Journal Of Mental Science 64.1918 Princeton

The journal of mental science.

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

http://hdl.handle.net/2027/nj p.32101074924133

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

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THE JOURNAL

OF

MENTAL SCIENCE.

EDITORS :

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

Assistant Editors:

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

VOL. LXIV.

LONDON:

J. & A. CHURCHILL,

7, GREAT MARLBOROUGH STREET.

MDCCCCXVI1I.

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Original from

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 highei
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. Bucknill,
M.D., F.N.S.

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PRINCETON UNIVERSITY

THE

MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

THE COUNCIL AND OFFICERS, 1917-18.

president.— DAVID GEORGE THOMSON, M.D.
PRESIDENT ELECT. —JOHN KEAY, M.D.
bx-pkebidbnt and treasurer. —JAMES CHAMBERS, M.A., M.D.

( JOHN R. LORD, M.B.

EDITORS OP JOURNAL. | r, DRAPES, M.B.

DIVISIONAL SECRETARY POH SOUTH-EASTERN DIVISION.

J. NOEL SERGEANT, M.B.

DIVISIONAL SECRETARY POR SOUTH-WESTERN DIVISION.

G. N. BARTLETT, M.B.

DIVISIONAL SECRETARY POR NORTHERN AND MIDLAND DIVISION.

T. STEWART ADAIR, M.D.

DIVISIONAL SECRETARY FOR SCOTTISH DIVISION.

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

DIVISIONAL SECRETARY FOR IRISH DIVISION.

RICHARD R. LEEPER, P.R.C.S.

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

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

CHAIRMAN OF PARLIAMENTARY COMMITTEE.

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

SECRETARY OF PARLIAMENTARY COMMITTEE.

R. H. COLE, M l)., F.R.C.P.

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

SECRETARY OF EDUCATIONAL COMMITTEE.

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

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

MKMHBRS OF COUNCIL.

REPRESENTATIVE.

R. ARMSTRONG-JONES
H. J. NORMAN
T. E. K. STANS FIELD
W. H. B. STODDART
NORMAN LAVERS
H. T. S. AVELINE
J. GEDDES
D. HUNTER
C. C. EASTERBROOK
It. L. OSWALD

jS.E. Div.

}S.W. Div.
}N.&M. Div
|Scotland.

REPRESENTATIVE.

F. E. RAINSFORD *
J. MILLS /

Ireland.

NOMINATED.

HELEN BOYLE
GEOFFREY CLARKE
RICHARD EAGER

F. W. MOTT
DAVID ORK

G. E. SHUTTLEWORTH

[The abore form the Council.]

ENGLAND'S

EXAMINERS.

fj G. PORTER- PHILLIPS, M.D., B.S., M.R.C.P.Lond.,
.ndt M.P.C.

I R. H. STEEN, M.D., M.R.C.P.

I JAMES H. MACDONALD, M.B., ChB.. F.R.F.P.S.Glasg.
Scotland | H> de M ALEXANDER, M.D., C.M.Edin.

(F. E. RAINSFORD, M.D., B.A.Dubl., L.R.C.P.I.
IRELAND- L.RC.P.&S.E.

(m. J. NOLAN, L.R.C.P.&S.I., M.P.C.

Examiners for the Nursing Certificate of the Association :
final- R. B. CAMPBELL, M.D., F.R.C.P.E.; J. REDING TON, F.R.C.S.,
L.R.C.P.I.; HENRY DEVINE, M.D., B.S., M.R.C.P., M.R.C.S., M.P.C.
Preliminary —DAVID ORK, M.D., C.M.Edin.; GEORGE DUNLOP ROBERTSON,
LB.C.S. & P.Edin!, Dipl. Psych.; A. W. DANIEL, B.A., M.D.,

B.C.Cantab., M.K.C.S., L.R.C.P.Lond. 4

AUDITORS.

MAURICE CRAIG, M.A., M.D., F.R.C.P. F.

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

X

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PRINCETON UNIVERSITY

11

PARLIAMENTARY COMMITTEE.

T. S. ADAIR.

SIR R. ARMSTRONG-JONES.

H. T. S. AVELINE.

FLETCH ER BEACH.

E. H. RERESFORI).

JAIMES V. BLACHFORD.
DAVID BOWER.

LEWIS C. BRUCE.

R. B. CAMPBELL.

JAMES CHAMBERS.

R. H. COLE.

M. A. COLLINS {ex officio).

J. O’C. DON ELAN.

THOS. DRAPES.

J. R. GILMOUR.

P. T. HUGHES.

D. HUNTER.

THEO. B. HYSLOP.

N. T. KERR.

R. L. LANGDON-DOWN.

R. R. LEEPER.

J. II. LORD.

P. W. MACDONALD.

T. W. McDOWALL.

W. F. MENZ1ES.

CHAS. A. MERCIER.
JOHN MILLS.

W. F. NELIS.

M. J. NOLAN.

JAMES ORR.

BEDFORD PIERCE.
HENRY RAYNER.

G. M. ROBERTSON.

SIR GEO. H. SAVAGE.

G. £. SHUTTLEWORTH.
R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE SPENCE.
T. E. K. STANSFIELD.
R. H. STEEN.

ROTHSAY C. STEWART.

F. R. P. TAYLOR.

DAVID G. THOMSON.
ERNEST W. WHITE.

J. R. WIIITWELL.

H. WOLSELEY-LEW1S.

EDUCATIONAL

T. S. ADAIR.

H. df M. ALEXANDER (ex officio).

3. SIR R. ARMSTRONG-JONES.

H. T. S. AVELINE.

FLETCHER BEACH.

J. V. BLACHFORD.

1. J. S. BOLTON.

LEWIS C. BRUCE.

R. B. CAMPBELL.

22. JAMES CHAMBERS.

18. R. H. COLE.

M. A. COLLINS (ex officio).

2. MAURICE CRAIG.

A. W. DANIEL (ex officio).

H. DEVINE.

J. FRANCIS DIXON.

10. J. O’C. DONELAN.

THOS. DRAPES.

J. R. GILMOUR.

17. B. HART.

16. P. T. HUGHES.

12. JOHN KEAY.

N. T. KERR.

R. R. LEEPER.

13. J. h. Macdonald.

P. W. MACDONALD.

4 THOS. W. McDOWALL.

15. W. TUACII MACKENZIE.

21. E. D. MACNAMARA.

8. R. MACPHAIL.

W. F. MENZ1ES.

COMMITTEE.

C. A. MERCIER.

JAMES MIDDLEMASS.
ALFRED MILLER (ex officio).
W. F. NELIS.

MICHAEL J. NOLAN.

25. H. J. NORMAN.

DAVID ORR.

JAMES ORR.

5. L. R. OSWALD.

23. J. G. PORTER PHILLIPS.
BEDFORD PIERCE.

F. E. RA1NSFORD (ex officio.)
J. REDINGTON (ex officio.)

14. WILLIAM REID (Aberdeen).

G. 1). ROBERTSON (exofficio).

6. GEORGE M. ROBERTSON.

R. G. ROWS.

20. W. SCO WCROFT.

G. E. SHUTTLEWORTH.

R. PERCY SMITH.

J. G. SOUTAR.

J. BEVERIDGE SPENCE.

T. E. K. STANSFIELD.

7. ROBERT’ H. STEEN.

8. W. H. B. STODDART.
FREDERICK R. P. TAYLOR.
DAVID G. THOMSON.

19. W. R. VINCENT.

24. J. K. WILL

H. WOLSELEY-LEWIS.

9. JAMES COWAN WOODS.

LIBRARY COMMITTEE.

FLETCHER BEACH.
HELEN BOYLE.

M. A. COLLINS (ex officio).
HENRY DEVINE.
BERNARD HART.

THEO. B. HYSLOP.

E. MAPOTIIER.

HENRY HAYNER (Chairman).
R. H. STEEN (Secretary).

W. H. B. STODDART.

DAVID G. THOMSON (ex officio).

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PRINCETON UNIVERSITY

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RESEARCH COMMITTEE.

T. STEWART ADAIR.

J. SHAW BOLTON.

J. CHAMBERS.

M. A. COLL1N8 ( ex-officio )
H. DEVINE.

T. DRAPES.

E. GOODAI.L.

JOHN KEAY.

J. R. LORD.

DAVID ORR.

FORD ROBERTSON.

R. G. ROWS.

R. PERCY SMITH.

R. H. STEEN.

D. G. THOMSON {ex-officio).
W. J. TULLOCH.

Lectures at:—(1) University of Leeds, (2) Guy’s Hospital; (3) St. Bartholomew’s
Hospital; (4) University of l)urhum; (5) University of Glasgow; (61 University of
Edinburgh and Medical College for Women, Edinburgh; (7) King’s College Hospital;
(8) St. Thomas's Hospital; (9) St. George’s Hospital; (101 University of Dublin and
National University of Ireland ; (11) Queen's University of Belfast; (12) Lecturer at
School of Medicine, Royal Colleges and Medical College for Women, Edinburgh;
(13) St. Mungo's College, Glasgow; (14) Aberdeen University; (15) St. Andrew’s
University and Dundee University; (16) Birmingham University; (17) University
College, London ; (18) St. Mury’s Hospital, London; (19) University of Sheffield;
(20) Victoria University, Manchester; (21) Charing Cross Hospital; (22) Middlesex
Hospital; (23) Royal Free Hospital; (24) London Hospital; (25) Westminster
Hospital.

LIST OF CHAIRMEN.

1841. Dr. Blake, Nottingham.

1842. Dr. de Vitre, Lancaster.

1843. Dr. Conolly, Hauwell.

1844. Dr. Thurnam, York Retreat.

1847. Dr. Wintle, Warneford House, Oxford.

1851. Dr. Conolly, Hanwell.

1862. Dr. Wintle, Warneford House.

LIST OF PRESIDENTS.

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

1855. J. Thurnam, M.D., Wilts County Asylum.

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

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

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

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

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

1861. Joseph Lalor, M.D., Richmond Asylum, Dublin.

1862. John Kirkman, M.I)., Suffolk County Asylum.

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

1864. Henry Munro, M.I)., Brook House, Clapton.

1866. 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., Sandy well Park, Cheltenham.

1869. T. Laycock, M.D., Edinburgh.

1370. Robert Boyd, M.I)., County Asylum, Wells.

1871. Henry Maudsley, M.I)., The Lawn, Hanwell.

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

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

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

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

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

1877. G. Fielding Blandford, M.D., London.

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

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

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

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IV

1881.

1882.

1883.

1884.

1885.

1886.

1887.

1888.

1889.

1890.

1891.

1892.

1893.

1894.

1895.

1896.

1897.

1898.

1899.

1900.

1901.
1902

1903.

1904.

1905.

1906.

1907.

1908.

1909.

1910.

1911.

1912.

1913.
1914-

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

Sir W. T. Gairdner, M.D., Glasgow.

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

Henry Rayner, M.D., County Asylum, Hanwell.

J. A. Eames, M.D., District Asylum, Cork.

Sir Geo. H. Savage, M.D., Bethlem Royal Hospital.

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

Sir T. S. Clouston, M.D., Royal Edinburgh Asylum.

H. Hayes Newington, F.R.C.P., Ticehurst, Sussex.

David Yellowlees, M.I)., Gartnavel Asylum, Glasgow.

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

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

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

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

David Nicolson, C.B.,M.D., State Criminal Lunatic Asylum, Broadmoor.
William Julius Mickle, M.D., Grove Hall Asylum, Bow.

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

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

J. B. Spence, M.D., Burntwood Asylum, nr. Lichfield, Staffordshire.
Fletcher Beach, M.B., 79, Wimpole Street, W. 1.

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

J. Wigleswortli, M.D., F.R.C.P., Rainliill Asylum, near Liverpool.
Erne8tW. White, M.B.,M.R.C.P.,City of London Asylum, Dartford, Kent.
R. Percy Smith, M.D., F.R.C.P., 36, Queen Anne Street, Cavendish
Square, Loudon, W. 1.

T. Outtersou Wood, M.D., F.H.C.P., 40, Margaret Street, Cavendish
Square, London, W. 1.

Robert Armstrong-Jones, M.D.Lond., B.S., F.R.C.P., F.R.C.S.Eng.,
Claybury Asylum, Wood lord Bridge, Essex.

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

Chas. A. Mercier, M.D., F.R.C.P., F.R.C.S., 34, Wimpole Street, London,
W. 1.

W. Bevan-Lewis, M.Sc., L.It.C.P., late Medical Director, West Riding
Asylum, Wakefield; Elsinore, Dyke Road Avenue, Brighton.

John Macpherson, M.D., F.R.C.P.Edin., Commissioner in Lunacy, 8,
Darnaway Street, Edinburgh.

Wm. R. Dawson, B.A., M.D., F.R.C.P.I., D.P.H., Inspector of Lunatic
Asylums, Dublin Castle, Dublin.

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

James Chambers, M.I)., M.Ch., The Priory, Roehampton, S.W.

David G. Thomson, M.I)., C.M.Edin., County Asylum, Thorpe, Norfolk.

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Honorary and Corresponding Members,

▼

HONORARY MEMBERS.

1896. Allbutt, Sir T. Clifford, K.C.B., M.D., D.Sc., LL.D., F.R.C.P., F.R.S.,

Regius Professor of Physic, Univ. Climb.. St. Radegund’s, Cambridge.
1881. Benedikt, Prof. M., Franciskaner Platz 6, Vienna.

1907. Bianchi, Prof. Leonardo, Manicomio Provinciale di Napoli. Musee N. 3,
Naples, Italy. ( Corr. Mem., 1896.)

1900. Blumer, G. Alder, M.D., L.R.C.P.Edin., Butler Hospital, Providence,
U.S.A. (Ord. Mem., 1890.)

1900. Bresler, Johannes, M.D., Oherurtzt, Liiben in Sclilesien, Germany.

(Corr. Mem. 1896.)

1881. Brosius, Dr.,

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

1887. Chapin, John B., M.D., Canandaigua, N.Y., U.S.A.

1917. Colies, John Mayne, LL.D. (Univ. Dub.), K.C., J.P., Registrar in Lunacy
(Supreme Court of Judicature in Ireland), Lunacy Office, Four
Courts, Dublin.

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

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. Coupland, Sidney, M.D., F.R.C.l’.Lond., Commissioner of the Board of
Control, 16, Queen Anne Street, Cavendish Square, London, W. 1.
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. 2..
and 45, Hans Place, S.W. 1. (Pbesidknt, 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. 2.

1879. Echeverria, M. G., M.D.

1895. Ferrier, Sir David, M.A., M.D., LL.D., F.R.C.P., F.R.S., 34, Cavendish
Square, Loudon, W. 1.

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

1909. Kraepelin, Dr. Emil, Professor of Psychiatry, The University, Munich.
1887. Lentz, Dr., Asile d’Alien6s, Tournai, Belgique.

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

Darnaway Street, Edinburgh. (Pbbsident, 1910-11.) (Ordinary

Member from 1886.)

1912. Maudsley, Henry, LL.D.Edin., (Hou.), M.D.Lond., F.R.C.P.Lond..

Heathbourne, Bushcy Heath, Herts. (Pbksidbnt, 1871.) (Formerly
Editor, Journal of Mental Science.)

1911. Moeli, Prof. Dr. Karl, Director, Herzberge 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.R.C.S.Eng.,
Commissioner of the Board of Coutrol, 19, Campdeu Hill Square,
Kensington, VV. 8. (Pbbsident, 1887.)

1909. Obersteiner, Dr. Heinrich, Professorof Neurology, The University, Vienna.
1881. Peeters, M., M.D., Glieel, Belgium.

1900. Ritti, Ant., 68, Boulevard Exelmans, Paris. (Corr. Mem., 1890.)

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

1911. Semelaigne, Rene, M.D.Paris, Secretaire des Seances de la Soci6t£
Medico-Psychologique de Paris, 16, Avenue de Madrid, Neuilly,
Seine, France. (Corresponding Member from 1893.)

1881. Tamburini, A., M.D., Reggio-Emilia, Italy.

1901. Toulouse, Dr. Edouard, Directeur du Laboratoire de Psychologic experi¬

mental k l’Ecole des Hautes Etudes Paris et Medecin en chef de
l’Asile de Villejuif, Seine, France.

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VI

1910. Trevor, Arthur Hill, B.A.Oxon., of the Iuner Temple, Barrister at Law,
Commissioner of the Board of Control, 4, Albemarle Street, London,
W. 1.

1917. Urquhart, Alexander Reid, The late, M.D.Aber., LL.D.Aber., F.R.C.P.

Edin., late Physician Superintendent, Jame9 Murray’s Royal Asylum,
Perth. [Died August, 1917.]

CORRESPONDING MEMBERS.

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

1911. Boedeker, Prof. Dr. Justus Karl Edmund, Privat Docent and Director,
Fichhenhof Asylum, Schlactensee, Berlin.

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

1904. Caroleh, Wilfrid, Manicomia de Sta. Crur, St. Andreo de Palamar,
Barcelona, Spain.

1896. Cowan, F. M., M.D., 107, Perponcher Straat, The Hague, Holland.

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

1911. Falkenberg, Dr. Wilhelm, Oberarzt, Irrenanstalt, Herzberge, Berlin.

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

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

1904. Koenig, William Julius, Deputy Superintendent, Dalldorf Asylum, Berlin.

1880. Kornfeld, Dr. Hermann, Fr. Schlesien, Hauptpostluyerstr., Breslau.

1889. Kowalowsky, Professor Paul, KharkofF, Russia.

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

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

1909. Moreira, Dr. Julien, M.D.Bahia, Professor and Director of the National
Manicomium of Rio de Janeiro ( Editor of the Brazilian Archive$ oj
Ptychiatry, etc.).

1886. Parent, M. Victor, M.D., Toulouse.

1909. Pilcz, Dr. Alexander (Professor of Psychiatry in the University of
Vienna), Superintendent Landcssanatorium furNerven und Geistes-
kranke Steinhof, Vienna.

1890. R6gis, Dr. E., 54, Rue Huguerie, Bordeaux.

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Members of the Association.

vri

MEMBERS OF THE ASSOCIATION.

Alphabetical List of Members of the Association on December 31 st, 1917, 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.Ircl., Medical Superin¬
tendent, Hants County Asylum, Farehaui.

1891. Adair, Tliomas Stewart, M.U., C.M.Edin., F.R.M.S., Medical Superin¬
tendent, Storthes Hall Asylum, Kirkburton, near Huddersfield.
(Hon. Sec. N. and M. Division since 1908.)

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

1913. Adams, John Barfield, L.R.C.P.iS.Edin., M.P.C., 119, Jledland Road,
Bristol.

1868. Adams, Josiab O., M.D.Durh., F.R.C.S.Eng., J.P., 117, Cazenove Road,

Stamford Hill, N. 16.

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

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

Plympton, Devon.

1899. Alexander, Hugh de Maine, M.D., C.M.Edin., Medical Superintendent,
Aberdeen City District Asylum, Kingseat, Newmachar, Aberdeen.
1899. Allmatin, Dorah Elizabeth, M.B., B.Ch.R.U.I., Assistaut Medical Officer,
District Asylum, Armagh.

1908. Andersou, James Richard Sumner, 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. fAnuandale, James Scott, M.B., Ch.B.Edin., Second Assistant Physician,
District Asylum, Murthly, Pertli; R.A.M.C.

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

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

1904. fArchdale, Mcrvyn Alex., M.B., B.S.Durh., (Medical Superintendent, East

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

1905. Arcbdall, Mervyn Thomas, L.R.C.P.&S.Edin., L.S.A.Lond., Brynn-y-

Nenadd Hall, Llanfairfechan, N. Wales.

1882. fArmstrong-Jones, Sir Robert, M.D.Lond., B.S., F.R.C.P., F.R.C.S.Eng.,
9, Bramhain Gardens, S.W. (and Pills Dinas, Carnarvon, North
Wales; Hon. Major R.A.M.C. (Oen. Secretary from 1897 to 1906.)
(Prbsidint 1906-7.)

1910. fAudeu, 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); Captain R.A.M.C. (T.) on active service.

1891. 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. (Hon. Sec. for S.W. Division, 1905-11.)

1903. Bailey, William Henry, M.D.Lond.. M.R.C.S.Eng., L.S.A., D.P.H.Lond.
Featlierstone Hall, Southall, Midd.

1894. Baily, Percy J.. M.B., C.M.Edin., 24, Barrack Road, Bexhill-on-Sea.

1909. fBain, John, M.A., M.B., B.Ch.Glasg.; Lt. R.A.M.C. (address uncom-

municated).

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

Assistant Medical Officer, Devon County Asylum, Exeter.

1906. Baird, Harvey, M.D., Ch.B.Edin. (Peritcnu, Winchelsea, Sussex);

Lieut. R.A.M.C.

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Members of the Association.

1878. Baker, H. Morton, M.B., C.M.Edin.,7, Belsize Square, London, N.W.3.
1888. Baker, John, M.D., C.M.Aberd., Medical Superintendent, State Asylum,

Broadmoor, Berks.

1916. fBallard, E. F. (13, Lyndliurst Road, Hove, Sussex); Capt. E.A.M.C. {T .)
1904. Barham, Guy Foster, M.A.. M.L)., B.C.Cantab., M.It.C.S., L.ll.C.P.Lond.,

Acting Medical Superintendent, Claybury Asylum, Woodford
Bridge, Essex.

1913. fBarkley, James Morgan, M.B., Cli.B.Edin. (Senior Medical Officer,
Bracebridge Asylum, Lincolnshire); c/o l)r. J. B. Hunter, Brace-
bridge Heath, Lincoln ; Capt. E.A.M.C.

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

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

Capt. E.A.M.C. ; attd. 43 E.G.A.

1902. Baugh, Leonard I). H., M.B., Cli.B.Edin., The Pleasaunce, York.

1874. Beach, Fletcher, M.B., F.R.C.P.Loud., formerly Medical Superintendent,

Harenth Asylum, Hartford ; Cane Hill, Coulsdon, Surrey. ( Secre¬
tary Parliamentary Committee, 1896-1906. General Secretary,
1889-1896. Phesident, 1900.)

1892. Bendles, Cecil F., M.R.C.S., L.R.C.P.Lond., Gresham House, Egharn Hill.
Eg ham.

1902. Beale-Browne, Thomas Richard, M.R.C.S.Eng., L.R.C.P.Lond., c/o
P.M.O. Lngos, Nigeria, West Africa.

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

caster.

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

1914. fBennett, James Wodderspoon, M.R.C.S., L.R.C.P.Lond. (Marsden, Ilkley,

Yorks); Capt. E.A.M.C., 10th Batt., Dnkeof Wellington W.R.R.
1912. Benson, Henry Porter D’Arcy, M.D., C.M.Edin., M.R.C.P., F.R.C.S.

Edin., Medical Superintendent, Farnhaui House, Finglas, Dublin.
1914. fBenson, John Robinson, F.lt.C.S.Eng., L.R.C.P.Lond., Resident Physi¬
cian and Proprietor, Fiddington House, Market Lavington, Wilts.

1899. Beresford, Edwyn H., M.It.C.S., L.R.C.P.Lond., Medical Superintendent,

Tooting Bee Asylum, Tooting, S.W. 17.

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

Officer, Croydon Mental Hospital, Warlingliam, Surrey.

1879. Bevnn-Lewis, William, M.Sc.Leeds, M.R.C.S., L.R.C.P.Lond., Elsinore,

Dyke Ron ! Avenue, Brighton. (Puesident, 1909-10.)

1894. tBlacbford, James Vincent, M.D., B.S.Durh., M.It.C.S., L.R.C.P.Lond.,
M.P.C. (City Asylum, Fishponds, Bristol); Lt.-Col. E.A.M.C.,
Beaufort War Hospital, Bristol.

1913. Black, Robert Sinclair, M.A.Edin., M.D., C.M.Aberd., D.P.H., M.P.C.,

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

1898. Blair, David, M.A., M.I)., C.M.Gla«g., Couuty Asylum, Lancaster.

1897. Bland ford, Joseph John Guthrie. B.A., D.P.H.Camb., M.R.C.S., L.R.C.P.
Lond.; Rainhill Asylum, Lancashire.

1904. Bodvel-Roberts, Hugh Frank, M.A.Cantab., M.It.C.S., L.R.C.P.Lond.,
L.S.A..Middlesex County Asylum, Napsbury, near St. Albans, Herts.

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

intendent, West Riding Asylum, Wakefield.

1892. Bond, Charles Hubert, D.Sc., M.D., C.M.Edin., M.It.C.P.Lond., M.P.C.,
Commissioner of the Board of Control, 6(i, Victoria Street, S.W. 1.
{Hon. General Secretary, 1906-12.)

1877. Bower, D.ivid, M.I)., C.M.Aher., Springfield House, Bedford. {Chairman
Parliamentary Committee, 1907-1910.)

1877. Bowes, John Ireland, M.R.C.S.Eng., L.S.A. (address uneommnnicated.)

1917. fBowie, Edgar Ormond, L.A.H.Dub., Dip. Grant Med. Coll. Bombay,

L.M.Coombe, Dublin; Lieut. I.M.S. (T.); e/o W. H. Hallibur¬
ton, Esq., 18, South Frederick Street, Dublin.

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IX

Bowles, Alfreil, M.R.C.S., L.R.C.P.Lond., 10, South Cliff, Eastbourne.
Boycott, Arthur N., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Medical
Superintendent, Herts County Asylum, Hill End, St. Albans, Herts.
(Hon. Sec. for S.-E. Division, 1900-05.)

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

Boys, A. H., L.R.C.P.Edin., M.R.C.S.Eng., L.S.A.Loud., The White
House, St. Albuns.

Braine-Hsrtnell, George M. P., M.R.C.S., L.R.C.P.Lond., Medical
Superintendent, County and City Asylum, Powick, VVorcester.
Brander. John, M.E., C.B.Edin., Assistant Medical Officer, London
County Asylum, Bexley, Kent.

1906. fBrown, Harry Egerton, M.l)., Ch.B.Glasg., M.P.C. (Mental Hospital,
Fort Beaufort, Cape Province, S. Africa) Major, 8. A. Medical Corps.
1908. fBrown, RobertCunyugham, M.D., B.S.Durh. (General Board of Lunacy,
25, Palmerston Place, Ediubnrgh); Major, R.A.M.C., Administrator,
Springlmrn and Woodside Central Hospital, Glasgow.

1908. Brown, R. Dods, M.D., Ch.B., F.R.C.P., Dipl. Psych., D.P.H.Edin.,
Physician Superintendent, James Murray’s Royal Asylum, Perth.

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.,T., 2nd Southern General Hospital,
Southmead, Bristol.

