathic
heredity, the intoxications and infections of the parents, such as syphilis,
tuberculosis, alcoholism, etc., the accidents of pregnancy and delivery,
premature birth, and infantile diseases.

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One fully agrees with Dr. Collin that precocity in a child is more
suspicious than slight backwardness, and one only wishes that parents
and particularly schoolmasters were of the same opinion.

From one’s own observation one would be inclined to say that in
many normal children, that is to say in children in whom there was no
suspicion of precocity, the syndrome infantile commences to break up
at an earlier age than two and a half years. J. Barfield Adams.

Movement Cencesthesia and the Mind. (.Psychological Review , May ,
1916.) Dearborn , George Van Ness.

The importance of cenaesthesia from the physiological standpoint has
long been admitted ; its deep significance with reference to psychology
is only beginning to be adequately realised, is probably scarcely
realised at all by a great body of psychologists. That a study of it in
its more comprehensive aspects is likely to be of supreme value, and is
destined to throw a flood of light on our psychical organisation, is made
abundantly evident in Dr. Dearborn’s paper.

The relation between mind and body is a well-worn theme. It has
furnished material for the pens of many writers. It constitutes one of
the riddles of the universe which is still unsolved. No will-o’-the-wisp
is more elusive than this problem of problems. The writer of this paper
is of opinion that there has been an excessive use of the deductive
method in psychology, which in its descriptive phases and in the
abnormal aspects as well as the normal “ has most often not been wisely
based, not founded ‘flat on the nether springs’ of universal bodily
movement and function.” This concept of universal motion is the key
to the situation, and the failure to explain mind, whether from the
dualistic or monistic standpoint, “ seems largely dependent on the
presumptuous and dogmatic refusal of many to admit this category',
spacial dislocation, motion, into their explanations, and almost into their
psychology at all.” The tendency of modern physical research is to
show that matter is in essence really motion, and motion is the source
of all forms of energy. It is in the light of this fact, probably, that Dr.
Dearborn argues that “ now, all the while and everywhere, the concep¬
tual bounds between mind and energy, before assumed impassable, are
felt to disappear like fog as we advance into the clear daylight of
understanding.” This great central truth that the organism is in
universal ?novement must never be lost sight of. It is absolutely indis¬
pensable if we are to form any adequate conception of what constitutes
Life and Mind. Moreover, this universal movement of the body must
mean something in the personality; it must be represented in the con¬
comitant mental aspect of the individual.

A moment’s consideration is sufficient to enable us to realise this
universality of movement. Muscular tonus prevails throughout the
entire muscular system. It is constant and spacially general, ranging
in various degrees from catalepsy through cramp, exertion, waking
activity, lassitude, sleep, coma, and paralysis to death itself, where its
zero is reached. In addition to this the necessity of maintaining
equilibrium is another universal need in the organism; the reciprocal
innervation of functional antagonists (eg., flexors and extensors, pronators

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-and supinators); the irradiation of neurility (as in convulsions, hysteria,
etc.); all these imply a continuous activity in the motor fabric of the
body. There are besides the great aggregate of voluntary movements,
and the probably still vaster range of “ vegetative ” motions,
which include automatic, reflex, autonomic, instinctive, emotional,
habitual, and, finally, what the writer terms “ mechanical ” processes—
respiration, circulation, digestion, and excretion. All this mass of
intelligent and beautifully adapted movement is practically ignored by
the average academic psychologist, ignored because not realised, nor its
meaning in the mental control of behaviour appreciated. It is not
regarded in its true light as a primary necessity to a successful
psychology.

Cenasthesia consists of two complementary groups of sense experi¬
ences : one kinaesthesia, particular sensation of movement; the other
cenaesthesia proper. Both together make up the sensation-fabric, the
“ empiric skeleton of mind.” The kinsesthetic functions are numerous,
and include (1) the representation to the integrating nervous system of
bodily and environmental movement, each of both the active and
passive kinds. (2) Posture, in a broad and general sense. (3)
Stereognosis, the recognition of shape internal, within the arms or legs,
and external, in a room or along a devious pathway. (4) Appreciation
of weight, weight of the external bodily parts as well as of external
objects. (5) Maintenance of equilibrium. (6) Sensing of jolts, jars,
and material vibrations coming from the environment. (7) Pressure
and impacts other than jolts and vibrations. (8) Elaboration (and
recording?) of the motor ideas through which the body is moved and
controlled. (9) The spacial relationship of local sensations, local signs.
(10) Rhythmic control of the circulatory compression of the veins.

This movement sense thus involves practically every portion of the
body, and is linked with a great variety of sensations or different
influences, differentiated, no doubt, by a corresponding number of
histologic receptors.

Cenaesthesia proper, the sensation-fabric comprising both the sub¬
conscious and the fully conscious aspects of mind, is a subject which in
its widest relations is beginning to engage the attention of neurologists,
physiologists, psychopathologists, and a few academic psychologists who
have not remained under “ the cataleptic influence of the ‘ five senses ’
bugaboo.” Vision, hearing, taste are part, but only part. A countless
multitude of impressions are every moment of our lives reaching the
sensorium, from within and from without. The sensations produced
there vary greatly in quality and intensity, and to properly analyse the
mere feeling of being alive, besides taking into account the fnfluence of
environment, it would be necessary to study exhaustively every part of
the body, every somatic region from which sensory impressions are
ceaselessly streaming inwards and contributing their quota to the content
of mind.

To take the head alone, apart from sensations of hearing, vision, taste,
and smell, which are all located here, a host of other'afferent impulses
are constantly issuing from the many and diverse structures which are
connected with this important region. Quite different sensations arise
from such parts as the scalp, eyes, mouth, nasal fossae, Eustachian tubes,

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middle-ear, the teeth, and the vascular system within and around the
brain. These are only some of the “ sensations ” coming from the head.

The same is true of all the various systems of the body. The
respiratory apparatus , the kincesthetic factor of which concerns the whole
thorax and abdomen, and even the arms and neck, is the source of a
flood of impressions proceeding from its special internal parts, nostrils,
larynx, etc., down to the pulmonary alveoli. This system “ probably
makes larger donation to the pleasantness of being alive than does any
other process whatever.”

The circulatory mechanism , including, of course, the heart itself,
whose functions in the normal condition are so intimately associated
with our emotional life, is an example of the same kind. The mere
change in diameter of the blood-vessels, vasomotor phenomena, may
make all the difference between the sensations of well- or ill-being, of
elation or depression. In connection with this we have well-ascertained
facts as regards the effect on the calibre of the blood-vessels of certain
drugs and other agents in common use, such as coffee and tobacco, and
allusion is made to the “ surprisingly general depression of both mind
and body late in the afternoon, euphoria depressed into dysphoria, by
simply the absence of an accustomed cup of coffee at lunch."

And so the writer points his argument by taking up each of the other
systems of the body, the digestive apparatus and nutritive mechanism,
the urinary and genital organs, the skin and mucous membranes, the
epithelial and gland tissues, osseous and connective tissues, from each
and all of which multitudinous afferent impressions, all differing in
quality, pass inwards to the central organs. “ Here at all events is
ample psychophysiologic country for survey, careful study, and carto¬
graphy. . . . No one has sufficient sanction to categorically deny

this flood of neurokinetic influences, dynamic index of the mind in its
relationship to matter."

A knowledge of cenresthesia is not merely of value as regards the
science of psychology, but, by being properly developed and adapted to
hygienic requirements, it would have practical educative and therapeutic
value for every individual. The thorough exploration of the “ living
executive house in which we live” is the indispensable basis of self-
control ; the basis also of that generalised skill on which depends the
making of a livelihood.

The subconscious phases of the human mind are intimately linked
with censesthesia. The “ sensational flood ” may reach subconscious
areas without giving rise to recognisable sensations. Of a vast number
of afferent impressions from the internal organs and other parts of the
body we are unaware ; but they have a potent influence nevertheless on
our conscious existence. To the deep and wide implications of the
subconscious the writer considers that psychologists are not yet awake.

In fine, centesthesia is the sensory and subsensory aspect of universal
bodily movement, director of the soul’s important business. It lends
the meaning to life because it is the index of the reactions of the
organism, dynamic index of our personal evolution. By elaborating,
this moto-cenaesthetic relationship can psychology become really
explanatory, and take its rightful place as the queen of the sciences.

T. Drapes.

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Pathological Findings in the Sympathetic Nervous System in the Psychoses.

(American Journal of Insanity, April , 1916.) Myerson , A.

This research is based upon the minute examination of the semi¬
lunar ganglia in fifty consecutive autopsies performed at the Taunton
State Hospital. The following outstanding variations were found:

(1) Axonal reaction, a frequent phenomenon in many cases, and pro¬
minent in five; (2) emigration of the nucleolus, a rare change, pro¬
minent in one case; (3) neurathrepsia, a term used to cover a number
of changes of a chronic type, e.g., pigmentation, oxyphilic granules ;
(4) nuclear changes; (5) capsular changes; (6) increase of interstitial
connective tissue.

The findings are thus summarised. First, the semilunar ganglion is
apparently often acutely injured in general infection and in enteritis.
Second, it is the seat of degenerative processes probably greater in
extent than cord, brain, or Gasserian ganglion. These changes prob¬
ably represent an early and marked senility. Third, there is a decided
absence of marked reactive changes (lymphocytes, plasma-cells, etc.) r
such as are prominent in the central nervous system, Gasserian ganglion,
and the related organ or adrenal. Fourth, there is a curious, though
not prominent, increase of eosinophilic connective tissue cells which
seemed, in one case, to have a phagocytic attraction for injured nerve-
cells. The writer emphasises that these findings apply, in his opinion,
only to the psychoses. He concludes that in so far as the sympathetic
system controls the vascular and glandular system, which plays such a
large part in all the great vital processes as well as in the creation and
modification of the emotions, a more comprehensive study of this
system may throw light on the problems of old age as well as on the
psychoses. Also the interpretation of morbid phenomenon needs to
take into account the presence of nerve-cells in the organs, such as in
the aorta, the heart, the intestines, stomach, genitalia, etc. Symptoms
may well arise because of injury to these peripheral cells, either as an
antecedent or as a consequent of the disease process. We have, as
recent experiments show, drugs that have a peculiar and selective power
on the nerve-cells of the autonomic and sympathetic systems. These
should be experimentally, as well as therapeutically, used in conditions
where the symptoms are even in part vasomotor and glandular.

H. Devine.

The Medico-legal Aspect of Dementia Prcecox [La Medicina legale della
Demenza precoce]. (Archivio Antropologia Criminale Psichiatria e
Medicma Legale , February , 1916.) Ottolenghi, Prof. Salvatore.

In his opening paragraph the author remarks that dementia priecox is
interesting from a medico-legal point of view on account of the following
circumstances:

(1) As its name expresses, it attacks the individual at an early age,
at the epoch, that is to say, the most favourable for criminal actions.

(2) The behaviour of the patient, especially at the commencement,
may be such as to mask the existence of mental disease.

(3) It is a very serious malady, causing the decay of all the mental

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faculties, but almost always irregularly, so that it may present intervals
in which the patient appears to be normal.

(4) From the commencement it attacks the faculties of the highest
psychical activity, especially the will and the moral sense.

(5) It is frequently met with in prisons, where it often presents
symptoms which may be confounded with common malingering.

(6) It may develop after, and in consequence of, an injury.

The general symptoms which characterise a well-established case of
dementia praecox may not offer favourable occasions for at least the
gravest medico-legal questions. But, above all, we ought to remember
two characteristics of the disease: the deficiency or weakness and
deviation of the intellectual, emotional, and volitional faculties, and
the disharmony among the various psychical manifestations. These
characters give the dominant note to the conduct of the precocious
dement, who presents from the beginning a diminution of the logical,
critical, and especially of the volitional activities. He shows himself
unskilful at work, and from a weakened will and characteristic apathy
he will be led into inaction and the most accentuated laziness. Sloth,
and a tendency to crimes against property, are favoured by the depres¬
sion of the sentiment of personal dignity and of the moral sentiment.
The depression of the sentiment of modesty finds expression in the
crimes against decency and morality, which are often the dominant note
of the hebephrenic variety of the disease.

Other crimes may be the consequence of special intellectual devia¬
tions, which may present to the patient strange ideas on a basis of
persecution—paranoidal delusions which are united to impulsiveness,
and then the sufferer from dementia praecox may be led to crimes
against the person, to violence, to false accusations, to delusions of
persecution, and even to suicide.

The initial period of dementia praecox is especially interesting from
a medico-legal point of view. The surprising frequency with which this
disease develops in young criminals, who are recognised as insane
during the expiation of their offence, and are sent to an asylum, gives
rise to the suspicion that at the moment of committing the crime
they were in the prodromic period, especially when the psychosis
reveals itself shortly after condemnation. Pighini maintains that 50
per cent, of the prisoners suffering from dementia praecox, studied by
him in the criminal asylum of Reggio Emilia, may have been unjustly
condemned.

Of the varieties of the diseases, the hebephrenic has the greatest
forensic interest, particularly that milder form (the eboidofretiia of De
Sanctis) so frequently met with. The patient becomes idle, incapable
of work, of study, and indeed of all fixed occupation. These phenomena
are often the cause of disorders in scholastic life. In given circum¬
stances such patients may wander away from home, commit petty crimes,
and even thefts. Others, carried away by an exaggerated opinion of
their own personality and genius, turn to new r occupations. They
abandon their ordinary employment for this new mode of life, in which
there is no solidity, and are often drawn into dissipation, illicit specula¬
tion or dishonest trickery, spurred on by vainglory and a desire to make
a figure in the world. These individuals are often brought before a

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court of justice, and are condemned to punishment for crimes which
are the undoubted result of the disease from which they are suffering, and
require not condemnation but appropriate medical treatment.

There are two points of special forensic interest in the catatonic form
of the disease.

(1) The value of such a patient’s evidence : In spite of the stupor,
immobility, and want of activity, the patient, being conscious, may
remember and be able to relate any violence to which he may have been
subjected. He also may be able to describe any scenes at which he has
been present. So that his evidence, with great reserve, may be worthy
of credence.

(2) In this phase of the malady the patient may develop a state of
excitement in which he may commit acts of impulsive violence against
himself or others. It being found that consciousness is present, in
spite of the patient’s inability to understand his own state of excitement,
or of being able to control it, it may happen that at the first superficial
examination he is believed to be a malingerer.

In the paranoidal form of the disease, characterised by delirious ideas,
hallucinations, and delusions of persecution and grandeur, the individual
may be guilty of false accusations and violence, but the absurdity of
the delusions, while sharply marking off this form of alienation from
the true paranoia, demonstrates the mental disorder.

In the first period of dementia pneco^x the patient from his inertia,
apathy, and general behaviour, may be confounded with the common
criminal, the idler, or the malingerer. In the later stages the disease
may be mistaken for paranoia or certain neuropsychopathic states.
When the differential diagnosis oscillates between dementia prcecox and
certain forms of paranoia, the legal consequences may not be very grave,
as in any case one is dealing with a psychopathy of a progressive form.
The question is more grave when dementia praecox is confused with
psychasthenic or neurasthenic states, for here the decision is especially
concerned with civil capacity. * In neurasthenia the judgment is not
serious, while in dementia praecox the prognosis of probable incurability
inclines the specialist to exclude the patient from every civil capacity.

J. Barfield Adams.

Bergson's Theory of the Dualism of Intelligence and Instinct applied to
Criminals , Fools , and Geniuses, and to a New Classification of
Mental Diseases. \Il dualismo Bergsoniano dell intelligenza e del?
istinto applicato ai criminali, ai pazzi, ai genii, e ad una tiuova
classificazione delle malattie mentali.~\ (Archivio Antropologia
Criminale, Psichiatria, e Medicina Legale. February, 1916.)
Lombroso, Dr. Gina.

From its commencement the science of criminal anthropology has
been faced with the problem of the intelligence of the criminal, which
from many points of view appears to be inferior to the normal, and from
others, especially in the cleverness shown in carrying out crimes, and in
the satisfying of passions, rises often to the level of genius.

The same contradiction exists in the question of genius. Csesare
Lombroso has demonstrated that geniuses, the gods “ before whom a

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man may without shame bend the knee,” pay for their mental strength’
with some defect—they cannot manage their private affairs, they have
infantile fears, technical incapacities, extravagant loves, etc.

The writer of this article believes that the key to this contradiction
is to be found in the doctrine of instinct and intelligence which Bergson
has propounded in his work, Evolution Creatrice.

Instinct and intelligence, according to Bergson, are not the evolution
of one faculty, but are two faculties very distinct and different, each of
which may be carried separately to the highest grade, without any
influence on the evolution of the other.

Instinct has for its domain practical life. Its duty is to satisfy the
passions, and the wants of mind and body, to utilise to the utmost and
to adapt the instruments, organic at first, afterwards inorganic (machines),
which serve for the satisfaction of human needs and passions. It is
almost always unconscious, but it may become conscious if some
obstacle interferes with the attainment of its aim.

Instinct, according to Bergson, improves and develops with exercise,
as intelligence does. To its jurisdiction belongs all our practical life,
including the professions, handicrafts, etc.; it is connected with
intelligence in so far as the latter must be concerned with the solving
of problems. But once solved, the fruit of intelligence passes into the
sphere of instinct, which utilises it, fixes it, and makes practical use
of it.

Intelligence is the faculty of abstracting, of synthesising, of creating,
of reflecting ; its duty at first is to solve the problems which instinct
places before it, and of aiding it to serve the necessities of life. But
from the moment in which it creates language, intelligence is able to
pass from the useful material creation to a disinterested creation ; from
the day on which it perceives that it can work in the abstract, it gives
itself up to the creation of ideas. Its essential duty becomes synthesis ;
it finds out the laws which govern facts, it deduces logical consequences,
and it discovers the connection between facts themselves.

This conception of instinct and intelligence throws light on Lombroso’s
theory of criminal anthropology, and explains its apparent contradic¬
tions. If we examine the manifestations of what is generally called the
intelligence of the criminal, such as the instruments of crime, the
elaborate plots and general craftiness, etc., we find that their object is
always the satisfaction of some passion, such as play, debauchery,
cheating, or revenge. These all enter into the category which Bergson
assigns to instinct. A great development of the faculty of instinct in
the criminal perfectly explains how, although endowed with a very weak
intelligence, he may be able to treat with success matters of practical
life which appear to be very difficult. This would explain the apparent
contradiction in the intellectual manifestations of a criminal, who from
one point of view appears to be almost a genius, and from another a
mental deficient.

If we examine the geniuses described by Lombroso and his disciples,
we find that they are always superior to the normal in matters of creating,
connecting together series of facts, searching into the secrets of Nature,
etc., but that they are inferior in the concerns of everyday life, in
family affections, in sexual tastes, in short, in instinct. If intelligence

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and instinct are two different faculties of the mind, there is no contra-
dication in the fact that a genius has an intelligence much greater than
normal, and at the same time an instinct mediocre, inferior to the
normal, or even diseased.