191G. Brown, William, M.A., M.B., B.Ch.Oxon., D.Sc.Lond., Reader in
Psychology iu the University of London (King’s College), (King’s
College, Strand, W.C. 2). Capt. R.A.M.C.

1917. fBruce, Alexander Ninian, M.D., D.Sc., F.R.C.P.E., Lecturer on Ncuro-
logy. University of Edinburgh, 8, Aiuslie Place, Edinburgh; Capt.
(Temp.) R.A.M.C.

1893. fBruce, Lewis C., M.D., F.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 1911-1916; Hon. Sec. for Scottish Division, 1901-1907.)

1913. fBrunton, George Llewellyn, M.D., Ch.B.Edin. (North Riding Asylum,

Clifton, York); temp. Lt., R.A.M.C., 2nd Cavalry Field Ambulance,
British Expeditionary Force, France.

1912. fBuchanan, William Murdoch, M.B., Ch.B.Glas., Kirklands Asylum,

Bothwell, Lanarkshire. Temp. Lient. R.A.M.C.

1908. Bullmore, Charles Cecil, J.P., L.R.C.P.&S.Edin., L.R.F.P.&S.Glas.,

Medical Superintendent, Flower House, Catford.

1911. Buss, Howard Decimus, B.A., B.Sc.France, M.D.Brux.ACnpe, M.R.C.S.,
L.R.C.P., L.M.S.S.A.Lond., Assistant Medical Officer, Fort
Beaufort Asylum, Cape Colony.

1910. fCahir, John P., M.B., B.Ch.R.U.I., 198, Camberwell New Road, Camber¬
well, S.E.5; Lieut. R.A.M.C.

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

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

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

1894. Campbell, Alfred Walter, M.D., C.M.Ediu., M.P.C., Macquarie Chambers,

183, Macquarie Street, Sydney, New South Wales.

1909. fCampbell, Donald Graham, M.B.,'C.M.Edin. (•’Auchinellan,” 12, Reid-

haven Street, Elgiu); Major R.A.M C. (T.) on active service.

1914. fCampbell, Finlay Stewart, M.D., C.M.Glas., Deputy Director of Medical

Services, Ministry of National Service, Ayr, Scotland.

1880. Campbell, Patrick E., M.U., C.M.Edin., Medical Superintendent, Metro¬
politan Asylum, Caterham, 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.)

1900.

1896.

1898.

1883.

1891.

1911.

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Members of the Association.

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.Glnsg., 43, Moray Place,

Edinburgh ; Commissioner-General, Board of Control, Scotland.
1874. Cassidy, D. M., M.D., C.M.McGill Coll., Montreal, D.Sc. (Public
Health) F.R.C.S.Edin., Medical Superintendent, County Asylum,
Lancaster; E.A.M.C.

1888. Chambers, James, M.A., M.D.R.U.I., M.P.C., The Priory, Roehampton,
S.W. 15 ( Co-Editor of Journal 1905-1914, Assistant Editor
1900-05.) (Pbksident, 1913-14.) {Treasurer, 1917.)

1911. fChambers, Walter Dnncauon. M.A., M.I)., Ch.B.Edin., M.P.C., Capt.

E.A.M.C., Inniskillings (address uncommunicated).

1865. Chapman, Thomas Algernon, M.D.Glas., L.R.C.S.Edin., F.Z.S., Betula,
Reigate.

1915. Ckeyne, Alfred William Harper, M.B., Ch.B.Aber., Assistant Medical
Officer, Royal Asylum, Aberdeen.

1917. Chisholm, Percy, L.R.C.P. AS.Edin., Assistant Medical Officer, Stirling
District Asylum, Larbert.

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

1880. Christie, J. VV. Stirling, L.R.C.P.&S.Edin., Medical Superintendent,
Countv Asylum, Stafford.

1878. Clapham, Win. Crochley S., M.D., F.R.C.P.Ed., M.R.C.S.Eng., F.S.S., The
Five Gables, Muyfield, Sussex. {Son. Sec. 2V. and M. Division,
1897—1901.)

1907. fClarke, Geoffrey, M.D.Lond. (Senior Assistant Medical Officer, London
County Asylum, Bunstead, Sutton, Surrey); Lieut. E.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; E.A.M.C.

1907. Clarkson, Robert Durward, 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., F.R.C.P.Lond., 25, Upper Berkeley

Street, W. 1. (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.Lond., Assistant Medical

Officer, Kent County Asylum, Maidstone.

1903. fCollins, 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. E.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. fConnolly, Victor Liudley, M.B., B.Cli.Belfast (Assistant Medical Officer
Colney Hatch Asylum, N.) ; Lieut. E.A.M.C.

1878. Cooke, Edward Marriott. M.D.Lond., M.R.C.S.Eng., Commissioner in
Lunacy; Acting Chairman Board of Control, 69, Onslow Square,
S.W. 7.

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

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

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

1891. Corner, Harry, M.D.Lond., M.R.C.S., L.R.C.P.Lond., M.P.C., 37, Harley
Street, W. 1.

1917. Costello, Christopher, M.B., Assistant Medical Officer, Portrane Asylum,
Ireland.

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

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Members of the Association.

1897. Cotton, William, M.A., M.D.Ediu., D.P.H.Cantab., M.P.C. (c/o D. N.

Cotton, Esq., 9, St. I>avid Street, Edinburgh) ; Capt. R.A.M.C.,
20, General Hospital, B.E.F., 1'rance.

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

Royal Albert Institution, Albert House, Haverbreaks, Lancaster.

1913. Court, K. Percy, M.R.C.S.. L.R.C.P.Lond., Severalls Asylum, Colchester.
1893. Cowcn, Thomas Philip, M.D., B.8. M.R.C.S., L.R.C.P.Lond., Medical

Superintendent, County Asylum, Raiuhill, Lancashire.

1911. Cox, Donald Maxwell, M.R.C.S., L.R.C.P.Lond. (2, Royal Park, Clifton,

Bristol) ; Lieut. R.A.M.C.

1893. Craig, Maurice, M.A., M.D., B.C.Cantab., F.R.C.P.Lond., M.P.C., 87,

Harley Street, W. 1. (Hon. Secretary of Educational Committee,
1905-8; Chairman of Educational Committee since 1912.)

1897. Cribb, Harry Gifford, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
Winterton Asylum, Ferryhill, Durham.

1911. Crichlow, Charles Adolphus, M.B, Ch.B.Glas. Roxburgh District
Asylum, Melrose.

1917. Crocket, James, M.D.Edin., D.P.H., Medical Superintendent, Colony of
Mercy for Epileptics, Consumption Sanatoria of Scotland, Craigielea,
Bridge of Weir.

1914. Crookshank, Francis Graham, M.D., M.R.C.P.Lond., 15, Harley Street,

W.l.

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

Kirkburton, 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.Glas., Pathologist, Crichton Royal Hospital,
Dumfries.

1907. Daniel, Alfred Wilson, B.A., M.D., B.C.Cantab., M.R.C.S., L.R.C.P.Lond.,
Acting Medical Superintendent, London County Asvlum, Hanwell,

W. 7.

1896. Davidson, Andrew, M.D., C.M.Aber., M.P.C., Wyoming, Macquarie
Street, Sydney, N.S.W.

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

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

1891. fDavis, Arthur N., L.R.C.P.&S.Edin. (Medical Superintendent, County
Asylum, Exminster, Devon); Major R.A.M.C., T.F.

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

of Lunatics in Ireland, 7, Ailesbury Road, Dublin. (Hon. Sec. to
Irish Division, 1902-11; PiiBSlDBNT, 1911-12.) Lt.-Col. R.A.M.C.
1901. De Steiger, Adhle, M.D.Lond., Countv Asylum, Brentwood, Essex.

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

Medical Superintendent, The Asylum, Milton, Portsmouth (Assist¬
ant Editor of the Journal since 1916).

1904. Devon, James, L.R.C.P. & S.Ediu., 1, North Park Terrace, Hillhead,

Glasgow.

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

1915. fDillon, 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. 4.); Lieut. R.A.M.C.
on actioe service, Craigenhall, Falkirk, N.B.

1909. Dillon, Kathleen, L.R.C.P.AS.l., 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, Huinberstone, Leicester);
Major R.A.M.C.

1879. Dodds, William J., M.D., C.M., D.Sc.Edin., Glencoiln, Bcllahoutton,
Glasgow.

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xii Members of the Association.

1908. Donald, Robert, M.D., Ch.B.Glas., 3, Gilmonr Street, Paisley.

1889. fDonaldson, William Ireland, B.A., M.D., B.Ch.Dubl., Medical Super¬

intendent (County of London Manor Asylum, Epsom, Surrey).
Lt.-Col. R.A.M.C. O.C. Manor County of London Wnr Hospital,
Epsom.

1892. Douelan, John O’Conor, L.R.C.P.&S.I., M.P.C., St. Dympbna’s, North
Circular Road, Dublin (Med. Supt., Richmond Asylum, Dublin),

1890. Douglas, William, M.D.R.U.I., M.R.C.S.Eng., F.R.G.S., Brandfold,

Goudhurst, Kent.

1905. Dove, Augustus Charles, M.D., B.S.Durli., M.R.C.S.Eng., “ Brightside,”

Crouch End Hill, N. 2.

1897. Dove, Emily Louisa, M.B.Lond., 11, Jenner House, Hunter Street,
Brunswick Square, W.C. 1.

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

1910. Downey, Michael Henry, M.B., Ch.B.Melb., L.R.C.P. & S.Edin.,

L.R.F.P.&S. Glasg., Assistant Medical Officer, Parkside Asylum,
Adelaide, South Australia.

1884. Drapes, Thomas, M.B.Dubl., L.R.C.S.I., Medical Superintendent, District
Asylum, EnniBCortby, Ireland. (Peksidhnt-BI.kct, 1910-11; Co-
Editor of Journal *ince 1912.)

1916. Drummond, William Blackley, M.B., C.M.Edin., F.R.C.P., Medical

Superintendent, Balduvan Institution, Dundee.

1907. Dryden, A. Mitchell, M.B., Ch.B.Edin., Senior A.M.O., Woodilee Mental
Hospital, Lenzie.

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.&S.l., Senior Assistant Medical Officer,
County Asylum, Bodmin, Cornwall.

1915. Duff, Thomas, L.R.C.P., L.R.C.S.Edin., L.R.F.P.&S.Glasg., Collington
Rise, Bexhill-on-Sea.

1917. Dunn, Edwin Lindsay, M.B., B.Ch.Dub., Medical Superintendent, Berks

County Asylum, Wallingford, Berks.

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

Koppies Asylum, Pretoria, South Africa.

1911. fDykes, Percy Armstrong, M.R.C.S., L.R.C.P.Lond., c/o Messrs. Holt

and Co., 3, Whitehall Place, S.W. 1. Capt R.A.M.C.

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

1906. fEager, Richard, M.D., Ch.B.Aber., M.P.C. (Assistant Medical Officer,

Devon County Asylum, Exminster); Major R.A.M.C.,T.F., The
Lord Derby War Hospital, Warrington, Lancs.

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, Hyde Park
W. 2.

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

Barrister-at-Law, Fenstanton, Christchurch Road, Streatham Hill,
S.W. 2.

1907. East, Wm. Norwood, M.D.Lond., M.R.C.S., L.R.C.P.Lond., M.P.C.,

H.M. Prison, Manchester; also 171, Cheetham Hill Road,
Manchester.

1895. Easterbrook, Charles C.,M.A.,M.D., F.R.C.P.Ed., M.P.C., J.P., Physician
Superintendent, Crichton Royal Institution, Dumfries.

1914. Eder, M. D., B.Sc.Loud., M.R.C.S., L.R.C.P.Lond. (Medical Officer,
Deptford School Clinic), 37, Welbeck Street, W. 1.

1895. Edgerley, Samuel, M.A., M.D., C.M.Edin., M.P.C., Medical Superinten¬
dent, VVest Riding Asylum, Meuston, nr. Leeds.

1897. Edwards, Francis Henry, M.D.Brux., M.li.C.P.Lond., M.R.C.S.Eng.,
Medical Superintendent, Camberwell House, S.E.5.

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xiii

Members of the Association.

1901 fElgee, Samuel Cliarleg, L.R.C.P.AS.I. (Colney Hatch Asylum, New
Southgate). The Manor (County of London) War Hospital,
Epsom ; Major B.A.M.C.

1889. Elkins, Frank Ashby, M.D., C.M.Edin., M.P.C., Medical Superintendent,
Metropolitan Asylum, Leavesden. Herts.

1912. Ellerton, John Frederick Heise, M.D.Brux., M.R.C.S.Eng., L.R.C.P.
Eiiin., Rotlierwood, Leamington Spa.

1917. Ellis, Vincent C., M.B., Assistant Medical Officer, Portrane Asylum,
Ireland.

1908. Ellison, Arthur, M.R.C.8., L.R.C.P.Eng., Deputy Medical Officer, H.M.

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

1899. Ellison, F. C., B.A., M.D., B.Ch.Dub., Resident Medical Superintendent,
District Asylum. Castlebar.

1911. Ernslie, Isabella Galloway, M.D., Ch.B.Edin., West House, Royal Asylum,
Morningside, Edinburgh.

1911. English, Ada, M.B., B.Ch.R.U.I., Assistant Medical Officer, District
Asylum, Ballinasloe.

1901. Erskinc, Win. J. A., M.D., C.M.Edin., Medical Superintendent, County
Asylum, Whitecroft, Newcroft, I. of W.

1895. Eurich, Frederick Wilhelm, M.D., C.M.Edin., 8, Moruington Villas,
Maningham Lane, Bradford.

1894. Eustace, Henry Marcus, B.A., M.D., B.Ch.Dubl., M.P.C., Medical
Superintendent, Hainiistead aud Richfield Private Asylum,
Glasnevin. Dublin.

1909. Eustace, William Neilson, L.R.C.S.&P.lrel., 38th General Hospital,

Salonika, c/o G.P.O., E.C. 1.

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

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

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

1907. Exley, John, L.R.C.P.I., M.lt.C.S.Eng., Medical Officer, H.M. Prison;
Grove House, New Wortley, Leeds.

1894. Furquharson, William F., M.D., C.M.Edin., M.P.C., Medical Superin¬
tendent, Cuuuties Asvlum, Garlands, Carlisle.

1907. fFarrieg, John Stothart, L.R.C.P.AS.Edin., L.R.F.P.AS.Gla*., R.N.B.,

communications to Yrthington, Carlisle.

1917. Fearnsides, Edwin Greaves, M.D.Camb., B.C., M.A., 46, Queen Anne
Street, Cavendish Square, W. 1.

1903. fFennell, Charles Henrv, M.A.. M.D.Oxon, M.R.C.P.Loud., Reform Club,
Pall Mall, S.W.; ’Lieut. R.A.M.C.

1908. Fenton, Henry Felix, M.B., Ch.B.Edin., Assistant Medical Officer,

County and City Asylum, Powick, Worcester.

1907. Ferguson, J. J. Harrower, M.B., Ch.B.Edin., Senior Assistant Medical

Officer, Fife and Kinross Asylum, Cupar, Fife.

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, Stonevgate, Leicester.

1889. Finlay, David, M.D., C.M.Glasg., Medical Superintendent, County
Asylum, Bridgend, Glamorgan.

1906. Firth, Arthur Harcus, M.A., M.l)., B.Ch.Edin., Deputy Medical Super¬
intendent, Barnsley Hall, Bromsgrove, Worcestershire.

1903. Fitzgerald, Alexis, L.R.C.P. & S.I., Medical Superintendent, District

Asylum, Waterford.

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

1908. Fitzgerald, James Francis, L.R.C.P.AS.Irel., Assistant Medical Officer,

District Asylum, Clonmel, co. Tipperary, Ireland.

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

Pirbright, Surrey.

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xiv Members of the Association.

1894. Fleury, Eleonora Lilian, M.D., B.Ch.R.U.I., Assistant Medical Officer,
Richmond Asylum, Dublin.

1908. fFlynn, Thos. Aloysius, L.R.C.P.&S.I., (County Asylum, Thorpe,
Norwich); R.A.M.C.

1902. Forde, Michael J., M.D., B.Ch.R.U.I., Assistant Medical Officer, Rich¬
mond Asylum, Dublin.

1911. Forrester, Archibald Thomas William, M.D., B.S., M.R.C.S., L.R.C.P.

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

1916. fForsyth, Charles Wesley, M.B.Lond., M.R.C.S., L.R.C.P. (Assistant
Medical Officer, Kesteven County Asylum, Sleaford, Lines.); Temp.
Lieut. R.A.M.C.

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

1913. Fothergill, Claude Francis, B.A., M.B., B.C.Cuntab., M.R.C.S., L.R.C.P.
Lond.; HetiRol, Chorley Wood, Herts.

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

Birmingham.

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

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

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

1902. Fuller, Lawrence Otway, M.R.C.S.Eng., L.R.C.P.Lond., Medical Super¬

intendent, Three Counties’ Asylum, Arlesey, Beds.

1914. +Gage, John Munro, L.R.C.P.&S.I., M.P.C., Temp. Capt. R.A.M.C.
Royal Earlswood Institution, Redhill. Surrey.

Gane, Edward Palmer Steward, M.D.Durh., M.R.C.S., L.R.C.P.Lond.,
City Asylum, Willerby, Hull.

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

Gavin, Lawrence, M.B., Cb.B.Edin,, L.R.C.P.&S.Edin., L.R.F.P.&S.

Glasg., Superintendent, Mullingar District Asylum, Ireland.

Geddes, John VV., M.B., C.M.Ediu., Medical Superintendent, Mental
Hospital, Middlesbrough, Yorks.

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

Gettings,Harold Salter, L.R.C.P. & S.Edin.,L.R.F.P.&S.G., D.P.H.Birm.,
Inoculation Dept., St. Mary’s Hospital, Paddington.

GilfillHii, Samuel James, M.A., M.B., C.M.Edin., Medical Superin¬
tendent, London County Asylum, Colney Hutch.

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

Gill, Stanley A., B.A.Dubl., M.D.Durh., 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., Wburncliffe War Hospital, Middle-
wood Road, Sheffield.

Gilmour, John Rutherford, M.B., C.M., F.R.C.P.Edin., M.I’.C., Medical
Superintendent, West Riding Asylum, Scalebor Park, Burley-in-
Wharfedale, Yorks.

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

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

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

1889. fGoodall, Edwin, M.D., 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.

1897.

1906.

1878.

1897.

1906.

1912.

1912.

1896.

1892.

1914.

1899.

1912.

1889.

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XV

Members of the Association.

1899. fGordon, James Leslie, M.D., C.M.Aberd. (Medical Superintendent,

Fountain Temporary Asylum, Tooting Grove, Tootiug Graveney,
S.W. 17.) ; Temp. Lieut. R.A.M.C.

1905. Gordon-Munn, John Gordon, M.D.Edin., F.R.S.E., Heighatn Hall,
Norwich.

1901. fGostwyck, C. H. G., M.B., Cli.B., F.K.C.P.Edin., M.P.C., Dipl. Psych.,
(Stirling District Asylum, Larbert); Lt., R.A.M.C. on active
tervice.

1912. tGruham, Gilbert Malise, M.B., Ch.B.Ediu., B.N., H.M.S. “ Emperor of
India.”

1914. fGrahain, Norman Hell, B.A., R.U.I., M.B., B.Ch.Belfast, (Assistant

Medical Officer, District Asylum, Belfast) ; Capt. R.A.M.C., 24,
Ocean Buildings, Belfast.

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

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

Somerset and Bath Asylum, near Taunton.

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

intendent, City Hiid County Asylum, Burgliill, 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.AP.Irel., J.P., Medical Superintendent,

District Asylum, Carlow.

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

1912. fGreeson, Clarence Edward, M.D., Ch.B.Aberd., Surgeon, R.N., c/o Messrs.
Holt & Co., 3, Whitehall Place, S.W. 1.

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

1915. Grigsby, Hamilton Marie, L.R.C.P.AS.Edin., 79, Victoria Road North,

Southsea.

1901. Grills, Galbraith Hamilton, M.D., B.Ch.R.U.I., Dipl. Psvch., Medical
Superintendent, County Asylum, Chester.

1916. Grimbly, Alan F., B.A., M.B., B.Ch., B.A.O., L.M.Rot.Dub. (Assistant

Medical Officer, St. Edmondsbury, Lucan, Ireland) ; Surgeon, R.N.,
Royal Naval Hospital, Haslur.

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

York.

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

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

1901. Harding, William, M.D.Edin., M.R.C.P.Loud., Medical Superintendent,
Northampton County Asylum, Berry \V T ood, Northampton.

1899. Harmer, W. A., L.S.A., Resident Superintendent aud Licensee, Redlands
Private Asylum, Tonbridge, Kent.

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

(Senior Assistant Medienl Officer, Brighton County Borough
Asylum, Haywards Heath), May Cottage, Lougbton, Essex;
Capt. R.A.M.C. (T.).

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, Wimpole Street, W. 1.,

aud Northumberland House, Finsbury Park, N. 4.

1886. fHarvey, Bageual Crosbie, L.R.C.P.&S.Edin., L.A.H.Dubl., Resident
Medical Superintendent, District Asylum, Clonmel, Irelund.

1892. Haslett, William John H., M.R.C.S., L.R.C.P.Lond., M.P.C., Resident
Medical Superintendent, Hnlliford House, Sunbury-on-Thames.
1891. Havelock, John G., M.D., C.M.Edin., Little Stodham, Li»s, Hants.

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xvi Members of the Association.

1890. Hay, J. F. S„ M.B., C.M.Aberd., Inspector-General of Asylums for New
Zealand, Government Buildings, Wellinirton, 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.l)., C.M.Edin., Medical Superintendent, Mid-
Yorkshire Institution, Whixley, Yorks.

1911. fHeffernan, Capt. P., B.A., M.B., B.CIi.C.U.I.

1916. tHenderson, David Kennedy, M.D.Edin., (Senior Assistant Physician,
Koyal Asylum, Gartnavel, Glasgow) ; Temp. Lieut. R.A.M.C., c/o
John Henderson and Sons, Solicitors, Dumfries, Scotland.

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

Peck ham, S.E. 15.

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

York.

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

1877. Hewson, It. W., L.R.C.P.&S.Edin., Medical Superintendent, Cotou Hill,
Stafford.

1914. Hewson, R. W. Dale, L.R.C.P.&S.Edin., L.R.F.P.&S.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. 2.

1882. Hill, H. Gardiner, M.R.C.S.Eng., L.S.A., Pentillie, Leopold Road,
Wimbledon Park, S.W. 19.

1914. tHills, Harold William, B.S., M.B., B.Sc.Lotid., M.R.C.S., L.R.C.P.Lond .;
Capt. R.A.M.C., Lord Derby War Hospital, Warrington.

1907. fHine, T. Gny Macaulay, M.A., M.D., B.C.Cantab., 37, Hertford Street,

Mayfair, W.; Temp. Capt. R.A.M.C.

1909. Hodgson, Harold West, M.It.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.Frcib., M.It.C.S., L.R.C.P.Lond, 57, Wimpole

Street, W. 1.

1912. Holyoak, Walter L., M.D., B.S.Lond., 45, Welbeck Street, W. 1.

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

tendent, York Citv Asylum, Fulford, York.

1894. Hotchkis, Robert I)., M.A.Glastt., M.D., B.S.Durh., M.R.C.S., L.R.C.P.

Lond., M.P.C., Renfrew District Asylum, Dvkebur, Paisley N.B.
1912. Hughes, Frank l’ercival, M.B., B.S.Loud., M.It.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, Barnesley Hall, Bromsgrove.

1904. Hughes, William Stanley, M.B., B.S.Lond., M.It.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. Division, 1910-1913.)

1909. fHuuter, Douglas William, M.B., Ch.B.Glusg., Assistant Medical Officer,

10, Halltield Road, Bradford; Capt. R.A.M.C.

1912. tHunter, George Yeates Cobb, Colonel, M.It.C.S., L.R.C.P.Lond.,

M.P.C., c/oMessrs. Griudlay & Co.. 54, Parliament Street, S.W. 1.
1904. Hunter, Percy Douglas, M.It.C.S., L.R.C.P.Lond., Three Counties
Asylum, Arlesey, Beds.

1888. Hyslop, Theo. B., 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. 1.

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

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

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Members of the Association. xvii

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

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

190,S. Jeffrey, Geo. Rutherford, M.I)., Ch.B.Glas., F.R.C.P.E., M.P.C.,
Medical Superintendent, Boot ham Park, York.

1910. fJohnson, Cecil Webb, D.S.O., M.B., Ch.B.Vict. (“ Cricklcwood,” East
Shecu, S.W.) ; Capt. (Temp. Major) R.A.M.C. ; 10th Middlesex
Regiment, Fort William, Calcutta, India.

1893. Johnston, Gerald Herbert, L.R.C.P.&S.Ediu., L.R.F.P.&S.Glas., Brooke
House, Upper Clapton, N. 5.

1906. Johnston,Thomas Leonard, L.R.C.P.&S.Edin., L.R. F.P&S.Glos.,Medical

Superintendent, Bracebridge Asylum, Lincoln.

1912. Johnstone, Emma May, L.R.C.P.& S.Edin., L.R.F.P.&S.Glas., M.P.C.,
Dipl. Psych., Holloway Sanatorium, Virginia Water, Surrey.

1878. Johnstone, J. Carlyle, M.I)., C.M.Glas., Melrose, Roxburgh.

1903. Johnstone, Thomas, M.D., C.M.Edin., M.lt.C.P.Lond., Anuandab-,
Harrogate.

1880. fjones, I). Johnston, M.D., C.M.Edin.; Temp. Major R.A.M.C.

1879. Kay, Walter S., M.I)., C.M.Edin., M.R.C.S.Eng., The Grove, Starbech,

Harrogate.

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

1909. fKeith, William Brooks, M.B., Ch.B.Aberd., M.P.C., Capt., R.A.M.C., T.,
81st Field Ambulance, 27tb Division.

1903. Kelly, Richard, M.D., B.Ch.Dub., Assistant Medical Officer, Storthes
Hall Asylum, Kirkburtou, near Hudderstield.

1907. Keene, George Henry, M.D., The Asylum, Goodmayes, 1 lford, Essex.
1899. Kennedy, Hugh T. J., L.R.C.P.&S.l., Assistant Medical Officer, District

Asylum, Enuiscorthy, Co. Wexford.

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

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

District Asylum, Hartwood, Slmtcs, N.B.

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

1897. tKidd, 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.,
Uraylingwell War Hospital, Chichester.

1916. Kilgarriff, Joseph O’Loughliu, A.B., M.B., B.Ch., B.A.O.Uuiv., Dublin,
Assistant Medical Officer, County Asylum, Prestwick, Lancs.

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

Medical Superintendent, Beckham House, Peck bam, S.E.

1902. King-Turner, A. C., M.B.,C.M.Edin., Tne Retreat, Fairford, Gloucester¬

shire.

1915. Kirwan, Richard R., M.B., B.Cli. R.U.I., Assistant Medical Officer,
West Riding Asylum, Menston, Leeds.

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

1903. Kough, Edward Fitzudain, 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., B.C.Cantab., Dixland, Hampton
Wick, Middlesex.

1896. Langdon-Down, Reginald L.. M.A., M.B., B.C.Cantab., M.R.C.P.Lond..
Normansfield, Hampton Wick.

A

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PRINCETON UNIVERSITY

Digitized by

xviii Members of the Association.

1914. fLailell, Ri G. Macdonald, M.B., Ch.B.Vict., The Gables, Killinghall,
Harrogate.

1909. fLaurie, James, M.B., Ch.M.Glasg. ( Medical Officer, Smithston Asylum ),
(Red House, Ardgowun Street, Greenock); Cupt. R.A.M.C., T.F.,
;ird Scottish Hospital.

1902. Laval, Evariste, M.B.,C.M.Edin., The Guildhall, Westminster, S.W. 1.

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

intendeni, Bailbrook House, Bath.

1892. Lawless, George Robert, F.K.C.S.I., L.R.C 1M„ Medical Superintendent,
District Asylum, Armagh.

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

1883. Layton, Henry A., M.R.C.S.Eng., L.R.C.l’.Ediu., 26, Kimbulton Rond,
Bedford.

1916. 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, VVilts) ; Capt. R.A.M.C.

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

intendent, St. Patrick’s Hospital, Dublin. (Hun. Sec. to the Irish
Hicision from 1911.)

1883. Legge, Richard J., M.D., R.U.I., L.R.C.S.Edin., " Comerugli,” Leck-

hnmptou Road, Cheltenham.

1906. fLeggett, William, B.A., M.D., B.Ch.Dubl. (Assistant Medical Officer,
Royal Asylum, Sunnyside. Montrose) ; Temp. Lieut. R.A.M.C.
1916. Lewis, Edward, L.R.C.P., L.R.C.S.Edin., L F.P.S.Glasg., Cwirlai, Ty-
Cross, Anglesey.

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

1908. Littlejohn, Edward Snlteine, M.R.C.8., L.R.C.P.Lond., Acting Medical
Superintendent, London County Asylum, Cane Hill, Surrey.

1916. Lloyd, Brindley Richard, M.B., B.S.Lond., D.P.H.Lond., Assistant
Medical Officer, Peckham House, S.E. 15.

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

Stone Asylum, Aylesbury, Bucks.

1898. fLord, John R.,M.B.,C.M.Edin. (Medical Superintendent, Horton Asylum,
Epsom); Lieut.-Colonel R.A.M.C., Horton County of London War
Hospital, Epsom, Surrey. (Co-Editor of Journal since 1911;
Assistant Editor of Journal, 1900-11.)

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

1904. Lyall, C. II. Gibson, L.R.C.P.&S.Edin., Leicester Borough Asylum,

Leicester.

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

1906. fMacartbur, John, M.R.C.S., L.R.C.P.Lond. (Assistant Medical Officer,
Colney Hatch Asylum, London, N. 11); R.A M.C., Mediterranean
Expeditionary Force.

1880 MacBryan, Henry C., L.R.C.P. & S. Edit)., Ivingsdown House, Box, Wilts.

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

Grove House, All Stretton, Church Stretton, Salop.

1901. MacDonald, James H., M.B., Cli.R., F.R.F.P.&S.Glasg., Govrji District

Asylum,Huwkhead, Paisley, N.B.

1884. MacDonald, P. W., M.D., C.M.Aberd., Grasmere, Spa Road, Weymouth.

(First Hon. Sec. S. W. Dir. 1894 to 1905.) (Pbesident, 1907-8.)
1911. fMacDonald, Ranald, M.D., Ch.B.Ediu. (London County Asylum, Bexley,
Kent); Lieut. R.A.M.C.

1905. MacDonald, William Fraser, M.B., Ch.B.Kdin., M.P.C., 96, Polworth

Terrace, Edinburgh.

1905. McDougall, Alau, M.D., Ch.B.Vict., M.R.C.S., L.R.C.P.Lond., Medical
Director, The David Lewis Colony, Sanole Bridge, near Alderley
Edge, Cheshire.

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Members of the Association. xix

1911. McDougnll, William, M.A., M.B., B.C.Cantab., M.Sc.Viet., 89, Banbury
Road, Oxford.

1906. McDownll, Colin Francis Frederick, M.D., B.S.Durh., Medical Superin¬
tendent, Ticehurst House, Ticehurst, Sussex.

1870. McDowall, Thomas W., M.D.Edin., L.R.C.S.E., Medical Superintendent,
Northumberland County Asylum, Morpeth. (PRESIDENT, 1897-8.)
1895. Macfarlane, 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.

1917. fMclver, Colin, M.R.C.S., L.R.C.P., Capt. e/o Messrs. Grindlay

<fc Co., 54, Parliament Street. London. S.W. 1.

1914. fMackay, Magnus Ross, M.l)., Ch.B.Edin., Capt. R.A.M.C./F.F., British

Expeditionary Force, France.

1917. Mnckny, Norman Douglas, M.D., B.Se., D.P.H., Dull-A von, Aberfeldy,
Perthshire.

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

Officer. Carlow District Asylum.

1911. Mackenzie, John Cosserat, 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 ()fficer.
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, Jan R., L.R.C.P.&S.Edin., L.R.F.P.&S.Glasg., 7, Mayfield
Gardens, Edinburgh.

1917. McMaster, AlPert Victor, B.A., M.R.C.S.Eng., “ The Mount,” Hills Road,
Cambridge.

1904. Macnnmara, Eric Danvers, M.A.Cumb., M.D., B.C., F.R.C.P.Lond., 87,

Harley Street, W. 1.

1914. fMacneill, Celia M»ry Colquhoun. M.B., Ch.B.Edin. (Pathologist, North-

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

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

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

1896. Macplierson, 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. (Assistant Editor of the
Journal since 1916).

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

Decbraont, Linlithgowshire) ; Lieut. R.A.M.C., M.E.F.

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

1915. Manifold, Robert Fenton, M.B., D.Ch.Dub., Senior Assistant Medical

Officer, Denbigh Asylum, North Wales.

1908. fMapother, Edward, M.l)., B.S.Lond., F.lt.C.S.Eng. (Assistant Medical
Officer, Loudon County Asylum,Long-Grove.Epsom); \j\owl.R.A.M.C.

1903. Martian, John, B.A., M.B., B.Ch.Duhl., Medical Superintendent, County

Asylum, Gloucester.

1896. fMarr, Hamilton C., M.D., C.M., F.R.F.P AS.Glusg., M.P.C., Commis¬
sioner in Lunacy (10, Succoth Avenue, Edinburgh); (Hon. See.
Scottieh Division, 1907-1910.); R.A.M.C.

1913. fMarshall, Robert, M.B., Ch.B.Glas. (Assistant Medicnl Officer, Giirtloch
Mental Hospital, Gnrtcosh, N.B.) ; Lieut. R.A.M.C., 19th General
Hospital, British Expeditionary Force.

1905. Marshall, Robert Macnab, M.l)., Ch.B.Glasg., M.P.C., 2, Clifton Place,
Glasgow.

1908. fMartin, Henry Cooke, M.B., Ch.B.Edin., Assistant Medical Officer,
Newport Borough Asylum, Caerleon; Lieut. R.A.M.C.

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XX

Digitized by

Members of the Association.

189G. fMartin, James Charles, L.R.C.S. & P.I., J.P., Assistant Medical Officer,
District Asylum, Letterkenny. Donegal; Temp. 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, Loudon County Asylum, Long-Grove
Epsom.

1907. Martin, Mary Edith, L.Il.C.P.AS.Edin., 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-Law (Senior

Assistant Medical Officer, St. Andrew’s Hospital, Northampton) ;
Lieut. R.A.M.C., British Mediterranean Expeditionary Force.

1911. fMartin, 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, Bruutsfield Place, Edinburgh; Major R.A.M.C. ( T .)

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. (Wiuterton Asylum,
Ferryhill, Durham); Lieut. R.A.M.C.

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

Lenzie, Glasgow.

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

tendent, Stafford County Asylum, Cheddleton, 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, Park stone, Dorset.
( Secretary Educational Committee, 1893-1905. Chairman do. from
1905-12.) (President, 1908-9.)

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

1893. Middlemass, James, M.A., M.D., C.M., B.Sc.Edin., F.R.C.P., M.P.C.,
Medical Superintendent, Borough Asylum, Rvliope, Sunderland.

1910. fMiddlemiss, James Ernest, M.R.C.S.Eng., L.R.C.P.Lond.; 131, North

Street, Leeds; Lieut. R.A.M.C.

1883. fMiles, George E., M.R.C.S., L.R.C.P.Lond., Lieut.-Col., R.A.M.C.,
D Block, Royal Victoria Hospital, Netlcy, Hants; British Empire
Club, St. James’ Square, S.W. 1.

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

1912. Miller, Richard, M.B., B.Ch.Dubl., Bethlem Royal Hospital, London,

S.E. 1.

1893. Mills, John. M.B., B.Ch., Dipl. Ment. Dis., It.U.L, Medical Superinten¬
dent, District Asylum, Balliuasloe, Ireland.

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

Albert Institution, Lancaster.

1911. Moll, Jan. Marius, Doc. in Arts and Med, Utrecht Univ., L.M.S.S.A.

Lond., M.P.C., Box2587, Johannesburg, South Africa.

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

House, St. Helens, Hastings.

1910. fMonnington, Richard Cahlicott, M.D., Ch.B., D.P.H.Edin. (Darenth
Industrial Colony, Dartford, Kent) ; c/o Rev. T. P. Monnington,
Lowick Green, Ulverston, Lancs.; Capt. 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, Rikshospitalet, Christiania.

1914. fMontgomery, Edwin, F.R.C.S.I., L.R.C.P.I. Dipl. Psych. Munch.,

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

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

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

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XX]

Member & of the Association.

1917. Morris, Bedlingtou Howel, M.B., B.S.Durh., Inspector-General of
Hospitals, South Australia; Pembroke Street, College Park,
St. Peter’s, S. Australia.

1896. Morton, W. B., M.D.Lond., M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent, Won t'ord House, Exeter.

1896. Mott. F. W., M.D., B.S., F.R.C.P.Lond., LL.D.Edin., F.R.S., 25,
Nottingham Place, Marylebone, W. 1; Lieut.-Col. R.A.M.C.

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

Yorks.

1897. Mould, Philip G., M.It.C.S.Eng., L.R.C.P.Lond., Ovordale, Whitelield,

Manchester.

iyi4. fMoyes, John Murray, M.B., Ch.B.Edin., D.P.M.Leeds, Crichton Royal
Institution, Dumfries; R.A.M.C.

19U7. Mules, Bertha Marv, M.D., B.S.Durh., Court Hall, Kenton, S. Devon.
1911. fMuncaster, Anna Lilian, M.H., B.Ch.Edin. (County Asylum, Chester);

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

1917. Munro, Robert, m!B., Ch.B.Aberd., Assistant Medical Officer, Dorset
County Asylum, Dorchester.

1916 Murray, Jessie M., M.B., B.8.Durham, 14, Emlsleigh Street, Tavistock
Square, London, W.C. 1.

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

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

1903. fXavarra, Norman, M.R.C.S., L.R.C.P.Lond. (City of London Mental
Hospital, near Dartford, Kent) ; Temp. Capt. R.A.M.C.

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

Oxford.

1903. Nelis, William E.,M.l).I)urh.,L.R.C.P.Edin.,L.R.F.P.&S.Glasg., Medical
Superintendent, Newport Borough Asylum, Caerleou, Mon.

1809. Nicolson, David, C.R., M.D.. C.M.Aber., M.R.C.P.Edin., F.S.A.Scot.,
201, Royal Courts of Justice, Strand, W.C. 2 (President, 1895-6).
1888. Nolan, Michael J., L.R.C.P.AS.L, M.P.C., Medical Superintendent,
District Asylum, Downpatrick.

1913. Nolan, James Noffi Green, M.B., B.Ch., A.B.Dub., The Hospital, Hel-

lingly Asylum, Sussex.

1909. fNorman, Hubert James, M.B., Ch.B., D.P.H.Edin. (Assistant Medical

Officer, Camberwell House Asylum, S.E. 5); Napsbury War Hos¬
pital, St. Albans; Major R.A.M.C.

1885. Oakshott, James A., M.D., M.Cli.R.U.I., The Green, Passage West,
Co. Cork, Ireland.

1916. O’Carroll, Joseph, M.D., F.R.C.P., Physician Richmond and Whitworth
Hospitals; Lord Chancellor’s Medical Visitor in Lunacy; 43,
Merrion Square, Dublin.

1903. O’Doherty, Patrick, 15.A., M.B., B.Ch.R.U.I., District Asylum,

Omagh.

1914. O’Flynu, Dominick Thomas, L.R.C.P. A S.I., Assistant Medical Officer

London County Asylum, Hanwell, Middlesex.

1901. Ogilvy, David, B.A., M.D., B.Ch.I)ub., Medical Superintendent, Loudon

County Asylum, Long Grove, Epsom, Surrey.

1911. fOliver, Norman H., Major, R.A.M.C., Special Hospital for Officers,

Latchmere, Ham Common, Surrey.

1892. O’Mara, Francis, L.R.C.P.AS.I., District Asylum, Ennis, Ireland.

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

Prestwich, Lancs.

1910. Orr, James H. C., M.l)., Ch.B.Edin., Rosslynlee Asylum, Midlothian.
1899. Osburne, Cecil A. P., F.R.C.S., L.R.C.P.Edin., The Grove, Old Catton,

Norwich.

1914. Osburue, John C., M.B., B.Ch.Dub!., Assistant Medical Officer, Lindville
Cork.

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xxii Members of the Association.

1890. Oswald, L&ndcl R., M.B., C.M.Glasg., M.P.C., Physician Superin¬

tendent, Koyul Asylum, Gurtimvel, Glasgow.

1916. fOverbeck-Wright, Alexander William, M.L)., Cli.B., M.P.C., D.P.H.,
Major l.M.S. Superintendent, Lunatic Asylum, Agra, U. P., India
(at present on military duty); Lecturer on Mental Diseases, King
George’s Hospital, Lucknow, and Agra Medical School, Agra.
Address 12, Rubislaw Terrace, Aberdeen.

1905. f Paine, Frederick, M.D.Brux., M.R.C.S.,M.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, Gartloch Asylum, Gartcosh, N.B.

1898. Pasmore, Edwin Stephen, M.D., M.R.C.P.Lond., Chelshatn House,

Chelsham, Surrey.

1916. fPatch, Charles James Lodge, L.R.C.P.&S.Edin., Assistant Medical
Officer, Renfrew District Asylum, Dykebar, Paisley; Capt.
R.A.M. C.

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

Asylum, Omagli, Ireland.

1907. Peuchell", George Ernest, M.D.. B.S.Loud., M.K.C.S., L.R.C.P.Lond.,

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

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

tant Medical Officer, London County Asylum, Horton, Epsom) ;
Capt. R.A.M.C., Lord Derby’s War Hospital, Warrington, Lancs.
1915. fPennant, Dyfrig Haws, D.S.O., M.R.C.S., L.R.C.P.Lond., 21, Bovintou
Street, Roath Park, Cardiff; Capt. R.A.M.C.

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., Medicul Superintendent,
County Asylum, l’restwich, Manchester. Lancashire.

1911. Perdrau, Jean Ren4, M.B., B.S., M.R.C.S., L.R.C.P.Lond., Senior

Assistant Medical Officer and Pathologist, Lambeth Infirmary,
Brook Street, S.E. 11.

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

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

1878. Philipps, Sutherland Rees, M.D., C.M.Q.U.I., F.R.G.S., Bredon, Fisher
Street, Paignton.

1875. Philipsou, Sir George Hare, M.A., M.D.Cantab., D.C.L., LL.D., F.R.C.P.
Loud., 7, Eldon Square, Newcastle-ou-Tyne.

1908. Phillips, John George Porter, M.D., B.S.Loud., M.R.C.S., M.R.C.P.Lond.,

M.P.C., Resident Physician and Superintendent, Bethlem Royal
Hospital, Lambeth, S.E. 1. (Secretary of Educational Committee

since 1912.)

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

1906. Phillips, Nathaniel Richard, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Assis¬

tant Medical Officer, County Asylum, Abergnvenny, Monmouthshire.
1905. Phillips, Norman Routh, M.D.Brux., M.K.C.S., L.R.C.P.Lond., 67,
Billing Road, Northampton.

1891. Pierce, Bedford, M.D., F.R.C.P.Lond., Medical Superintendent, The

Retreat, York. {Hon. Secretary N. and M. Division 1900-8.)
1888. Pietersen, J. F. G., M.R.C.S., L.R.C.P.Lond., Ashwood House, Kingswin-
ford, near Dudley, Stafford.

1896. 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 Curuow, M.R.C.S., L.R.C.P.Lond. (Medical Superin¬

tendent, Laverstock House, Salisbury); Capt. R.A.M.C., British
Expeditionary Force.

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PRINCETON UNIVERSITY

Members of the Association. xxiii

1889. Pope, George Stevens, L.R.C.P.AS.Edin., L.R.F.P.&S.Glasg., Medical
Superintendent, Somerset and Bath Asylum, “ Westfield,” near
Wells, Somerset.

1913. Potts, William A., M.A.Camb., M.D.Edin.&Birm., M.lt.C.S., L.R.C.l*.

Bond., Medical Officer to the Birmingham Committee for the Care
of the Feeble-minded, 118, Hagley Road, Birmingham.

1876. Powell, Evan, M.R.C.S.Eng., L.S.A., Medical Superintendent, City
Lunatic Asylum, Nottingham.

1910. Powell, .lames Farquharsou, M.lt.C.S., L.R.C.P., D.P.H.Lond., M.P.C.,
Assistant Medical Officer, 'lhe Asylum, Caterham, Surrey.

1916. Power, Patrick William, L.K.C.P., L.R.C.S., Senior Assistant Medical
Officer, County Asylum, Chester.

190S. Prentice. Reginald Wickham, L.M.S.S.A.Lond., Beauworth Manor,
Alresford, Hants.

1901. Pugh, Robert, M.D., Ch.R.Edin., Medical Superintendent, Brecon and
Radnor Asylum, Talgarth, S. Wales.

1904. fltace, John Percy, M.lt.C.S., L.R.C.P., L.S.A.Loud., Journals and
notices to Winterton Asylum, Ferrj'hill, Durham (Wheatley Hill,
Doncaster); Capt. R.AM.C.

1899. Itaiusford, 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. ltambaut, Daniel F., M.A., M.D., H.Ch.Dub. (Medical Superintendent,
St. Andrew's Hospital. Northampton.

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

M.P.C.

1889. fltaw, Nathan, M.l)., B.S.Durh., L.S.Sc., F.R.C.S.Kdin., 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 Expcd. Force, France.
1870. Rayner, Henry. M.D.Aberd., M.R.C.P.Edin., Upper Terrace House,
Hampstead, N.W. 3. (President. 1881.) ( General Secretary,

1887-89.) ( Co-Editor of Journal 1895-1911.)

1913. fltead, Charles Stanford, M.B.Lond., M.R.C.S.. L.R.C.P.I.ond. (Assistant

Medical Officer, Fisbcrton House, Salisbury); Lieut. R.A.M.C.,
Royal Victoria Hospital, Netley.

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

1899. Redington, John, F.R.C.S.&L.R.C.P. L, Portrane Asylum, Donabate,
Co. Dublin.

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

(Senior Assistant Med cal Officer, County A-ylum, ltainhill, Lancs.) ;
Lieut. R.A M.C.

1911. tlieid, Daniel McKinley, M.D., Ch.B.GIasg. (Royal Asylum, Gartuavel,
Glasgow); Lt., R.A.M.C.

1910. tReid, William, M.A.St. And., M.B., Ch.B.Edin. (Senior Assistant Medical
Officer. Burutwood Asylum, Lichfield) ; Major R.A.M.C.

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

Revington, George T., M.A.. M.D., B.Ch.Dubl., M.P.C., Medical Superin¬
tendent, Central Criminal Asylum, Dundrum, Ireland.

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

Richard, William J.. M.A., M.B., Ch.M.Glusg., Medical Officer.
Richards, John, M.B., C.M.Edin., F.R.C.S.E., Medical Superintendent,
Joint Counties Asylum. Carmarthen.

Roberts, Henry Howard, M.D., Ch.R.Edin., D.P.H.Glasg., Ennerdale,
Haddington, Scotland.

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

(129. Bath Street, Glasgow); Hawkstone, Cambusluug, Glasgow
Capt. R.A.M.C.

1887.

1886.

1899.

1897.

1899.

1911.

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Members of the Association.

1903. + Roberts, Norclilfe, M.D., B.S.Dnrh., (Senior Assistant Medical Officer,
Horton Asylum, Epsom, Surrey) ; Major R.A.M.C., Horton 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, Hnrtwood, Lanark.

1916. Robertson, June I., M.B., Ch.B.GIasg., Gartnavel Asylum, Glasgow.

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

1900. Robinson, Harry A., M.D., Ch.B.Vict., 140, Edge Lane, Liverpool.

1911. fltobson, Cupt. Hubert Alan Hirst, l.M.S. , M.R.C.S., L.R.C.P.Lond.,

Punjaub Asylum, India.

1914. fRodger, Murdoch Mann, M.D., Cb.B.Gifts., The Rowans, Bothwell,

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

1908. fRodgers, Frederick Millar, M.D., Ch.B.Vict., D.P.H. (Senior Medical
Officer, County Asylum, Winwick, Lancs.); Temp. Major, R.A.M.C.,
Lord Derby’s War Hospital, Winwick.

1908. Rollestou, Charles Frank, B.A., M.B., Cb.B.Dub., Assistant Medical
Officer, County of London Manor Asylum, Epsom.

1895. fRolleston, Lancelot W., M.B., B.S.Durh., (Medicai Superintendent, Mid¬

dlesex County Asylum); Lieut.Col. R.A.M.C., Napsbury War
Hospital, Napsbury, near St. Albans.

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. fRoss, Donald, M.B , Ch.B.Edin., Argyll and Bute Asylum, Lochgilphead ;
Temp. Lieut. R.A.M.C.

1905. Ross, Sheila Margaret, M.D., Ch.B.Edin., 83 a, Friar Gate, Derby.

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. 1.

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., I.S.O. (attached R.A.M.C.), 71, Main
Street, George Town, Demerara, British Guiana.

1902. fRows, Richard Gundry, M.D.Loud., M.B.C.S., L.R.C.P.Lond. (Patho.

logist, County Asylum, Lancaster). Major U.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. tltu6sell, John Ivison, M.B., Ch.B.Glasg. (Jeantield, 18, Woodcnd Drive,

Jordan Hill, Glasgow; Temp. Cupt. R.A.M.C.

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

Assistant Pnysician, Pretor ia Mental Hospital, S. Africa.

1912. fRutherford, Cecil, M.B., B.Ch.Dubl. (Assistant Medical Officer. Holloway

Sanatorium, Virginia Water, Surrey); Temp. Capt. 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.H., St.

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

1896. Rutherford, James Muir, M.B., C.M.,F.R.C.P.Ediu.. M.P.C., BrDlington

House, Bristol.

1913. fRyan, Ernest Noel, B.A., M.D., B.Ch.Dub., R.A.M.C., 6th 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.Dubl., Medical Superintendent

Central Asylum,Tangoug, Rambutan,Perak,Federated Malay States.
1894. Sankev, Edward H. O., M.A., M.B., B.C.Cautab., Resident Medical
Licensee, Boreatton Park Incensed House, Bnscluirch, Salop.
Sankey, R. H. Heurtley, M.R.C.S.Eng., 3, Marston Ferry Road,
Oxford.

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Digitized by

187S. Savage, Sir (Jeo. H., M.D., F.R.C.P.Lond., 26, Devonshire Place, W. 1.

{Late Editor of Journal.) (Pbbsidbnt, 1886.)

1906. fScanlan, John J.,L.R.C.P.&S.Edin., L.R.F.P.AS.Glasg.,D.P.H. (1 Castle
Court, Cornhill, E.C.) ; Capt. R.A.M.C., 5th London Field
Ambulance, 47tli (London) Division, British Expeditionary Force.
1896. Scott, James, M.B., C.M.Edin.. 98, Baron’s Court Road, West Kensing¬
ton, W. 14.

1915. Scott, Janies McAlpine, M.l)., Ch.B.Glasp., Junior Assistant Medical
Officer, Stirling District Asylum, Larbert.

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

1911. Scroope, Geoffrey, M.B., B.Ch.Dub., Assistant Medical Officer, Central

Asylum, Duudrum.

1880. Seccotnbe, George S., M.lt.C S., L.R.C.P.Lond., e/o Messrs. H. S. King
and Co., 65, Cornhill, E.C. 3.

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

Superintendent, Newlands House, Tooting Bee Common, S.W. 17.
(Secretary South-Eastern Division from 1913.)

1882. Seward, William J., M.B.Lond., M.R.C.S.Eng., 15, Chandos Avenue,
Oakleigh Park, N. 11.

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

Officer,City Mental Hospital, Wiuson Green, Birmingham); Journals
to Capt., R.A.M.C.,'So.ti Clearing Hospital, British Expeditionary
Force.

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

1909. fShaw, William Samuel J., M.B., B.Ch.R.U.I., Major I.M.S., Superin¬
tendent, North Veravola, Poona, India.

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

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

1917. Shaw, John Custanee, M.R.C.S.Eng., L.R.C.P.Lond., Medical Superin¬
tendent, West Ham Borough Asylum, Goodmayes, Essex.

1904. Shaw, Patrick, L.R.C.P.&S.Ediu., Senior Medical Officer (Hospital for

the Insane, Kew, Victoria, Australia); “ Lingerwood,” Wills Street,
Kew, Victoria, Australia. On active service.

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

1900. Shera. John E. P., M.D.Brux., L.R.C.P.AS.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 Burhall, M.D., B.Sc., D.P.U.Lond., Medical Superin¬

tendent, Darenth Industrial Colony, Dartford.

1914. fShield, Hubert, M.B., B.S.Durh. (Assistant Medical Officer, Gateshead
Borough Asylum, Stnnnington, Newcastle-ou-Tvne); Capt.,.ft. A.M. C.
( T .), 1st Nottingham Field Ambulance, British Expeditionary Force,
France.