The writer of this article thinks that possibly this dualistic theory of
Bergson may aid in the classification of mental diseases. He suggests
the following:

(1) Diseases of the instinct.

(2) Diseases of the intelligence.

(3) Mixed diseases of the intelligence and of the instinct.

(1) Diseases of the instinct would include many of those forms of
mental aberration which the public will hardly admit to be such, but
which are very serious for the patient and dangerous to society.

(a) Genius (?). In which the intelligence is healthy and even
superior, but the instinct is abnormal or deficient. This includes all
those cases of clever men, who are stupid in the affairs of practical life,
suffer from phobias, lack of natural affection, and have sexual perver¬
sions.

(b) Hysteria. In which the intelligence is normal, but instinct, which
presides over the affairs of practical life, and the co-ordination of sensa¬
tions and affections, is diseased.

(c) Moral insanity. In which the intelligence is healthy, but the
instinct is partially but gravely diseased.

(d) Sexual psychopathia. In which the intelligence is normal,
but the instinct is diseased in one direction only, namely, in sexual
affairs.

( e) Obsessions. Here we have patients with healthy intelligence,
but instinct is deviated or diseased, though in one direction only.

(/) Folie circulaire. Here we have patients with healthy intelligence
and diseased instinct, but only temporarily and periodically. The disease
extends, either for some days or some months, in almost all directions,
even to those of vegetative life, but after a certain lapse of time
the action of the evil ceases and the patient reacquires his normal
instincts.

(2) Diseases of intelligence. To this class belong the forms of
mental disease in which the patients reason badly, connect ideas badly,
synthesise badly, but in which instinct, the faculty, that is to say, which
co-ordinates the means to the ends of practical life, is healthy.

(a) Delirium. In which the instinct is normal, or even better than
normal, but the intelligence is diseased—it may be in all directions.

( b ) Monomania. Here we have patients in whom instinct is normal,
who know how to manage their practical affairs, but in whom intelli¬
gence is diseased, but only partially and in one direction.

( c) Hypochondria. Here we have the same form of mental aliena¬
tion as in monomania, only the intelligence is diseased in one given,
fixed direction, that of melancholic ideas.

(d) In cretinism, subcretinism, and imbecility we have patients in-
whom intelligence is inferior and almost absent, and in whom instinct
is inferior but not deviated.

(3) Mixed diseases of the intelligence and of the instinct. To this
class belong the most apparent forms of mental diseases: those in-

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which the patients can neither reason nor connect their ideas, and
further, cannot even manage the affairs of practical life.

(a) Mania. In this disease not only are the faculties of reasoning,
of idealising logically, of language, and of the association of ideas, dis¬
ordered, but all the senses, even those of hunger, of cold, and of sexual
instincts, are altered. The passions also are altered, together with the
co-ordination of the acts which ought to satisfy them.

( b) Dementia. Here we have patients in whom both instinct and
intelligence are weakened by disease. Hence we have confusion and
general uncertainty, incoherence, and want of connection of ideas as
much in the field of intelligence as in that of instinct.

(c) Idiocy. Here we have patients in whom from their birth intelli¬
gence has been almost completely suppressed, and in whom instinct is
weak and diseased.

The writer does not propose this as a finished scheme, but only as
an outline, the details of which can be easily filled in. He thinks that
this application of Bergson’s theory to mental diseases would have the
advantage of reminding alienists how great an interest they have in
keeping themselves au courant with philosophical studies. It would
also interest philosophers to unite their forces with those of the alienists
to search together for the origins of mental diseases.

J. Barfield Adams.

2. Clinical Neurology and Psychiatry.

A Clinical Study of Epileptic Deterioration. (Psychiatric Bull., April,

1916). Mac Curdy.

This elaborate study of the mental symptoms of epilepsy (somewhat
on the same lines as the work of Pierce Clark) is presented in the hope
that it may prepare the ground for a sound theory which will dispel the
present confusion in epileptology. All students of epilepsy, the author
remarks, have noted the glaring mental symptoms and yet no progress
has been made in defining the specific psychic characteristics as a guide
to diagnosis and prognosis. At present, epileptic deterioration cannot
be associated with any constant pathological change, nor can it be
correlated with the other most obvious symptom, the convulsions.
Even the descriptions of epileptic deterioration are unsatisfactory.
There has been no effort to establish the epileptic as a specific type of
dementia.

The essential process is defined as consisting in a “ progressive loss of
interest associated with a failure of mentation in respect to normal
stimuli in which interest is lost.” The general make-up of the character
is typical. The key-note is an overweening egoism. This shows itself
positively by purely personal desires and ambitions, and negatively by
callousness and inability to see things as others see them. This make¬
up may precede the convulsions, and is not the result of them. A
weakness or absence of the social instinct is a specific factor in the
formation of epileptic character. The normal development from the
egocentric attitude of the infant to the objectivation attained by
the adult fails to be completely carried on. Even the religiosity of the

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epileptic is purely a selfish regard for his own salvation. The disap¬
pointments necessarily resulting from an egocentric attitude are regarded
by MacCurdy as very significant. The patient is engaged in a losing
struggle with life and his adaptations break down. He gives up the
struggle in temporary flights from the world (unconsciousness) or
exacerbates it in impulsive acts of wantonness or crime. There is a
marked contrast with the schizophrenic reaction of dementia praecox.
There we see an imaginary world replacing the real world, delusions
instead of realities, friends turned to foes. Here love does not turn to
hate but to indifference. The personality is not distorted but blotted
out. Contact is not lost at a few points but at all points. A diffused
and persistent lack of mental tension becomes typical.

A prominent feature of epileptic defect is the contrast between auto¬
matic and purposeful mentation. When the patient’s interest can be
aroused his mind acts, but it becomes progressively more difficult to
arouse his interest. The intellectual impairment, consequent on loss of
interest, itself facilitates loss of interest and a vicious circle is established.
The result on the personality is that the patient apparently ceases to be
an egotist, for egotism is bound up with interest. Hence the hypo¬
chondriacal stage in which the patient falls back into a mere childish
insistence on trivial comforts and discomforts.

When the deterioration begins to affect the intellectual centres, the
clinical picture resembles that of arterio-sclerosis. But with a difference.
The arterio-sclerotic dement arouses sympathy, he seems a struggling
fellow creature in distress. The epileptic, on the other hand, has lost
social and human interest, he is now a type rather than a human being
There is another point of difference. While the arterio-sclerotic show
an all-round defect, nearly every epileptic is apt to show at some time
or another a localised ability combined with his general dilapidation.
There is a still greater degree both of slowness and of perseveration ;
there is also a typical but not invariable tendency to repeat questions
put to the patient.

Even before the final stage the epileptic resembles the defective, but
is more stolidly indifferent to ordinary stimuli and more variable when
reaction is induced. Healy, indeed, regards variability in response to
tests as diagnostic of epilepsy.

Clark’s “ voice sign ” of epilepsy—the lack of inflexion, modulation,
or change of pitch, to be detected in every patient by a trained ear—
becomes more obvious when deterioration sets in. The aphasia-like
stage proceeds to absolute mutism. As speech is more or less lost the
patient’s whole existence tends to become vegetative. He becomes
like an infant and sleeps in the foetal position, and walks on the balls of
the toes like an infant learning to walk. But the epileptic goes back on
the whole to an earlier stage than the infant, whose experience is living
and intelligent. The changes in the epileptic’s expression are distinctive.
At first “dour ” and sullen, it acquires a far-away disinterested look,
then rigidly impassive with lack-lustre eyes; finally the eyes acquire a
meaningless brightness. All this is very unlike dementia prsecox, and
when that disorder is combined with epilepsy there is an invariable
absence, in the author’s experience, of “dissociation of affect,’’ and no
silly smiling, etc., is seen. The epileptic bleaching of the emotions

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seems strong enough to counteract the emotional vagaries of dementia
prrecox.

Notwithstanding the epileptic’s tendency to allow unbridled outlook
for selfish tendencies, we are not to accept the current opinion that he
is a highly sexualised animal. He has very little sexual feeling, and
the removal of barriers between the sexes in epileptic colonies causes
much less trouble than was at first anticipated.

The author regards insistence on loss of interest in the aetiology as
important in view of treatment. Even a severe degree of epileptic
dementia may yield to treatment, when the treatment consists of a
persistent effort to awaken the patient’s lost interest. The idea of
an organic change being exclusively responsible for the dementia
must be eliminated. It is the loss of interest which is the dynamic
factor.

Surveying the whole group of phenomena and seeking to explain
them, it is found that the epileptic is one unable to objectivate his
affections and to subordinate himself to the social world. He is, there¬
fore, bound to meet trouble and bound to avoid the world that causes
that trouble. He retires from the world. His mental content grows
smaller and smaller. The world is shut out. That is what the epileptic
gains by his dementia.

The acute symptoms serve a similar purpose. They are all marked
by loss or clouding of consciousness. When consciousness is clouded
the striving for personal childish expression can be given an unhampered
outlet. The difference is that, when contact with the world is acutely
lost, the patient’s potential energy is suddenly liberated in a fit of fury;
when it is slowly lost his energy and interest are being sapped. In both
cases there is a flight from adaptations difficult to maintain. The
grand vial attack is a sudden reaction of the same type as the chronic
one of deterioration. The attempt of Ferenczi and Clark to account
for the convulsive fit on Freudian lines as a symbolic outlet for uncon¬
scious wishes MacCurdy cannot accept. Its origin must for the present
be left an open question.

A few final observations of general psychiatric interest are appended.
If curtailment of interest involves relaxation of mental tension and
secondary mental impairment, we may have here a sequence which is
more than a peculiarity of epilepsy; it is probably a general psychiatric
principle. If so we can no longer preserve a sharp clinical line between
functional and organic psychoses. Again, it is a truism that all insanity
is anti-social. But nowhere is egoism so clearly the key-note as in
epilepsy. It is obvious that there are innumerable gradations to quite
dissimilar forms. But wherever we find the egoistic and anti-social
tendencies strong we may well say that there is an “ epileptic reaction.”
“ We all have traces of the epileptic reaction when we give way to
temper, choose the easier path, or allow our egoism to sway our judg¬
ment. . . . To put the matter in lay terms, we must love, not merely

be loved; we are under compunction to love or cease to be ourselves,
cease even to think.”

Throughout this lengthy paper every phase dealt with is illustrated
by detailed cases of patients in the Craig Colony of New York.

Havelock Ellis.

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On the Interpretation of Symptoms in the Infective Exhaustive Psychoses.

{Journal of Nervous and Mental Disease, June, 1916.) Brown ,

Sanger.

The toxic exhaustive psychoses are well recognised as a clinical group,
and they are easily diagnosed in typical cases, but in cases presenting
unusual features the symptomatology is obscure and the diagnosis diffi¬
cult. The writer feels that the clinical descriptions should be improved,
and with this end in view he adopts a schematic arrangement by which
the symptoms are grouped under different headings according to the
basis on which they arise. The various symptoms are thus described
under these three headings: the organic part of the reaction, the
affective part, and the psychogenic part.

The organic part of the reaction .—Delirium is the symptom-complex
most closely associated with the physical disorder—toxaemia, elevation
of temperature, etc. In delirium, clouding of consciousness, disorien¬
tation, amnesia, fabrication, perceptual defects, elaborate and vivid
hallucinations of sight, hearing, taste, smell, and touch, are the charac¬
teristic elements. Frequent changes in the degree of clouding are
usual, and at times complete stupor ensues. Associated with these
mental symptoms are various physical disturbances toxic in origin, viz.,
rapid action of the heart, dilated pupils, gastro intestinal derangements,
slurring and ataxic speech, and, in some instances, multiple neuritis.

The affective part of the reaction .—Apart from the plainly organic
mental symptoms, affective or mood changes are responsible for a
certain group of symptoms. These are depression, diffuse anxiety and
suicidal impulses, or frank mania and elation with its characteristic
features. These reactions may be slight, but frequently dominate the
clinical picture and thereby lead to a faulty diagnosis.

The psychogenic part of the reaction .—This includes the delusional
trends, peculiarities of behaviour, symbolism, etc. These symptoms
are either superficial, and dependent upon the state of perplexity and
confusion, or are of definite psychogenic origin, the expression of under¬
lying trends of the personality which the state of impaired mental control
allows to come to the surface. These latter symptoms often come to
the surface after the delirium has entirely subsided.

These views may be utilised for the better understanding of certain
clinical conditions. Since the organic part of the reaction is a very
definite reaction on the part of the nervous system to toxic and
exhaustive factors, the symptoms may be expected to appear when such
factors are found. They are thus seen in drug psychoses, alcoholic
deliria, as secondary symptoms in a number of psychoses of gross brain
disease, as well as in the exhaustive toxic psychoses. The reaction does
not appear in dementia praecox, and only in manic-depressive insanity
when exhaustion or toxaemia supervenes. This schematic grouping
of symptoms helps us to determine what aetiological or diagnostic signifi¬
cance to give to each. Cases of short duration will show mainly organic
features ; others of equally benign character may show marked affective
reactions. Those with psychogenic reaction will be more serious, unless
«uch symptoms are purely superficial, and the result of confusion.
Further study is desirable in the direction of a fuller understanding of

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the personality, and also in regard to the cell findings and pathological
changes. To carry out these studies successfully a clear clinical differen¬
tiation is a preliminary necessity. H. Devine.

The Rdle of Hallucinations in the Psychoses. (Journal of Nervous
and Mental Disease , March , 1916,//. 231-250, vol. xliii, No. 3.)
Harrison, Forrest M., M.D.

Dr. Harrison prefaces his remarks on the subject in particular by a
summary of historical instances of hallucinosis as exemplified in certain
Biblical stories, and as in the cases of Mohammed, Luther, Jeanne d’Arc,
Socrates, Swedenborg, and others; and he notes the influence which
those suffering from hallucinations have had in the making of history.

The number of hypotheses advanced as explanations of the mechanism
of hallucinations is an indication of the speculative nature of our know¬
ledge of cerebral function. Two main points were considered in the
elucidation of the problem—the sensory character of the phenomena
and the part played by the mental state in determining what the hallu¬
cinatory object should be. The ideational centres were assumed to be
locally separated from the sensory centres, and, this being the case, it
•was but natural to relegate the imaginative factors of fallacious percep¬
tion to the higher elements of the cortex, and to assign the sensory part
to those cells where incoming impressions are transformed into sensa¬
tions. Ideas of sensation can, however, never rise to the level of true
sensation ; the ideational image lacks the feeling of objectivity, of
externality. The centrifugal sensorial theories sought to explain this by
assuming that the sensorial channels become the seat of a centrifugal
nerve current, originating in the higher ideational cortical centres,
passing to the sensorium, and in some cases to the sense organ, where
the condition present indicated a local disturbance. As this was found
to be inconsistent with accepted physiological beliefs, a reverse, or cen¬
tripetal, process was assumed. Once the conclusion is reached, how¬
ever, that the centres of sensation and of imagination are not separated,
these beliefs become untenable. James held that in the cortex the
sensory and ideational elements are the same, and that the difference in
the process depends on the intensity of the stimulus ; that from the
periphery is usually more intense than that from the neighbouring
regions of the cortex, and because of the difference in intensity, we tell
reality from phantasy. If, however, for any reason the stimulation of
these centres becomes as intense as that from the periphery the mind
can see no difference, and an hallucination results.

In regard to the frequency of hallucinations among the 514 cases
studied, Dr. Harrison found that they were present in 4474 per cent.;
and he notes that this figure would have been higher had he excluded
readmissions and those diagnosed as not insane. Comparing the
statistics of various observers (and including his own) he arrives at a
percentage of 407; this is for a total of 3,160 cases. Of 230 cases which
were subject to hallucinations, auditory fallacious perceptions, either
separately or combined, were present in 210, or 91 '3 per cent. Next in
frequency came auditory and visual combined, 23.91 per cent. Then,
visual alone, 6 08 per cent.

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Tabulation of the “ content of the various hallucinatory percepts ” was
almost impossible on account of their diversity. It was difficult to
isolate hallucinations of taste from those of smell in some cases. Hal¬
lucinations of smell were rare, and were generally of an unpleasant
character. The most frequent hallucinations of touch were the various
paresthesias and electric shocks.

“ No two cases were alike, each presenting its own individual charac¬
teristics and peculiarities, and the content of the hallucinations seemed
to point to no form of psychosis in particular.”

In the alcoholic psychosis hallucinations were present in 80 per cent.
of the cases; but the total number of cases (5) was too small to render
this figure any value from a statistical standpoint. Of 170 cases of
dementia precox 70-58 per cent, were hallucinated. Of 50 cases which
were not apparently hallucinated, 10 were catatonic in type ; but in only
30 cases of the entire number studied could it be stated, with any degree
of certainty, that hallucinations did not exist. It is noted that these
conclusions are in conformity with those arrived at by such authorities
as White, Tanzi, and Bleuler. In the largest number of cases there were
auditory hallucinations. Six cases in which the hallucinations were
visual were all of the catatonic type.

Of 13 cases diagnosed as prison psychosis, 9, or 69-23 per cent., were
hallucinated -, auditory hallucinations were again the most prevalent.
Of 15 cases of epilepsy, 46-66 per cent, experienced auditory and visual
hallucinations. In the cases of general paralysis of the insane 45'28
per cent, were hallucinated, auditory hallucinations again predominating.
In the manic-depressive group only 21-50 per cent, were hallucinated ;
17-85 per cent, of these were auditory. This conforms to the finding of
others.

Their rarity in the manic-depressive group is suggested as an important
diagnostic factor in helping to differentiate between the maniacal phase
of this psychosis and the excitement of dementia precox.

Hallucinations were found to be rare in imbecility, in senile dementia,
and in cases of psychosis associated with arterio-sclerosis.

The following conclusions are deduced :

(1) Hallucinations are among the commonest symptoms met with in
the insane, occurring in approximately 40 per cent, of the cases.

(2) Of the various types, those of hearing are most frequent,
occurring either separately or combined in 90 per cent, of the cases
hallucinated.

(3) The content of the hallucinatory percepts is not characteristic for
any particular psychosis.

(4) Visual disturbances seem extremely common in the catatonic
variety of dementia precox.

(5) Hallucinations are common in dementia precox, occurring in
practically all the cases. On the other hand, they are rare in the manic-
depressive group, seldom if ever occurring typically.

(6) Hallucinations are rare in arterio-sclerotic dementia and senile
dementia.

(7) Hallucinations are rare in sane persons, even though they be of
a psychopathic make-up.

Hubert J. Norman.

lx 11. 5 1

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A Comparison of the Mental Symptoms found in Cases of General
Paresis with and without Coarse Brain Atrophy, (journal of
Nervous and Mental Disease , March , 1916, pp. 204-216.)
Southard , E. E.