1877. Shuttleworth, George E., B.A.Lond., M.D.Heidelb., M.K.C.S. and L.S.A
Loud., 25, New Cavendish Street; 8, Lancaster Place, Hampstead,
N.W. 1.

1901. fSimpson, Alexander, M.A., M.D., C M.Aber. (Medical Superintendent,

County Asylum, VVitiwick, Newton-le-Willows, Lancashire); Lt.-Col.,
R.A.M.C., Lord Derby War Hospital, Warrington.

1905. Simpson, Edward Swan, M.D., Ch.B.Edin., East Riding Asylum,

Beverley, Yorks.

1888. Sinclair, Eric, M.D., C.M.Glnsg., Inspector-General of Insane, Richmond
Terrace, Demain, 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. Skinner, Ernest VV., M.D., C.M.Edin., J.P., Mountstield, Rye, Sussex.

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1914. Slaney, Chas. Newnham, M.R.C.S., L.R.C.P.Loud., The Elms, Parkbm-st,

l.W.

1901. Slater, George N. O., M.D.Lond., M.R.C.S., L.R.C.P.Loud., Assistant
Medical Officer, Essex County Asylum, Brentwood.

1914. Smith, Charles Kelman, M.B., Cb.B.Aberd., Assistant Medical Officer,
Parkside Asylum, Macclesfield.

1910. fSmith, Gayton Warwick, M.D.Lond., B.S.Durh., D.P.H.Cantab.,

M.R.C.S., L.R.C.P.Loud., Assistant Medical Officer, Middlesex
County Asylum, Tooting, S.W. 17 ; Capt. R.A.M.C.

1905. Smith, George William, M.B., Ch.B.Edin. (Assistant Medical Officer,

Holloway Sanatorium, Virginia Water, Surrey).

1907. Smith, Henry Watson, M.D., Ch.B.Aberd., Medical Superintcudent,
Lebanon Hospital for the Insane, Asfurujeh, near Beyrout,
Syria.

1899. Smith, John G., M.D., C.M.Ediu., 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
Anne Street, Cavendish Square, W. 1. ( General Secretary, 1896-7.
Chairman Educational Committee, 1899-1903.) (PHBS1DBNT,
1904-5.)

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

1911. Smith, Thomas Waddelow, K.R.C.S., L.R.C.P.Loud., M.P.C., Assistant

Medical Officer, City Asylum, Mapperley Hill, Nottingham.

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

Melbourne, Victoria.

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

Officer, County Asylum, Shrewsbury.

1899. Smyth, Walter S., M.B., B.Ch.R.U. 1., Assistant Medical Officer, County
Asylum. Antrim.

1913. Somerville, Henry, B.Sc., M.R.C.S., L.R.C.P.Loud., F.C.S., Harrold,
Siiariibrook, Bedfordshire.

1885. Soutur, James Greig, M.B., C.M.Ediu., M.P.C., Medical Superintendent,

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

1906. Spark. Percy Churles, M.R.C.S., L.R.C.P.Loud., Medical Superintendent,

Londou County Asylum, Banstead, Surrey.

1876. Spence, J. Beveridge, M.D., M.C.Q.U.I., Medical Superintendent, Burut-
wood Asylum, near Lichfield. ( First Regittrar, 1892-1899;
Chairman Parliamentary Committee, 1910-12.) (PBBSIDBNT,
1899-1900.)

1913. Spensley, Frank Oswold, M.R.C.S., L.R.C.P.Loud., Senior Medical

Officer, Darenth Asylum, Hartford, Kent.

1891. fStansfield, T. E. K., M.B., C.M.Ediu., Medical Superintendent, London
County Asylum, Bexley, Kent; Hon. Major, R.A.M.C.

1901. Starkey, William, M.B., B.Ch.R.U.I., Medical Superintendent, Borough
Asylum, Blackadoo, Ivybridge, S. Devon.

1907. fSteele, Patrick, M.D., Cli.B., M.R.C.P.Edin. (Assistant Medical Officer,

District Asylum, Melrose; Lt. R.A.M.C.

1898. Steen, Robert 11., M.D.Lond.. M.R.C.P.Lond., Medical Superintendent,
City of London Mental Hospital, Stone, Hartford. (Hon. Sec. S.E.
Dirieion, 1905-10; Acting Hon. Gen. Sec. siuce 1915.)

1914. Stephens, Harold Freize, M.R.C.S.Lond., L.R.C.P.Eng., 9, Belmont

Avenue, Palmer’s Green, Middlesex.

1914. fStevenson, George Henderson, M.B., Ch.B.Edin., 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, Wiuncell Down Camp, Winchester.

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

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

1915. Stewart, A. H. L., M.R.C.S., 72, Wimpolo Street, W. 1.

1868. Stewart, James, B.A.Belf., F.R.C.P.Ed., L.R.C.S.I., Junior Constitutional
Club, Piccadilly, W. 1.

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

Glasgow) ; Capt. R.A.M.C., No. 38 Hospital, Mediterranean Expe¬
ditionary Force.

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

1914. fStewart, Roy M.. M.B., Cli.B.Edin. (Assistant Medical Officer, County

Asylum, Prcstwich) ; Capt. R.A.M.C., Mediterranean Expedi¬
tionary Force, c/o G.P.O.

1905. Stilwell, Henry Francis, L.R.C.P.AS.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.D., B.S., F.R.C.P.Loud., M.R.C.S.

Eng., M.P.C., Harcourt House, Cuvendisli Square, W. 1. (Hon. Sec.
Educational Committee, 1908-1912.)

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

1905. Stratbearu, John, M.D., Ch.B.Glasg., F.R.C.S.E., 23, Magdnlen Yard
Road, Dundee.

1903. Stratton, Percy Hnughton, M.R.C.S., L.R.C.P.Lond., 10, Hanover
Square, W. 1.

1885. Street, C. T., M.R.C.S., L.R.C.P.Lond., Huydock Lodge, Ashton,
Newton-le-Willows, Lancashire.

1909. fStuart, Frederick J., M.R.C.S., L.R.C.P.Lond. (Senior Assistant Medical

Officer, Northampton County Asylum, Berry wood); Major R.A.M.C.,
War Hospital, Dunston, Northampton.

1900. Sturrock, James Prain, M.A.St.Aud., M.D., C.M.Ediu., 25, Palmerston

Place, Edinburgh.

lSSG. Suffern, Alex. C., M.D., M.Ch.R.U.I. (Medical Superintendent, Rubery
Hill Asylum,near Bromsgrove, Worcestershire); Lt.-Col. R..A.M.C.,
1st Birmingham War Hospital, Rubery Hill, Worcestershire.

1894. Sullivan, William C., M.D., B.Ch.R.U.I., Hampton Criminal Lunatic
Asylum, Retford, Notts.

1910. fSutherlnnd, Joseph Roderick, M.B., Ch.B.Glasg., M.R.C.S., L.R.C.P.

Loud., D.P.H., County Sanatorium, Stonehousc, Lanarkshire.

1908. Swift, Eric W. I)., M.B.Loud., Medical Superintendent, Government
Asylum, Bloemfontein.

1908. Tattersall, John. M.D.Lond., M.R.C.S., M R.C.P.Lond., Assistant
Medical Officer, Loudon County Asylum, Hanwell, W. 7.

1910. Taylor, Arthur Loudoun, B.Se., M.B., Ch.B., M.R.C.P.Edin., 30,

Hnrtington Place, Edinburgh.

1897. Taylor, Frederic Ryott Percival, M.D., B.S.Lond., M.R.C.S., L.R.C.P.

Lond., Medical Superintendent, East Sussex Asylum, Hellingly.
1908. Thomas, Joseph 1)., B.A., M.B., B.C.Cantab., North woods House, Winter¬
bourne, Bristol.

1911. fThomas, William Rees, M l)., 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.

1880. tThomson, David (i., M.D., C.M.Ediu. (Medical Superintendent, County
Asylum, Thorpe, Norfolk); Lieut.-Col. R.A.M.C., Norfolk War
Hospital, Thorpe, Norwich. (PRESIDENT, 1914-15.)

1903. Thomson, Herbert Campbell, M.D., F.R.C.P.Loud., Assist. Physician
Middlesex Hospital. 34, Queen Anne Street, W. 1.

1905. fTidburv, Robert,M.D., M.Ch. R.U.I.(Hcathlands,Foxhall Road, Ipswich);
Lieut. R.A.M.C.

1901. Tiglie, John V. G. B., M.B., B.Ch.R.U.I., Medical Superintendent,

Gateshead Mental Hospital, Stanuington, Northumberland.

1914. fTisdall, C. .1., M.B., Ch.B. (Crichton Roval Institution, Dumfries) ;

R.A.M.C.

1903. Tophtun, J. Arthur, B.A.Cantab., M.R.C.S., L.R.C.P.Lond., County
Asylum, Chartham, Kent.

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1896. Townsend, Arthur A. 1)., M.D., B.Ch.Birm., M.R.C.S., L.H.C.P.Lond.,
Assistant Medical Officer, Hospital for Insane, Barnwood House,
Gloucester.

1904. Treadwell, Oliver Pereira Naylor, M.R.C.S.Eng., L.S.A.Loud., 102,
Belgravia Road, S.W. 1.

1903. Tredgold, Alfred F., M.R.C.S., L.R.C.P.Lond. (6, Dapdune Crescent,

Guildford, Surrey).

1908. Tuaeh-MacKenzie, William, M.D., Ch.B.Aberd., Medical Superintendent,

Royal and District Asylums, Dundee.

1881. Tnke, Charles Molesworth, M.R.C.S.Eng., Chiswick House, Chiswick.

1888. Tuke, John Batty, M.D., C.M., F.K.C.P.Edin., Resident Physician,

New Saughton Hall, Polton, Midlothian.

1915. Tulloch, William John, M.D.St. Andrews, Director Western Asylums
Research Institute, 10, Claytbon Road, Glasgow.

1906. tTurnbull, Peter Mortimer, M.B., B.Cli.Aberd., Tooting Bee Asylum,
Tooting, S.W. 17; Temp. Lieut. R.A.M.C.

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.l)., C.M.Edin., Plyinpton House, Plympton, S. Devon.
1906. Turner, Prank 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.

1917. Vevers, Oswald Henry, M.R.C.S., L.R.C.P.Lond., Acting Medical Superin¬
tendent, Laverstnck House, Salisbury.

1904. Vincent, George A., M.B., B.Ch.Edin.,Assistant Medical Superintendent,

St. Ann’s Asylum, Port of Spain, Trinidad, B.W.l.

1894. fViucent, William James N., M.B., B.S.Durh., M.R.C.S., L.R.C.P.Lond.

(Medical Superintendent, Wadsley Asylum, near Sheffield); Lt.-Col.
R.A.M.C., Wharncliffe War Hospital, Sheffield.

1914. Vining, Charles Wilfred, M.D., B.S.Loud., M.R.C.P.Lond., D.P.H.,
M.P.C., Assistant Physician, Leeds General Infirmary, 40, Park
Square, Leeds.

1913. jWalford, Harold It. S., M.R.C.S., L.R.C.P.Lond. (Assistant Medica

Officer, Kent County Asylum, Banning Heath, Maidstone); Lieut.
R.A.M.C.

1914. Walker, Robert Clive, M.B., Cb.B.Edin., West Riding Asylum, Menston,

near Leeds.

1908. Wallace, John Andrew Leslie, M.D., Ch.B.Edin., M.P.C.

1912. Wallace, Vivian, L.R.C.P. & S.I., Assistant Medical Officer, Muilingar
District Asylum, Mullingar.

1889. Warnock, John, C.M.G., M.D., C.M., B.Se.Edin., Medical Superintendent,
Abbasiyeh Asylum, nr. Cairo, Egypt.

1895. Waterston, Jane Elizabeth, M.D.Brux., L.li.C.P.I.,L.R.C.S.Edin., M.P.C.,

85, Parliament Street, Box 78, Cape Town, South Africa.

1902. Watson, 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, itainhill,
Liverpool.

1908. Watson,H. Ferguson,M.D.,Ch.B.Glas.,L.R.C.P.&S.E.,L.R.F.P.&S.Glas.,
D.P.H., Northcote, Edinburgh Road, Perth.

1911. fWebber, Leonard Mortis, M.R.C.S., L.lt.C.P.Loud. (Assistant Medical
Officer, Netherne, Merstham, Surrey); Temp. Lieut. R.A.M.C.
1911. fWhite, Edward Barton C., M.R.C.S., L.R.C.P.Lond. (Seuior Assistant
Medical Officer, CarditF City Mental Hospital, Whitchurch) ; Major,
R.A.M.C., Welsh Metropolitan War Hospital, Whitchurch.

1884. f White, Ernest William, M.B.Lond., M.R.C.P.Lond. (Betley House, nr.

Shrewsbury). (Hon. Sec. South-Eastern Division, 1897-1900.)
(Chairman Parliamentary Committee, 1904-7.) (Pbksidxnt
1903—4.) ; Temp. Hon. Lieut.-Col. R.A.M.C.

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XXIX

Members of the Association.

1905. fWhittington, Richard, M.A., M.D.Oxon., M.R.C.S., L.R.C.P.Lond.,
(Downford, Montpelier Road, Brighton); Major, R.A.M.C.,T.F.,
2nd East General Hospital, Brighton.

1889. Whitwell, James Richard, M.B., C.M.Ediu., Medical Superintendent,
Suffolk County Asylum, Melton Woodbridge.

1903. Wigan, Charles Arthur, M.D.Durh., M.lt.C.S.Eng., L.S.A.Lond., Deep-
dene, Portishead, Somerset.

1883. Wiglesworth, Joseph, M.D., F.R.C.P.Lond., Springfield House, Wins-
combe, Somerset. (Pkbsidbnt, 1902-3.)

1913. fWilkins, William Douglas, M.B., Ch.B.Vict., M.lt.C.S., L.R.C.P.

Lond. (County Mental Hospital, Cheddleton, Leek, Staff.);
Capt. R.A.M.C.

1900. fWilkinson, H. B.. M.R.C.S., L.R.C.P.Lond. (Assistant Medical Officer
Plymouth Borough Asylum, Blackudon, lvybridge, Soutli Devon);
Lieut. R.A.M.C.

1887. Will, John Kennedy, M.A., M.D., C.M.Aberd., M.P.C., Bethnal House,
Cambridge Road, N.E. 1.

1914. Williams, Charles, L.R.C.P. & S.Edin., L.S.A.Lond., Assistant Medical

Officer, The Warneford, Oxford.

1907. tWilliam*, Charles E. C., M.A., M.D., B.Ch.Dubl.; Greystoncg, Carnford
Cliffs, Bournemouth ; Capt. R.A.M.C., No. 12 General Hospital,
British Expeditionary Force, France.

1905. Williams, David John, M.lt.C.S., L.R.C.P.Lond., Medical Superintendent,
The Asylum, Kingston, Jamaica.

1915. fWilliams, Gwilym Ambrose, L R.C.P.Lond., M.R.C.S.Eng. (Pathologist

and Assistant Medical Officer. East Sussex County Asylum,
Hellinglv); R.A.M.C., 27th General Hospital, Mediterranean

Expeditionary Force.

1910. Wilson, Marguerite, M.B., Ch.B.Glasg., Gl, Selly Park Road, Selly
Park, Birmingham.

1912. Wilson, Samuel Alexander Kinnier, M.A., M.I)., B.Sc.Edin., F.R.C.P.

Lond., Registrar, National Hospital, Queen’s Square, 14, Harley
Street, W. 1.

1897. Winder, W. H„ M.R.C.S., L.R.C.P.Lond., D.P.H.Cantab., Deputy
Medical Officer, H.M. Borstal Institution, Borstal, Kent.

1875. Winslow, Henry Forhes, M.D.Lond., M.R.C.P.Lond., M.R.C.S.Eng.,
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,
Mnidstone. (Secretary Parliamentary Committee, 1907-12. Chair¬
man tince 1912.)

1869. Wood, T. Ontterson, M.D.Durh., M.R.C.P.Lond., F.R.C.P., F.R.C.S.

Edin., 7, Abbey Crescent, Torquay. (President, 1905-6.)

1912. fWoods, James Cowan, M.I)., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
(10, Palace Green, Kensingtou, W. 8); Temp. Major R.A.M.C.
1885. +Woods, J. F., M.D.Durh., M.R.C.S.Eng. (7, Harley Street, Cavendish
Square, W.) ; Capt. R.A.M.C.

1912. Wootton, John Charles, M.R.C.S.Eng., L.R.C.P.Lond.. Haydock Lodge,
Newton-le-Willows, Lancs.

1900. fWorth, Reginald, M.B., B.S.Durb., M.R.C.S., L.R.C.P.Lond. (Medical

Superintendent, Middlesex Asylum, Tooting, S.W.17); Maj.

R.A.M.C.

1917. fWright, Maurice Beresford, M.D., C.M. (118, Harley Street, London,
W. 1); Major R.A.M.C., 10, Palace Green, Kensington, W. 8.

1862. Yellowlees, David, LL.D.Glas., M.D.Edin., F.R.F.P.iS.Glnsg., 6, Albert
Gate, Dowan Hill, Glasgow. (President, 1890.)

1914. fYellowlees, Henry, M.lL.Ch.B.Glas., 6, Albert Gate Dowan Hill, Glasgow ;

Lt. R.A.M.C., 26th British Genernl Hospital, British Exped. 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. 1.

Digitized by Google

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PRINCETON UNIVERSITY

XXX

Digitized by

Ordinary Members .

... 627

Honorary Membbrs .

... 33

Corresponding Members .

... 18

Total.

... 678

t Serving with H.M. Forces.

Member» are particularly requested to tend 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. Adtard Sf Son Sf West Newman, Ltd., 23, Bartholomew Close,
London, B.C.

OBITUARY.

Honorary Members.

1898. Magnan, V., M.D., Agile de Ste. Anne, Paris.

1917. Urquhart, Alexander Reid, M.D.Aber., LL.D.Aber., F.R.C.P.Kdin., late
Physician Superintendent, James Murray’s Koval Asylum, Perth.

Members.

1906. 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.

1908. fBlandy, Gurth Swinncrton, M.D., Ch.13.Edin., M.C. (Assistant Medical
Officer, Middlesex County Asylum, Napsbury, Herts) ; Capt.
R.A.M-C. (T.) (killed in action).

1892. Bullen, Frederick St. John, M.R.C.S.Eng., L.S.A.Lond., 3, Richmond

Park Road, Clifton, Bristol.

1889. Cnllcott, James T., M.D., B.S.Durh., M.R.C.S.Eng., Medical Superin¬

tendent, Borough Asylum, Newcastle-on-Tyne.

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.

1884. Ewart, C. T., M.D., C.M.Aberd., Medical Superintendent, Claybnry

Asylum, Woodford Bridge, Essex.

1897. Fielding, James, M.l)., Viet. Univ., Canada, M.R.C.S.Eng., L.R.C.P.

Ediu., 18, The Crescent, Norwich.

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

1882. +Hyslop, James, Col. L.S.O., M.B., C.M.Edin., Medical Superintendent
The Huts, Pietermaritzburg, Natal.

1898. Macnnughton, George W. F., M.D., F.K.C.S.Edin., M.R.C.P.Lond..

M.P.C., 33, Lower Belgrave Street, Eaton Square, London, S.W. 1.
1871. Mickle, William Julius. M.D.. F.R.C.P.Lond., Ottawa, Canada.
(President, 1896-7.)

1893. Murdoch, James William Aitken, M.B., C.M.Glasg., Medical Superin¬

tendent, Berks County Asylum, Wallingford.

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

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

Medical Officer, City of London Asylum, Hartford.

1893. Rawes, William, M.D.Durh., F.R.C.S.Eng., Medical Sui)erinteudent, St.

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

1901. Smyth, Robt. B., M.A., M.B., Cli.B.Dubl., Medical Superintendent,
County Asylum, Gloucester.

1885. Tnke, T. Seymour, M.A., M.B., B.Ch.Oxon., M.R.C.S.Eng., Chiswick

House, Chiswick, W.

1885. Watson, William Riddell, L.R.C.S. A P.Edin., 6, Queen’s Mansions,
Brook Green, LoudoD, W.

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PRINCETON UNIVERSITY

XXXI

Lilt of those who have paiied the Examination for the Certificate of Efficiency
in Psychological Medicine, entitling them to append M.P.C. (Med.-Psych.
Certif.) to their names.

Adams, J. Barfield.

Clayton, Frank Herbert A.

Adamson, Robert 0.

Clayton, Thomas M.

Adkins, Percy, R.

Clinch, Thomas Aldous.

Ainley, Fred Shaw.

Colei, Richard A.

Aiuslie, William,

Collie, Frank Lang.

Alcock, B. J.

Collier, Joseph Henry

Alexander, Edward H.

Conolly, Richard M.

Anderson, A. W.

Conry, John.

Anderson, Bruce Arnold.

Cook, William Stewart.

Anderson, John.

Cooper. Alfred J. S.

Andriezeu, W.

Cope, George Patrick.

Apthorp, F. W.

Corner, Harry.

Armour, E. F.

Cotton, William.

Attegalle. J. W. S.

Coupcr, Sinclair.

Aveline, H. T. S.

Cowan, John J.

Kallautyne, Harold S.

Cowie, C. G.

Barbour, William.

Cowie, George.

Barker, Alfred James Glanville.

Cowper, John.

Bashford, Ernest Francis.

Cox, Walter H.

Bazalgette, S.

8 Craig, M.

Begg, William.

Cram, John.

Belben, F.

Crills, G. H.

Bird, James Brown.

Cross, Edward John.

Blachford, J. Vincent.

Cruickshank, George.

Black, E. J.

Cullen, George M.

Black, Robert S.

Cunningham, James F.

Black, Victor.

Dalgetty, Arthur B.

Blackwood, John.

Davidson, Andrew.

Blandford, Henry E.

Davidson, William.

Bond, C. Hubert.

6 Dawson, W. R.

Bond, R. St. 0. S.

Do Silva, W. H.

Bowlati, Marcus M.

11 Devine, H.

Boyd, James Paton.

Distin, Howard.

Boyd, William

Dixon. J. F.

Bradley, J. T.

Donald, Wm. D. D.

Bristowe, Hubert Carpenter.

Donaldson, R. L. S.

Brodie, Robert C.

Donelan, James O’Conor.

Brough, C.

Douglas, A. R.

Brown, William.

Downey, Augustine.

Browne, Hy. E.

Drummond, Russell J.

Bruce, John.

Eager, Richard.

Bruce, Lewis C.

Karnes, Henry Martyn.

Brush, S. C.

Earls, James H.

Bulloch, William.

East, W. Norwood.

Calvert, William Dobree.

Easterbrook, Charles C.

Cameron, James.

Eden, Richard A. S.

Campbell, Alex Keith.

Edgerley, S.

Campbell, Alfred W.

Edwards, Alex. H.

Campbell, Peter.

Elkins, Frank A.

Carmichael, W. J.

Ellis, Clarence J.

Carruthers, Samuel W.

English, Edgar.

Carter, Arthur W.

Eustace, J. N.

Chambers, James.

Eustnce, Henry Marcus.

Chambers, W. I).

Evans, P. C.

Chapman, H. C.

Ewan, John A.

Christie, Willinm.

Ezard, Ed. W.

Clarke, Robert H.

Falconer, A. R.

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PRINCETON UNIVERSITY

XXX11

Digitized by

Falconer, James F.

Farqnharsou, Wm. Fredk.
Fennings, A. A.

Ferguson, Robert.

Findlay, O. Landsborough.
Fitzgerald, Gerald.

Fleck, David.

Fortune, J.

Fox, F. G. T.

Fraser, Donald Allan.

Fraser, Thomas.

Frederick, Herbert John.

Gage, J. M.

Gaudin, Francis Neel.

Gawn, Ernest K.

Gemmell, William.

Gennev, Fred. 8.

Gibb, H. J.

Gibson, Thomas.

Giles, A. B.

Gill, J. Macdonald.

Gilraour, John R.

Goldie, E. M.

Goldschmidt, Oscar Bernard.
Goodall, Edwin.

Gostwyck, C. H. G.

Graham, Dd. James.

Graham, F. B.

Grainger, Thomns.

Grant, J. Wemyss.

Grant, Lacklan.

Gray, Alex. C. E.

Gray, Theodore G.

Griffiths, Edward H.

Haldane, J. R.

Hall, Harry Baker.

Halsted, H. C.

Haslnm, W. A.

Haslett, William Johu Handfield.
Hassell, Gray.

Hector, William.

Henderson, Jane B.

Henderson, P. J.

Hennan, George.

Hewat, Matthew L.

Hewitt, D. Walker.

Hicks, John A., jun.

Hitcliings, Robert.

Holmes, William.

Horton, .Tames Henry.

Hotchkis, R. D.

Howden, Robert.

Hughes, Robert.

Hunter, U. T. C.

Hutchinson, P. J.

2 Hyslop, Thos. B.

Ingram, Peter R.

Jeffery, G. R.

Jagannadhan, Annie W.

Johnston, John M.

Johnstone, Emma M.

Keith, W. Brooks

Kelly, Elizabeth M. V'.

Kelly, Francis.

Kelso, Alexander.

Kelson, W. H.

Ker, Claude B.

Kerr, Alexander L.

Keyt, Frederick.

King, David Barty.

King, Frederick Truby.

Laing, C. A. Barclay.

Laing, J. H. W.

Law, Thomas Brvden.

Leeper, Richard R.

Leslie, R. Murray.

Livesay, Arthur W. Bligh.
Livingstone, John.

Lloyd, R. H.

Lothian, Norman V. C.

Low, Alexander.

McAllum, Stewart.

Macdonald, David.

Macdonald, G. B. Douglas.
Macdonald, John.

Macdonald, W. F.

Macevoy, Henry John.
McGregor, George.

Maclnnes, Ian Lamont.
Mackenzie, 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, Donald A.

Mallannah, Sreenagula.

Marr, Hamilton C.

Marsh, Ernest L.

Marshall, R. M.

Martin, A. A.

Martin, A. J.

Martin, M. E.

Martin, Wm. Lewis.

Masson, James.

McDowall, Colin.

Meikle, T. Gordon.

Melville, Henry B.

Middlemass, James.

Miller, R.

Miller, R. H.

Mitchell, Alexander.

Mitchell, Charles.

Moffett, Elizabeth J.

Moll, J. M.

Monrad-Krohn, G. H.

Monteith, James.

Moore, Edward Erskine.

1 Mortimer, John Desmond Ernest

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PRINCETON UNIVERSITY

xxxm

Munro, M.

Murison, Cecil C.

Murison, T. D.

Myers, J. W.

Nair, Charles R.

Nairn, Robert.

Neil, James.

Nixon, John Clarke.

Nolan, J. N. (1.

Nolan, Michael James.
Norton, Everitt E.
Oldershaw, G. F.

Orr, David.

Orr, Janies.

Orr, J. Fraser.

Oswald, Landel R.
Overbeck-Wright, A. W.
Owen, Corbet W.

Paget, A. J. M.

Parker, William A.

Parrv, Charles P.

Patterson, Arthur Edward.
Patton, Walter S.

Paul, William Moncriet.
Peach ell, G. E.

Pearce, Francis H.

Pearce, Walter.

Penfold, William James.
Perdrau, J. A.

Philip, James Farquhar.

12 Philip, William Marshall.
Phillips, J. G. Porter.
Phillips. J. R. P.

Pieris, William C.
Pilkington, Frederick W.
Pitcairn, John James.
Porter, Charles.

Powell, James F.

Price, Arthur.

Priug, Horace Reginald.
Rainy, Harry, M.A.

Ralph, Richard M.

Rankine, 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.

Digitized by

Rust, Montague.

10 Rutherford, J. M.

Sawyer, Jas. E. H.

Scanlon, M. P.

Scott, F. Riddle.

Scott, George Brebner.

Scott, J. Walter.

Scott., William T.

Senwright, H. G.

Sheen, Alfred W.

Simpson, John.

Simpson, Samuel.

Skae, F. M. T.

Skeen, George.

Skeen, James H.

Slater, William Aruison.

Slattery, J. B.

Smith, Percy.

Smith, T. Waddelow
Smith, William Maule.

Smyth, William Johnson.
Snowball, Thomas.

Soutar, James G.

Sproat, J. H.

Stanley, John Douglas.

Staveley, William Henry Charles.
Steel, John.

Stephen, George.

Stewart, William Day.

Stoddart, John.

9 Stoddart, William Hy. B.
Strangmau, Lucia.

Strong, D. R. T.

Stuart, William James.

Symes, G. D.

Taylor, W. J.

14 Thomas, 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.

Umney, W. F.

Vining, C. W.

Walker, James.

Wallace, J. A. L.

Wallace, W. T.

Wnrde, Wilfred B.

Waters, John.

Waterstou, Jane Elizabeth.
Watson, George A.

Welsh, David A.

West, J. T.

White, Hill Wilson.

Whit well, Robert R. H.
Wickham, Gilbert Henry.

Will, John Kennedy.

Williams, D. J.

C

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PRINCETON UNIVERSITY

XXXIV

Digitized by

Williamson, A. Maxwell.
4 Wilson, G. R.

Wilson, James.

Wilson, John T.

Wilson, Robert.

Wood, David James.

15 Woods, J. C.

Yeates, Thomas.
Yeoman, John B.
Young, D. P.

Younger, Henry J.
Zimmer, Carl Raymond.

1 To whom the Gaskell Prize (1887) was awarded.

2 To whom the Gaskell Prize (1889) was awarded.

3 To whom the Gaskell Prize (1890) was awarded.

4 To whom the Gaskell Prize (1892) was awarded.

5 To whom the Gaskell Prize (1895) was awarded.

6 To whom the Gaskell Prize (1896) was awarded.

7 To whom the Gaskell Prize (1897) was awarded.

8 To whom the Gaskell Prize (1900) was awarded.

9 To whom the Gaskell Prize (1901) was awnrded.

10 To whom the Gaskell Prize (1906) was awarded.

11 To whom the Gaskell Prize (1909) was awarded.

12 To whom the Gaskell Prize (1911) was awarded.

13 To whom the Gaskell Prize (1912) was awarded.

14 To whom the Gaskell Prize (1913) was awarded.

15 To whom the Gaskell Prize (1917) was awarded.

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

JOURNAL OF MENTAL SCIENCE, JANUARY, 1918 .

Alexander Reid Urquiiart, LL.D., M.D.Aberd., F.R.C.P.Edin.

Obiit July 31 st, 1917 . President, 1898 . Co-Editor of Journal 1894 - 1910 .

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Adlard & Son & /Vest Nnvman, Ltd.

Original from

PRINCETON UNIVERSITY

THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.']

No. 264 [ToTr] JANUARY, 1918. Vol. LXIV.

Part I.—Original Articles.

Aphasia in Relation to Mental Disease. Presidential Address by
R. Percy Smith, M.D., in the Section of Neurology of the Royal
Society of Medicine, at Meeting held on October 25th, 1917.

My first duty is to express my thanks to the members of the Section
for having done me the honour to elect me as its President for the
ensuing year, an honour which I felt bound to accept, although it
involved the burden of a Presidential Address, in addition to one a
year ago to the Section of Psychiatry, of which I am still President.
Perhaps the accident that I was for some years the editor of Brain ,
which w'as at that time the journal of the Neurological Society, in
succession to Dr. de Watteville, induced the Section to place me in this
chair, to hold which, however, I feel myself unworthy in presence of
and in succession to so many distinguished neurologists.

To one whose work has lain for so many years in the domain of
psychiatry the choice of a subject for a Presidential Address to this
Section has seemed somewhat difficult, but it appeared to me that my
best course was to search through my case-books for cases which
might be of interest both to the neurologist and the alienist and lie in
the borderland between the practices of the two, and as to which
either of them may be consulted by the general practitioner. In this
way many cases of disease of the nervous system where there has been
more or less pronounced mental disorder have come before me.

It has seemed to me that those cases in which there has been
aphasia more or less pronounced whether with or without hemiplegia
(apart from cases of general paralysis where it has been an occasional
symptom), and in which I have been consulted as to the patient’s
mental condition would be the most likely to be of interest to the
Section.

LXIV. I

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PRINCETON UNIVERSITY

2

APHASIA IN RELATION TO MENTAL DISEASE, [Jan.,

The subject of aphasia has, of course, a voluminous literature, both
from the side of neurology and of psychiatry, and with regard to this
I think we owe an eternal debt of gratitude to Dr. Henry Head, the
present editor of Brain , and our senior Vice-President, for having in
vol. xxxviii of that journal reprinted many of the important papers
of our great master, Hughlings Jackson, and so prevented them from
passing into obscurity, and for having in his paper, “ Hughlings Jackson
on Aphasia and Kindred Affections of Speech,” given so admirable a
summary of the views and conclusions of that great English neuro¬
logist. I may also mention the valuable reviews and summaries
given by James Collier ( Brain , 1908, xxxi, p. 523), and by S. A. K.
Wilson (Review of Neurology and Psychiatry , 1909, vii, p. 151) on the
subject.

As recently as 1915 Head writes : “Speech is a function of mental
activity and however much that mental activity may ultimately be
linked up with the integrity of some portion of the brain substance the
problem is primarily a psychological one,” and again, “no one but
Plughlings Jackson has recognised that all the phenomena are primarily
psychical and only in the second place susceptible of physiological or
anatomical explanation ” (loc. cit , p. 4).

Therefore, no apology is needed for examining those cases of aphasia
which come under the notice of the alienist. In any particular case it
is important to ascertain whether there has been mental disorder of any
kind preceding more definite affection of the speech mechanism, as well
as to see in what way cases beginning with aphasia are associated with
mental disorder. There frequently arises also in any of these cases the
question of business or testamentary capacity.

Although during my tenure of office at Bethlem Hospital a few
cases of aphasia associated with certifiable insanity were admitted, in
some of which an autopsy was obtainable, the larger number of cases
which I have met with in consulting practice have only been seen
clinically, and there has been no opportunity of ascertaining how far
the affection of speech corresponded with any particular pathological
condition of the brain. With regard to this, however, I may again quote
Head’s remarks in reference to Hughlings Jackson’s views : “ But no
one has assimilated his views on defect of speech and applied them to
a series of actual cases of this condition. We failed to appreciate how
much closer these conceptions would lead us to the phenomena of
aphasia than the glib generalities founded on the anatomical facts
of cortical localisation.” And again, “ Neurology has become frozen
stiffly in the grip of pseudo-metaphorical classifications which neither
explain the condition nor correspond to the clinical fact ” (Joe. cit., p. 3).

Hughlings Jackson has said, “We shall do no harm to clinical
medicine, if we simply record all the facts ” (Brain, 1915, xxxviii, p. 37).

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I hope, therefore, that the absence of pathological findings in this paper
may not render this communication entirely worthless.

The alienist may be called in consultation for the following reasons
in cases where there is aphasia :

(1) Because of the confused or incomprehensible speech of the
patient and other conduct suggesting confusion or disorder of mind,
the nature of the speech affection being misunderstood by his relatives,
and not always recognised by the practitioner. This is especially soin
those cases where there is no hemiplegia associated with the aphasia,
but also occasionally in cases where there has been a previous transient
hemiplegia, or even some slight right-sided paralytic signs or unrecog¬
nised hemianopia, so that in taking the history one may be confronted
by such descriptions as “ talks incessantly, uses the same word again
and again, shouts at times and shows excitement ”; “ on waking up was
unable to speak, did not know anything, and was mumbling”; “could
not find words, was worried and excited, then violent and resistive ”;
“ was light-headed, could not see or read properly ” ; “ makes inarticu¬
late noises ”; “ talked babble, emotional and angry, but no loss of
consciousness”; “talked gibberish, cannot put six words together”;
“ said to be * mad ’ and could not speak properly ” ; “ was brought back
home and did not know how to eat, was thought to be intoxicated ”;
“speech incoherent”; “said to be childish and incompetent and
imbecile ”; “ emotional and confused, unable to read, does not ask
for anything or propose anything ”; “ speech inarticulate ” ; “ found
walking about in his office unable to speak, then talked gibberish.”
Sometimes such patients are found wandering in the street, unable to
give any account of themselves, and are regarded at first as being
demented. Brissot calls attention to the various speech disorders met
with in insanity, which require careful differentiation from true aphasia
of organic origin.

(2) Because of definite signs of mental disorder predominating over
the aphasic speech troubles. Previous attacks of insanity may have
occurred and been recovered from and the attack of aphasia may occur
in association with a return of the previous symptoms, or be masked
by loss of memory, mental confusion, or apraxia. As Brissot says
( L'aphasie dans ses rapports avec la dimence et les vlsanies, Paris, G.
Steinheil, 1910): “Many aphasics are met with in asylums whose
internment is justified by demential or vesanic troubles.” Ideas of
persecution (sometimes justified) may be met with, or temporary
excitement, delusions and hallucinations, coming on immediately after
a “stroke.” During my residence at Bethlem Hospital some eleven
patients who had either previously been aphasic, or were so at the time
of admission, were admitted under certificates, and many such may be
met with in the wards of county asylums.

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(3) To decide on the proper care and treatment of patients in whom
aphasia of various degrees of severity is associated with disorder of
mind and conduct. Many of these, of course, can be treated at home,
if the means and accommodation allow of proper nursing and super¬
vision, but, as Savage has often said, “ the treatment of insanity
frequently depends on the length of the purse,” and the infirmary
wards of county asylums afford better care in such cases in the poorer
classes than can be met with in any but the best of the workhouse
infirmaries.

(4) To assist in forming a prognosis as to mental recovery or other¬
wise, or in the diagnosis from other organic conditions, such as general
paralysis.

(5) To give an opinion as to the business or testamentary capacity
of a patient suffering from aphasia, or occasionally to assist in the
solution of the question of responsibility of an aphasic in criminal
cases.

(6) Occasionally it has happened to me to be consulted by a patient
with manifest aphasia, about his or her own mental condition, as to
why there was difficulty in writing letters, and in getting “ command of
words,” and what was the outlook for the future.

In all some forty-five cases of varying degrees of severity of aphasia
and mental disorder have come under my notice in the last thirty years.

Dejerine (Semiologie des affections du systhne nerveux , 1914) points
out that the degree of change of intelligence in cases of aphasia depends
on (1) the extent and intensity of the lesion, (2) its reaction on neigh¬
bouring regions, (3) on the state of the vessels, (4) on the condition
of the circulation and kidneys, (5) especially on the age of the patient,
and says : “ II ne faut pas oublier qu’un aphasique peut devenir dement,
de meme qu’un dement peut devenir aphasique.”

It will be wjell to give statistical particulars of my cases as to the
age of the patient, the condition of the heart, vessels, and kidneys, the
presence or absence of definite hemiplegia, and also as to heredity,
previous attacks of insanity, and history of syphilis or alcohol.

(1) Age .—The average age of the male patients was 57 6. But,
excluding syphilitic cases, four of whom were under 40 years of age,
the average age was 62. The average age in the cases with a history
of syphilis was 47, showing the much more detrimental effect of this
poison on the arterial supply of the brain than mere senile or presenile
degenerative changes. The average age in women was 62, and there
were no syphilitic cases. In each sex the average age was somewhat
higher in those cases seen in consultation than in those found at
Bethlem Hospital.

(2) Definite heart disease, either valvular or degenerative, was found
in 26 per cent, of the men and 22 per cent, of the women.

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(3) Renal disease was found in 26 per cent, of the men and
11 per cent, of the women, and there was glycosuria in one of
each sex.

(4) Arteriosclerosis was found in '29 'G per cent. of the men and nearly
17 percent, of the women.

(5) A history of alcoholism was found in 26 per cent, of the men and
nearly 17 per cent, of the women. In many cases several of these
factors were combined.

(6) Definite hemiplegia more or less pronounced was found in
nineteen out of twenty-seven cases in men In all but one of these
cases the hemiplegia was on the right side at the time of observation,
and in that one case the patient, who was syphilitic and was under care
in Bethlem Hospital for acute mental excitement, suffered from seizures,
with left hemiplegia and anaesthesia ending in coma and death. There
was, however, a history of a former attack of right hemiplegia and
aphasia which had ended in recovery. Post-mortem there was found
obliteration of the right middle cerebral artery by syphilitic arteritis
with recent softening of the area supplied by it, and also old syphilitic
arteritis of the left middle cerebral with an old cavity in the left
internal capsule accounting for the former attack. Ten women out of
eighteen had right hemiplegia either early or late in the case, and one
of them had had a previous attack of left hemiplegia. In no case was
left hemiplegia immediately associated with aphasia.

(7) A family history of insanity, neuroses, or alcoholism was found in
33 per cent, of the men and 39 per cent, of the women. In one case
the patient’s brother .and sister had both died of right hemiplegia with
aphasia.

(8) Previous attacks of insanity which had passed off had been
present in three cases, but in many mental disorder or failure was
present for some time before the onset of definite aphasia.

The cases which have come under my notice seem to me to be
divisible mainly into four groups, viz. :

(1) Those in which dementia, or mental disorder or failure sometimes
amounting to certifiable insanity, preceded the more definite and
classical affection of speech designated as aphasia.

(2) Those in which considerable mental failure was concurrent with
or subsequent to an attack of aphasia. In severe and fatal cases the
extreme mental dissolution of coma is seen.

(3) A third group in which, although there is severe affection of
speech, the patient possesses such a degree of mental capacity as to
permit of business or testamentary capacity.

(4) Cases in which there is some slight hampering of speech with
very little mental disorder, although some may be present.

With regard to the first group it will be manifest that a patient who

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has already become disordered in mind is likely to have his mental
capacity further deteriorated by the additional weight of an attack of
aphasia, though this result does not always follow.

Hughlings Jackson has well said: “To speak is not simply to utter
words, it is to propositionise ” ; “ the unit of speech is a proposition.”
And again : “ Loss of speech is, therefore, the loss of power to propo¬
sitionise. It is not only loss of power to propositionise aloud (to talk),
but to propositionise either internally or externally, and it may exist
when the patient remains able to utter some few words ” {Brain, 1915,
xxxviii, pp. 113, 114).

If, therefore, his mind has first failed and his ideas and propositions
have become morbid ones or there has been such defect of memory
that recent events are not recorded and the patient lives in the past, as
in many senile cases, it will be evident that as he has been “lame in
his thinking ” before the occurrence of definite aphasia, the lameness
of thought will tend to be worse afterwards. The addition of
“inferior speech” and “ inferior comprehension ” makes the ruin more
complete.

To quote Head {Brain, 1915, xxxviii, p. 23): “Suppose, however,

‘ imperception ’ is added to the defect of speech, the formation of
images, abitrary symbols and those unconscious processes which pre¬
cede their development will be disturbed. The ‘general intelligence’
will then appear to suffer greatly ; for the mind will be struck, not only
on its emissory, but also on its receptive side.”

In this first group “ imperception ” has in many cases preceded the
defect of speech, and the “ general intelligence ” has already suffered.

I have already pointed out that, excluding syphilitic cases, the average
age of patients has reached the seventh decade of life, and that cardiac,
arterial, or renal changes are frequent, therefore it may be safely assumed
that there is commonly in these cases some degenerative-change in the
cortex or other tissues of the brain with deficient blood supply, the
occurrence of aphasia marking a more definite pathological change in
some part of the speech areas of the cortex. This complication
naturally increases the gravity of the prognosis so far as life is concerned,
and such cases frequently die of cerebral haemorrhage or softening.

A few selected cases are given :

(a) Mrs. R—, widow, aet. 60, seen May 25th, 1908. No heredity,
no history of alcohol. For several years memory had progressively
failed so that it was said to have become blank. Two months before I
saw her she had had seizures with loss of consciouness and stertorous
breathing, after which she appeared not to recognise her children and
lost control over the bladder. She was said to be “ incoherent and not
able to put six words together.” When I saw her she had no hemi¬
plegia, she could not express herself, constantly using wrong words in

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trying to answer questions. She could not name objects, and could not
tell the time by a watch. She was word-blind, and could not read even
her own name, or do what was written, and could not write. She was
not, however, word-deaf, but did simple things she was told to do, and
repeated words she heard. She was certainly deficient both in internal
and external speech and very “ lame in thinking.”

(b) Mrs. L—, a widow, set. 78, first seen in August, 1902. Father
insane, sister had senile dementia, brother insane, two cousins insane.
For some years there had been failure of recent memory ; for one year
delusions, followed by excitement and confusion, with delusions of
poisoning and of her son being arrested. She mistook the identity
of people; for instance, mistook her daughter for her own sister, spoke
of her husband, who had long been dead, as being alive, then gradually
became more childish and demented, and lost control over the bladder.
In 1905 she had a seizure, followed by right hemiplegia and loss of
speech. She was unable to frame words, but understood such simple
orders as to put her tongue out. On one occasion, however, an “occa¬
sional utterance” took place under emotional stress. An enema was
being given with some difficulty, and a nurse told her not to worry,
when she suddenly said : “ I will worry.” Apart from this, there was
absence of external speech, and no test for reading or writing could be
made in consequence of the profound dementia. Death followed very
shortly.

, (c) P,— jet. 63, an accountant, who had been pensioned five years
before, in consequence of failing memory and confusion of ideas, by
the railway company in whose employment he had been. There was a
doubtful history of alcohol and his arteries were thickened. For nearly
a year he had become much worse mentally, and was disorientated as
to time and locality, did not recognise his own house, had forgotten his
age, talked chiefly of his boyhood, thought he was still employed by the
railway company, had been threatening violence to his wife and others,
was dirty in habits, and apraxic in dressing. On examination, he was
found to have slight paralysis of the right side of the face, but no other
paralysis. He could talk in a hesitating way, but could not give the
name of the town or road in which iie lived, could not give his
son’s name, could not name objects— eg., “ glove,” “ watch,” or “ pen ”
—but recognised the names when spoken ; he could not write his
name correctly and had not written a letter for some months. He could
not say what was the use of a pen, but when asked what I was doing
said “writing.” He could read print, but did not understand what he
had read.

The association of apraxia in dressing and writing with some aphasia,
but without hemiplegia, is interesting, and will be referred to later.

{d) Mrs. B—, jet. 48, no heredity, had lived in the Tropics, and had
suffered from malaria and dengue fever. There was a history of frequent
“ whisky and soda,” and she acknowledged a craving for it. For some
months she had become irritable, she had ceased to write letters, found
everything an effort, was said to be talkative and muddled and to forget
where she had put things, recent memory had failed, and she never
knew the date or day of the week. She was advised to return to
England, and on the voyage was alarmed by an impending attack by

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torpedo. When seen on July 27th, 1917, her recent memory was found
to be bad, but remote memory good, she could not name the month or
day. She recognised her failure of memory and craving for alcohol,
sleep was defective, and she dreamed of standing by the boats when the
torpedo attack was impending. Heart, lungs, and urine were normal,
knee-jerks were found to be absent without any other signs of tabes, and
there was some tenderness of the muscles of the legs. Catamenia were
irregular (impending climacteric). Speecli was then normal. She
appeared to be a case of alcoholism with some failure of memory and
alcoholic neuritis. She had never had a fit. She was advised against
alcohol and against returning to the Tropics, which she had a great
desire to do when her husband went back in the autumn. Four
days afterwards, July 31st, she had a seizure in which she was generally
convulsed, bit her tongue badly, passed water and motion, and was
unconscious. When seen again on August 2nd, in consultation with
Dr. Friend, she had recovered consciousness, and had no paralysis on
either side of the face. Extensor plantar response was found on both
sides, but knee-jerks were still absent. There was no ocular paralysis,
pupils reacted normally, and optic discs were normal. She was, how¬
ever, aphasic. She talked a great deal, but her conversation was
generally quite irrelevant, and she could not ask for anything or give any
account of her symyptoms. When asked where she had seen me she
said, “ I am getting nearer, I shall get old and die nearer, and will die
in the streets (? Straits), I am getting old, I am getting in the streets *
soon, 1 will have to 47, will die in the streets, I am getting tired
and cross and nearer 80, soon nearer 97.” Then again she said,

“ Somebody said, never soon die in the streets one day nearer 85 soon.”
When asked to do so she at once put out her tongue, and it was pro¬
truded straight, but was badly bitten on the right side. After being
asked several times, “ Which is Dr. Smith ?” she pointed and said, “ It
is you.” Then she went back at once to her recurring utterances about
dying soon. When asked if her tongue was sore she kept rubbing it on
the right side, and after being asked several times “ Is it sore?” said
distinctly “ Yes.” When asked if she had slept the night before, she
said, “Oh yesterday will soon die on Saturday”; then again, “I am
getting old and cross and stout nearer 50,” “ it was on Sunday morning
will soon die all nearer 80.” When asked if she had headache, she did
not answer for a long time, and then said “ No.” Her answers “ Yes ”
and “ No ” apparently had propositional value. She could not give the
address of the house, kept on saying “nearer 86.” She could not read
or recognise letters, could not name objects— e.g. t watch, knife, etc.—
but laughed at the suggestion that these objects were a toothbrush or
pencil. She recognised the word “watch” when correctly applied,
but could not tell the time. She could not name or count fingers.
She could not write. She got out of bed when told to do so for testing
knee-jerks and gait, but was rather slow in understanding what was
wanted, and all the time kept on with the recurring utterance. She
seemed to be word-blind but not word-deaf. Examination of the blood
showed a negative Wassermann reaction. On August 23rd the aphasia
had passed off with the exception of some difficulty in remembering
names ; she had a very indistinct memory of the attack or of seeing me

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and Dr. Friend ; her memory for dates was still very bad, but she had
written a letter and could read. The attack having passed off so quickly,
there was no apparent increase of mental failure, but she was evidently
in need of nursing supervision. It is very likely, as Hughlings Jackson
suggested, that the recurrent utterances referred, however imperfectly, to
what she had been thinking or discussing about her case immediately
before she had the seizure.

The second group of cases— viz., those in which considerable menial
failure is concurrent with or consequent on an attack of aphasia—
contains many examples of the different ways in which aphasia may
manifest itself, and here I make no claim as it were to “ pigeon-hole ’’
the cases according to the various speech-centres which have been
described in works on aphasia. As Collier says (“ Recent Work on
Aphasia,” Brain, 1908, xxxi, p. 539): “ Recorded cases show every
degree both of severity and permanence, and they give no means of
clinical distinction between cases claimed as examples of Rroca’s
aphasia and of Wernicke’s aphasia respectively.”

The following are some examples from my case-books:

(a) Mrs. S—, set. 67, widow, seen November 27th, 1902. Sister and
daughter had been insane. Her urine contained albumen and some
sugar. On November 23rd she complained of headache, and the next
day “ could not find words,” was worried and excited and repeated the
word “come,” possibly a recurring utterance due to a feeling of need
for help when the attack began. She became violent and resistive,
especially after visits by relatives, who considered that she must have
“ something on her mind ” to account for her conduct. When seen she
had no hemiplegia. She took along time to understand what was said,
but did simple things such as putting out her tongue when asked. She
used w'ords in a wrong sense, saying “ upstairs ” instead of “downstairs.”
Speaking of herself she said “ she is very bad.” Some of her utterances
had a propositional value, for instance she said to the doctor, “ I don’t
want you; go away.” She had other ejaculatory utterances such as,
“ Albert wants to get to get,” and “ I don’t want it,” which were incom¬
prehensible to others. She could not find the word “ key ” when she
wanted to open a box, but called it “ linen,” then took out some
securities, but could not explain what she wanted to do with them.
She could not read or write. She remained mentally enfeebled and
unfit to manage herself or her affairs, and died four years later without
any definite hemiplegia.

\b) Mrs. D—, ret. 73, widow, seen November 23rd, 1904. Six years
before she was said to be deaf, possibly there was some word-deafness
at first, but there was no deafness when I saw her. She had begun to
miscall objects and gradually lost speech, being able only to make
inarticulate noises. Her friends had to stop her from going to church
on account of these noises. There was no definite seizure or hemi¬
plegia at the outset. She refused to spend money, and was said to
have the delusion of poverty. She became unable to care for herself,
and needed constant supervision. When I saw her she could not

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speak at all and did not try to, but occasionally made an inarticulate
noise. She understood what was said, and at once got her daughter’s
photograph when her name was mentioned. She could read what was
written, and did what she was in this way instructed to do. She could
write, but expressed herself wrongly, though the sense of it could be
made out; for instance, she had written to her nurse, “ I will wash her
hair,” meaning her own. In answer to my questions as to how she
occupied herself and what her age was she wrote, 4 ‘ I am read papers,
you are 73.” She wrote firmly and quickly in answer to written
questions, but always using wrong expressions or pronouns. The
proper names of relatives were given correctly. She had no paralysis.
The chief defect seemed to be in the motor, or emissory side, as there
was no word-deafness or word-blindness. She gradually failed, and
died the next year, but no autopsy was made.

There was no doubt in this case of the presence of “internal speech,”
as shown by her ability to express her thoughts in writing, although
there was some defect in this.