The writer is of opinion that, though the endeavour to find struc¬
tural change as the basis for psychopathic conditions is the more
valuable method of procedure and the one which gives rise to the most
promising results, the position that mental disease may be a disease of
function involving no more than normal and inevitable physiological
changes in the nervous system is still perfectly tenable, perhaps even
correct for some cases. Referring to former investigations, he states
that the characteristic delusions of general paresis are in regard to the
patient’s personality, and that they can be roughly correlated with
frontal lobe lesions; and that non-autopsychic delusions cannot be so
correlated. These conclusions were in general harmony with findings
in dementia praecox.

In answer to the question whether anatomical appearances can be
safely trusted to gauge severity of processes, he concludes that, though
in certain cases these appearances can not be trusted, the assumption
is justified that the “atrophic brain is more deeply affected than the
normal-looking brain ”; and it is questionable whether “ the microscope
can be trusted much farther quantitatively at the present time.”

The method adopted was that of dividing a series of paretic cases
on which autopsies were done into two categories. One was of brains
which showed substantial gross lesions, the other of brains which did
not exhibit such signs. All of the cases showed the “ characteristic
microscopic lesions developed by the Nissl-Alzheimer school.” These
two groups—of “normal-looking” and “abnormal” brains—were not
in the one case early and in the other late phases of the disease. “ Mild
cases are often the longest cases. There is no question of a progressively
severer disease in many cases.”

The mental symptoms associated with the brains in these two cate¬
gories were compared with those occurring in a series of 17,000 cases
of mental disorder, “ only a small portion of which have ever come to
autopsy and many of which are still alive.” The symptoms are tabulated
in their order of frequency in (1) the anatomically mild cases; (2) the
anatomically severe cases; and (3) in the seventeen thousand cases of
mental disease in general. The results are as follows; the symptoms
are given in their order of frequency: In (1) amnesia, motor restless¬
ness, disorientation, allopsychic delusions, dementia, depression, irrita¬
bility, defective judgment, psychomotor excitement, autopsychic delu¬
sions, destructiveness, resistiveness, insomnia, violence, aphasia,
hallucinations {not specified), convulsions, hallucinations (visual),
sicchasia; in (2) amnesia, motor restlessness, disorientation, dementia,
depression, aphasia, defective judgment, autopsychic delusions, irrita¬
bility, hallucinations (not specified), hallucinations (visual), euphoria,
psychomotor excitement, incoherence, confusion, expansiveness, in¬
somnia, convulsions, exaltation; in (3) psychomotor excitement, allo¬
psychic delusions, dementia, auditory hallucinations, motor restlessnesss,
depression, autopsychic delusions, insomnia, incoherence, amnesia.

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i 91 6.] CLINICAL NEUROLOGY AND PSYCHIATRY. 799

violence, visual hallucinations, irritability, defective judgment, disorien¬
tation, destructiveness, confusion, resistiveness, somatic delusions.

Hubert J. Norman.

Tumour of the Centrum Ovale of the Right Prefrontal Lobe. \Tumore
del centro ovale del lobo prefrontale destro.\ (Rivista di Patologia
Nervosa e Mentale , April, 1916.) Giannuli, Dr. F.

T. T—, set. 50. Family and personal history good. In her twenty-
sixth year she married a syphilitic. She aborted in her first pregnancy.
Four other pregnancies went to full time. She lost a male child, when
he was set. 8, of convulsions. When she was set. 40 she commenced to
suffer from pains in her bones, which were called rheumatic, and did
well under iodine treatment. At the age of forty-five the pains returned
with greater violence. Wassermann reaction positive. Patient improved
under treatment by mercury and iodides. In forty-ninth year, after
having nursed a daughter through a long illness, her friends noticed
that she had lost her usual gaiety. Later, her daughters observed a
certain apathy and loss of memory. She forgot what she had done
during the day, and lost hours looking for things she had mislaid.
She complained of an almost constant, painful feeling of weight in
the frontal region of her head. Disorientation, both for time and
space, made its appearance and increased rapidly. Her daughters
frequently saw her return late in the afternoon quite exhausted, and
she confessed that she had not been able to find the shops where she
was accustomed to buy the daily provisions, and that it was only with
difficulty that she had been able to discover the door of her house.
She was often brought home by policemen, not being able to find
her own habitation without a guide. All the while, her behaviour was
normal, she quite understood what was said to her, and she realised
her weakness of memory.

In May, 1914, she swooned, and remained unconscious for two days.
There were no paralytic sequelae to this fit. In the following month
she had another fit, which only lasted one hour. After this she com¬
plained again of pain in the frontal region. Her memory became
worse, and she seemed to have lost all ideas of orientation. In July
she began to suffer from frequent vomiting, and she was sent to a
general hospital. Here anti-syphilitic treatment was resumed, and the
patient appeared to benefit. But one day she had a serious attack of
haematemesis, which nearly proved fatal, and was followed by profound
anaemia, which was treated by iron and arsenic. As the mental pheno¬
mena did not improve, after a month in the general hospital the patient
was sent to an asylum, and came under the observation of Dr.
•Giannuli.

The condition of the patient on her admission was rather serious:
there was profound anaemia, small and frequent pulse, liquid food only
'Could be taken, tongue dry and furred, and a tendency to vomit.

The right pupil was more dilated than the left. Slight nystagmus.

Tremor of the muscles around the mouth, and of those of the tongue.

The patient’s gait was slightly ataxic.

Speech a little slow, but not aphasic.

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SOO EPITOME. [Oct.,.

Handwriting gave evidence of tremors, disgraphia, and substitution,
of words.

No deficiency in special senses, or in general sensibility.

Reflexes exaggerated on right half of body.

Functions of rectum and bladder normal.

Cranio-percussion was painful bilaterally in the fronto-parietal region.

The patient’s expression was that of a tired and dejected person.

She replied to questions slowly, but coherently. Recognised objects
correctly, and carried out commands properly. She complained often
of a painful weight inside her head, but did not manifest delusions nor
complain of sensorial disturbances.

At first the lack of orientation of which her daughters had spoken
was not noticeable, but after a few days it was evident that her
surroundings were always new to her ; she was like a person who was
constantly arriving in a new place. Although she saw the doctor and
the nurse every day, she treated them as persons whose acquaintance
she was making for the first time.

She could not remember the events of the day nor of the hour, but
she remembered a sensorial stimulus for a few minutes ; however, after a
brief lapse of time she could not recall even that, consequently it was
impossible for her to enrich her intelligence by new acquisitions.

In this case mnemonic falsifications were not lacking. When the
doctor came to visit her in the morning, the patient would ask him if
he had seen her daughters, who, she said, had just gone out; another
time she would describe a pleasant walk which she said she had
taken, although she had not been out of doors ; or she would speak of
a succulent supper she had prepared for her family.

She was generally apathetic, occasionally depressed. She spent
several hours of the day in sleep.

An atypical case of general paralysis was suspected.

A fortnight after her admission to the asylum she had an attack of
hoematemesis, which produced a state of profound anaemia. Afterwards
there was an increased tendency to vomiting. There was no pain in
the back or in the region of the stomach or in that of the umbilicus.
Digestion appeared to be easy.

Ten days later there was another attack of haematemesis, followed by
a succession of vomitings. The patient afterwards began to complain
of cramp and pain in the right leg. These symptoms were more intense
at night. A slight contraction of the painful limb was noticed. A
certain amount of paresis, accompanied by parmsthesia, of the right
limb was observed.

In October the patient had an attack of epilepsy with froth at the
mouth and involuntary urination. The nurse observed that the convul¬
sions were most marked on the right side. The monoparesis, vomiting,
epileptiform attack, and the pain in the head gave rise to the suspicion
of an intracranial neoplasm. Ophthalmic examination was negative.

A week later epileptic attacks recurred, this time in a series, which
continued all day. Although the outlook was not good and the diagnosis
doubtful, energetic anti-syphilitic treatment was adopted, with the result
that the pain in the head and the paraesthesia became better, but there
was no improvement in the paresis.

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1916.] CLINICAL NEUROLOGY AND PSYCHIATRY. 8oi

After forty days of this treatment the disorientation in time and space
was less marked, and the patient could hold a more satisfactory con¬
versation with her daughters and the nurse, and even recall more
faithfully the events of the day. She was also less sleepy.

For sixty days longer she was treated with iodides and arsenic.
During this tifne epileptiform attacks of a type clearly Jacksonian
occurred at intervals.

On February 24th the patient was attacked by a series of epileptiform
fits of the Jacksonian type, which continued for three hours and ended
in death.

Post-mortem examination.

Dura mater slightly thickened, but not adherent to the cranium. Pia
mater thickened and oedematous, and in some places could not be
separated from the cortex without bringing away with it shreds of the
brain substance, the principal points of adhesion being the dorsal half
of the left Rolandic area and the orbital surface of the anterior pole of '
the right frontal lobe.

The cerebral gyri in general did not present any alteration and were
not thinned out; in the frontal lobe of the right hemisphere, however,
the gyri appeared to be crushed, their surfaces smoothed out, the sulci
made shallow, and the convexity of the right frontal lobe was more
vaulted than that of the corresponding left lobe.

Palpation of the cortical substance revealed two areas of hard elastic
consistency, one more extensive, being in the orbital region of the right
frontal pole; the other, more circumscribed, in the dorsal half of the
(left) ascending frontal convolution, this (latter) hardness was felt a
little deeply, and did not pass posteriorly and anteriorly beyond the
bottom of the sulcus Rolandi and the prefrontal sulcus. The sense of
resistance was softer in the frontal lobe of the right hemisphere than in
that of the left.

In the orbital portion of the frontal pole of the (right) hemisphere
the hardness, which was almost wooden, was very superficial. Here a
shred of brain substance had been torn away in stripping off the pia.

In this region the sulci and the gyri had lost their normal morphology,
and it was with much difficulty that the former could be individualised.
The surface of all the gyri, which were near the neoplasm, was
granulous and coloured dark grey. The gyrus rectus was compressed.
The olfactory sulcus was no longer recognisable. The olfactory
peduncle was displaced medially, and one could no longer distinguish
on the right side the figure H which furrows the orbital surface of the
frontal pole.

A transverse section was made about 30 mm. behind the frontal pole.

It was then seen that the centrum ovale of the right hemisphere was the
seat of a new formation of a rounded form, of the hardest consistency,
and well defined from the surrounding nervous substance. The cut
surface of the neoplasm was smooth, of a hard-wood consistency, with its
margins indicated by a rose-coloured, ribbon-like line. All around the
new formation the white substance of the centrum ovale was softened to
the extent of 5 mm.

The gyri of the medial and inferior faces of the right hemisphere were
visibly compressed. Segments of the gyrus cinguli, of the first convolu-

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PRINCETON UNIVERSITY

802

EPITOME.

[Oct. r

tion of the limbic lobe, and of the medial face of the first frontal
convolution were compressed and atrophied. Ventrally, the lateral half
and orbital portion of the second frontal convolution were very much
compressed and atrophied.

The new formation measured in its dorso-ventral diameter 3 cm., and
in its transverse diameter 2’5 cm.

The area occupied by the new formation was that region of the
centrum ovale in which radiates the foot of the corona radiata, and
medially to the foot, the region of the terminal radiations of the
occipito-frontal fasciculus, and more medially still by the region of the
radiations of the forceps corporis callosi.

The new formation rapidly decreased in size, until at a distance of
about 43 or 44 mm. behind the frontal pole there was no trace of it.
Thus it reached the point where the lateral ventricle terminates in a
cul de sac , and it compressed the subependymal grey substance. It also
reached the point where are found the anterior terminations of the
occipito-frontal fasciculus, and more laterally still the uncinate fasci¬
culus. The posterior extremity of the neoplasm touched and com¬
pressed the head of the right caudate nucleus.

In the left hemisphere a gummatous infiltration had invaded the
convolutions of the Rolandic area.

The valves of the heart were not indurated, and there was no
atheroma of the arch of the aorta.

There was passive congestion of the inferior lobe of both lungs.

Liver enlarged, yellowish in colour, cut surface soft, borders rounded,
signs of commencing fatty degeneration.

Spleen and kidneys congested.

In the stomach was a small quantity of blood. Around the pylorus
was an annular infiltration, which extended about a finger’s breadth into
the walls of the stomach and duodenum. The infiltration, which was
of the hardest consistency, had dilated the pyloric orifice, and presented
a saucer-like ulcer with raised and eroded edges. The ulcerated surface
was covered with a yellowish-white liquid, suffused with blood. In the
centre of the ulcer one observed a gaping blood-vessel, the mouth of
which was blocked with a clot.

Intestines normal; mesenteric glands not infiltrated.

Anatomical diagnosis : Gummatous infiltration of the centrum ovale
of the right pre-frontal lobe and of the dorsal half of the frontal and
ascending parietal convolutions of the left lobe ; ulcerating carcinoma
of the pylorus with vascular erosion; incipient degeneration of liver
congestion of spleen and kidneys.

After a lengthy review of the physiology and pathology of the pre¬
frontal lobe and its centrum ovale, particularly with reference to the
points brought out by the case under consideration, the author sums up
as follows :

(1) The symptomatology of this tumour of the centrum ovale of the
right pre-frontal lobe was of a nature especially psychopathic.

(2) The psychopathic syndrome was precocious and manifested itself
long before the developmeut of the general phenomena of an endo-
cranial tumour.

(3) The whole group of psychopathic phenomena was made up of two-

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1916.] CLINICAL NEUROLOGY AND PSYCHIATRY. 803

orders of symptoms : symptoms specific of the seat of the tumour, and
symptoms generic of an endocranial tumour.

(4) The specific symptoms may be divided into:

(a) The fundamental symptoms of the defect of the static memory and
of fixation (attention ?).

(b) The correlative symptoms of disorientation in space and time, the
moria of Iastrowitz, and the mnemonic falsifications.

(5) The generic symptoms of an endocranial tumour were the intel¬
lectual torpor and the intercurrent states of somnolence.

(6) The predominant function of the centrum ovale (of the pre¬
frontal lobe) is the function of anatomical and psychical association
which presides over the static memory and fixation (attention ?).

J. Barfield Adams.

Aphemia due to a Tumour of the Right Cerebral Hemisphere in a Right-
handed Patient [Afemia da tumore delP emisfero destro in destri-
mane\ (Rivista di Patologia Nervosa e Mentale , April , 1916.)

Buscaino.

This is an abstract of the report of a case by U. Raggi, which appeared
in the Rivista Italiatia di Neuropatologia, Psichiatria ed Elettroterapia,
vol. viii, fasc. 4, 1915.

A right-handed individual commenced to suffer from Jacksonian
convulsions, and contemporaneously he developed an incapacity of
pronouncing words. The disturbances were irregularly periodic, but
always contemporary, and increased constantly in violence. In the
intervals the patient presented noticeable alterations in speech—incom¬
prehensible words, paraphasia, etc.

Post-mortem examination showed that a tumour occupied all the
cortical and subcortical substance of the second, third, and ascending
right frontal convolutions. Microscopical examination excluded the
existence of any alteration in the left hemisphere.

The case is noteworthy because “ it demonstrates that in the right-
handed, Broca’s centre may be localised in the right hemisphere; it
demonstrates further that the special use of the right hand and arm
does not necessarily induce the development of the centres of language
in the opposite hemisphere, and makes one doubt the value of Leip-
mann’s suggestion for the prophylaxis of aphasia, that is to say, cultiva¬
tion of a motor ambidexterity in order to obtain a consequent cerebral
ambidexterity.”

Seeing then the frequent proofs of abnormalities in the seats of the
centres of language, one may ask “ if in the number of such abnormalities
one may not place many of the cases of lesions of Broca’s centre without
aphasia collected by P. Marie and by his school?”

J. Barfield Adams.

Contribution to the Diagnosis of Tumours of the Corpus Callosum [ Con-
tributo alia diagnosi dei tumori del corpo calloso\. (Rivista di Pato¬
logia Nervosa e Mentale , April, 1916.) Buscaino.

This is an abstract of the report of a case by A. Agosta, which appeared
in the Rivista Italiana di Neuropatologia , Psichiatria ed Elettroterapia ,
vol. viii, fasc. 2, 1915.

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PRINCETON UNIVERSITY

804

EPITOME.

[Oct.,

A woman, aet. 52, in a state of good health, was seized unexpectedly
by a fit, which was immediately followed by psychical disturbances,
interrupted by apoplectic phenomena, and intervals of complete well¬
being. The disease progressed rapidly, left paresis appeared, signs of
slight deficiency of left abducens and left facial nerve, cephalalgia,
somnolence, cachexia, and coma. Psychically : Delirium with fanciful
ideas, apathy, unconsciousness of her own condition. The left pupil
was completely rigid to light, the right pupil reacted very slowly.

Post-mortem examination revealed a glio-sarcoma limited to the
antero-inferior part of the corpus callosum. There was also a pedun¬
cular hsemorrhage, which explained the pupillary symptoms.

From the analysis of this case, in the light of others described in
literature, Agosta draws the following conclusions :

(1) Tumours located in the corpus callosum give a specially psychical
symptomatology from the beginning; the general signs of an intra¬
cranial tumour being few, the somatic alterations, which an objective
examination reveals, being few also.

(2) The hypothesis of a tumour of the corpus callosum ought always
to be discussed when a patient suddenly develops psychical disturb¬
ances, such as lack of connection of ideas, strangeness of acts, amnesia,
irritability of character, and emotional indifference in contrast with a
mental lucidity which is often present.

(3) Left motor apraxia maybe considered as an important diagnostic
sign if it be present, but its absence may not have any value.

(4) In the differential diagnosis one ought especially to think of
progressive paralysis, and of tumours of the frontal lobes.

J. Barfield Adams.

The Diseases of Characters. \Les maladies des caracicres.] (Revue Philo-
sophique , May, 1916.) Piessittger, Dr. Ch.

The title gives one a wrong idea of this work, which is concerned not
with the diseases of characters, but with the way in which characters are
affected or altered by disease.

Disease, says the writer, acts on the character as a shock. Acute
diseases are the least interesting, for here the natural disposition of the
patient is quickly buried under the ruins of his moral and physical
forces. In chronic diseases, on the contrary, a defence is organised.
The instinct of conservation increases the egoistic tendencies of the
sufferer. The forms under which these tendencies present themselves
depend generally on the traits of the original character—the bitter
becoming more bitter, the irritable more irritable, the jealous more
jealous. Others, on the contrary, lose their defects, not by wisdom
but by weakness—for example, the glutton and the rake are often
rendered sober and chaste by their maladies.

The writer gives the following illustration of the way in which
character may modify the course of disease: “ The tender-hearted, the
susceptible, the timid, and all those who feel keenly, in the case of
fever reach to higher degrees of temperature than slanderers and fools.
So that to attempt to lower a degree of temperature in these cases is to
struggle against the sensibility ol the patient.”

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PRINCETON UNIVERSITY

1916.]

NOTES AND NEWS.

805

Some of the following statements are in accordance with general
experience, but others require confirmation. “ The dyspeptics are sad
and depressed; sufferers from thyroid disease are irascible; the
hepatics sulk in sour temper, which results from the laziness of the
nervous elements bathed in humours vitiated by bile or cholesterin.
The cardiacs, when they are confined to an armchair, are subject to
fits of jealousy—particularly of their wives. The tuberculous easily
become wicked—novelists will have to look this matter up, for the con¬
sumptive in fiction is usually angelic. Finally, those suffering from
disease of the adrenals are easily discouraged.’'

The writer lays stress on the psychological difference between the obese
from gluttony and the obese by fault of nutrition—faults of digestion,
I suppose he means. The first have dull sensibility, and an intelligence
in repose; the others a keen sensibility excited by malutrition, which,
joined to a feebleness of movement, “ develops a taste for analytical
and minute conceptions.” Physical weakness and obesity, according
to the writer, incline the mind towards scepticism. Had Renan been
thin instead of stout, Les Origines du Christianisme would never have
been written.

That disease, particularly chronic disease, does modify character, all
will be ready to admit, but it is doubtful whether it always does so in
the ways indicated by Dr. Fiessinger. The control of passion, for
example, is a matter of education—of the development of the power of
inhibition, and disease probably acts by weakening this power. It is
the latest acquirements which disappear first in the moral and physical
debacle of disease. The weakening of the power of inhibition, or self-
control, probably accounts for the appearance during an attack of illness
of traits apparently foreign to the patient’s character, but always latent
therein. J. Barfield Adams.

Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Seventy-Fifth Annual Meeting of the Association was held at
No. 11, Chandos Street, London, W., on Thursday, July 27th, 1916, Lieut.-Colonel
David G. Thomson, M.D., President, in the chair.

There -were present: Sir George H. Savage, M.D., and Drs. D. Bower, R. Brown,
W. Brown, R. H. Cole, M. Craig, J. F. Dixon, E. L. Dove, R. Langdon-Down, T.
Drapes, J. H. Earls, C. F. Fothergill, J. W. Geddes, H. E. Haynes, G. H. Johnston,
E. M. Johnstone, A. Miller, W. F. Nelis, H. H. Newington, H. J. Norman, J. G.
Porter Phillips, J. N. Sergeant, G. E. Shuttleworth, R. Percy Smith, J. G. Soutar,
T. E. K. Stansfield, R. C. Stewart, J. Tattersall, F. R. P. Taylor, T. S.Tuke, H.
Wolseley-Lewis, and R. H. Steen'(Acting Hon. General Secretary).

Visitor: Dr. S. E. White.

Present at the Council Meeting : Lieut.-Colonel D. G. Thomson, M.D. (Presi¬
dent), in the chair, Drs. R. H. Cole, Thos. Drapes, A. Miller, H. H. Newington,
H. J. Norman, J. G. Porter Phillips, J. N. Sergeant, J. G. Soutar, T. E. K.
Stansfield, T. S. Tuke, H. Wolseley-Lewis, and R. H. Steen (Acting Hon. General
Secretary).

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8o 6

NOTES AND NEWS.

[Oct.*

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The following sent communications expressing regret at their inability to be
present: Drs. G. D. McRae, James Chambers, G. S. Pope, C. C. Easterbrook,.
R. B. Campbell, G. E. Peachell, H. C. MacBryan, T. S. Adair, L. R. Oswald,
D. Orr, H. T. S. Aveline, John Keay, and R. Armstong-Jones.

Minutes.

The President said that as the minutes of the previous Annual Meeting were
printed in the Journal for October, 1915, he assumed that the meeting would
agree to take them as read, and authorise him to sign them. Agreed.

Obituary.

The President said that before commencing the ordinary business it was his
duty to announce that the Association had to deplore the loss of a member in the
person of Surgeon George B. Moon, of the Royal Navy. Dr. Moon was formerly
Assistant Medical Officer to the Kent County Asylum, at Barming Heath. He
joined the Navy, with a temporary commission, on November 27th, 1914.

The Association has also to deplore the death of Second Lieutenant Godfrey
Wiglesworth, of the Royal Flying Corps, and to express condolence with his rela¬
tives. Lieutenant Wiglesworth was the only son of a former President of this
Association, Dr. Wiglesworth, of Rainhill. He was killed at the front in a flying
accident on July 8th, aet. 21. He was educated at Clifton and King’s College,
Cambridge.

Another death to be deplored was that of a son of Dr. MacBryan.

The members present would wish to approve of a vote of condolence being sent
to the respective relatives of these gallant men who had given up their lives for
their country.

The motion was carried by members rising in their places.

Congratulations.

The President said that on the other side of the picture it was a pleasure to
him to congratulate Captain (temporary) Swinnerton Blandy on his having been
awarded the Military Cross. Dr. Blandy had served in a number of asylums, his
(the speaker’s) own among others, and at the time of joining he was Assistant
Medical Officer at the County Asylum, Napsbury.

Election of Officers, Council, Auditors, and Standing Committees.

The President said members had papers containing the nominations which had
been made under Rule 67 (c), and the statement of attendances. The election of
Officers, Council, and Auditors would be taken first. He nominated as scrutineers
Dr. Dixon, Dr. Haynes, Dr. Tuke, and Dr. Langdon-Down.

During the taking of the ballot he asked members to proceed with the election-
of the Standing Committees. The names of these were printed on the agenda. If
any member had any additions or alterations to suggest, he would please notify
such now.

The nominations were agreed to.

The scrutineers reported that the President and Council and Auditors recom¬
mended were duly elected.

Reports.

Dr. R. H. Steen (Acting General Secretary) read the report of the Council as
follows:

Annual Report of the Council for the Year 1915.

The number of members—ordinary, honorary, and corresponding—as shown in.
the list of names published in the Journal of Mental Science for January, 1916,,
was 696, as compared with 731 in January 1915.

The following table shows the membership for the past decade:

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PRINCETON UNIVERSITY

19 1 6 .]

NOTES AND NEWS.

807

Members.

1906.

1907.

1908.

1909.

1910.

I9II.

1912.

190 -

1914.

I9IJ.

Ordinary

638

645

652

673

680

690

696

695

679

644

Honorary

32

30

29

32

33

34

35

34

34

34

Corresponding

15

15

‘5

17

17

19

19

.8

18

18

Total

685

690

696

722

730

743

750

747

73 «

696

1

The number of new members elected and registered during the year 1915 was
24, a decrease of 7 on the previous year. The names of 3 members which had
been removed were restored. The number of members who resigned or whose
names were removed by the Council under Bye-law 17, owing to arrears of subscrip¬
tion, was 46.

It is with regret that 16 deaths have to be recorded. Many among these were
old and valued members of the Association.

The result of these changes is that there has been a decrease of 35 in the
ordinary membership. This was expected for the"following reasons : The majority
of new members are drawn from the ranks of Assistant Medical Officers who join
the Association on taking up mental work. During the past year men of this class
have received commissions in the Military and Naval forces. Then, again,
members who have joined the Army and have left England naturally feel uncertain
about the future and have handed in their resignations. The death-rate, too, has
been abnormally high; in fact, it constitutes a record of a melancholy nature in
the annals of the Association within recent years.

Owing to the war the Annual Meeting was a purely business one, and was held
in London. The February meeting, which is usually held at a provincial centre,
was also held in London. The quarterly meetings in November and May took
place as usual. None of these meetings had the usual social accompaniments.

With so many of the members absent on military service the supply of scientific
papers was not so plentiful as in ordinary times. There have been forthcoming,
however, papers of great practical importance which have produced interesting
and valuable discussions.

Divisional meetings also were held with satisfactory attendances. The member¬
ship as reported to the Council in May was as follows :

South-Eastern.239

Northern and Midland ....... 146

South-Western ......... 104

Scottish.91

Irish ........... 59

The Council feel that it is only right and proper to place on record the valuable
services rendered by the members of the Association in connection with the war.
From the returns compiled last January, 133, or 20 per cent., of the ordinary
members have joined His Majesty’s forces, and three members, Lieuts. Edgar
Faulks, Arthur Kellas, and Pierce Power have laid down their lives for their
country. Ten asylums have been emptied of their patients and are in use as war
hospitals, for which purpose they have been admirably converted by the efforts of
those of our members who have been appointed their Commanding Officers. The
valuable paper of our President read at the November meeting gave an insight
into the difficulties contended with and successfully surmounted.

Those of our members who have not donned uniform have carried on their work
with diminished professional assistance. Their anxieties have been increased by
the large number of trained attendants who enlisted for the war. Matters were
becoming so serious in this respect that it was thought advisable to summon a
special meeting of Council in March, when strong representations were made to
the Board of Control. The correspondence which ensued will be found in the
Journals for April and July of this year.

The Parliamentary and Educational Committees have met regularly. Both these

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PRINCETON UNIVERSITY

NOTES AND NEWS.

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808

[Oct.,

Committees present reports. Special Committees have been formed to deal with
matters requiring detailed consideration.

The Journal has continued to be much appreciated, and our thanks are due to
Dr. Drapes, who, single handed, conducted the arduous work of editor for many
months. In order to relieve him of a portion of the labour Drs. Devine and
McRae were appointed Assistant Editors.

Gratitude is due to the Treasurer, Registrar, and Divisional and Committee
Secretaries for time and trouble so willingly given, and also to the Acting Hon.
General Secretary, who has most unselfishly and successfully taken up the duties
of office to replace Dr. Collins.

The Association is greatly indebted to the President (Lieut.-Colonel D. G.
Thomson), who has guided its destinies during a second term of office, and has
presided over the meetings with dignity and courtesy.

The report was duly approved and adopted.

Dr. Hayes Newington (Hon. Treasurer) presented the Financial Statement,
and spoke highly of the work of Dr. Steen as Secretary. He laid the statement of
accounts and the bank-book on the table, and he invited inspection of them, and
any questions which members might feel disposed to ask. He might wish to make
one or two remarks later on the report of Auditors.

The report was duly received and adopted.

Dr. T. Drapes read the report of the Editors of the Journal, and moved its
adoption. This was agreed to.

Report of the Editors.

In their report to the Council at the Annual Meeting in July, 1915, the Editors
felt themselves compelled to express their apprehension that there would probably
be difficulty in obtaining literary material for the Journal during the ensuing year.
This anticipation was, unfortunately, realised as regards the-October issue of that
year, which it was found necessary, greatly to the regret of the Editors, to restrict
to merely a record of the business affairs of the Association. They are glad, how¬
ever, that it has been possible to bring the first three numbers of the current year
up to, or nearly up to, the normal proportions of the Journal previous to the war,
for which they are indebted to those contributors who kindly placed papers at their
disposal. In particular they feel under special obligation to Dr. Mercier, who was
good enough to offer for publication in the Journal an important new work of
his on “ Causation,” previous to its appearance in book-form.

The Editors cannot shut their eyes to the possibility of a similar contingency
again occurring such as happened in October last. Still, from their experience
during the present year up to this, they are not without hopes that sufficient
material may be forthcoming for future issues. They also regret the lateness of
the appearance of the Journal. This has been unavoidable, partly to the fact
that some contributions came into their hands at an advanced stage of the quarter,
but mainly to labour troubles, the printers having found it very difficult to obtain
an adequate supply of hands to carry out the work. The total cost of the pro¬
duction of the Journal for the calendar year 1915, as shown in the Treasurer’s state¬
ment, was £361 10s. 4 d., as compared with £453 5s. 9 d. for the previous year.*
This reduction in expense is hardly a matter for congratulation, as it was chiefly
caused by the shrinkage of material which occurred. The number of copies pub¬
lished during the year has been the same as heretofore, vit., 1,125 of each issue-

The Editors wish to express their thanks to Dr. McRae and Dr. Devine for
their valuable help as Assistant Editors in the compiling of the Journal.

John R. Lord.

Thomas Drapes.

* The discrepancy between the amounts given for Journal expenses in 1914 in
the Editors’ Report and the Treasurer’s Statement respectively is due to the fact
that (as mentioned in both the Treasurer’s and Auditors’ Reports for 1914, pp. 507
and 509, Journal, 1915) in the Treasurer's Accounts the cost of the January number
of the Journal in 1914 was, by a clerical error, included in the 1913 account. The
expenditure in the latter year under this heading was therefore increased, while
that of 1914 was decreased by that amount.

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PRINCETON UNIVERSITY

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$ 10

NOTES AND NEWS.

[Oct.,

Dr. Percy Smith read the report of the Auditors, and moved that it be
adopted.

Report of the Auditors.

We beg to report that we have examined the Treasurer's accounts and vouchers
for payments made on behalf of the Association for the year ending December 31 st,
1915, and find them perfectly correct. During the past year there has been a
diminution both in the receipts and expenditure, but the balance of revenue
account stands at ,£588, or £70 more than at the end of 1914. The amount
written off for non-payment of subscriptions was £65 35., or £4 4s. less than in
1914, but £199 19 s. 6 d. was still owing for unpaid subscriptions, which is too large
an amount.

Many members of the Association are, however, abroad on military sesvice.
Some of them have been excused from paying current subscriptions at their own
request, while still retaining their membership but not receiving the Journal at
present. In spite of the value of the stocks held by the Association having been
written down by no less an amount than £288 in the past four years, the value
of the assets of the Association at the end of 1915 stands £412 higher than at the
end of 1914.

We are glad to see that the Association possesses .£1,000 of War Loan stock,
and to learn that the Treasurer is empowered to apply any surplus cash to the
purchase of Exchequer Bonds.

We must again express our high appreciation of the Treasurer’s work for the
Association, which owes him its best thanks for his constant care for its financial
stability. He is also most fortunate in having very capable assistants, whose
valuable help must not be forgotten by the Association.

David Bower,
R. Percy Smith

,}

Auditors .

Dr. Hayes Newington, referring to the remark in the Auditors’ report concern¬
ing investments, said that this year the Association had taken up £300 of
Exchequer Bonds, and another £200 had just been obtained, making, in all, £500
this year lent to the Government, in addition to what was loaned before, some
£1,500 in the last three years.

The Report was received and adopted.

Annual Report of the Educational Committee, 1915-16.

The Educational Committee, as in former years, has met on four occasions.

We regret to report that, during the year, there has been a decrease in the
number of entrants both for the Preliminary and Final Nursing Examinations—in
the case of the former a decrease of 170, and in the latter a decrease of 94.

It was decided that the Gaskell Prize Examination should be held as usual this
year, but no candidates presented themselves.

The Professional Certificate Examination has been held, and there were two
candidates; up to the present moment the result has not been published.

The Certificate which has hitherto been forwarded to successful candidates in the
Preliminary Examination for the Nursing Certificate, which was remodelled last
year, now takes the form of a Notice only and, in this way, any unfair use of the
Preliminary Examination has been obviated.

An application has been made by the Inspector-General of Hospitals, South
Australia, for recognition of certain regulations regarding the Nursing Certificate.
This matter is to be dealt with by a Special Committee.

It has been recommended that a reprint be made of the Handbook of Nursing,
but, up to the present, it has not been definitely settled whether a set of questions
of a synoptic character should be included in the book or published separately.

A Special Committee has been appointed to deal with any questions which may
affect this Association, which may arise in the formation of the proposed College
of Nursing. Meetings of this Committee have been held, and the matter is still
under consideration.

Maurice Craig, Chairman.

J. G. Porter Phillips, Secretary.

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Original from

PRINCETON UNIVERSITY

1916.]

NOTES AND NEWS.

8ll

GASKELL

MEMORIAL PRIZE

FUND.

Statement brought on from Journal

of Mental Science, Vol. LV 1 I, p. 729.

1911.

£ s- d.

1911.

£ s. d.

July 13th—

July 1st—

. 83 17 11

Prize, Dr. Porter Phillips

45 0 0

Balance ...

Additional Prize (Dr.

Dividends

. 27 10 5

Moll).

15 0 0

Examiners' Fees...

440

Gold Medal

5 5 0

*

Balance ...

41 19 4

8 4

£111 8 4

1912.

£ s. d.

1912.

£ s. d.

December 31st—

January 1st—

Prize, Dr. Boyd.

Examiners’ Fees

45 0 0

Balance ...

. 4 i 19 4

440

Dividends

. 55 0 10

Medals ...

6 11 6

Balance ...

41 4 8

£97 0 2

£97 0 2

* 9 l 3 -

£ s. d.

1 9 , 3 -

£ s. d.

December 31st—

January 1st—

Prize, Dr. Rees Thomas

45 0 0

Balance ...

. 4 * 4 8

Additional prize (Dr.

Dividends

. 55 0 10

McKinley Reid)
Examiners’ Fees

10 10 0

4 4 0

Medal ... .

5 5 0

Balance ...

31 6 6

£96 5 6

£96 5 6

1914.

£ s. d.

1914.

£ s. d.

December 31st— ,

January 1st—

Examiners’ Fees

440

Balance ...

. 31 6 6

Balance.

81 18 II

Dividends

. 54 16 5

£86 2 11

.£86 2 11

I 9 , 5 -

£ d.

I 9 » 5 -

£ i- d.

December 31st—

January 1st—

Balance ...

133 14 1

Balance ...

. 81 18 11

Dividends

. 5 * 15 2

£ l 33 14 1

I

£'33 H 1

1916.

January 1st—

£ s. d.

Balance ...

. 133 *4 »

July 27th—

Dividends

. 42 4 8

The Investments of the Gaskell Memorial Prize Fund consist of:—

£ s. d.

New Zealand 3$ per cent. Stock

... ••• ...

1,380 11 4

New South Wales 3 per cent. Stock...

••• ... ...

337 11 0

War Loan, 4i per cent.

... ...

... ... ...

... 200 0 0

H. HAYES NEWINGTON,

September, 1916.

Treasurer.

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PRINCETON UNIVERSITY

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812 NOTES AND NEWS. [Oct.,.

Report of the Parliamentary Committee, 1915-16.

Your Committee has held four meetings during the past year.

Its deliberations have been mostly concerned with the National Registration Act,
Lord Derby's Recruiting Scheme, and the Military Service Act.

These measures have been discussed especially in regard to the retention of a
sufficient staff of trained attendants in asylums, and action has been taken with
the object of safeguarding the welfare of the insane in this respect.

National Insurance Certificates for patients in asylums have received attention,
and Medical Superintendents have been circularised on the subject with a view to
promoting uniformity of practice in giving them.

The proposed formation of a College of Nursing has been considered, as has
also the question of employing asylum patients at war work.

H. Wolseley- Lewis, Chairman.

R. H. Cole, Secretary.

The President said that with regard to items V and VI, the Educational and
Parliamentary Committees’ Reports, he did not know whether the Chairman of
either of these Committees wished to add anything in supplement of what had
been printed.