(0) S—, ajt. 58, widower, seen May 31st, 19x1. Father died of
apoplexy, mother of cancer. He had an enlarged and irregularly acting
heart. Eighteen months before he had suffered suddenly from loss of
speech while staying in an hotel, and since then had lost business
capacity, so that his business failed, and had to be wound up. There
was no hemiplegia. He had no energy, had lost control over his
bladder, was apraxic in dressing and feeding himself, and speech was
said to be “ incoherent.” On examination he was very conscious of
his speech defect, recognised that he made mistakes in words, and had
lost bladder control, and wept about it. He could understand every¬
thing said, but answered confusedly, could not always name objects,
but knew their uses, for example called a watch “timepiece.” After
naming “penknife” there was marked perseveration of idea, all subse¬
quent objects shown being called “penknife.” In attempting to write
he was quite unable to finish words.

This was again a case in which aphasia, apraxia, and agraphia were
associated, without hemiplegia.

(d) B—, aet. 83, married twice, had eleven children, had been a
hard-headed business man, and was described as a bon viveur , and
always full of energy. Until five years before he had ridden regularly,
but then broke his leg, and ceased to take active exercise. Two years
before he had had pneumonia, and since then he had shown signs of
cardiac degeneration. For one year he had begun to lose words and to
lose his memory. His speech became progressively worse, he was
emotional and violent if opposed. He was disorientated in time and
place, would get up in the middle of the night and mistake time, would
insist on going to the City, but did nothing when there, and on returning
could not always recognise his house. He lost control in cleanliness.
When first seen on July 12th, 1917, he could slowly understand what
to do when told— e.g., to put out his tongue, put his hand on his head,
get out of bed’and walk round the room. He imitated movements.
He tried to talk, but his speech was generally incomprehensible. He
could not name a watch or other things, could not-tell the time, could
not give his address or the name of the road, but recognised names of

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objects when repeated to him. It was interesting that although lie had
lived seventy-four years in this country he could not make sentences in
English. He gave his first name in German, and made some attempt
to answer in German. For instance, when asked if he knew me he
said, “ nie gesehen.” He could say “ Yes ” in answer to some questions,
but it was often irrelevant and of no propositional value. With regard
to his attempt to answer in German, I subsequently learned from his
son that the first nine years of his life had been spent in Germany.
He was apraxic in various ways, especially in fastening his clothes, and
when an attempt was made to get him to write, he did not seem to
know the use of the pencil, holding it upside down or letting it drop.
He could not write and could not read. He was undoubtedly word-
blind, but not word-deaf. There was no hemiplegia, his tongue was
not well protruded, but there were no other bulbar symptoms. A
fortnight later he was more confused and silly, did not seem to under¬
stand so much, was vacant, and had been noisy and violent at times;
he was also more apraxic. He said much less, but still tried to use
German, and when asked if it was a cold day (it was really very hot)
said “ein Bischen.” On August 3rd he made inarticulate noises, did
not try to speak, was drowsy and confused, failed to recognise people,
had no control over emunctories, and had pulmonary congestion with
rise of temperature. There was still no definite paralysis. He died in
a few days.

It will be noted that in this case also there was apraxia and agraphia
with no definite hemiplegia.

(e) Mrs. M—, ret. 81, widow, seen October 3rd, 1904. There was a
history of chronic arthritis, of phlebitis ten years before, and of a
“threatening of a fit” at the same time. As a child she had lived in
Italy, and then habitually talked Italian and French more than English.
Since marriage, at the age of seventeen, she had lived in England. On
August 5th, 1904, she had an attack or seizure in which she was said
not to have lost consciousness but to have “ talked babble,” and was
emotional and angry. When seen she appeared to understand what
was said, but screamed when others did not understand her, she talked
volubly, but could not frame intelligible sentences which contained
many adjectives but no nouns. It was interesting that she spoke
Italian and French but no English at this time, the law of dissolution
holding good as in the previous case. She could not name objects in
any language, but recognised wrong names. She was completely word-
blind, could not read or do what was written, and could not write
spontaneously or copy. There was at first no hemiplegia, but later
weakness of the right side with deviation of the head and eyes and
inability to stand developed. Some improvement followed for a time,
in which she became more intelligible, and her English returned.
Eventually she died.

( f) B—, 02t. 56, widower, a German who had long been resident in
this country, seen December 12th, 19x4. There was a history of
syphilis thirty-five years before. In November, 19x3, he had had slight
right hemiplegia with “ some difficulty in words,” which had passed off.
His urine was albuminous, and he had hypertrophy of the left
ventricle. One week before I saw him he had become dizzy, com-

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plained of weakness of the legs, and would have fallen if not prevented ;
seemed unable to read, and was confused and emotional. The day
before I saw him he was unable to sign his will, which had been drawn
up and to which he had given his approval. On examination he had no
paralysis, but some defect in localising sensation. He was apraxic in
that he could not feed himself, although there was no paralysis, and on
being given a pen held it with the nib reversed. He did not ask for
anything or propose anything. He could answer questions slowly, but
could not volunteer information about himself or talk spontaneously.
He was not word-deaf and did what he was told. He could not name
objects, but recognised the correct name. He could not even give
the names in German, his native language, with the exception of a
watch, which he called “ Uhr.” He could not tell the time by it, could
not give his address, or name the locality in which he lived, or give the
month. He seemed to be word-blind, or nearly so, could not read
except one or two isolated words, and could not name the letters in words
pointed out to him. He was quite unfit to exercise testamentary
capacity or to transact business. He died shortly afterwards.

(g) The last case of this group which I shall narrate was H—, ret. 62,
married. There was a history of excess in alcohol and sexual irregu¬
larity. I saw him on October 12th, 1916. In the previous May he had
had a seizure without resulting paralysis, but following which he was
unable to read for some days. Three w r eeks ago he had had another
attack, in which he could not speak for one whole night, and could not
write or read, and had slight loss of power in the right arm and right
side of the mouth. He then recovered speech, but became very
depressed and worried, accused himself of moral lapses, especially of
sodomy with women, and dreaded prosecution for this, although none
was pending, and be could not remember the circumstances. He was
completely obsessed by this dread, and had spoken of suicide. On
examination he was found to have a systolic mitral murmur and
auricular fibrillation. The hemiplegia had passed off. He talked con¬
nectedly and answered questions, did not seem depressed, and said he
had exaggerated the idea of prosecution, and was not troubled about it
any more. He could not give the name of pencil, chain, matchbox,
etc., but after giving the name to a watch, he showed perseveration by
afterwards calling everything a watch. He could repeat names of
objects when told, and recognised their correctness. He could not tell
the time or name coins or give their value. He was word-blind and
totally unable to read. He could not write even his name spon¬
taneously, but could just copy it. He was quite unable to transact
business. His condition was at first masked by his ability to talk. It
was quite evident that he could “ propositionise,” but he had evidently
had insane propositions, and this, together with the manifest organic
disorder of at least the visual speech area, led to the advice that he
should be sent away from home for care and treatment. While arrange¬
ments were being made for this he eluded his relations, although they
had been warned, went out and bought a gun-licence and a revolver,
and shot himself.

It is difficult to say whether this result was determined by the
morbid dreads which he had shown or by the difficulty in which he

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13

found himself by his inability to write or read; no doubt both
factors acted. Evidently he had sufficient speech, both internal and
external, to enable him to come to a decision and carry out his desire.

I have called attention to cases in which apraxia, agraphia, and
aphasia were associated. I may say that of eight cases which have
come before me in which apraxia in various forms was noted all were
also agraphic, but none of them had definite right hemiplegia. In
nearly all of them the aphasia was chiefly of the motor type.

S. A. K. Wilson, in a comprehensive study of apraxia (Brain, 1908,
xxxi, p. 164), calls attention to the reason for believing that there is a
centre in the first and second convolution of the left side where move¬
ments are combined ideationally analogous to the centre for the co¬
ordination of movements requisite for speech in Broca’s area, and
points out that in motor aphasia we have a form of apraxia, and that
agraphia is a variety of apraxia, which may be either of sensory or
motor origin, and that there may be agraphia without any paralysis.
J. S. Collier (Brain, 1908, xxxi, p. 529) also refers to the evidence
pointing to a lesion of the first and second frontal convolutions of the
left side in cases of apraxia, and says “ the bearing of this evidence
upon the localisation of a motor speech centre in the left third frontal
convolution is obvious and striking, for motor aphasia bears the same
relation to movements of the muscles concerned in speech as does
apraxia to the movements of the limbs.”

We now come to the third group, in which, in spite of severe
affection of speech, the patient possesses internal language and such
a degree of mental capacity as to permit of business or testamentary
capacity. I shall refer to three cases of this nature.

(a) M—, single, act. 64, seen May 31st, 1912. There was a history
of syphilis twenty-five years before, and he had lived a great deal in
South America, where Spanish was his usual language. In August,

1909, he had a seizure, followed by right hemiplegia and loss of speech
except for one or two Spanish words. Between July and December,

1910, he had six fits, and two others up to May, 1912. He was con¬
sidered by a relative to whom he was unfriendly to be childish and in¬
competent, but he had always been found by his solicitor to be alive to
what he thought right for himself. He had exercised volition in signing
an authority to his solicitor, and had made a will twelve months before.
On examination he was found to have right hemiplegia with wasting and
contracture of the right arm. His right leg was weak, and he walked
stiffly. His right knee-jerk was exaggerated. He was unable to speak
spontaneously, but could say “ Yes ” and “No” correctly in answer to
questions, and they certainly had propositional value. He could not
say his own name, he could not give the names of places he had lived
in, but recognised the name of a South American town, saying “ Yes,
yes.” He could not always name objects seen, but could repeat the
word when it was said, and afterwards there was perseveration of the

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APHASIA IN RELATION TO MENTAL DISEASE, [Jan.,

idea when a fresh object was shown. He could not name coins, but
knew if a wrong name was given. He could say the names of his
solicitor and two relatives. His expression was that of intelligence, his
hearing and sight were good, he was able to do what he was told, and
could pick out objects of which he heard the names. He could not
read aloud, but recognised one or two words and repeated them. He
appeared to read to himself and could answer correctly “ Yes ” and
“ No ” as to what it was about. His right arm being completely
paralysed he could not write with it. He was, however, able to sign his
name slowly with the left hand and had signed an authority in this way
to his solicitor to receive money and make disbursements for him. He
could copy from print to writing with his left hand, and could write
slowly from dictation. In consequence of the laboriousness of writing
with his left hand he did not write letters. He showed by gestures and
by saying “No, no,” that he had antipathy to the relation who thought
he was an imbecile. He knew perfectly well whom he wanted to
manage his affairs. He could answer as to his income by exclusion
when wrong amounts were suggested to him. He was quite happy in a
nursing home.

In this case there was no word-blindness or word-deafness, and it
seems a fair presumption that this was one of the cases in which Broca’s
region was chiefly affected as far as speech was concerned, and the
history of seizures suggests cortical damage. Internal speech seemed to
be unaffected. There was no difficulty in reporting that he was able to
understand and execute a legal document, which was the question at issue.

(b) D—, oet. 83, widower, seen March 13th, 1917. He had lived
abroad for many years and most of his immediate relatives being well
provided for he had made a will in December, 1915, leaving various
legacies to friends and a nurse who had attended him through a severe
illness five years previously and one to a nephew. On May 15th, 1916,
he had an attack of right hemiplegia with aphasia. He was speechless
except for occasional ejaculatory words. He could not read aloud or
understand written language, he could write his name automatically, but
could not copy it, and could write nothing else. He was certainly
“word-blind.” He was not, however, “word-deaf,” but could under¬
stand what was said and do what he was told. He could by gesture
express agreement with or dissent from leading questions. On July 7th,
1916, he had another attack depriving him entirely of speech. His
mind was said to be much more confused but not blank. Some months
later he appears to have made some improvement in intelligence although
he remained speechless, and was said to show dislike to the will he had
made and appeared to want to improve the position under it of the
relative who had shown much attention to him in his illness. Although
he could not speak he went through the gesture of striking out the
name of an old friend to whom he had left money, and he seemed
agitated and emotional. He was unable to give instructions either
orally or by writing to his solicitor, and neither the latter nor another
physician considered him at that time to be in possession of testamentary
capacity. Further improvement in his condition took place and he
frequently conveyed the impression of dislike to his will as it stood and
was often looking at it. When seen on March 14th, 1917, he was still

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15

suffering from defect of speech, but the hemiplegia had to a great extent
passed off. He could answer questions in monosyllables, but frequently
used wrong words in trying to speak. He often took hold of his tongue,
as if he felt it would not work properly and knew he was using wrong
words. His answers “ Yes ” and “ No ” were to the point, and had
propositional value, and his memory appeared to be good when
interrogated about his past life and occupation, the names of his
relatives, and the extent of his property. He gave assent readily and
emphatically to the question as to whether he wished to alter his will.
He occasionally said a short sentence, and gave the names of relations.
He definitely expressed affection or dislike for individuals, and was
found to have knowledge of those whom he would naturally benefit and
of the reasons for doing so. All this was elicited by a long series of
questions, and by propounding to him suggestions to which he was able
by gesture and emphasis and by the tone of his answers to give reason¬
able assent or dissent. His expression was that of a man alert and
appreciative of the position. He was unable to read aloud, but was
able to read to himself and showed by answers that he appreciated what
he read. He could not write his name but made attempts to do so.
On this occasion he was neither word-deaf nor word-blind, the chief
defect appearing to be a motor one both in speaking and writing. A
full report was made as to his condition, and the opinion given that he
now appeared to have testamentary capacity. At a subsequent inter¬
view with his solicitor and another physician it was possible to take
instructions from him and a fresh will was executed.

(c) Miss R—, ret. 60, seen April 12th, 1913. Brother and sister both
had right hemiplegia and aphasia. Both ovaries had been removed some
years before, and she had also had the operation of “short circuiting”
in consequence of intestinal trouble. After this a drug habit had begun,
dating from the use of morphia to relieve pain. In the autumn of
1912 she had had a short attack of mania from which she had recovered.
A short time before I saw her she had had an attack of what was
supposed to be influenza, followed by right hemiplegia and hemi-
anaesthesia. For three days she could not talk clearly and for ten days
she could not sign her name. She had recovered writing to some
extent but complained that she could not “ make the pen spell.” In
talking she missed words and used wrong words, could not name
objects, but knew their uses. She complained of losing her brain, and
said she had better be locked up. She knew who were her relations
and the extent of her means and whom she wished to benefit, and had
no delusions. She was anxious to know if she was fit to make her will,
and after a full consideration of her condition the opinion was given
that she had testamentary capacity.

In these testamentary cases the same general rules apply as in cases
where there is no aphasia —namely, that the testator “shall understand
the nature of the act and its effects; shall understand the extent of the
property of which lie is disposing ; shall be able to comprehend and
appreciate the claims to which he otjght to give effect; and, with a
view to the latter object, that no disorder of the mind shall poison his

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16 APHASIA IN RELATION TO MENTAL DISEASE, [Jan.,

affections, pervert his sense of right, or prevent the exercise of his
natural faculties, that no insane delusions shall influence his will in
disposing of his property, and bring about a disposal of it, which, if
the mind had been sound should not have been made.”

In cases such as I have mentioned the extreme importance of long
unhurried interviews need not be emphasised. Moreover, there is the
more need in such cases for an accurate record of the questions put to
the patient and his answers, whether in faulty speech or writing, or
associated with gestures and emotional emphasis. The use of shorthand
in this respect is very great.

Sir William Gairdner, in opening a discussion on “ Aphasia in
Relation to Testamentary Capacity” (British Medical Association,
Annual Meeting, Edinburgh, 1898; British. Medical Journal , 1898, ii,
p. 581), laid stress on the point that “The fact of aphasia (unless it be
very limited in extent) interferes either with the graphic and visual
speech processes or with the auditory and vocal speech processes, and
therefore throws the onus probandi upon those who consider the will
genuine or wish to prove the will genuine.”

Hughlings Jackson has well said : “ Such a question as ‘ Can an
aphasic make a will ? ’ cannot be answered any more than the question,

‘ Will a piece of string reach across the room ? ’ can be answered.
The question should be : * Can this or that aphasic person make a
will?’” {Brain, 1915, xxxviii, p. 115).

In other words every case must be considered on its merits after the
most careful examination.

I shall not give any details of very slight cases, or of those cases
which have come under my notice where a severe vascular lesion
causes right hemiplegia and aphasia, ending quickly in death.

It will be well to consider how far these cases correspond with
Hughlings Jackson’s views on aphasia. I may take it that his great
principle that dissolution occurs first in the most highly organised
products of neural or mental activity, leaving the more lowly at liberty
to express themselves freely in the resulting symptoms, is beyond
dispute. Positive and negative symptoms are seen both in the mental
state and in the condition of speech, but the preponderance of senile
cases accounts for the fact that the negative side is the more con¬
spicuous, as shown by the frequent occurrence of loss of memory and
perception, of judgment and control.

The return to an early acquired language and the loss of a more
recent one in attempting to speak has been exemplified in some of the
cases narrated.

Hughlings Jackson divided cases of aphasia into two classes :

(1) Severe cases in which the patient is speechless or nearly so, or in
which speech is very much damaged, and

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BY R. PERCY SMITH, M.D.

1 7

(2) Cases in which there are plentiful movements but wrong move¬
ments, or plenty of words but mistakes in words.

These groups have been exemplified in various degrees in my cases,
as have also his differentiation of speech into superior and inferior,
internal and external, his description of recurring utterances and
occasional utterances, and his insistence as to the use of the words
“ Yes ” and “ No ” as being in some cases of propositional value, though
often otherwise.

With regard to recurring utterances, I may refer to Jackson’s view
{Brain, 1915, xxxvii, p. 158) that the lesion in the left half of the brain
“ is not the cause of the recurring utterance,” and that if the patient
had not been “ taken ill ” he would not have had such a recurring
utterance as “he would have been able not to utter it ” (italics in
original).

Again, he says (p. 174) : “A patient who recovers soon from aphasia
loses his recurring utterance, becomes able not to utter it.” In other
words the higher centre has regained control and prevented the over
action of lower centres. It appears to me that the case of one lady
mentioned above is a good illustration of this.

Hughlings Jackson held that speech was a part of mind and that we
must get rid of the feeling that there was abrupt and constant separation
into mind and speech. At the same time he pointed out clearly the
fact that in some cases there may be great affection of external speech
and yet little affection of mind, as shown by the evidences of internal
speech especially in writing. In one of the cases I have narrated the
patient having practically no external speech was also unable to write
with his right hand and very little with his left, yet there was no doubt
that he had considerable mental capacity. On the other hand, a
patient who had a considerable amount of external speech, but who had
lost writing, was so disordered in mind that he had delusions and
committed suicide.

I have shown that aphasia may supervene on pre-existing insanity
or mental decay, no doubt due to vascular or degenerative changes,
which might have led to the same result in the absence of the mental
disorder, and that, on the other hand, aphasia may be the first symptom
indicative of cerebral and mental decay. In such cases the question
arises how far the mental disorder is intimately associated with the
aphasic disturbance of speech or is due to widespread vascular and
nutritive changes in the brain. The mental disorder does not neces¬
sarily amount to certifiable insanity, but may in varying degrees affect
such mental processes as perception, memory, emotion, and volition,
without much disorder of conduct. It appears to me that in all my
cases, except those which may be looked upon as' examples of Broca’s
aphasia, there has been some disorder of mind, though not always

LXIV.

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18 TOXI-INFECTION OF CENTRAL NERVOUS SYSTEM, [Jan.,

marked failure of intelligence. In a review of the question of aphasia
(Reviezv of Neurology and Psychiatry, 1909, vii, p. 151) S. A. K. Wilson
says : “Speech is but a specialised part of the intellect. And, therefore,
there can be no disturbance of the function of speech, however slight,
in which there is not a disturbance of certain psychical states.” He,
however, combats Marie’s view “ that in cases of aphasia (/. e., in Marie’s
sense) defect of intelligence only occurs and always occurs in lesions
behind an imaginary line drawn from the posterior end of the island of
Reil transversely to the lateral ventricle.” I cannot believe that the
disorder of mind in such cases as I have observed is only associated
with a lesion of a single centre of intellect specialised for language, but
believe that, on the contrary, it is associated with widespread vascular
and nutritive changes in the brain, such as are commonly found in
senile or syphilitic cases.

Once more to quote Hughlings Jackson (Brain, loc. cit., p. 167):
“We must bear in mind that ‘will,’ ‘memory,’ and ‘emotion’ are only
the names men have invented for different aspects of the ever present
and yet always changing latest and highest mental states which in their
totality constitute what we call consciousness.”

In conclusion, I may say that my observation of those cases of
aphasia which have come under my notice leads me to agree com¬
pletely with the views expressed by Henry Head in the Summary at the
end of his paper, to which I have already referred.

1

Further Observe ,s on Experimental Toxi-Infection of the Central
Nervous , .tem ('). By David Orr, M.D.; and Major Rows,
R.A.M.C.’ V

This communication is a continuation of our experimental work on
the action of bacterial poisons upon the nervous system.

In 1914 (2), after several series of experiments, we drew attention
to the differences between lymphogenous and haematogenous infection.
The first was induced by infecting the ascending lymph stream of
nerves; the second by placing celloidin capsules containing a culture
of bacteria in the abdominal cavity. Lymphogenous infection was
found to be characterised by :

(1) Reaction of the cells of the fixed tissues.

(2) Proliferation of the cells of the adventitial sheath of veins and
capillaries.

(3) The appearance of scavenger cells to remove disintegrated
myelin.

(4) Nerve-cell degeneration and neuronophage phenomena.

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1918.] BY DAVID ORR, M.D., AND MAJOR ROWS, R.A.M.C. I 9

In haematogenous infection we found :

(1) The nerve-cells suffered least of all.

(2) Primary degeneration of the myelin sheath round the cord margin
and along the postero-median septum.

(3) (Edema of the cord.

(4) Dilated vessels and hyaline thrombosis.

In brief, lymphogenous infection produces an inflammatory lesion
of the central nervous system, while in the hcematogenous variety
inflammation is reduced to a minimum, and primary degeneration of
the myelin sheath is a prominent feature.

We drew attention to the implication of the sympathetic system in
the abdominal operations, but did little more than hint at its role in
the causation of the cord lesions.

At this stage .certain conclusions were drawn— viz., that general
paralysis and tabes dorsalis were lymphogenous infections ; and that
the non-systemicdegenerative lesions found in cancer cachexia, pernicious
anaemia, Addison’s disease, etc., came under the heading of haemato¬
genous infections.

In the above experiments the results of toxic action were studied in
the spinal cord only ; in the present series the research has been
extended to the brain, and the capsule containing a culture of the
Staphylococcus aureus was placed in contact with the common carotid
artery in the neck. The experiments, though limited in number, have
given positive results so far, and are worthy of record, as they help to
explain the pathogenesis of certain obscure lesions of the central
nervous system found in man. Hyaline thrombosis was found to be a
constant result in the cord examined when the msules were placed
in the abdominal cavity, and we find the same me 1 change in the
vessels of the brain when the capsule is placed a'^ar.ist the carotid
sheath. The lesions to be described are the direct result of this
thrombotic change, and vary in kind with the situation c>f the local
ischaemia and the degree to which the local vascular supply is interfered
with.

Rabbits were used for experiment, and we have observed two types
of lesions so far.

(1) Coagulation necrosis of the nerve cells in the cornu ainmonis,
in the cerebral cortex, and in the amygdaloid nucleus.

(2) Softening in the stratum moleculare of the cornu ammonis.

Before entering upon a description of the lesions in the cornu

ammonis, it is necessary to look for a moment at the structure of this
organ. The cornu ammonis of the rabbit consists in, from without
inwards, the alveus, the stratum moleculare, the lamina ganglionaris,
which is composed of pyramidal cells, the stratum radiatum, and, most
iuternal of all, the lamina involuta, whose tangential fibres surround

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20 T 0 XI-INFECTI 0 N OF CENTRAL NERVOUS SYSTEM, [Jan.,

folia of the pia-arachnoid invaginated from the mesial surface of the
cerebral cortex.

In one case an area of about one-sixth of the circumference of the
lamina ganglionaris showed a marked degree of coagulation necrosis of
the pyramidal cells.

In frontal sections, stained by toluidin blue, the cells of the lamina
ganglionaris are densely packed together. Normally, each shows a
thin cell body prolonged into an apical dendrite, which projects into the
stratum radiatum ; the nucleus is relatively very large, is clear, round,
or slightly oval; it possesses a nucleolus and two or three particles of
chromatin. The chromophile material of the cell body is in an
amorphous condition; the apical process stains exceedingly faintly, and
is perceptible in the stratum radiatum for a short distance only. The
area of the ganglionic lamina affected by coagulation necrosis stands out
in marked relief owing to the strong affinity for the aniline dye possessed
by the degenerated nerve-cells. This area is sharply marked off from, and
is appreciably narrower than, the normal portion on either side. Even
with a low power the distortion of the altered cells is perceptible, and
the sharp definition of the degenerated zone is strongly suggestive of
local vascular occlusion. With higher magnification the nerve-cell
body and nucleus are seen to be deeply and diffusely stained; both
are shrunken and much distorted. The axis-cylinder, which normally
is scarcely distinguishable, can be followed into the molecular layer, in
which it is seen to give off numerous branches. The apical proto¬
plasmic dendrite is quite prominent, is stained diffusely, at times
slightly granular in appearance, and pursues a tortuous course into the
stratum radiatum. These alterations are typical of the condition
known as coagulation necrosis.

With Van Gieson’s method the degenerated area is very distinct.
Normally, the nerve-cell nucleus stains a violet colour by this method
and is clear. In the affected cells the structure of the nucleus can no
longer be seen, and the degenerated shrunken cell body is yellow in the
centre, while its edge is of a reddish-orange colour. The tortuous apical
process stains in a similar fashion, and can be followed for a consider¬
able distance into the stratum radiatum.

In another case two small areas of coagulation necrosis were
observed in the cornu ammonis, one at the inner and one at the outer
pole. The morbid area at the inner pole of the cornu ammonis was
larger than that at the outer, and not so extensive as in the experiment
described above.

By toluidin-blue staining there is no shrinkage of the ganglionic
lamina in the areas affected, and the nerve-cells are not quite so dis¬
torted as in the previous case. Both cytoplasm and nucleus stain very
diffusely. By Van Gieson’s method they stain a diffuse orange-yellow,

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1918 .

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Fig. 1. — Photomicrograph of frontal section through brain of rabbit. Stained
by toluidin blue. 1, cortex cerebri ; 2, ganglionic layer of cornu ammonis ;
3, fimbria fornicis. The higher power photographs are taken in areas 2
and 3.

Fig. 2. —High-power view of lamina ganglionaris of cornu ammonis. Toluidin
blue. 1, note the shrinkage and diffuse staining of the nerve-cells; 2,
junction of morbid with normal area, in which the clear nucleus of the
healthy nerve-cells is prominent.

To illustrate paper by Dr. David Okr and Major Rows, R.A.M.C.
By courtesy of the Editor of' Brain.'

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1918.] BY DAVID ORR, M.D., AND MAJOR ROWS, R.A.M.C. 2 1

and stand out sharply from the normal cells of the lamina. The centre
oft he cell, i.e., the area occupied by the nucleus, is a deeper yellow than
the periphery.

The second type of lesion, ischremic softening, was met with in one
experiment and consists in the softening proper plus the accompanying
secondary inflammatory phenomena, the result of the irritative effects
of degenerative products on the surrounding tissues, and in the reaction
incidental to repair. The softening proper is situated in the stratum
moleculare; it just touches the lamina ganglionaris on the one side
and the fornix on the other. It consists in layers which can be
differentiated into four for purposes of description. The first, in the
centre, is composed of detritus, amongst which can be seen altered red-
blood corpuscles, fragments of nuclei deeply stained, and some clear,
faintly stained, distorted, oval nuclei. Immediately outside this area is
a narrow band of round, deeply-stained nuclei, some of which are
surrounded by a small quantity of protoplasm. These are loosely
arranged and amongst them lie many granular epithelioid cells. The
third layer of epithelioid cells or compound granular corpuscles is not
sharply marked off from the second of small round cells, and is a dense
layer. These epithelioid cells possess a large cell body of varying
shape—the result of pressure—which is finely fenestrated, and the
nucleus, almost invariably of medium size, is round or oval and clear.
A large number of epithelioids show vacuolation, and it is worthy of
note that in only a very small number the nucleus is of the small, dark,
shrunken, and excentrically placed type so characteristic of the scavenger
cell in softenings of long standing. Outside the area of scavenger cells
the inflammatory phenomena consists in round cells, reaction on the
part of the neuroglia, and in proliferation of the adventitial cells of the
neighbouring vessels.

The small round cells lie free in the tissue and possess a rounded or
oval nucleus deeply stained and filled with chromatin. The cytoplasm
is finely granular and varies considerably in quantity. In some it forms
a very narrow band round the nucleus, in others it is in greater quantity,
placed for the most part to one side of the nucleus and is vacuolated.
These features are found in the plasma cell in the early phases of its
development.

The neuroglia participates actively in the inflammatory reaction, and
round the area of softening there is much neuroglial proliferation and
hypertrophy. In those cells undergoing active hypertrophy the nucleus
is enlarged, round or oval, and clear; the cytoplasm is greatly increased
in quantity, is vaguely granular, stains more deeply at its edge, and is
prolonged into short, thick processes. This is the amoeboid type and
between this an^ the normal are many pre-amoeboid stages. Lying
amongst the above are cells with an oval, pale nucleus situated at one

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PRINCETON UNIVERSITY

22 TOXI-INFECTION OF CENTRAL NERVOUS SYSTEM, [Jan.,

extremity of a large protoplasmic body. There are others, somewhat
similar in type to these, in which the body is more fusiform. Both
varieties resemble young fibroblasts very closely. Many neuroglia cells
are in a degenerative phase; the cytoplasm is disintegrating, and the
nucleus has undergone shrinkage and stains diffusely. In another type
of glia cell, found at the periphery of the softening, the nucleus is small,
dark, and usually rounded, though in some instances it is slender. The
cytoplasm streams away from either end of the nucleus in a thin
elongated process which is not uncommonly branched, when the cell
is quite indistinguishable from the “ stabchenzell” so frequently found
in certain inflammatory conditions, and acknowledged to be a derivative
of the neuroglia or adventitial cells, though for the most part from the
former.

There is a high degree of proliferation of the adventitia of the small
vessels in the immediate vicinity of the softening. The adventitial
nucleus has become rounded, reduced in size, rich in chromatin, and
surrounded by a finely granular, protoplasmic body. The adventitial
sheath is packed with young plasma cells similar to those lying free in
the surrounding tissues. The small venules and capillaries at a little
distance from this softened area show a lesser degree of adventitial
proliferation. This reaction can be followed inwards as far as the
median portion of the fornix, laterally amongst the venules of the lateral
ventricles, and affects in a marked degree the small vessels in the
stratum radiatum and the lamina involuta which form the inner parts
of the cornu ammonis.

In the cerebral cortex there are no gross lesions such as the ischaemic
softening in the cornu ammonis, but the nerve-cells exhibit varying
degrees of coagulation necrosis. A description of this morbid change
has been already given in the case of the ganglionic layer of the cornu
ammonis. The cortical cells show' precisely the same morbid features
and staining reactions so characteristic of this type of affection. The
coagulation necrosis is not distributed in a uniform manner throughout
the cortex in each experiment. Sometimes the upper and lateral
regions may contain the degenerate cells, while the mesial, insular, and
under surfaces are quite normal or practically so. On the other hand,
the morbid change may involve the mesial, upper, lateral, and under
surfaces of the cerebrum, thus embracing the pallium and rhinen-
cephalon. When the olfactory lobe shares in the necrotic change its
necrosed cells show up very prominently, owing to the sharp contrast
between the ganglionic layer and its covering clear molecular lamina.

In the superior and lateral areas of the pallium the morbid change
varies in degree from point to point, contiguous territories showing
slight variations in intensity ; and all the cortical cell laminae are not
involved in the necrotic change. For our present description we may

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JOURNAL OF MENTAL SCIENCE, JANUARY, 191S.

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Fig. 3 .— 1 , Lamina ganglionaris of cornu ammonis; 2, area of ischaemic
softening; 3, vessel showing periarteritis; 4, lateral ventricle.

Fig. 4 .—1, Area of softening under higher magnification ; the central necrotic
zone is surrounded by compound granular corpuscles and small round cells ;
2, nerve-cells of lamina ganglionaris; 3, periarteritis.

To illustrate paper by Dr. Okk and Major Rows, R.A.M.C.

By courtesy of the Editor of * Brain.'

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

1918.] BY DAVID ORR, M.D., AND MAJOR ROWS, R.A.M.C. 23

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divide the cortex into, from without inwards: (1) The molecular zone,
(2) the external granular zone, (3) pyramidal layer, (4) internal granular
zone, (5) ganglionic layer, (6) multiform layer. All these zones are not
always distinct or present; certain variations in cell lamination occur in
different portions of the cortical field, but the layers as given above
serve our present purpose.

The whole depth of the grey matter does not exhibit coagulation
necrosis of the nerve-cells. The morbid change includes all the outer
layers as far inwards as the ganglionic lamina ; it is rare to find morbid
nerve-cells in the deepest or multiform layer. In the outer layers the
degenerate nerve-cells may be very numerous or in fewer numbers
according as one passes from one point to another, and granule and
pyramidal cells are affected indiscriminately.

So far we have not met with any proliferative changes in the
neuroglia of the cortex, either in the molecular zone or elsewhere, but
in the capillary walls there is evidence of an early reaction shown
by the hyperchromatism and rounding of the wall nuclei. The vessels
throughout the brain are dilated, congested, and are the seat of hyaline
thrombotic changes to which further reference will be made.

In addition to the cortical areas above referred to there are two other
regions whose cells are necrotic, and one, the cornu ammonis, has
already been dealt with. But there is another, the amygdaloid nucleus,
whose cells show as intense a degree of morbidity as in any of the areas
already described. The amygdaloid nucleus is situated in the anterior
portion of the temporal lobe. Its lower part joins with the tail of the
caudate nucleus, above it is carried into the putamen of the lenticular
nucleus, while anteriorly it is continuous with the temporal grey cortex.
In the sections under description, it appears as an elongated oval
beneath the basal ganglia, and its cells show the shrinkage and diffuse
staining so characteristic of coagulation necrosis, throwing the entire
nucleus into sharp contrast with the surrounding parts. It is, perhaps,
not without significance that in the experiment in which this nucleus
was affected the cornu ammonis of the same side showed a definite
band of coagulation necrosis in the ganglionic layer. Still, for the
present, one would hesitate in the absence of more extensive observa¬
tion and confirmation to lay stress upon what may be a coincidence.

The areas which show lesions in these experiments are the cortex of
the pallium and rhinencephalon, the cornu ammonis, and the amygda¬
loid nucleus. In the cornu ammonis there are two distinct zones
affected, and in each the pathological lesion is widely different in type.
In the one where the ganglionic layer is the seat of the lesion the cells
show coagulation necrosis, precisely the same variety of morbid change
exhibited by the cells of the cerebral cortex and the amygdaloid
nucleus; on the other hand, where the white matter of the cornu

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PRINCETON UNIVERSITY

24 TOXI-INFECTION OF CENTRAL NERVOUS SYSTEM, [Jan.,

ammonis is involved, i.e., in the stratum moleculare, the lesion is of a
totally different nature. Here a localised ischaemic necrosis has
occurred with all the hajmorrhagic and inflammatory phenomena
peculiar to a thrombotic infarct.

It is of importance to note that the above areas and no other are
the seat of morbid changes, and that they are supplied by cortical vessels
derived from the pia-arachnoid. This is obvious in so far as the pallial
and olfactory cortices are concerned, but at first sight not quite so
apparent in regard to the cornu ammonis and amygdaloid nucleus.
VVe know, however, that the central portion of the cornu ammonis—the
lamina involuta—is penetrated by folia of the pia-arachnoid accom¬
panied by vessels ; while the amygdaloid nucleus is continuous with the
grey matter of the temporal lobe. The affected areas, therefore, all
possess one important point in common, viz., their blood-vessels are
derived from the pial system, a fact which explains the inclusion of the
above-mentioned nuclei in the morbid process.

The lesions in the brain agree anatomically with what was observed in
the spinal cord in an earlier series of experiments on animals when,
after the abdominal cavity had been infected by toxins, the myelin was
found degenerated round the margin of the cord and on either side of
the postero-median septum, while the central portions, including the
grey matter, remained intact. Here, again, the degenerated elements
lay within the zone of pial supply and had suffered exclusively. If we
substitute grey for white matter in the two series of experiments the
anatomical distribution of the morbid lesion is essentially similar, i.e,
the peripheral portions of the central nervous system subserved by
branches from the pial vascular system are affected.

The morphological character of the lesions in the brain point very
clearly to the disturbance of the circulation and therefore of nutrition.
This, in the cerebral cortex, affects a wide area and finds its expression
in the necrosis of nerve-cells in all laminre except the deep multiform
layer, unaccompanied, however, by any local ischaemia indicative of
complete vessel blockage. The evidence of a much more severe local
nutritional disturbance is very obvious in the ganglionic and molecular
layers of the cornu ammonis, where, in the former, a short segment of
nerve-cells is necrosed, and sharply defined from the normal cells on
either side ; and in the latter, where a necrotic softening with all the
histological phenomena incidental to an infarction have occurred. The
cause of the disturbance of the circulation is to be found in the morbid
condition of the cerebral vessels, which are dilated, engorged, and show
many varieties and degrees of hyaline degeneration of their contents.

In some vessels the corpuscles are normal or nearly so, but the
majority show hyaline changes, and as a result of this hyaline thrombosis
has occurred, which is recognisable in its various stages from the early,

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JOURNAL OF MENTAL SCIENCE, JANUARY, 191 S.

Fig. 5 .—To show: 1, the compound granular corpuscles surrounded by 2,

small round cells.

To illustrate paper by Dr. Okk and Major Rows, R.A.M.C

By courtesy of the Editor of ‘ Brain.'

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PRINCETON UNIVERSITY

1918.] BY DAVID ORR, M.D., AND MAJOR ROWS, R.A.M.C. 25

where the vessel is still permeable, to the complete, where occlusion
becomes inevitable. Arteries, veins, and capillaries are affected, and
the thrombotic change, accompanied by dilatation of the perivascular
and pericellular spaces due to oedema, is found in the vessels of the
pia-arachnoid, the grey, and the white matter.

All elements of the blood participate in the thrombotic process.
In incomplete thrombosis the hyaline material, in longitudinal section,
is seen lying along the side of the intima as two bands of varying
density, each of which connects with the other by trabeculae so forming
a network in the lumen of the vessel. Within this network are many
red corpuscles, obviously hyaline, and these at times clump together
to form a homogeneous mass. The leucocytes also undergo hyaline
degeneration. Their affinity for acid fuchsine is intensified, they lose
their normal shape, become clumped into masses in which lie numerous
granules deeply stained with haematoxyiin, and at times arranged in a
fashion suggestive of a horse-shoe. We regard these granules as the
remains of degenerate leucocyte nuclei. There are many hyaline
threads in the vessel lumen to which the leucocytes contribute fre¬
quently, forming a hyaline syncytium. Purely fibrinous thrombi are
not infrequently observed.

We have previously observed these hyaline changes in our experi¬
ments upon the spinal cord. They are evidence of toxic action upon
the blood elements. We find them also in man in cases of acute colitis,
and their presence has been noted by others in measles, influenza,
diphtheria, typhoid fever, malaria, pneumonia, and pyogenic infection.
We have noted this type of vascular lesion also, and its effects, in the
cervical enlargement of the cord in a case of cancer of the head of
the pancreas. Here the resultant ischsemic softenings, situated in the
posterior columns, had been followed by an acute ascending degenera¬
tion of the sensory fibres, which we traced, segment by segment, into
the nucleus cuneatus and nucleus gracilis of the medulla. This obser¬
vation in a clinical case, confirmed by our experiments upon the rabbit’s
brain, proves the ante-mortem genesis of the changes in the vessels.

Reference has been made already to the effects of disturbances of the
circulation and of nutrition upon the nervous elements, and attention
has been directed to the different character of the lesions in the cerebral
cortex and the cornu ammonis. Before attempting an explanation of
this difference we must in the first place look at some points in connec¬
tion with the vascular supply of the brain.

A concise statement in reference to this subject will be found in an
article on hajmorrhagic encephalitis by Bignami and Nazari (Rivista
Sperimentale di Freniatria , vol. xlii, fasc. 1), in which many important
points are mentioned with a direct bearing upon our research. These
authors have found that the lesions in the white and grey matter in

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PRINCETON UNIVERSITY

26 TOXI-INFECTION OF CENTRAL NERVOUS SYSTEM, [Jan.,

haemorrhagic encephalitis differ very materially, and their views regarding
the cerebral circulation are based upon this. A sharp distinction is
drawn between miliary haemorrhages, which are characterised by their
ring-like form around a necrotic focus and by their situation in the
white matter, and the haemorrhagic infiltration which follows thrombosis
of the cerebral sinuses or meningeal veins. The haemorrhage in this
latter condition is extensive, affects the grey cortex, and decreases from
without inwards. There are no necrotic foci surrounded by a ring of
haemorrhage, such as occur in the white matter. According to the
opinion of the authors both conditions are caused by a local disturb¬
ance of the circulation and not by an inflammatory process. In the one
case the thrombosis of the cerebral veins induces haemorrhage in the
cortex from stasis; in the other, blockage of a pre-capillary arteriole
results in a circumscribed necrosis in the white matter followed by
haemorrhage in the immediately surrounding parts from the collateral
vessels, the pathogenetic mechanism here being precisely the same as
in infarction of other organs. If a similar lesion is not produced in the
grey matter through occlusion of the arterioles it seems more than likely
that there is some difference between the circulation in the cortex and the
medullary substance. These observations incline the above-mentioned
authors to the admission that although the pre-capillary arterioles in the
white matter are physiologically terminal, those in the grey cortex are not
so. In the white matter occlusion of an arteriole is followed by infarc¬
tion ; if this does not occur in (he grey matter, evidently then we must
admit the possibility of an anastomosis which is functionally adequate.

Many questions regarding the cerebral circulation are still only
partially solved or remain obscure, but we are now in possession of
certain facts which bear on the subject before us. All are agreed that
the cortical arteries do not communicate with the basal arteries. Duret
regards the cortical arteries as terminal, but Cordiat and Ferd do not
agree with this, although they grant that anastomosis is not sufficient
to permit of re establishment of the circulation when obstructed by
thrombosis or embolus. Heubner supports the view that numerous
anastomoses occur amongst the pial arteries, but that after their
branches have penetrated the cortex anastomosis ceases. On this latter
point he is supported by Duret and Beevor, who hold that the cortical
arteries are terminal; but in spite of these definite statements, it would
appear that the whole question is worthy of further study, since it has
been shown that the myocardial arteries are not completely terminal in
•the anatomical sense as has hitherto been held.

Of great importance in the field of pathogenesis is a knowledge of
the relationship between the short cortical and the long subcortical
arterioles. Both are derived from pial arteries. The short are purely
cortical, while the long pass straight down into the white matter, where

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PRINCETON UNIVERSITY

I 91 8.] BY DAVID ORR, M.D., AND MAJOR ROWS, R.A.M.C. 27

each supplies a very narrow territory owing to the small number of
branches given off. Cortical arteries divide at once and very frequently,
forming a fine capillary network which is richest in the deepest cortical
lamina. Further, it seems that the short cortical arterioles anastomose
in the depth of the grey matter with the long or medullary branches.
The important point to be specially noted, however, at this stage of
our knowledge is that the cortical vascular network is far richer than
that of the white matter.

Whatever our present knowledge may be, from the anatomical side,
of the ultimate distribution and connections of the cerebral vascular
system, we seem to be justified in assuming from morbid lesions that
there is a difference in the two systems which subserve the grey and
white matter respectively. The evidence of this is seen in the histo¬
logical difference between the cortical and subcortical lesions. The
former are diffuse, and consist in necrosis of the nerve-cell units; the
latter—in the cornu ammonis—involve a circumscribed locality and are
typical of infarction. As the arterioles which supply the cortex and the
adjacent subcortical zone have a common origin—the pial arteries—
and both systems are affected by toxic hyaline thrombosis in these
experiments, the difference in type of the resultant lesions must depend
upon the anatomical arrangement of fine capillary branches. The
definite restriction of the subcortical lesion with its patho-histological
elements can only be interpreted as ischcemic in origin, and secondary
to blockage of a terminal artery. But the pathogenetic mechanism of
the diffuse coagulation necrosis of the cortical nerve-cells presents a
more complex problem and is very far from clear. From the character
of this lesion we can say definitely that no infarction has occurred, and
therefore, the presumption might be advanced that cortical arterioles
are not terminal. The highest elements, the individual nerve units,
alone have suffered, and in a manner which points to interference with
their nutrition; but the histological picture is far from what one
associates with an ischaemia, and rather suggests a stasis due to blockage
of veins, a deficiency of nutriment from narrowing of the lumen of
arterioles and capillaries; or both combined, as is most probable. It
is only some anatomical factor within the cortex itself which could
explain this different type of lesion, and for the present one would be
inclined to ascribe importance to the richness of the cortical vascular
network which may counterbalance the effects of mechanical inter¬
ference with the vascular supply. This seems to us the most reasonable
view to take of a question which is still controversial, and stands in
need of much special investigation.

In the above observations we have two types of lesion which illustrate
• how the two factors, degree and situation, can produce dissimilar patho¬
logical results, although the pathogenesis is the same; and if we apply

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PRINCETON UNIVERSITY

28 TOXI-INFECTION OF CENTRAL NERVOUS SYSTEM, [Jan.,

this to clinical neurology it becomes apparent that certain nervous
syndromes, though widely different in symptomatology are patho-
genetically one and the same disease. The difference in symtomatology
is in large measure due to the anatomical site of the lesion, but the
degree to which the nerve structures are involved is an equally important
factor. These points are well illustrated by the implication of part of
the pyramidal layer only of the cornu ammonis in two experiments, and
a definite softening in its molecular layer in one other. Both varieties
of morbid change are the result of blockage of vessels by hyaline
thrombosis, and the picture to which this gives rise depends in the first
place upon the calibre of the vessel implicated, and varies with the
time which elapses between the onset of the lesion and its examination.

One of the practical applications of these experiments is that they
throw light upon the genesis of the infantile cerebropathies, which are
now regarded as the result of toxi-infections of medium or even slight
intensity, contracted, as a rule, between the fifth and eighth month of
foetal life, or more rarely in early infancy. Infantile cerebropathies
vary in range from aberrations in type of gyri or sulci to absence of the
corpus callosum—sometimes accompanied by absence of the fornix—
and on to such gross lesions as porencephaly or even absence of one
hemisphere. Evidence of antecedent inflammation and vessel occlusion
are found in the brain with both naked-eye and microscopic examina¬
tion, and the degree of interference with development, and the resulting
mental deficiency, depend upon the extent of the lesion and the
functional importance of the nervous tissues involved. Our later
experiments can be closely correlated, therefore, with what is known at
present of the pathogenesis of many forms of mental deficiency, and
show how toxic hyaline thrombosis of capillaries or even larger vessels
can contribute very largely in the production of nervous lesions of
different degree.

The precise mechanism of production of these thromboses is still
obscure. Whether they are produced directly by the toxins spreading
along the vessel sheaths, or more indirectly through a general intoxica¬
tion, must remain for the present open questions ; and as all vascular
phenomena are closely connected with the sympathetic mechanisrrii
this must come under examination in future experiments.

Several arguments can be advanced in contradiction of the view
that a general intoxication of the blood-stream is the sole pathogenetic
factor in the causation of the thrombotic changes and of the lesions
above described, and the most cogent is to be found in the distribution
of the morbid changes, viz. : In the cortex of the brain, in the cornu
ammonis, and amongst the white fibres round the periphery of the cord
and the postero median septum. This has been already referred to,
and it has been pointed out that these changes lie precisely within the

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1918.] BY DAVID ORR, M.D., AND MAJOR ROWS, R.A.M.C. 2 Q

area of the pial vascular supply. There must be some significance in
the fact that this portion of the vascular system of the brain and spinal
cord is, so far as our present knowledge goes, alone connected with
nerves from the sympathetic system. It is accepted that sympathetic
nerves—grey fibres—leave the prevertebral ganglia to supply the menin¬
geal vessels : they do not penetrate the nervous tissue however. This
may be the explanation of the peculiar localisation of the nerve lesions
under discussion; in any case it is a factor worthy of our consideration,
especially when we remember that in the series of experiments in which
the capsules were placed in the abdominal cavity we found inflammation
of the prevertebral sympathetic ganglia, and primary degeneration of
the spinal myelin in the area of pial vascular supply. The presumption
would seem to be, therefore, that disturbance of sympathetic cell
function can exert an effect on that portion of the cord whose vessels
are under the control of the injured neurons; and it is reasonable to
argue that in the experiments where the carotid sheath was infected a
similar result in the brain would be obtained, as the carotid vessels
are surrounded by a rich sympathetic plexus. As a matter of fact,
we find both series of experiments entirely in agreement in this,
that only the areas within the realm of pial supply show any morbid
change of the nerve elements.

Evidence has been gradually converging towards the opinion that
there is a much closer interaction between the central nervous system
and the sympathetic chain than we have been accustomed to believe.
These two systems have been regarded far too much as separate organs,
anatomically and physiologically. But recent studies in comparative
anatomy, embryology, and research in connection with the ductless
glands and their influence upon the entire nervous system demonstrate
clearly that the sympathetic chain of ganglia exerts a powerful, though
subconscious, influence upon the higher nerve centres, and, in all
probability, assists in controlling the mechanism of nutritive exchange
there; while the higher centres on the other hand, exercise an action
upon the lower or vegetative functions subserved by the sympathetic
system. There is thus a constant interaction between the two ; and
hence further study of the symptomatology resulting from disturbance
of the nervous mechanism must embrace both systems.

References.

(1) Bignami and NazAri. —Rivista Sperimentale di Freniatria, 1916,
vol. xlii, fasc. 1, 109.

(2) Orr and Rows.—“ Lymphogenous Infection of the Central
Nervous System,” Brain , 1914, vol. xxxvi, pts. iii and iv, p. 271.

(') This research has been carried on with the aid of a grant from the Lunacy
Board of Control.

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3 ®

EPILEPSY AND THE DUCTLESS GLANDS, [Jan.,

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Epilepsy and the Ductless Glands. By Guy P. U. Prior, M.R.C.S.,
L.R.C.P., Medical Superintendent, Mental Hospital, Rydalmere;
and S. Evan Jones, M.B., Medical Officer, Mental Hospital,
Callan Park, New South Wales.

The actions of the ductless glands are very complex, and become
greatly complicated when one of them is either under or over acting,
because of its stimulating or inhibitory effect upon some other endocrine
organ. To help in the difficulty of understanding their action, as an
aid in diagnosing abnormalities in their secretion and in administering
extracts of these glands, we drew up the following tables. So as to do
no injustice to the authors upon whose works we have taken the liberty
to base these tables, we should like to repeat that in many cases, the
author to whom we attribute a statement, is himself frequently quoting
someone else, and often does not support the view we have credited to
him. It is only by reference to the original work that the author’s
meaning can be appreciated. Accepting as probably correct Gower’s
theory, that epilepsy is due to some chemical affecting the nerve-cells (i),
and considering the great influence the endocrine glands have on
chemical changes of the body, we have endeavoured to study these
glands in their relation to epilepsy, and to discover if there is any
evidence of their abnormal action in this disease.

Explanation and Abbreviations in Tables.

The statements as to the action of the glands have been taken from books or
papers of various authors. In many cases the author to whom a statement is
attributed is himself quoting some other authority, and does not of necessity
support that statement. It is only by reference to the original work that the
author’s meaning can be fully appreciated. .

The authority for any given remark is indicated by an initial, as:

S

B

P

F

Sajous =
L. Pr. =

B. Pr. «

W. Pr. =
W. L. Pr. =
H. Pr.
Herty.Pr.
E. Pr.

V. Pr.

Ei & E2

Schafer, The Endocrine Organs.

Bell, Blair, The Sex Complex.

Paton, Noel, Regulators of Metabolism.

Falta, The Ductless Glandular Diseases.

Sajous, paper in Practitioner, Feb., 1915.
Leopold-Levi, paper in Practitioner, Feb., 1915.
Bell, Blair,

O

T

Waller, H. E.,

Williams, L.. „ „ „ Jan., 1915.

Hertoghe, E.,

Herty, Pr.,

Elliott, T. R.,

Vincent, Swale
statement is to be found in Endocrinology,
vol. 1 or vol. 2.

= increases.

= diminishes.

= ovarian.

= testicular.

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I

Pituitary.

i

/ nsufficiency or
Removal.

Action or
Overaction.

Parathyroid,

Removal or
Insufficiency.

Action or
Overaction.

Parathyroid.

M.B.

Pulse.

Blood-pressure. 1.

Slow. S.