Dr. Alfred Miller (Registrar) said he would like to add one paragraph to the
Report. Two papers were sent in in competition for the Divisional Prizes, and the
first prize had been awarded to Dr. Hubert J. Norman, for his essay entitled
“ The Cerebral Associations of Raynaud's Disease.” The second prize was won
by Dr. David K. Henderson, for his contribution entitled “ Katatonia as a Type
of Mental Reaction." He had also to report that two candidates presented them¬
selves for the Professional Certificate, and one of them had passed.

The Report was duly approved.

Dr. Steen read the Report of the Library Committee, and moved that it be
adopted. This was carried.

Report of the Library Committee.

The Library Committee report that during the past year the use made by
members of the Library has not been so extensive as in previous years owing to-
the war. The Committee are, however, anxious to maintain the Library unim¬
paired in its sphere of usefulness, and they propose, at the appropriate time, to ask
for the grant of £25 which the Association has made annually in recent years.
The Committee are gratified at the gifts of books which have been made by
authors and others. These gifts have been recorded in the Journal from time to
time. The Committee wish to remind members that arrangements have been
made with Messrs. Lewis to enable the Association to obtain the loan of books not
in the Library. They also wish to state that a sympathetic reception will be given
to any suggestions made by members as to the advisability of purchasing new
books or as to any method by which the value of the Library may be increased.

Henry Rayner, Chairman.

R. H. Steen, Secretary.

Report of Research Committee.

The Research Committee begs to report to the Council that with respect to the
Resolution passed by the Annual Meeting in 1915 as follows: “That the Associa¬
tion empowers the Council, should it think fit, to make grants in aid of original
research on the recommendation of the Research Committee," the acting secretary'
of the Committee (Dr. David Orr) made inquiries regarding research in connection
with hospitals for treating mental cases from the front, and found that the National.
Health Committee was in touch with them. Under these circumstances it seemed
unnecessary to recommend any financial assistance from the funds of the Associa¬
tion. Moreover, as the President of the Association, Col. D. G. Thomson,
R.A.M.C., and the General Secretary, Capt. M. A. Collins, R.A.M.C. (both of
whom are members of the Research Committee) were aware of the resolution
passed by the Association and its willingness to help, and might be considered
representatives of the Association at meetings of the staffs of military mental

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PRINCETON UNIVERSITY

NOTES AND NEWS.

1916.]

813

hospitals, there seemed no need at present for any special activity on the part of
the Research Committee.

It has therefore only held one meeting since the Annual Meeting of 1915, and
no change has been made in its constitution.

R. Percy Smith, Chairman.

David Orr, Secretary.

The Presi-dent said the Report of the Research Committee had also been
circulated. Dr. Orr, the Secretary of that body, was unable to attend to-day, but
the Chairman, Dr. Percy Smith, who was present, might like to say a word.

Dr. Percy Smith thought there was nothing material which he could add to
the Report. It was mainly a negative report. The Association empowered the
Research Committee to recommend grants-in-aid of original research, and then
Dr. Orr made inquiries regarding research in connection with hospitals for mental
cases from the front, and found that the National Health Committee was in
touch with them, and were prepared to make grants. Therefore it seemed
unnecessary to call upon the funds of the Association, which, in that way, was
saving money. At present the Research Committee had done very little, but its
report was before the members.

Dr. Hubert Norman desired to ask the Chairman of the Committee in what
way the Research Committee or the National Health Committee had got into
touch with the men who were working at the front. He, the speaker, had himself
been working for some time in one of the hospitals, and this was the first time he
had heard of the matter. There were a large number of men working throughout
the country: some may have heard of the Committee's intentions, but at the
hospital he had been working there seemed to be no information on the subject.

Dr. Percy Smith, in reply, said he had not himself had any direct communi¬
cation from the National Health Committee. Their Secretary reported to his
Committee as stated, and perhaps the best way was to stir up the National Health
Committee. He did not think anything could be added to this Report. He would
ask Dr. Orr about the point raised by Dr. Norman.

The Report was duly approved.

Dr. Steen, in reference to the item on the agenda providing for motions involving
expenditure of funds, moved that £25 be voted to the Library to meet expenses
for the coming year. This sum had been annually given by the Association for
many years, and he was sure it would be well expended.

Dr. Bower seconded, and, as part of the Library was housed in his premises, he
wished to remind members that there were a great many back numbers of the
Journal, which he would be very glad to dispose of at a moderate price.

The dates of future meetings, as suggested, were agreed to as follows:

Suggested by the President, vie.: Tuesday, November 21st, 1916; Thursday,
February 15th, 1917; Tuesday, May 15th, 1917; July , 1917.

The Divisional Meetings are proposed as follows :

South-Eastern Division. —October 4th, 1916, at n.Chandos Street, W.; and
April , 1917.

South-Western Division. —October 27th, 1916; April 27th, 1917.

Northern and Midland Division. —October 26th, 1916, at Wharncliffe War
Hospital, Sheffield ; and April 26th, 1917, at the County Asylum, Macclesfield.

Scottish Division. —November 17th, 1916; March 16th, 1917.

Irish Division. —November 2nd, 1916; April 5th, 1917; July 5th, 1917.

The following lady and gentlemen were elected as ordinary members :

Brown, William, M.A., M.B., B.Ch.Oxon., D.Sc.Lond., Reader in Psychology
in the University of London (King’s College), Capt., R.A.M.C., Alexandria
(17th General Hospital), Maghull, and the Maudsley Hospital, Denmark Hill,
S.E. (Permanent address : King’s College, Strand, W.C.)

Proposed by Drs. R. H. Steen, Bernard Hart, and S. A. K. Wilson.

Forsyth, Charles Wesley, M.B.Lond., M.R.C.S., L.R.C.P., Assistant Medical
Officer, Kesteven County Asylum, Sleaford, Lines.

Proposed by Drs. J. Alfred Ewan, Arthur E. Patterson, and R. H. Steen.

LXII. 52

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PRINCETON UNIVERSITY

NOTES AND NEWS.

[Oct.,

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814

Kilgarriff, Joseph O'Loughlin, B.A., M.B., B.Ch., B.A.O.Univ Dub., Acting
Assistant Medical Officer, Storthes Hall Asylum, Kirkburton, near Hudders¬
field.

Proposed by Drs. T. Stewart Adair, Richard Kelly, and R. H. Steen.

Lewis, Edward, L.R.C.P., L.R.C.S.Edin., L.F.P.S.Glasg., Medical Officer to
Glamorgan Mental Deficiency Committee, Glamorgan County Hall, Cardiff.

Proposed by Drs. J. McGregor, Edwin Goodall, and R. H. Steen.

Overbeck-Wright, Alexander William, M.B., Ch.B., M.P.C., D.P.H.,
Major I.M.S. Superintendent, Lunatic Asylum, Agra, U.P., India (at present
on military duty) ; Lecturer on Mental Diseases, King George's College,
Lucknow, and Agra Medical School, Agra. 12, Rubislaw Terrace, Aberdeen,
Scotland; and Agra, U.P., India.

Proposed by Drs. William Reid, H. de M. Alexander, and R. B. Campbell.

Power, Patrick William, L.R.C.P., L.R.C.S., Senior Assistant Medical
Officer, County Asylum, Chester.

Proposed by Drs. G. Hamilton Grills, H. Dove Cormac, and T. Stewart
Adair.

Wilson, Marguerite, M.B., Ch B.Glasg., Assistant Medical Officer, The
Retreat, York.

Proposed by Drs. Bedford Pierce, Henry J. Mackenzie, and R. H. Steen.

The President said it was now his pleasing duty to present the prizes and
medals which had been awarded during the year. As the Registrar's report
showed, there were no entries for the Gaskell Prize or for the Bronze Medal of the
Association ; but two admirable papers had been sent in for the Divisional Prize
Competition. The first of these had been awarded to Captain Norman for his
essay on “ The Cerebral Relations of Raynaud’s Disease.” He had much pleasure
in asking Dr. Norman to accept the prize. Dr. David Henderson, the winner of
the second prize, was not present. His subject was “ Katatonia as a Type of
Mental Reaction.”

Thanks to the President.

Sir George Savage said he had the pleasure to propose a cordial vote of
thanks to the President for the manner in which he had discharged the duties
of his office during the year just ended. He, Sir George, was perhaps the oldest
member present, and he had known Dr. Thomson for more years than he cared to
realise. He knew that the President’s work as Superintendent of an asylum had
always been of the very highest description, and in the County of Norfolk he was
respected, and, what was more, liked, an indication that his work had always
proved satisfactory. Since the war broke out the President had shed his skin and
taken on another, and certainly khaki seemed to suit him very well. He, Sir
George, learned from Norfolk that Colonel Thomson’s services were efficient and
fully appreciated. It was a record in the annals of the Association for anyone to
have occupied the presidential chair three years in succession. He had felt, and
perhaps wisely, that it was not necessary to deliver a presidential address each year.

Dr. Percy Smith expressed the great pleasure he felt in being chosen to second
the vote of thanks to Colonel Thomson. He believed all the members felt that
Colonel Thomson had filled the office of President in a most efficient, and, at the
same time, most ornamental, way. It seemed appropriate that during this year
of war the President should be in khaki. All of them could not be, although they
might be doing military or semi-military work. It had always been a great
source of gratification that he introduced to the President the lady who had become
his wife.

The vote was carried by acclamation.

The President, in acknowledging the vote, said it was exceedingly kind of the
proposer and seconder to place the motion before the meeting, and the members
for having approved of it. He felt that he was only a figure-head, who was, as it
were, " carrying on,” and that it was not necessary to add to his considerable
labours by delivering a presidential address, nor, therefore, to inflict such an
address on those who were present. It was very charming of Dr. Percy Smith to
have alluded to the personal incident which took place, now some thirty years ago,
at Sir George Savage's house. He felt very grateful to the Association for the
vote of thanks.

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Original from

PRINCETON UNIVERSITY

•19 l6 -] NOTES AND NEWS. 8 I 5

Sir George Savage made the following introductory remarks before reading
his paper on “ Mental Disabilities for War Service.”

Mr. President, Lady and Gentlemen,—This is a duty. The Secretary said there
would be some difficulty in filling up the interest of the meeting, and asked me,
therefore, if 1 would contribute something. Not having been occupied in any
original research, and having only memories and pleasant impressions to work
upon, the subject of the war naturally appeared largely before my vision. And
then the question struck me, What was my definite relation to the war? And then
1 began to wonder whether there might not be some clause in the Defence of the
Realm Act which might apply to me, as I found myself so frequently under the
necessity of saying that men who had been called up were unfit for active service.
These cases were so numerous that 1 was thankful to find that numbers of them
•were in different areas, so that my name did not occur very frequently before any
one Tribunal. Therefore I have put together the results of my observations.
There is nothing very original about these, but as the matter has been of interest
to me, I thought it might interest others also.

The paper appears at page 653 of the present issue of the Journal.

Dr. Percy Smith said he had been very much interested in Sir George
Savage’s paper, because it had been his own experience to meet with a great
many similar cases. As the author said, a great many patients who had consulted
one long years before came now to know what was the right thing for them to do.
In some, undoubtedly, there had been produced, as the result of their anxiety
about the war, a feeling of worry, and a return of some of the symptoms which
they had previously suffered from. In most cases of the kind, of course, one said
enlistment was wrong, and that such persons ought to be exempted. And, as
Sir George said, one gave so many certificates of this kind that there seemed a
danger, almost, of becoming a suspected person, that one was oneself the subject
of delusions. Medical officers of the Army who did not know the history of the
persons concerned, and in many cases were not familiar with mental diseases as
members of the Association knew them, did not recognise that a man who looked
perfectly well, and had nothing wrong with heart or lungs, might yet be a person
thoroughly unstable, and possessing a non-resistive mental and nervous organisation,
. and therefore one who, under the stress of military requirements, was liable to
break down. He had picked out from his case-book a few illustrative cases.
With regard to epilepsy one felt, as Sir George Savage said, there was no question
as to any case of epilepsy, under any conditions or consideration, being allowed
to. enter the Army. Some had gone in, but had been made much worse thereby. A
boy was at the present time attending his, the speaker's, out-patient department at
St. Thomas’Hospital, who had suffered from epilepsy since he was fourteen, i.e., four
years ago. At first his attacks were fairly regular, about once a month. They
were serious attacks, coming on in the night, and without warning the day
previous. They were severe convulsive seizures, followed by intense drowsi¬
ness. Headache was experienced for a day or so afterwards, and during that
time the patient was thrown out of all work. Under treatment the boy had
been gradually improving. At first his attacks were reduced to one every two
months or so, and subsequently the gaps of freedom became longer. He had not
now had an attack since last September (over nine months). He had been able
to undertake work, and was now engaged in what would be regarded as the
dangerous position of an employe on the Electric Railway, though not in driving
trains. He had warned the young man that the occupation was not without
danger. This man looked very strong and healthy, and was weil built and of
a good colour, and as a consequence he was being constantly pestered by people
asking him why he did not join the Army’. He naturally shrank from telling all
these busy people that he was subject to fits; and such people came to him to
know what was the right thing for them to say and do. He, the speaker, had felt
no hesitation in saying they ought not to join the Army, and he gave the young
man just referred to a certificate to save him from being pestered by recruitiug
people. Another patient had been attending him for a long time with petit mal,
and he also was totally unfit to join. Of cases who had had other attacks before,
or who had a bad neurotic inheritance, he had seen many instances, and those of
this character who had joined were afterwards quickly rejected. One such case
was that of a youth whom he saw in March, 1915. His mother was insane, a

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sister insane, and an uncle committed suicide. The young man was apparently
healthy, and joined the New Army in September, 1914, and went into training.
Almost at once, as the result of the strenuous work, the early hours, the hard
digging of trenches, etc., in this country, he began to get run-down, and complained
of something going wrong in his head. Then he got am attack of influenza, which
precipitated the collapse. He had a renewal of the feelings in his head, became
depressed, lost interest in things, lost confidence in himself, thought he was not
doing right in having sick leave, and was on the verge of a bad breakdown. He,
Dr. Smith, advised that he should be invalided out. Another case was that of a
youth, aet. 21, who had a first attack of insanity in 1910, when his age was 16, and
was placed in an asylum. He had a second attack in another asylum. Without
his history being divulged he enlisted in October, 1914, joining the Public Schools
Corps. By the following April, six months afterwards, he was confused and
depressed and peculiar, his memory was bad, and he had to go into the Herbert
Hospital. Thence he was discharged as medically unfit. Sir George referred to
some of the cases which, though congenitally weak-minded, had, somehow,
managed to get into the Army. He, the speaker, saw a youth, a;t. 22, who had
had infantile convulsions; he had always been slow at school. He had been
intended, in pre-war days, for the Army, and, after two failures, entered Sandhurst
with that in view. At Sandhurst there was a preliminary test as to whether the
person was likely to make an efficient officer. This young man was declined a
commission because he was adjudged unlikely to become an efficient officer. As
he could not under these circumstances get a commission, he enlisted in September,
1914. When he, Dr. Smith, saw him he had been three times in the Herbert Hos¬
pital, because of an odd mental condition : the officers said they could make nothing
of him. Then he got rather out of hand, assaulting people if they irritated him, and
when he found his rifle inconveniently heavy, he threw it away. His memory was
bad, he was depressed, and was frequently under arrest for minor offences. Of
course, he was congenitally defective, and somewhat weak-minded, and unfit to be
in the Army, and he was invalided out of it. Apart from the young cases, there
were those who, at 45 years of age or thereabouts, had thought it their duty to
join. One had seen a good many such people, who had been in civilian occupations
of various kinds. One case was that of a man who had always been neurotic, and
more or less an invalid, and had been following a quiet civilian occupation until
45 years of age. In September, 1914, he joined an anti-aircraft company, and was
put on to searchlight duty. This man had never slept well, and was never able
to sleep during the day. Therefore searchlight night duty was about the worst
thing he could do. Immediately after starting the work he had insomnia, and
acute neurasthenia developed, and he had what he described as a condition of
blank despair: he had also a suicidal tendency. Of course he was the sort of man
who ought never to have joined. Another case was that of a man, aet. 23, whose
father was insane. He was always feeble, and of nervous constitution. He
enlisted in the Public Schools Battalion, but was rejected on account of flat-foot.
He was given a commission in the Army Service Corps in June, 1915. He only
served on his commission one week, and then broke down. He made an attempt
at suicide, prior to which he was nervously broken down. Unfortunately nobody
in the R.A.M.C. at that place recognised that there was anything wrong with the
man, and they refused him sick leave. This precipitated matters, and led up to
the attempted suicide, by taking chlorodyne. He was in an acute delirious state,
with hallucinations: he thought he had been in the trenches and had been
wounded. He had just emerged from that condition when he, Dr. Percy Smith,
saw him. He seemed to be in a weak-minded state, possibly only temporarily: at
any rate, he was totally unfit to be in the Army. With regard to cases of officers
whom he had seen in connection with a Hospital for Officers, he would mention
one or two. One man whom he saw had, in 1908, an attack in which he supposed
a bullet had got into the brain and was extracted afterwards. In 1913 he had
depression again, and was in a hospital in France. He joined the Army in Sep¬
tember, 1915, !>., after recovering from this attack of depression. About a month
after joining he again developed severe depression, and was alternately depressed
and excited. Eventually he got through his attack. Another officer had been,
before the war, clerk to a stockbroker. He had never been strong-minded, and
had had twelve situations in as many years. He took a commission early in the

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war, and then he, unfortunately, acquired syphilis. In August, 1915, he broke
down, and was found to be peculiar in camp. He lost his power of concentration,
and was dull and irrelevant in his remarks. He also was a case which, though he
had never been abroad, nor in the war at all, had the delusion that he had been
wounded through the heart by a bullet in France. After a considerable period he
improved, and now seemed to be about to recover. But, of course, he was a
person of very doubtful mental constitution, and he believed the man had
always been somewhat weak-minded. Those were some of the cases which
occurred to one as having been totally unfit to join the Army. With regard to
homosexual cases, which Sir George Savage mentioned, he, the speaker, had seen
some of those also, in which the youth in question had been subject to psychas-
thenia with a history of self-abuse, and who had joined, perhaps, to try and cure
himself, but matters had been made worse since joining, and he had had to be
invalided home and enter an asylum. With regard to hallucinatory cases, he
would very much hesitate to let anybody go who he thought had hallucinations.
He had seen one or two people who had come back, and who evidently had had
hallucinations for a long time. One particular man he remembered, who got a
commission out in France. He always imagined he saw his fiance in the opposite
trenches, and was incited to go for the Germans in consequence of that. When
he came back to this country he was evidently mentally weak, and totally unfit for
the Army. With regard to general paralytics he had seen many apart from officers
who had broken down on account of the stress of war, which appeared to have
precipitated the disease. There were other patients who, in the early stage of
general paralysis, had been either thinking they ought to join—and it was then
part of their condition of exaltation—or had had special "revelations” about
Zeppelins or other methods of warfare, and were prepared to put their special
knowledge or their schemes before the War Office, and hence were people who
needed placing under care before they developed any more pronounced symptoms.
With regard to shirkers, he had seen a number of people who were afraid that
they were regarded as shirkers, some of them having been so definitely ill in other
respects that they ought to be exempted, apart from their mental condition. But
undoubtedly many had been strained by the feeling that they were not bearing
their share in the war, although they were manifestly unfit.