•

Low. S. retained ;

mperfect.
sted or

1 . S.

ret small;
ary deve-
les; per-
sial line.

Anterior ^ytimulates
has an .^.tuitary. S.
thyroid »**
ence. El.

If thyroid
ficient, P**
tary secretK
increased.

Slows with Increases with of bones
increased force, fall on repeatedbs. An-

S.

dose. S.

imulates
’oung. F

Increases

activity. S

Rapid. S.

r; .

delayer
\. F.

Takes over
action of thy¬
mus after sex¬
ual life is
reached. P.

Hyperplasia
in pregnancy.
B.

Antagoni* _

P.

Inhibitory

S.

Slows. Hertz After injec-
Pr. j tion, first +.

j later —. S.
Lowers. P.

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Thymec
Thymus
containing
The fum
the lymphc
combinatio
the osseou
deveiopmei
Atrophy
young aniir
Thymus
plantation

causes resu

!

I

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PRINCETON UNIVERSITY

Remarks.

Thymectomised hens lay eggs without shells.

Thymus is rich in nucleinates, its lymphoid cells
containing a nucleo-protein rich in phosphorus.

The function of the thymus is to supply through
the lymphocytes the excess of phosphorus in organic
combination or nucleins which the body, particularly
the osseous and nervous systems, require during
development and growth. Sajous.

Atrophy of thymus is hastened by breeding from
young animals, and is delayed by castration. W. Pr
Thymus is absent in mentally weak children ; im¬
plantation of thymus in thymectom sed animals
causes resumption of growth. Sajous.

Adrenalin secretion, which, after absorbing oxygen
from pulmonary air and being taken up by the red '
orpuscles, supplies the whole organism, including
he blood, with its oxygen. Sajous.

The cortex is the seat of manufacture of the lipoids
af the body, and may be related to the formation of
nyelin. S.

Adrenalin normally in the blood plays no part in
naintaining the tone of blood-vessels. P.

Adrenalin produces same effect as stimulation of
ympathetic nerve. S.

Stimulation of splanchnic* raises blood-pressure;
ut not if suprarenal vessels are ligatured.

Adrenalin destroys toxic waste of muscular origin I
nd reduces fatigue. Sajous.

It is dangerous to give adrenalin while under the
ifluence of chloroform. E. Pr.

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ie in a After
s with markedly
ions. B. Thyroi
mamman
L. Pr

Its sect
Its sen
the functi
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PRINCETON UNIVERSITY

Remarks.

After removal of thyroids from newts, regeneration of amputated limbs is
markedly interfered with. P.

Thyroid insufficiency is sometimes associated with excessive development of
mammary glands ; this mav be accompanied with hypertrophy of the parotids.
L. Pr.

Its secretion possesses both antitoxic and bactericidal properties. Sajous.

Its secretion takes an active part indirectly in general immunity, by increasing
the functional activity of the adrenals, and through these organs general oxida¬
tion and metabolism. Sajous. ,

The thyro-parathyroid secretion enhances oxidation by increasing the inflam¬
mability of phosphorus, which all cells, particularly their nuclei, contain. All
pathogenic elements in which phosphorus is present are rendered more vulner¬
able to the digestive action of phagocytic. Sajous.

Iodothyrin causes a marked increase in the output of sodium, sodium chloride,
and phosphoric oxide. Sajous.

Tadpoles fed with thyroid; growth stops and development occurs rapidly.
Limbs grow and tail atrophies while tadpole is very small. P.

Thyroid governs the formation and growth of tissues and the processes by j
which waste material resulting from incessant regeneration of organs is eliminated.
H. Pr.

Children of mothers suffering from Graves’ disease are mostly degenerate. W. Pr.

Castrated stags do not develop antlers; or, if already developed, they fall I
off. P.

Atrophy of ovary in birds, followed by assumption of male plumage. P.

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19 * 8 -]

HY GUY P. U. PRIOR, M.R.C.S.

31

Epileptiform convulsions may occur after removal of the thyroid
parathyroid system (2), in extreme cases of Addison’s disease (3), in
hypopituitarism (4); also in cases with minus parathyroid action, as when
associated with tetany (9). In two young epileptics, who died suddenly,
we found considerable enlargement of the thymus gland and small
heart and aorta ; in both these cases the aorta would only admit one
finger, and in both these cases the suprarenal glands microscopically
showed a large extent of vacuolation. These cases, in their mode
of death and in their tiost-mortem findings, much resemble status
lymphaticus.

Is there usually, in epilepsy, any change in the ductless glandular
system, and can treatment with these glands in any way influence the
disease for better or worse? We think that we can show that both
these questions can be answered in the affirmative.

Pituitary.

Schafer says that in conditions of hypopituitarism a tendency to
epilepsy has occasionally been described (4). Several authors have
recorded cases of epilepsy making great improvement with anterior
pituitary extract. Spears (5) relates a case of a man, set. 28, an epileptic
since 6 years of age, with an average of three or four fits weekly, who,
after four months’ treatment with anterior pituitary, had no fit, and has
continued without for eight months. Tucker (6) records a number of
cases that improved with the same treatment; and Joughin(7) the case
of a girl, set. t6, who improved within two weeks of taking anterior
pituitary extract, and has been without major seizures for two years.
This case was clinically one of hypopituitarism.

G. C. Johnston (8) claims that there are often changes about the
pituitary in cases of epilepsy unattended by gross evidence of pituitary
disorder, and advises the use of radiography in these cases. We have
under our care eighty male epileptics, of whom four are clinically
unmistakable cases of hypopituitarism. They all have abundance of
adipose tissue, and have no hair on the body except pubic hair, two
have no hair in the axilla, and the other very little. Three have but a
scanty amount of hair on the face, one case has rather an abundant
beard. All four have large mammary glands. They all have a low
blood-pressure, their highest record being 115 mm. Hg., which was
reached once in one case in the recumbent position ; the majority of
their blood-pressure readings were higher lying down than standing.

Although these cases, from their general appearance and clinical
signs, may be taken to be typically apituitary, the improvement they
have made on treatment with whole gland pituitary has been but
slight. We have used the whole gland pituitary in preference to the

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32 EPILEPSY AND THE DUCTLESS GLANDS, [Jan.,

anterior gland, as one case in which we used this latter was so much
worse while taking this that we had to discontinue the treatment, when
improvement immediately followed.

At the time of treating these cases we were unaware of the success
that others had obtained with the anterior gland, and intend to give
this a more extended trial.

Case 43, witho'U any medicinal treatment', has an average of 7 fits a
month, varying from 2 to 14. For four months he was taking pituitary
extract, gr. 2^ t.i.d. ; for these months he averaged 10 fits a month,
ranging from 8 to 14.

Case 8 has been treated over a longer period; without treatment for
a period of twelve months he averaged 13 attacks monthly, ranging
from 7 to 15 ; for four months he was taking pituitary extract, for
which time he averaged 10 fits a month, being a slight reduction from
his former average. For a second period of four months, he received
calcium chloride, gr. x, every four hours, with a resulting average of
10 fits monthly. For three months he has been taking potass, brom.,
g. vii 4 tis horis, with an average of 5 fits a month. This patient
appears to have received slight benefit from pituitary gland, but to
have received more from bromide.

Case 38.—For nine months, while being treated with pot. brom.,
gr. xx t.i.d., averages 18 attacks a month ; for two months he takes
pituitary gland in addition to the bromide, when the average rises to
22 monthly. With suprarenal gland for three months in place of the
pituitary, the average number of attacks monthly drops to 18. For
three months didymin, gr. xv, daily is given, and the average rises to 20.

If, in any way, the epileptic attacks in this type of patient are directly
associated with or due to insufficient pituitary action, an increased
number of fits is to be expected with didymin, as the gonads are stated
to inhibit the action of pituitary (10).

Parathyroid.

Falla (9) states that epileptic attacks in tetany are not rare, and that
Redlich collected seventy-two cases where these diseases have been
associated. He also states that in parathyroprivic individuals unilateral
or bilateral epileptiform convulsions with loss of consciousness have been
observed. Blair Bell (2) says that animals from which he removed both
the thyroid and parathyroid glands died of convulsions. Know(n)
records cases of epilepsy which improved with parathyroid and calcium
lactate. One of our cases on admission presented many signs that
might be accounted for by parathyroid insufficiency.

Case 39.—A male, ict. 21, had an insane inheritance, and had suffered
from epilepsy since he was two years old.

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JOURNAL OF MENTAL SCIENCE, JANUARY

To illustrate paper by Drs. Prior and Jones

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1918.

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JOURNAL OF MENTAL SCIENCE, JANUARY, .918.

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PRINCETON UNIVERSITY

191 8.] BY GUY P. U. PRIOR AND S. EVAN JONES.

LXIV.

3

33

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Case No. 26. Case No. 18.

Charts showing the specific gravity and the amount of phosphates and chlorides in
grammes per cent, in 12-hourly in Case No. 26, and in 24-hourly in Case No. 18,
specimens of urine and their relations to epileptic attacks.

Fits thus O. Equivalents in form of tremors thus-.

34

EPILEPSY AND THE DUCTLESS GLANDS, [Jan.,

On admission he was extremely thin and wasted, of light build, and
with small bones, saliva flowed from his mouth in one constant stream,
his teeth were carious, nails badly developed, he had but little appetite,
mentally he was dull and tearful, all reflexes were so greatly exaggerated,
together with tremor of tongue and facial muscles and inco-ordination
of speech, that it was at first thought that he was an advanced infantile
general paralytic. By referring to the table on parathyroid action it
will be seen that most of this boy’s symptoms are consistent with under¬
action of this gland. His mother stated that for many months previous
to admission he had been having more than 100 fits a month while
taking bromides. During the first month under our observation, while
having no treatment, he had 102 fits. He was for one month given a
mixture of calcium lactate and potassium bromide and his fits fell to
30 for the month. For six months he took parathyroid gland, gr.
x-io daily, he put on weight, ceased to salivate, the reflexes became
normal, and after two months of treatment he was sufficiently well to
work at gardening. During the fifth month he became very dull, with
unsteady gait and almost cessation of the epileptic attacks, having for
this month only 6 fits. His blood-pressure was at this time very low,
varying from 85 to 105 mm. Hg. ; because of this low blood-pressure,
and because it is stated that parathyroid action is antagonistic to supra¬
renal, he was given for six weeks suprarenal gland extract instead of
parathyroid, and the bromide and calcium were suspended. He
improved in physical health, his blood-pressure rose, and the monthly
average of his fits rose to 43. For the next three months he was
again given parathyroid gland and the mixture of calcium and bromide.
For this period he remains well, physically and mentally, and resumes
his work and averages 14 attacks a month.

Another case of similar type and build and with exaggerated reflexes
we have treated in the same way.

This patient, Case 40, has been an epileptic since 10 months of age,
and is now ret. 26. A record of his attacks has been kept by his
mother for several years. She states that for four months previous to
admission he had averaged 18 fits a month while being treated; for
two years previous to this he had averaged 10 attacks monthly. For
the first month after admission, without treatment, he had 10 fits. For
seven months he had been treated with parathyroid gland together with
bromide and calcium chloride, with an average of 3 fits monthly,
ranging from 1 to 4. Before being treated he was subject to attacks of
irritability and violence, which were the reason of his being admitted.
He has since had no trouble in this way, but is, in fact, a quiet and
trusted worker.

Case 7 is another case that has made considerable improvement on
parathyroid gland.

He had been an epileptic since 15 years of age. He was dull and
lethargic, the sort of case that, apart from epilepsy, often improves on
thyroid gland. This patient, without treatment, averaged 20 fits a
month ; treated for nine months with calcium and bromide alone or in
combination, together with thyroid or thymus glands, he averaged

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PRINCETON UNIVERSITY

1918.] BY GUY P. U. PRIOR AND S. EVAN JONES. 35

24 fits a month ; treated for five months with parathyroid gland and
calcium and bromide he averaged 10 fits a month.

Thymus.

In a former article (12) we stated that thymus gland was the one we
had found most useful, and the only one from which apparent harm had
not in some case or other occurred. After a more prolonged use we
have seen in one or two cases more epileptic attacks taking place while
this gland was being used and an immediate fall on its discontinuance.
We believe that it has a distinct use in epilepsy. To form a clear idea
as to what might be taken for thymus insufficiency is not easy, but there
are several reasons why thymus might be expected to be useful in this
disease.

(1) Epilepsy more commonly commences at the time of life that the
thymus becomes functionless.

(2) It causes a retention of calcium (13), and in cases of thymus
insufficiency there is an excessive excretion of this salt (14).

(3) It prevents an excessive accumulation of acids in the body,
especially phosphoric acid (16). Epileptic attacks can be increased by
giving this acid to patients (17). It has been shown by Pugh (18), and
confirmed by ourselves, that the blood of epileptics is less alkaline than
normal, and at the time of taking a fit this becomes more accentuated.

(4) The thymus is stated to be absent in the mentally deficient
children (15); the majority of epileptics whose attacks commence in
early life are mentally deficient.

In thymus insufficiency there is increased action of the thyroid (19),
suprarenals (20), and gonads (21). Thyroid and suprarenals will in
some epileptics increase the number of attacks, but in many others
suprarenal seems decidedly beneficial. Many epileptic patients show
an increased sexual irritability at the time of taking fits, this irritability
we think can be lessened by giving thymus gland.

In our series of nineteen post-mortem examinations all but six showed
microscopically some signs of persistence and activity of the thymus
gland. In Cases 48 and 49 the thymus was of extreme size ; in both
the thymus was about as large as the palm of the hand. Both were
cases of sudden death in young and apparently healthy subjects, death
in each case, for want of a better reason and with hardly sufficient
justification, being attributed to suffocation while in a fit. In Case 50,
also one of sudden death, in which there was no question of suffocation,
as the patient, who was thought to be in his usual health, had a fit
while an attendant was beside him, and died immediately afterwards,
while on his back. This man had a large and very vascular thymus, he
was an alcoholic, set. 37, and his first epileptic attack had occurred five
years before. Might not the enlargement of his thymus be a com-

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36

EPILEPSY AND THE DUCTLESS GLANDS, [Jan.,

pensatory one, to combat the chemical changes that alter the calcium
metabolism in epilepsy or which lessen the alkalinity of the blood ? It
is said by Blair Bell that this gland will enlarge after removal of the
ovaries (22), and it is said to persist in eunuchs (23).

Case 6.—For twelve months while taking bromides, had an average of
16 attacks monthly; for sixteen months has been taking thymus gr. x
daily, in addition to calcium and bromide, for which time he averaged
8 fits a month.

Case 37.—A lad, who, without treatment for eleven months, averaged
6 fits a month. His epileptic attacks are preceded by much sexual
irritability. For the first month on thymus gland he had no fit, a thing
that had not been recorded against him before; for the first three
months on this treatment he averaged if attacks a month, and during
this time the sexual irritability was much less. For nine months on
thymus gland he has averaged 4 fits a month. Whether the apparent
wearing-off of effect is due to the action of the thymus in inhibiting or
stimulating some other gland, it is difficult to say.

In Case 3 it appears as if a change in the glandular treatment is
helpful. This patient on bromide averaged about 100 attacks monthly;
after three months’ treatment with calcium, bromide, and suprarenal
gland, the average falls to 9 ; in the third month he has only 2 attacks.
In another period of treatment, after the patient returns from leave of
absence, when the number of attacks return to their former average,
during the third month on suprarenal extract, he has 2 or 3 attacks
daily, which immediately fall to about 2 weekly when thymus replaces
the suprarenal gland.

Case 28.—For seven months without treatment, averages iS attacks a
month; on calcium lactate for three months averages 10; with
calcium, bromide, and thymus for five months the average is 7 a
month.

Suprarenals.

Of the suprarenal glands from fourteen epileptics examined micro¬
scopically eleven showed considerable vacuolation of the cortex. After
removal of these glands, death is preceded by convulsions (36).

Epilepsy may be associated with Addison’s disease (3), and the
suprarenals play an important part in the calcium metabolism. From
these facts, it might be expected that suprarenal extract would be of use
in epilepsy.

We have been much interested in seeing a reference to the work of
Cotton. Carson-White, and Stevenson (25), who, by the aid of Abder-
halden reaction, concluded that at least one type of epilepsy may be
produced by over-action of these glands. They lessened the activity of
the adrenals by giving pancreatin, and with good results. It is stated
by Waller (37) that in cases of pneumonia the suprarenals are pro
foundly affected. We have under our care a chronic case, who was an
epileptic, and who, about sixteen years ago, had an attack of lobar

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1918.] BY GUY P. U. PRIOR AND S. EVAN JONES.

37

pneumonia and has not had a fit since ; we have also read of one similar
case, in which epilepsy ceased after an attack of acute pneumonia. We
have seen 2 or 3 epileptic attacks occurring daily during the course of a
double pneumonia. Is it not possible that the first two cases were of
thekindin which there is over-action of this gland, which the attack of
pneumonia might have reduced? We think we can show that in some
cases suprarenal extract is of benefit to the epileptic patient.

Case 20 was for twelve months taking bromide, with an average of
41 fits monthly. With calcium chloride combined with bromide for
nine months the average is reduced to 13 a month. For two months
he receives suprarenal extract in addition, with a resulting monthly
average of 10 fits. This patient has since died of pneumonia, and the
result of the microscopic examination of his glands is given below,
where it will be seen that his suprarenals had undergone fibrotic
changes.

Case 20.—For five months without treatment averages 33 fits a
month. On bromide for three months and on bromide combined with
calcium for five months, averages 28 attacks a month. On the latter
treatment, together with suprarenal gr. x daily for eight months, averages
17 attacks a month.

Cases 30 and 23 have improved on suprarenal, the latter having
without treatment for six months an average of 21 attacks monthly,
with calcium and suprarenal extract and without bromide for three
months, this average is reduced to 7. Case 30, having an average
without treatment of 15 attacks a month, with calcium and bromide
for eight months, an average of 9, which for the next five months is
reduced to a monthly average of 4, when suprarenal gland is added.
With the exception of Case 30, which is one of alcoholic origin,
occurring late in life, they are all young patients, of poor physical
development and with low blood-pressure. Suprarenal gland in
Case 39, already referred to as having improved under parathyroid,
seemed to increase the number of attacks, but while on the gland the
patient made considerable physical improvement.

Thyroid.

It is said by Falta (38), that the thyroid is intimately associated with
the control of the central nervous system, and that “ this is instanced in
the association of epilepsy with thyroid disease, especially exophthalmic
goitre.” He also records a case of epileptiform convulsions occurring
for the first time while the patient was taking large doses of thyroid
extract (39).

Murray Auer (40), quoting from Bolton, says, “ Genuine epilepsy is
a chronic auto-intoxication arising through metabolic processes in which,
as a result of hypofunction of the thyroid and parathyroid glands, the
poisons are not thoroughly neutralised or removed.” Auer confutes
the statement. Thyroid is also stated to be harmful in epilepsy, as by
its action the excretion of calcium is increased. In one case of

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38

EPILEPSY AND THE DUCTLESS GLANDS, [Jan.,

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myxcedema we have seen epileptiform convulsions occurring shortly
before death. We have seen epileptic cases made worse by the use of
thyroid gland.

Case 34.—A girl who never excreted more than a trace of calcium in
her urine, was given thyroid extract gr. v. daily for four months, the
average number of her fits remained almost unaltered. Without treat¬
ment for six months, the monthly average was 4, while taking thyroid
it was 3 a month ; for three months she received calcium chloride
as well as the thyroid extract, for which time the monthly average was
the same as on thyroid alone.

Case 9. —In this case thyroid was apparently of slight use. This
patient, on bromide for twelve months, averaged 14 fits a month ; for
seven months while taking thyroid gland as well as bromide, the average
was 10 attacks a month ; for seven months on calcium chloride and
thyroid, but without bromide, the average was 11 a month.

Case 23.—Referred to as having improved with suprarenal extract,
was for one month on thyroid gland, during which month she had the
greatest number of fits ever recorded against her, viz., 34, which fell
immediately the gland was discontinued.

Gonads.

In our series of post-mortem examinations the female patients have
shown more constant changes in these glands than the male patients.
The ovaries for the most part were found fibrotic with atrophy of the
interstitial cells ; in one case the testicle showed atrophy of the corre¬
sponding cells.

Menstruation in most epileptics is irregular. Of forty of our cases in
whom the function was established, and upon whom note had been
kept as to their catamenia for twelve months, in only three did the
periods recur twelve times during the year. Eighteen of the total
number menstruated six times or less in the twelve months, and eight
of these only once. In only two cases was the period at all prolonged
or the loss exccessive, and in these two only occasionally.

This irregularity and slight loss might point to deficient ovarian
action (26). In thyroid (27) or anterior pituitary (28) deficiency there
may be absence of, or irregular menstruation, also when there is
a deficiency of calcium in the system (29). The epileptic attacks are
very apt to occur at about the time of the period, probably due to the
increased amount of calcium excreted at these times. Contrary to
what might have been expected, we do not find the average number of
fits much greater in the months in which there is menstruation than in
those in which there is amenorrhoea, but in the former the fits are
mostly grouped around the period. One of the female patients at times
shows pronounced erotic tendencies, but this is not especially associated
with the fits or menses. The epileptic attacks in three male patients

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_ [

IQ 1 8.] BY GUY P. U. PRIOR AND S. EVAN JONES. 39

are directly associated with symptoms of sexual activity, two are sexually
perverted, and in several sexual irritability is a common symptom, but
we think that perverted or excessive sexual manifestations are not
commoner in epileptics than in other insane patients.

We have used didymin extract in cases with high blood-pressure,
acting upon the dictum of Ludlum and Corsin-White (30), that Brown-
Sequard fluid is useful in a somewhat similar type of cases of primary
dementia. We have also used didymin or ovarian extract in cases that
habitually excrete but little calcium in the urine ; with didymin we have
increased the amount of calcium excreted, but cannot say that in these
cases the epileptic attacks have been diminished, nor have we observed
cases improve on ovarian extract.

Case 19.—One with a high blood-pressure and an average of 35 fits
a month while taking bromide, and 32 a month while taking calcium
and bromide ; for six months has didymin gr. xv. daily in addition, for
which time he averages 17 attacks a month.

Report of Microscopical Examination of Endocrine Glands.

Case 2.—L—, died October 9th, 1916, aet. 26. Pneumonia.

Testis. —Tubular epithelial cells show mitotic figures. Large numbers
of interstitial cells which contain yellow granular pigment.

Thyroid. —Colloid vesicles large. Epithelium very much flattened.
Colloid neutrophil.

Pituitary: Pars anterior: —Eosinophil cells greatly predominate.
Pars intermedia : No colloid vesicles. Pars posterior: Very few hyaline
bodies. Some intermedia cells are seen invading this portion.

Pineal. —Alveolar arrangement well shown. A large area shows
degenerative changes like area of softening in brain.

Thymus. —Not examined.

Suprarenal. —Capsule much thickened. Cells stain well and show
no degenerative changes.

Pancreas. —Very few islets are seen, and these show degenerative
changes, staining poorly and apparently disorganised.

Case 20.—W. S. L. W—, died June 20th, 1916, set. 28. Suddenly.

Testicle. —The tubular cells are actively proliferating and mitotic
figures are seen. Groups of interstitial cells are present here and
there, but appear to be deficient.

Thyroid. —The vesicles vary in size, and are filled with eosinophil
colloid. The epithelium is cubical. There is an increase of interstitial
cells.

Pituitary. —This organ was extremely small, and was evidently
missed when the sections were being cut.

Thymus. —This consists of fatty tissue with islets of thymus tissue here
and there. These are acutely congested.

Suprarenal. —The cytoplasm of the cortical cells has a reticular
appearance. The medullary cells appear granular. There are several
round cell masses in the medulla.

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EPILEPSY AND THE DUCTLESS GLANDS, [Jan.,

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Liver. —Shows congestion, fatty degeneration, and cloudy swelling.

Pancreas. —Exhibits cloudy swelling: The islets appear normal.

Case 58.—C. C—, died November 26th, set. 50. Pneumonia.

Testicle. —The tubules are normal, and the usual interstitial cells are
present, and contain yellow pigment.

Thyroid. —The vesicles are very large, and the lining epithelium is
flattened. There are no interstitial changes.

Pituitary.—Anterior lobe: Is much larger than usual, the cells are
mostly eosinophil. Pars intermedia: There are no colloid vesicles.
Pars posterior: Is small, there are no hyaline bodies or invading cells.

Suprarenal. —The cortical cells stain well and show very slight
degenerative changes. The medulla is normal, and the cells contain
much pigment.

Thymus. —Apparently of persistent infantile type, with large masses
of gland tissue. HassalPs corpuscles are in evidence.

Liver. —Normal.

Spleen. —The capsule is thickened, and arterioles show thickening of
their walls.

Case 56.—J. T—, died June 1st, 1916, set. 28. Status. Onset of
fits at 17.

Testicle. —Not examined.

Thyroid. —Vesicles of uniform size, lining epithelium flattened.
There is an increase of interstitial fibrous tissue.

Pituitary .—Not examined.

Thymus. —Not examined.

Suprarenal. —The cortical cells stain very poorly, some show finely
granular cytoplasm, but in most the cytoplasm does not stain at all,
except as a network of fine threads. The medulla does not show these
changes, and the cells contain much pigment, either fine yellow granules
on large dark brown particles.

Liver. —Exhibits cloudy swelling.

Case 57.—G. J. D—, died April 4th, 1916, aet. 51. Convulsions.

Testis. —Not examined.

Thyroid. —The vesicular epithelium is cubical, in places the cells
appear to be proliferating. There is also a great increase of the inter¬
stitial cellular elements.

Pituitary. — Pars anterior: Eosinophil cells predominate. Pars inter¬
media : There is a large colloid vesicle, the lining cells are degenerating.
Parsneurosa: Contains a few hyaline bodies. There are no invading
cells. The whole organ is acutely congested.

Thymus. —There are scattered foci of lymphoid tissue in which an
occasional corpuscle may be seen. It is noticeable that the blood¬
vessels are large in proportion to the amount of gland tissue. The
gland is probably of regenerative type.

Suprarenal .—The cortical shells show advanced degenerative changes.
Everywhere the cytoplasm fails to stain, except as a network of fine
fibrils. The medullary cells appear normal and contain pigment.

Liver .—Shows early fatty degeneration and chronic venous con¬
gestion.

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Case No. 44. Case No. 60.

Charts showing amount of urine passed, its specific gravity, the amount
of phosphates and chlorides in grammes per cent, in 24-hourly
specimens, and their relations to epileptic attacks.

Fits thus O. Equivalents in form of tremors thus-.

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42 EPILEPSY AND THE DUCTLESS GLANDS [Jan.,