Dr. G. Shuttleworth said that his own field of work was rather apart from
lunacy, but in the period which had elapsed since the war started he had seen
some young men who previously had been feeble-minded boys, and who came to
him now because they had arrived at military age, and desired to be certified as
unfit for military service. He had not always given such a certificate straight
away. He had had some experience in these matters in connection with the
South African War. At that time some of the ex-patients of the Royal Albert
Asylum, with which he was formerly connected, acted very creditably in that
campaign, and brought good characters with them. One died of disease in the
Service. There were certain boys who, at some period of their career, had been
reputed to be feeble-minded, and yet who made very good soldiers. The kind of
patients he had been seeing at the present time were usually of a better social
class, and their parents were more convinced than in the case of those of the
poorer kind of boy, that their sons were not fit to become soldiers. There was a
large number of boys who had been educated at the Special Schools of London and
Birmingham—the two towns of which he happened to know the statistics—and
had joined the forces, and, so far as was known at present, they served with fair
credit. Towards the end of 1915 it was reported that seventy had joined of those
who had been at the London Special Schools, and who afterwards came into the
lists of the After-Care Committee : and he believed the corresponding number in
respect of the Birmingham Special Schools was 100. With regard to institutional
cases, at any rate, he thought there was something to be said in favour, first of all,
of their fitness for soldiering, because they had been accustomed to a great deal of
drill in the institution, and consequently they had acquired the habit of smartly
carrying out orders. Secondly, the kind of discipline operative in the Army was
likely to keep them out of whatever mischief they might have an inclination for,
if they had sufficient nervous force to withstand the shock and strains incidental
to the life, and with many that seemed to be the case. With regard to the class
•of patients whose parents were in a better social position, one had particularly to

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use one's discretion, and not grant a certificate to everyone who said his or her
boy would certainly break down if he were forced to be a soldier. When knowing
the previous history, one was able to fairly gauge the amount of resistance
possessed. For instance, one boy whose mother was very neurotic lived with him
for three or four years, and at the end of the fourth year he had sufficiently
improved to go to an ordinary board school, and he passed very creditably
through it. He was now over 18 years of age, and was preparing for some uni¬
versity examination at the time he was included in the lists for military service.
The medical officer, whom his father had seen before, said he was a fine, good-looking
youth—and that was true—and that if he were passed for the Army they would
make a man of him, and he, the speaker, was not sure that that would not be so.
In that case, therefore, he contented himself by writing the history of the boy's
youth, so far as he knew it, and asking the father to submit that document to the
Medical Board before which the young tnan would be examined. He, the speaker,
had not heard what was the result. With regard to the epileptic cases, he thought
everyone knew that in a youth who had been subject to epilepsy there was every
prospect of a recurrence. He did not mean the ordinary convulsions associated
with the teething period in early childhood, because many such cases grew out of
their tendency to fits in later years. Real epilepsy, however, should constitute a
definite bar to enlistment, or the acceptance of such a man as a candidate for the
Army, though he believed there was a legend that the great Napoleon was occa¬
sionally subject to epileptic fits. He did not know whether that was a mere
tradition, or was founded on fact: and, if true, it was not an argument in favour of
excluding epileptics from the Army. He had had one or two cases of moral
imbecility, an interesting but very difficult group. One case was that of a son of
a Welsh Congregational minister, who had been brought up in, perhaps, the
straitest sect. When he arrived at the age of puberty, he took to lying and
thieving, and was for some time under his, Dr. Shuttleworth’s, observation. He
improved to some extent, and finally went home to his parents. When the war
broke out, he enlisted “ on his own.” Three months iater he, the speaker, had a
letter from the young man's mother in which she said that unfortunately her son
was getting into great trouble in Flanders, that he was frequently under arrest and
punishment, because he did not keep his hands off the property of other men. In
addition, he was not very obedient to his officers. He was getting so much
punishment, for which he did not seem really responsible, that she would be glad
if he could be got out of the Army. He, Dr. Shuttlevvorth, wrote to the Medical
Officer attached to the particular company, giving what he knew about the case,
and the result was that the boy was discharged, and he thought very justly too.
In the case of another moral imbecile he had in mind it was doubtful if anything
would be done, because the young man’s course was not affected by punishment,
and there were still signs of that tendency acting. It seemed cruel that such a boy
should be in the Army, because he was sure to get into a lot of trouble and receive
punishment which, perhaps, he really did not deserve, considering he sinned from
infirmity rather than from intention.

Dr. Seymour Tuke said he supposed it had fallen to the lot of most members
of the Association to see similar cases to those spoken of in the paper, men whose
fitness or otherwise to enter the Army had to be certified ; and he was glad to find
himself in agreement with Sir George Savage in everything that gentleman had
said. He had had one or two cases which were on all fours with instances the
author mentioned. He was particularly struck in the case of one strong-looking
man who broke down when he came in for advice. He, Dr. Tuke, had recently
had a good deal of trouble with the members of a particular family, who, collec¬
tively, had an extraordinary history : the father was a desperate drunkard, the
mother was neurotic, the only sister was fairly well, but the first brother in the
family was now in an asylum, the second brother— i.e., the man he was now
particularly referring to—was a very healthy-looking man, and closely resembled
a case alluded to by Sir George Savage, so that on looking at him one would say
there was nothing the matter with him; he not only looked very fit, but was very'
active-minded. He was engaged in rather responsible work not far away from the
centre of London, and was much honoured and respected in his particular calling.
He, Dr. Tuke, was first engaged in the case of another brother—not the one in th&
asylum—who got into desperate trouble in the South of England not long ago.

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1916 .]

and had to be put into an asylum on account of indulging in homosexuality. The
healthy-looking brother in London, whom he had just referred to, came to him,
the speaker, recently about being supplied with an exemption certificate, and he
had some talk with him about himself. He had suffered very much from insomnia,
at times he had definitely “ lost himself,” particularly if he was worried, and he
had recently been very anxious about his other brother, whom he had nursed and
looked after for four or five weeks. He told the man he would do what he could
for him, and he certainly thought that on his own and his family history he ought
to be exempted: he believed that would be so, as it should be. He thought the
cases in which there was a definite history of neurosis in the family should certainly
be regarded as very doubtful ones. He had the interesting case of a man, act. 26,
who had been all through the African campaign with General Botha, and did fairly
well there, though when he arrived home he was in a rather excitable state. He
developed such an excellent readiness of tongue that he was put upon recruiting
service, and he addressed a number of meetings. That went on fairly well for a
time, but he became more excited, and at last he broke down with subacute mania,
in which state he at present remained, though it had cleared up somewhat. There
was an old history of tubercle in the case, otherwise he was a strong man. But he
did not think it would be wise to allow him to do anything again. He thought
one should stretch a point in the cases in which the family history was markedly
neurotic.

The President remarked that before calling upon Sir George Savage to reply,
he would like to say how indebted members were to him for bringing forward some
of the fruits of his wide and ripe experience in these very difficult cases. At this
stage of the meeting he did not want to enlarge on the subject, which was a large
and interesting one, and one also upon which it was very difficult to lay down
general principles. Those who were now in charge of war hospitals saw the
results of admitting persons to the Army who had suffered mentally, or who at
least were potential lunatics. It was very interesting to observe and watch the
attitude of recruits before the Military Service Act came into operation a few
months ago, and since. For instance, in the volunteer days, when the recruits
voluntarily came forward, the suppression of the history of all kinds of epilepsy,
and even actual insanity, was rampant; hence there were now in war hospitals
patients who undoubtedly were insane on enlistment, and others who had been
epileptics for years. Those facts were suppressed when dealing with the recruiting
sergeant and the medical man, especially at the rushing times of six to twelve
months ago, when voluntary recruiting was at its height. The trouble and expense
of that were being reaped now. The attitude adopted since universal service was
operative was very curious, for now many men, in their eagerness to be excused, not
only did not disguise past mental trouble and epilepsy, but seemed even proud of it.
He frequently got, recently, letters asking him for certificates stating the dates
when particular persons were inmates in his asylum, with a view, of course, to
securing exemption. The paper was entitled “ Mental Disabilities for War
Service,” and the only remark he had to make upon that was, that when the
Norfolk County Asylum at Thorpe was vacated, there was great difficulty in
finding accommodation in the receiving asylums for the patients transferred,
therefore in doubtful cases one stretched a point, and discharged a considerable
number of men who, in ordinary times, would have been regarded as barely fit to
be discharged; and he had been astonished to get letters, certainly from five of the
male patients so discharged, from Egypt and from the trenches in France, stating
that they were as happy as possible, and were doing very well, at the same time
asking how their old friends at the asylum were. He did not know whether it
would be lasting, or whether he heard only of those cases which had been a success.
Certainly half of those he heard from seemed to be doing well, and had had little
promotions. Yet those were cases which, normally, he would have kept in the
Norfolk County Asylum.

Sir George Savage, in reply, said he agreed with the President that it was
important the other side of the matter should be heard. The very existence of the
After-Care Association, of which he was the Treasurer, meant that men and women
who had had attacks of insanity should be got well enough to return to their
ordinary avocations. He did not doubt that joining the Army had done some
people good ; to many it seemed to have brought about moral good. The fact

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that so many magistrates all over the country were now being presented with white
gloves seemed to be evidence that at all events evils were being removed from civil
life. But for those who were looking at the matter from the outside point of view
one would run certain risks, but it depended upon whom the risks would fall.

Paper.

Captain Colin McDowall, M.D., R.A.M.C.: “ Functional Gastric Disturbance
in the Soldier.”

The President, in view of the fact that most of the members had left the
meeting, asked whether the author would care to defer the reading of the paper
until another meeting.

Captain MacDowall intimated that he was willing to fall in with the
President’s suggestion.

Concluding letter of the correspondence which has taken place between the Board
of Control and the Secretary of the Association, and which was published in
the last two numbers of the Journal.

July 31 st, 1916.

Sir,

1 am directed by the Council of the Medico-Psychological Association of Great
Britain and Ireland to thank you for your letter of July 1st, and to say that they
note with satisfaction that the Board have recognised the necessity of recom¬
mending full conditional exemption in a considerable number of cases in which
only temporary exemption had been previously recommended, and of recommending
additional temporary exemptions in the case of many other attendants.

I am further to add with regard to the comments made in your letter that the
Council find nothing to modify in the arguments adduced or opinions expressed
in their communication of May 17th.

I am, Sir,

Your obedient servant,

R. H. Steen,

Acting Hon. General Secretary.

The Secretary,

Board of Control.

ABSTRACT OF THE FINAL REPORT OF THE ROYAL
COMMISSION ON VENEREAL DISEASES.

Prepared by T. C. Mackenzie, M.D., F.R.C.P.Ed.,

District Asylum, Inverness.

To the King's Most Excellent Majesty.

May it please Your Majesty,

We, the Commission appointed to inquire into the prevalence of venereal diseases
in the United Kingdom, their effects upon the health of the community, and the
means by which those effects can be alleviated or prevented, it being understood
that no return to the policy or provisions of the Contagious Diseases Acts of 1864,
1866 or 1869, is to be regarded as falling within the scope of the inquiry, humbly
submit this our Second and Final Report for Your Majesty’s most gracious
consideration.

We have, since the commencement of our inquiry, held eighty-six meetings and
examined eighty-five witnesses, to whom 22,296 questions were put.

Prevalence.

The materials available for estimating the prevalence of venereal diseases are,
for various reasons, incomplete and unsatisfactory. In some countries partial

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-attempts to obtain a census of syphilitics have been made, but the results are
vitiated by several sources of error, while generalisations from one country or one
town to another cannot be trusted.

We have examined statistics obtained from the following official sources, with
which we deal separately :

( a) Registrar-General. ( e ) Local Government Board.

( b) Navy. (f) Prison Commissioners.

(c) Army. (^-) Lunacy Commissioners.

(d) Police.

Distribution.

The tables given in Section II (a) show that the highest mortality recorded for
syphilis occurs in England and Wales, where, in the year 1910, the crude annual
death-rate per million from this cause is stated to be 46, as compared with 42 for
Scotland, and only 22 for Ireland. Such consequential diseases as general paralysis,
locomotor ataxy, and aneurysm closely follow syphilis in relative order of distribu¬
tion, except that aneurysm stands highest in Scotland, and, together with general
paralysis, is markedly low in Ireland.

Table I (Appendix I) brings out the fact that syphilis is essentially a town
disease, and that the distribution of the three other diseases above referred to
follows the same law. County boroughs return the highest mortality under each
heading in the four divisions of the country dealt with, and are followed at some
distance by the smaller towns, while the rural mortality is relatively low in every
instance.

The comparative immunity of miners and agricultural labourers from aneurysm,
although both classes are subjected to physical strain, corresponding closely with
their freedom from syphilis, provides confirmation of the intimate connection
between aneurysm and syphilis.

Except in the case of the navy and army, there are at present no means of
arriving at an accurate estimate of the prevalence of venereal diseases. The
tendency to concealment, which is a marked characteristic of those who have
acquired these diseases, by militating alike against the acquisition of full knowledge
of the extent of their incidence and against prompt treatment, render them
peculiarly dangerous to public health. Moreover, it is only in comparatively recent
years that their varied effects have begun to be recognised, while more in this
direction still remains to be discovered.

Sir William Osier considers that “ of the killing diseases syphilis comes third or
fourth,” and his evidence shows clearly that the number of deaths actually due to
this cause which escape recognition must be very large. While we have been
unable to arrive at any positive figures, the evidence we have received leads us to
the conclusion that the number of persons who have been infected with syphilis,
acquired or congenital, cannot fall below 10 per cent, of the whole population in
the large cities, and the percentage affected with gonorrhoea must greatly exceed
this proportion.

Effects.

The immediate effects of syphilis are inconsiderable as compared with the later
developments.

Since acquired syphilis is the most frequent cause of arterial disease between 30
and 50 years of age, it follows that a widespread disease like syphilis must tend
thereby to shorten life in many ways. It is a common saying that “ a man is as
old as his arteries,” and we have received a mass of evidence pointing to the fact
that arterial disease of syphilitic origin may directly or indirectly be the cause of
many fatal diseases bearing another name than that which was primarily respon¬
sible for their occurrence. ,

Syphilitic disease of the arteries of the brain and spinal cord is frequently
followed by clotting of the blood in these vessels (thrombosis), resulting in localised
patches of softening which produce symptoms depending upon the function of the
nervous structures involved, such as a stroke of paralysis, loss of speech, speech
disorders, loss of memory, and mental enfeeblement.

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The most serious late effects of syphilitic infection are observed in diseases of
the brain and spinal cord, which are very important.

These morbid conditions give rise to the most varied symptoms and signs of
nervous disease. Some of the more important paralytic conditions are hemiplegia
(paralysis of one half of the body) where the brain is affected, paraplegia (paralysis
of the lower extremities) when the spinal cord is affected, blindness, deafness,
disorders or loss of speech, loss of memory, mental enfeeblement, epileptiform con¬
vulsions, in fact almost any symptom or sign arising from organic disease of the
nervous system.

Tabes dorsalis (a wasting disease of the spinal cord) or locomotor ataxy, as it is
generally termed on account of one of its most obvious symptoms, is a very frequent
result of late syphilis.

Not infrequently blindness occurs (optic atrophy), and about io per cent, of cases
are either associated with general paralysis or terminate in this rapidly fatal
disease.

General paralysis of the insane is the most serious late result of syphilis. It is
a fatal disease which attacks both sexes in the prime of life, and it is responsible
for 14-15 per cent, of the male admissions to the asylums of London and other
large cities annually, and for 2 to 3 per cent, of the female admissions.

Gonorrhoea is generally regarded by the public as a trifling ailment, though it
has in reality serious and far-reaching consequences. Since the gravity of the
disease is insufficiently realised it follows that early treatment is often neglected,
and the opportunity of attacking the disease in the incipient stages, when it is
much more amenable to treatment than later, is lost. The treatment of gonorrhoea
if neglected becomes extremely difficult, and the disease may be contracted time
after time, rendering the patient more and more liable to complications on each
successive occasion.

It will be seen, therefore, that the consequences of gonorrhoea in males are grave
and far-reaching, and that the disease is a source of the greatest danger to the
community at large.

It is impossible to exaggerate the importance of gonorrhoea in women. In the
earlier stage it inflicts on her a serious ailment; subsequently it may cause sterility,
and in later years it frequently leads to conditions which may necessitate grave and
difficult operations, to chronic invalidism, and sometimes to death.

Knowledge of these facts should, in our opinion, cause both the medical profession
and the public to take a far more serious view of gonorrhoea than has hitherto been
adopted.

Relation between Alcohol and Venereal Diseases.

Abundant evidence was given as to the intimate relation between alcohol and
venereal diseases. Alcohol renders a man liable to yield to temptations which he
might otherwise resist, and aggravates the disease by diminishing the resistance
of the individual.

Alcoholism makes latent syphilis and gonorrhoea active. It makes the treatment
of syphilis and gonorrhoea much more refractory. If alcohol is absolutely stopped
during the treatment of syphilis and gonorrhoea, the result is much more
satisfactory.

A person who suffers from syphilis of the nervous system has an invalid brain,
and if he drinks he will certainly suffer seriously.

The facts point to the conclusion that decrease in the use of alcohol will be an
important factor in diminishing the prevalence of venereal diseases.

Economic Effects of Venereal Diseases.

The grave economic losses to the State which venereal diseases involve constitute
a powerful argument for the initiation of general measures of prevention and
treatment at the earliest possible date.

These diseases take effect at every stage of life, and in the case of syphilis any
part of the body may be temporarily or permanently affected. Both gonorrhoea
and syphilis lead to an enormous annual loss of child-life.

The effects of syphilis in producing miscarriages, still-births, infantile mortality,
and diseased offspring are strikingly illustrated in the records of family histories.

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contained in Appendix XVI. At the earlier stages of life, therefore, the total loss
to the State is certainly very large.

Congenital syphilis also frequently leads at an early age to blindness and deaf¬
ness. The figures laid before us by Mr. Bishop Harman (Appendix XVII) show
that more than half of all cases of blindness among children are the result of
venereal diseases in the parents.

To the expenditure incurred in the treatment of these children must be added
the additional cost of their education. The figures published by the London
County Council indicate that the total cost of educating a child in the day schools
for the blind is about seven times the cost of the education of the ordinary child.

Among adults the loss of working power from the earlier effects of the diseases
is important. The naval statistics for the year 1912 show, for an average strength
of 119,540 men, a total number of 269,210 days lost as a result of venereal
diseases; in the army at home during the same year it appears from the returns
that, with a strength of 107,582 men, there was an average of 593 constantly sick,
equivalent to a loss of 216,445 days, from the same causes. If corresponding
figures for the civil population could be obtained, they would be found to be
extremely large, and it must be borne in mind that the civil population has not at
present the advantage of easy access to the best modern treatment which has been
provided for the navy and army. The evidence we have taken clearly establishes
the fact that the neglect of venereal diseases, apart from the risk of later
manifestations, has the effect of rendering the treatment more difficult, protracted,
and expensive, thus entailing a large aggregate loss of working power.

The statistics of the London County Council asylums show that in the quin¬
quennial period 1908-1912 rather more than 9 per cent, of the total admissions, or
16 per cent, of the male and 2 6/er of the female admissions, are cases of
general paralysis of the insane.

In England and Wales as a whole the average number for the three years
1910-1912 of cases of general paralysis under care in county and borough asylums
was 2,307. Taking the average cost per patient as 15s. per week, the expenditure
on cases of general paralysis alone.would amount to nearly £90,000 annually.

If to these cases be added other forms of insanity resulting from syphilis and
requiring asylum treatment, the annual cost to the asylum authorities in England
and Wales cannot be less, and may be much more, than £150,000.

The Poor Law infirmaries also contain a number of persons suffering with
incapacitating diseases of syphilitic origin such as locomotor ataxy, various forms
of paralysis caused by disease of the brain and spinal cord, arterial disease, heart
disease, and chronic skin and bone diseases. These disabling diseases are not
necessarily fatal, and many cases live on in the infirmaries ten, twenty, or even
thirty years.

Untreated, or inefficiently treated, syphilis is the main cause of the occurrence
of these fatal and incapacitating diseases in asylums and Poor Law infirmaries ;
consequently early efficient treatment, by curing syphilis and preventing the spread
of infection, cannot fail to have an important influence in lessening the great
economic burden entailed by the maintenance of patients suffering with incapaci¬
tating and incurable disease in asylums and Poor Law infirmaries.

It is clear that if the various sources of loss above referred to could be rendered
in terms of annual expenditure, the resulting total must be enormous. We cannot
expect that the whole of this loss can be avoided ; but we are satisfied that a large
proportion of the total expenditure can in the future be saved, and that the safvings
would far more than counterbalance the cost of the measures we propose for the
prevention and treatment of the disease.

Means of Treating or Preventing Disease.

It has been shown that success in treatment and in the prevention of the more
serious later symptoms of syphilis depends upon prompt recognition of its presence.
It follows that the most urgent requirement is to secure for every patient the freest
and earliest possible access to medical assistance when there is suspicion of venereal
disease. This implies inter alia that all temptation for the patient to have resort
to an unqualified person shall be removed. This point we shall discuss in a later
section of the Report.

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The recent advances in knowledge with regard to venereal diseases, and the
improvements which have followed in their treatment, have no doubt resulted in
increased attention being paid to these diseases both by the medicaj profession
and by the general public. It was, however, the general opinion of the witnesses
who appeared before us that no adequate system of treatment would be organised
unless responsibility for the measures to be adopted were undertaken by the State.

In this opinion we concur. We recognise that the medical practitioners of the
country must form the first line of defence against these diseases, but the diseases
are so widespread, and their consequences are, as we have shown, so serious—not
only to the individual, but also to the race—that concerted action by a private
authority is, in our view, essential. It appears to us that such action can best be
secured through the medium of the larger local authorities who are already under¬
taking important work in relation to tuberculosis and other diseases.

We therefore recommend that the State should look to the Councils of the
larger local authorities (i.e., the Councils of Counties and County Boroughs or
such areas as the Local Government Board may determine) to undertake definite
schemes for the treatment of venereal diseases in their areas.

We have recommended that treatment of venereal disease should be available
for the whole community, and that a person should, irrespective of his place of
residence, be able to obtain treatment at any institution dealing with these diseases
under a scheme formulated by a local authority. These two considerations, as well
as the great national importance of the diseases, and the urgent need for action
throughout the country, lead us to the conclusion that the greater part of the cost
should be borne by the. Exchequer. We appreciate, however, the desirability
of throwing some part of the cost of schemes administered by local authorities on
the authorities themselves, and we therefore recommend that 25 per cent, of the
expenditure should be met from local rates. The remaining 75 per cent, should,
we consider, be provided by Imperial grants.

Treatment of Venereal Diseases by Unqualified Persons.

The fear of disgrace and the consequent desire for concealment necessarily
render the sufferer from venereal disease specially liable to attempt self-treatment,
or to entrust his treatment to persons who are in no way qualified to deal with
the disease. This appears to be true of all sections of the community, and we are
informed that the upper classes resort to quacks as readily as the poor. The
unqualified person, however, trades not only on the desire of his clients for secrecy,
but also on their credulity and upon their ignorance of the seriousness of their
disease. He promises quick cures, without publicity, without inconvenience, and
at small cost.

We have no hesitation in stating that the effects of unqualified practice in regard
to venereal diseases are disastrous, and that, in our opinion, the continued existence
of unqualified practice constitutes one of the principal hindrances to the eradication
of those diseases.

We strongly endorse the recommendations of the Select Committee on Patent
Medicines that all advertisements of remedies for venereal diseases should be
prohibited. The direct and indirect effects of these diseases upon the race are so
grave, and the deception practised upon the public is so extensive, as, in our
opinion, to justify repressive measures. We should have advocated legal provisions
making the treatment of venereal disease by unqualified persons a penal offence,
but we recognise the practical difficulties in securing the effective operation of such
a law in present circumstances. The prohibition of advertisements is open to
much less objection on this ground, and we believe that it would go far to remedy
the great evils which have been emphasised by the evidence given before us.

Marriage and Communication of Disease.

The question whether or not the fact that one of the parties is, at the time of the
marriage, suffering from disease “ in a communicable form ” should be ground for
the other party obtaining a declaration of nullity was discussed before the Royal
Commission in Divorce and Matrimonial Causes.

We have come to the conclusion that in substance the recommendation of the
Royal Commission should be adopted by the Legislature. We think it most

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important that it should be laid down by law that the presence of venereal disease
in an infectious state constitutes an incapacity for marriage, whether or not the
presence of disease is known. We regard this question as one affecting not only
the married persons themselves, but also the public welfare in respect of the birth¬
rate and death-rate, and the effects of congenital disease upon the health and
happiness of the offspring. The process should be made available for all persons,
however poor.

Education of the Public.

We attach great importance to the educational aspect of the question with which
we are called upon to deal. It is, in our opinion, absolutely necessary that the
public should have fuller knowledge of the grave evils which exist among us, and
of their effect upon the national life, present and future.

We have indicated the need for carefully-considered instruction in schools and
colleges; we desire to point out that such instruction cannot relieve parents of their
responsibility in this respect. We hope that the wider knowledge of danger which
the publication of our Report may secure will have the effect of bringing home to
parents the duty of warning and guidance which they should be able and willing
to discharge.

We hope that the information which our Report contains, and the important
evidence which we have received, will have an educational effect in the widest
sense. We believe that they will go far to secure the enlightenment of the general
public in regard to the grave dangers to the national health arising from the
prevalence and spread of venereal diseases, and that this knowledge may lead to
some change in the attitude of mind which still persists with respect to these
diseases. That they are intimately connected with vicious habits is evident, but it
is too often forgotten that large numbers of sufferers are absolutely innocent.

General Conclusions.

We have endeavoured to make clear the grave and far-reaching effects of venereal
disease upon the individual and the race. The evidence we have taken proves
conclusively that these effects cannot be too seriously regarded, and that they result
in a heavy loss not only of actual but of potential population, of productive power,
and by expenditure actually entailed:

The terms of our reference precluded consideration of the moral aspects of the
questions with which we have dealt. We are, however, deeply sensible of the need
and importance of the appeals to conscience and honour which are made by the
religious bodies and by associations formed for this purpose. We believe that
these appeals will gain force if the terrible effects of venereal disease upon innocent
children and other persons who have no vicious tendencies are more fully realised.
Our evidence tends to show that the communication of disease is frequently due to
indulgence in intoxicants, and there is no doubt that the growth of temperance
among the population would help to bring about an amelioration of the very serious
conditions which our inquiry has revealed. We are also conscious of the fact
that overcrowded and insanitary dwellings indirectly contribute to the spread of
disease, and from improvements in this direction we should expect some diminution
of its prevalence.

Our Report must issue at a time when all public activities are preoccupied in
fulfilling the manifold needs of war. We are conscious of the-disadvantage thus
arising, and we feel that there is some risk that our recommendations may not
receive the immediate attention which their national importance demands. We
desire, therefore, to place on record our strong opinion that the conditions now
existing and those which must follow on the conclusion of the war imperatively
require that action should be taken without delay. There is no reason to believe
that the percentage of infection in the naval and military forces is now greater than
in normal times, but there can be no doubt that the total of infected persons has
increased. The military authorities are doing their utmost to provide treatment,
but the civil population requires corresponding measures, and all experience shows
that after a war an excessive incidence of disease is certain to occur, even in
districts previously free. In order to meet present and future conditions it is
essential to make provision, and no time should be lost.

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We realise the claims of economy at the present moment, but, for reasons we
have given, we believe that all necessary expenditure will be recouped by the
results which can be obtained.

Lastly, we wish to lay stress upon the needs of the future. The diminution of
the best manhood of the nation, due to the losses of the war, must tell heavily
upon the birth-rate—already declining—and upon the numbers of efficient workers.
The reasons for combating, by every possible means, diseases which in normal
times operate with disastrous effects alike upon the birth-rate and upon working
efficiency are therefore far more urgent than ever before. Now and in the ye*ars to
come the question of public health must be a matter of paramount national
importance, and no short-sighted parsimony should be permitted to stand in the
way of all means that science can suggest and organisation can supply for guarding
the present and future generations, upon which the restoration of national prosperity
must depend.

List of signatories to Report:

Sydenham of Combe.

D. Brynmor Jones.

Kenei.m E. Digby.

Ai.meric Fitzroy.

Malcolm Morris.

John Collie.

Arthur Newsholme.

J. W. Horsley.

J. Scott Lidgett.
Frederick W. Mott.
Mary Scharlieb.

J. Ernest Lane.
Philip Snowdon.
Louise Creighton.

E. M. Burgwin.

E. R. Forber, Secretary.

SOUTH AFRICAN ASYLUMS.

Successful Candidates, Nursing Examination, May, 1916.

Final.

Pretoria. —E. Stolesburg, S. H. Perry, J. M. Coetzee, W. Commins, H. G.
Terveen.

Valkenberg. —N. E. Westley, A. M. Searle, G. Norlin, E. M. A. Reyneke, I. M.
Smuts.

Bloemfontein .—Annie Roe, Marguerita Redlinghuys, Johannes Marx, Petrus
Jacobus Meyer.

Robben Island .—James Ellison Curry, William James Clarke, George Frederick
Haupt, Bailey Jordaan, Thomas Monahan, Blanche Schutte.

Grahamstosvn. —B. Moller.

Preliminary.

Fort Beaufort .—Charlotte Gilson, Clara Gertrude Vice.

Pietermaritoburg .—Virginia Julia Daniell, Agnes Fisher.

Valkenberg .—Jessie Asher, Minnie Lister, Margaret Amelia Fairweather,
Bernadette Bennett, Anne Forsyth Murray Little, Anna Maria Elizabeth van der
Merwe, Annie Catherine van Tonder, Lucy Jane Hall.

Pretoria .—Rose Edith Baldwin, Elizabeth Johanna Groenewald, Anne Susan
Prinsloo, Margaretha Catharina de Klerk, Nellie Pryde Rennie, Frederick Christian
Mienie, Eric Brown, George Fredrick Hendrick van Altena, Eleanor Wolley.

Bloemfontein .—Chrissie Johanna Parkin, Jan Hendrik Buys, David Hercules
Victor, Lawrance Hartig.

Robben Island .—Albert Henry Saville, Denis Phelan.

Grahamstosvn. —J. A. Nell, H. J. Bessinger, N. Carroll, J. E. Mundell, B. C.
Dutton, A. I. Boardman, K. C. Gray, H. J. Groenewald, E. A. Wright.

RETIREMENT OF DR. ROBERT ARMSTRONG-JONES.

The resignation of Dr. Armstrong-Jones and his retirement from the position of
Medical Superintendent of Claybury Asylum cannot be allowed to be passed
without notice in these pages. For the past thirty-six years he has been devotedly
engaged in asylum work. After some years of service at Coinev Hatch he was

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appointed Resident Physician at the Royal Earlswood Institution, and from there
he was called to fill the highly important position of Medical Superintendent of
the London County Asylum at Claybury at its opening, which post he held for a
period of close on twenty-four years; a distinguished position which has involved
no small expenditure of energy, physical and mental, in the fulfilment of the
arduous and responsible duties, medical and administrative, connected with such
a large institution. And it is not a matter of surprise that the health of any
individual so circumstanced should eventually break down ; an event which we
greatly regret has occurred in the present instance.

Indications of the esteem in which Dr. Armstrong-Jones was held have been
unmistakably shown on the occasion of his retirement. He was the recipient of
an illuminated address from the Asylums Committee of the London County
Council, which conveys in generous terms a well-deserved tribute to his services
while in the asylum, along with an expression of sincere regret at the necessity for
his retirement. He was also presented with a handsome tea and coffee service by
the medical and lay staff of Claybury Asylum, and a number of the very numerous
patients yho are, or have been, under his care have expressed their regard for him
by the gift of a silver inkstand.

Dr. Armstrong-Jones has had a long and intimate connection with the Medico-
Psychological Association. He acted as General Secretary for nine years, 1897-
1906, and in the latter year he was elected to the Presidential chair, being thus
awarded the highest honour which it is in the power of the Association to bestow.
He has contributed valuable and interesting papers to various periodicals, including
our own Journal. While regretting his retirement from the asylum service, we
hope that his health may in time be fully reinstated, and that he may yet be in a
position to do useful work, and that his talents, his long experience, and his
versatility will not be lost to psychiatry and social progress.

OBITUARY.

Dr. J. St. L. Kirwan.

The death of Dr. Kirwan, late Medical Superintendent of Ballinasloe Asylum,
on August 8th, was as sudden as it was unexpected. He did not appear to have
been suffering from ill-health in any way, although it was stated at a meeting of
the Committee held subsequently to his death that for some time past his life was
uninsurable. It was only in May last that he returned to the asylum after
six months' service in connection with recruiting, having volunteered to assist
with his motor car in that department in the autumn of last year. On the
day of his death he was working in his office, and finding the heat there oppressive
he went to the front door in search of coolness. When conversing there with his
brother-in-law he complained of the sun being too hot, and withdrew into the
house in the direction of his office. Very shortly afterwards he was heard to fall
heavily, and when assistance arrived life was found to be extinct. His death was
apparently due to heat apoplexy.

Dr. Kirwan had filled the office of Medical Superintendent of Ballinasloe
Asylum for the preceding twelve years, having succeeded the late Dr. Fletcher
after having served some years as second assistant there. He seems to have
enjoyed the confidence of his Committee, the members of which, at a meeting held
shortly after the sad event, spoke in high terms of his ability, honesty, and
straightforwardness, and passed a resolution of sympathy with his bereaved
relatives. He has left a widow and one child to mourn his loss. Dr. Kirwan had
been a member of the Medico-Psychological Association since the year 1899.

ASYLUM ACCOMMODATION.

On August 21st Sir William Byles asked a question in the House as to the
amount of overcrowding in asylums, whether any further reduction was proceeding
•or was in contemplation, and what was the present proportion of doctors to
patients in the county asyulms which remained available for the care and
treatment of their original inmates. Mr. Brace said that the amount of over-
■crowding varied in different asylums, but intimated that on an average it might be

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NOTES AND NEWS.

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stated to be 17 per cent .—that was to say there were 117 patients in wards which
were normally intended for 100. The number of beds by which the total accommo¬
dation of county and borough asylums in England and Wales had been reduced
by the use of certain asylums as war hospitals was 15,750. No further reduction
of accommodation was now proceeding or in contemplation. The present pro¬
portion of doctors to patients in the county and borough asylums was 1 to 390.

THE LIBRARY.

Members of the Association are reminded that the Library at 11, Chandos-
Street, W., is open daily for reading and for the purpose of borrowing books.
Books may also be borrowed by post, provided that at the time of application
threepence in stamps is forwarded to defray the' cost of postage. Arrangements,
have been made with Messrs. Lewis to enable the Association to obtain books from
the lending library belonging to that firm should any desired book not be in the
Library. In addition, the Committee is willing to purchase copies of such books
as will be of interest to members. Certain medical periodicals are circulated
among such members as intimate their desire to be included in the list.

The Committee desire to acknowledge with thanks the donation by the author
of Organic to Human, Psychological, and Sociological, by Henry Maudsley, M.D.

Applications for books should be addressed to the Resident Librarian, Medico-
Psychological Association, 11, Chandos Street, Cavendish Square, W.

Other communications should be addressed to the undersigned at the City of
London Mental Hospital, Dartford, Kent.

R. H. Steen,

Hon. Secretary, Library Committee.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Acting General Secretary will be glad if Medical Superintendents and
other members will advise him of any service news with regard to members.
He wishes to keep a record of the names of members who have been wounded
or killed, or to whom military honours have been given.

NOTICES BY THE REGISTRAR.

Dates of Nursing Examinations.

Preliminary .... November 6th, 1916.

Final.November 13th, 1916.

NOTICES OF MEETINGS.

Quarterly Meetings: Tuesday, November 2ist, 1916, London; Thursday, Feb¬
ruary 15th, 1917; Tuesday, May 15th, 1917.

The Divisional Meetings are proposed as follows :

South-Eastern Division .—October 4th, 1916, at 11, Chandos Street, W.; and
April , 1917.

South-Western Division .—October 27th, 1916; April 27th, 1917.

Northern and Midland Division .—October 26th, 1916, at Wharncliffe War
Hospital, Sheffield ; and April 26th, 1917, at the County Asylum, Macclesfield.
Scottish Division .—November 17th, 1916; March 16th, 1917.

Irish Division .—November 2nd, 1916; April 5th, 1917; July 5th, 1917.

APPOINTMENTS.

Starkey, William, M.B., B.Ch., B.A.O., R.U.I., Medical Superintendent of
Plymouth Borough Asylum.

Mills, John, M.B., B.Ch., B.A.O., R.U.I., Medical Superintendent of Ballinasloe
District Asylum, vice Dr. J. St. L. Kirwan, deceased.

English, Adeline, M.B., B.Ch., B.A.O., R.U.I., First Assistant Medical Officer
of Ballinasloe Asylum.

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NOTICE TO CONTRIBUTORS.

N.B .—The Editors will be glad to receive contributions of interest, clinical
records, etc., from any members who can find time to write (whether these have
been read at meetings or not) for publication in the Journal. They will also feel
obliged if contributors will send in their papers at as early a date in each quarter
as possible.

Writers are requested kindly to bear in mind that, according to Lix(a) of the
Articles of Association, “ all papers read at the Annual, General, or Divisional
Meetings of the Association shall be the property of the Association, unless the
author shall have previously obtained the written consent of the Editors to the
contrary."

Papers read at Association Meetings should, therefore, not be published in other
Journals without such sanction having been previously granted.

LXII.

53

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INDEX TO VOL. LXII.

Part I.—GENERAL INDEX.

Aberdeen Asylum report, 436

Albumen content of the spinal fluid in its relation to disease syndromes, 428
Alcoholism, chronic, degeneration of the cerebral commissures and the hemi¬
spheres in, 218

Amentia, compluetic reaction in, 657 \

Annual meeting, 1916, 805

Antipathy, results of a questionary on, 611

Aphemia due to tumour of the right cerebral hemisphere, 803

Appointments, 239, 468, 828

Armstrong-Jones, Dr. Robert, retirement of, 826

Asylum accommodation, 827

„ County, conversion of a, into a war hospital, 1915, 109
„ reports, 429, 627

„ Workers’ Association, annual meeting, 639
Asylums, list of, converted into military hospitals, 123, 174
„ roll of honour, 467
Auditors, report of, 810

Balance sheet, 809
Ballinasloe asylum, 467
Ballinasloe Asylum inquiry, 651
Banning Heath Asylum report, 432
Barmwood Hospital report, 436

Bergson’s theory of the dualism of intelligence and instinct, 789
Biological point of view in psychology and psychiatry, 777
,, significance of delusions, 135
Binet-Simon method and the intelligence of adult prisoners, 214
Board of Control and the Council of the M.P. Association rt the shortage of
experienced male staffs in asylums, 455, 636, 820
„ „ first annual report for the year 1914, 399

Cairo Hospital for the Insane, Abassia, twenty-first annual report, 439

Catatonia as a type of mental reaction, 556

Causation, with a chapter on Belief, 1, 241

Cenaesthesia, movement, and the mind, 784

Cerebral associations of Raynaud’s disease, 730

,, cysts of cysticercus cellulosae (larvae of taenia solium), death due to, i*
case of status epilepticus, 180
Characters, diseases of, 804

Children between two and four years, delay and precocity in the development of,
7 8 3

Cholesterol content of serum in mental diseases, 168
Clinical neurology and psychiatry, 213, 428, 616, 792
„ notes and cases, 179, 411, 595

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832

^INDEX.

Colony treatment of epileptics, report of, 151

Compluetic reaction (Wassermann), in amentia, 657

Correspondence, 236, 465, 651

Council, report of, 806

Criminal trials, unfitness to plead in, 763]

Daughter’s destiny, father’s significance for the, 210
Delusions, biological significance of, 135
Dementia, arteriosclerotic, 612

„ praecox, characteristic attitude assumed by many cases of,[i79
„ „ crises in, 213

„ ,, manic-depressive insanity and, 622j

„ „ medico-legal aspect of, 787 5

„ „ observations on, 209

„ „ paraphrenia and paranoia, 215

Diet as a factor in the causation of mental disease, 505
Dorsetshire Asylum report, 429
Douglas, Dr. A. R., obituary, 225
Dreams, practical application of, 426

East Sussex County Asylum report, 435
Edinburgh, Morningside Asylum report, 437
Editors, report of the, 808
Educational Committee, report of, 8ioj^„,

Election of members, 225, 446, 813

Emotion of love, formation of the erotic complex in the, 205

Epilepsia tarda, or senile epilepsy, and arteriosclerotic dementia, study of, 612

Epilepsy, cerebral, pathogeny of essential, and, 618

Epileptic deterioration, clinical study of, 792

Epileptics, report of, following colony treatment, 151

Epitome of current literature, 203, 424, 609, 777 ,

Erythromelalgia and Raynaud's disease, 748
Essex County Asylum report, 430

Examination for nursing certificate: list of successful candidates, 233, 645

„ for nursing certificates: successful candidates (South Africa), 826
» •> 1, questions. May, 1916,644

„ nursing, November, 1915, resolutions, re, 235

Faulks, Lieut. Edgar, obituary, 225, 236

Federated Malay States, general paralysis of the insane in the, 411
Feeble-minded, National Association for the, report for 1915, 421
Female nurses, employment of, in male wards of mental hospitals in Scotland,
351, 416, 446
Fox, Dr., obituary, 445

Gaskell Memorial Prize Fund, balance sheet, 1911-1915, 811
Gateshead Borough Asylum report, 431
Glasgow, Gartnavel Asylum report, 438J
Govan Asylum report, 439

Hallucinations, diagnostic value of, 427 ’

1 , rile of, in the psychoses, 796

Heredity, Zola’s study of, 530
Hine, G. T., obituary, 635, 649

History, study of, from a psycho-pathological point of view, 609
Homosexuality, newer work upon, 209'

Honours, 806

Hospital " preparedness ” in England, 643T

Human Nature, dualism of, and its social conditions, 626

Hysterical phenomena, mechanism of, 378

Ideas, doctrine of association of, opposition to the, 780

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INDEX.

833

Inebriety, modern treatment of, 219
Infantile sexuality and the neuroses, 206
Infantilism, psycho-sexual, 207
Insane, male, female nursing of, 351, 416
Insanity, pathology of, 218
„ treatment of, 219, 624
Inverness Asylum report, 439

Ireland, sixty-fourth annual report of the Inspectors of Lunatics for the year ending
December 31st, 1914, 190
Irish Division meeting, 231, 460

Kellas, Capt. Arthur, death of, 225
Kent, Barming Heath Asylum, report, 432
Khanka Asylum, fourth annual report, 439
Kirwan, D. J. St. L., obituary, 827

Library Committee report, 812

„ of the Association, 467, 828
Love, emotion of, formation of the erotic complex in the, 205

Macfarlane, Dr. W. H., obituary, 465

Manic depressive insanity and dementia praecox, 622

Medical Psychological Association : special council to receive report re the
shortage of experienced male staffs in asylums, 453
Medico-legal aspect of dementia praecox, 787
Medico-Psychological Association meetings, 224, 443, 634

„ „ „ seventy-fifth annual meeting, 805

Meetings, dates of, 238, 468, 813 |

Members and officials of the M.P. Association, i-xxxii
Mental After-Care Association: report of the Council, 461
Mental and Nervous diseases, reaction time in, 698

„ defectives, tests to throw light on capacities of, 214
„ Deficiency Act, occasional notes on, 469
„ deficiency, cases of high grade, 485

„ deficiency, prostitution and, 222

„ disabilities for war service, 653

„ disease, diet as a factor in the causation of, 305
„ diseases, cholesterol content of serum in, 168
„ „ new classification of, 789

„ disorders in general hospital, treatment of, 624
„ „ use of nucleinate of soda in, 403

„ hospitals in Scotland, employment of female nurses in male'wards, 331,416

„ processes, physiological basis of, 424
„ reaction, catatonia as a type of, 556
Metropolitan Asylum Board report, 433

Military hospitals, use of asylums as, scheme of the Board of Control, 109, 116
i, „ asylums converted into, 123

1, „ use of asylums as, 174

Montrose Asylum report, 439
Moody, Sir James, obituary, 223
Moon, Surgeon G. B., obituary, 806
Morrison, Dr., obituary, 445, 463

Negroes, psychoses among, a comparative study, 223
Nervous and mental diseases, reaction time in, 698
„ debility, 620

„ system, integrative functions of the, 203

Neurasthenic element in disease, 618
Neuroses, infantile sexuality and the, 206

N omadism, or the wandering impulse, with special reference to heredity, 615
Northern and Midland Division meetings, 229, 639
N otes and news, 224, 445, 634, 805

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INDEX.

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*34

Notices by the Registrar, 238,468, 828
Notices of meetings, 238, 468, 813

Nucleinate of soda, its use in acute mental disorders, 403

Obituary.—Douglas, Dr. A. R., 225

Faulks, Lieut. E., 225, 236
Fox, Dr., 445
Hine, G. T., 635, 649
Kellas, Capt. A., 225
Kirwan, Dr. J. St. L., 827
Macfarlane, Dr. W. H., 465
Moody, Sir James, 225
Moon, Surg. G. B., 806
Morrison, Dr., 445, 463
O’Neill, Dr. E. D., 236, 445
Wiglesworth, 2nd Lieut. G., 806
Wisely, Dr. F., 225
Occasional notes, 182, 416
Occultism—a review, 200
Officers and Council, election of, 806
O'Neill, Dr. E. D., obituary, 236, 445

Paralysis, general, of the insane, in the Federated Malay States, 41X
Paraphrenia and paranoia, 215
Paresis, general, mental symptoms found in, 798
Parliamentary Committee, report, 812

Pathological findings in the sympathetic nervous system in the psychoses, 787
Pathology of insanity, 218

Personality in its relation to the hygiene of mind, 425
Phipps psychiatric clinic, review of the first year's work, 216
Physiological education, Slguin and, 720
„ psychology, 203, 424
Pragmatism and the problem of the idea, 775

President’s address: discussion on, asylum converted into war hospital, 225
Prisoners, adult, Binet-Simon method and the intelligence of, 214
Prostitution and mental deficiency, 222
Pseudologia phantastica, or pathological lying, 595
Psychiatric dispensary, the role of the : review of the Phipps clinic, 21$
Psychiatrists, our work as, and its opportunities: an address, 578
Psychiatry, clinical, 428

„ „ neurology and, 616

Psychical research, religious problem in, 779
Psychanalysis, criticism of, 204
Psychoanalysis, theory of, 607

Psychological phenomena, do they exist in the vegetable world, 610 t

Psychology and Psychopathology, 206, 425, 609, 777
„ experimental, and psycho-pathology, 2X2
„ physiological, 203, 424

Psycho-pathological point of view, study of history from a, 609
Psychopathology, psychology and, 206, 425
Psycho-sexual infantilism, 207
Psychoses among negroes ; a comparative study, 223
„ infective exhaustive, symptoms in the, 795
„ rbl* of hallucinations in the, 796

Rabbit’s brain, experimental toxic lesions in the, and their bearing on the genesis
of acquired idiocy in man, 635
Raynaud’s disease, cerebral associations of, 730
„ „ erythromelalgia and, 748

Reaction time in nervous and mental diseases, €98
Religious problem of psychical research, 779

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INDEX.

835

Report, 21st annual report of the Government Hospital for the Insane at Abatsia,
Cairo, and the fourth annual report on the asylum at Khanka, 439
„ of auditors, 810

„ of council, 806

„ of editors, 808

„ of Educational Committee, 810

„ final, of the Royal Commission on Venereal Diseases, 820
„ of Parliamentary Committee, 812

„ of Library Committee, 812

„ of Research Committee, 812

Reports: London County Council, 1914, 627
„ of asylums, 429
Research Committee, report, 812
Reviews, 184, 421, 599, 775
Royal Medical Benevolent Fund, 651

4

Schoolchildren, relative degrees of dulness and backwardness in, and their causa¬
tion, 394

Scotland, first annual report of the Board of Control for, 184

Scottish Division meetings, 230, 460

41 Secretes of Alexis,” a sixteenth century Psychiater, 363

Seguin and physiological education, 720

Serum, the cholesterol content of the, in mental diseases, 168

Sex complex, 605

Shame, 756

Sociology, 222, 626

South-Eastern Division meetings, 230, 638
South-Western Division meetings, 230, 638
Staffordshire County Asylum report, 434
Statistical intermission, a, 182

“Status epilepticus,” case of, and death due to cerebral cysts of cysticercus
cellulosae (larvse of Taenia solium), 180

Taenia solium, larvae of, case of " status epilepticus ” due to, 180
Temperament, inheritance of, 616
Tics, genesis and meaning of, 427

Tumour of the centrum ovale of the right pre-frontal lobe, 799
,, of the corpus callosum, diagnosis of, 803

Vegetable world? do psychological phenomena exist in the,610
Venereal diseases, Royal Commission on, abstract of final report, 820

War hospital, conversion of a county asylum into a, 109
War service, mental disabilities for, 653
Wassermann reaction in amentia, 657
Wigelsworth, 2nd Lieut. Godfrey, obituary, 806
Wisely, Dr. Francis, obituary, 225

York, the Retreat, report, 436

Zola’s study of heredity, 530

Part II.—ORIGINAL ARTICLES.

Adams, J. Barfield, Zola’s study of heredity, 530

Brush. Dr. Edward N., Presidential address: "Our work as Psychiatrists, and its
opportunities,” 578

Burpitt, Dr. H. R., relative degrees of dulness and backwardness in school
children and their causation, 394

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836

INDEX.

Cruickshank, Dr. J., and Tisdall, D. C. J., cholesterol content of serum in mental
diseases, 168

Devine, Henry, biological significance of delusions, 135

Donkin, Sir Bryan, occasional notes on the Mental Deficiency Act, 469

Dunn, Dr. Williamina Shaw, pseudologia phantastica of pathological lying, in a
case of hysteria with moral defect, 595

Griffiths, Dr. A. Hume, report of epileptics following colony treatment, com¬
municated by Sir George Savage, 151

Henderson, Dr. David K., catatonia as a type of mental reaction, 556

McDowall, Dr. Colin, nucleinate of soda: its use in acute mental disorders, 403

Mercier, Dr. Charles A., causation, with a chapter on belief, 1, 241

„ „ diet as a factor in the causation of mental disease, 505

Norman, Dr. Hubert J., cerebral associations of Raynaud’s disease, 730

„ „ " The Secrets of Alexis,” a sixteenth century Psychiater

3<53

Peachell, Dr. G. E., a case of " Status Epilepticus " and death due to cerebral
cysts of cysticerus cellulosae (larvae of Taenia solium), 180

Rae, Dr. James, on shame, 756

Redfield, Casper L., extracts from an address April 12th, 1916, before the
Zoological Department of the University of Chicago, 573

Robertson, Dr. George M., employment of female nurses in the male wards of
mental hospitals in Scotland, 351

Robertson, Dr. Jane J., cases of high grade mental deficiency, 485.

Salmon, Albert, mechanism of hysterical phenomena (trans. by T. Drapes), 378

Samuel, William F., general, paralysis of the insane in Federated Malay States,
411

Savage, Sir George, M.D., mental disabilities for war service, 653

Scripture, Dr. E. W., reaction time in nervous and mental disease, 698

Shuttleworth, Dr. George E., S£guin and physiological education, 720

Smith, D. M. Hamblin, unfitness to plead in criminal trials, 763

Steen, Dr. R. H., a characteristic attitude assumed by many cases of dementia
praecox, 179

Stephens, Harold Freize, compluetic reaction (Wassermann) in amentia an
original study of 100 cases, with discussion on, 657

Thomson, Lieut.-Col. D. G., M.D., descriptive record of the conversion of a
county asylum into a war hospital for sick andjwounded^soldiers in 1915, 109

Tisdall, Dr. C. J., see Cruikshank, Dr. J.

Vincent, Lieut.-Col. Wm., M.D., use of asylums as military hospitals, 174

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INDEX.

837

PART III.—REVIEWS.

*

Bell, Dr. W. Blair, The Sex Complex, 1916, 605

Driscoll, Rev. John T., Pragmatism and the Problem of the Idea, 775

First Annual Report of the Board of Control for the year 1914, 599 v

First Annual Report of the General Board of Control for Scotland, 184

Healy, Dr. William, The Individual Delinquent, 1915, 194

Jung, Dr. C. G., Collected papers on Analytical Psychology, translated and edited
by Dr. Constance E. Long, 1916, 776
„ C. G., Theory of Psychoanalysis, 1915,607

McDougall, William, F.R.S., An Introduction to Social Psychology, ninth edition,
1915,602

National Association for the Feeble-minded: Annual Conference Report, 1915,
421

Occultism—a Review, 200

Ogden, Robert Morris, Introduction to General Psychology, 1914, 199

Ricklin, Dr. Franz, Wishfulfilment and Symbolism in Fairy Tales (translated by
Dr. W. A. White), 1915, 422

Sixty-fourth Report of the Inspectors of Lunatics (Ireland) for the year ending
December 31st, 1914, 190

Stoddart, Dr. W. H. B., The New Psychiatry, 1915, 197
Valentine, C. W., Introduction to Experimental Psychology, 200

Part IV.—AUTHORS REFERRED TO IN THE EPITOME.

Abbott, E. Stanley, 777
Acqua, C., 610
Austregesilo, 620

Bignami, 218
Bolten, G. C., 618
Boriac, E., 779
Brown, Sanger, 795
Buscaino, 803
Burr, Dr. C. W., 204

Campbell, Dr. C. Macfie, 216
Clark, Pierce, 209
Clarke, Walter, 222
Collin, Dr. Andr£, 783
Craig, James, 618

Davenport, C. B., 615, 616
Dearborn, George Van
Ness, 784

Delage, Yves, 424, 426
Dercum, D. F. X., 204
De Sarlo, 61»

Dugas, L., 780

Durkheim, 626

Fanciulli, 611
Fiessinger, Dr. Ch., 804

Giannuli, Dr. F., 799
Green, E. M., 223

Haiberstadt, 213
Harrison, Dr. F. M., 796

Juliusburger, O., 207

Kempf, Dr. E. J., 203
Knapp, Dr. P. C., 624
Kostyleff, 205

Laumonier, Dr. J., 206
Legrand, 213
Lombroso, Dr. Gina, 789

MacCurdy, 792
Marshall, Dr. R. M., 622
Morselli, E., 212

Myerson, A., 428, 787

Nazari, 218
Neff, Irwin H., 219

Potts, W. A., 214
Proal, L., 609

Ruby, G. H., 215

Sadger, J., 210
Salvatore, Professor, 787
Smith H. Hamblin, 214
Solomon, Meyer, 427
Southard, E. E., 798
Stearns, A. W., 427

Treadway, W. L., 209

Warnoch, Dr. John, 441
Wells, F. L., 425

Ziveri, Alberto, 612

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838

INDEX.

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ILLUSTRATIONS.

Drawings and tables to illustrate Dr. Scripture’s paper, 701, 703, 705-719

Drawings to illustrate Dr. Shuttleworth’s paper, 726-9

Genealogical tree to illustrate Mr. J. Barfield Adams’s paper, 534

Photograph of G. T. Hine, F.R.I.B.A., 469

Photograph to illustrate Dr. Robertson’s paper, 352

Photographs „ Dr. Steen’s paper, 178

Tables to illustrate Dr. Cruikshank’s and Dr. Tisdall’s paper, 172, 173

Tables „ Dr. A. Hume Griffith’s paper, 151-67

Tables „ Mr. H. F. Stephens’s paper, 670-4, 676, 677, 682,683,686,

689,694

"A

"T

ADLARD AND SON AND WEST NEWMAN, IMPR., LONDON AND DORKING.

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY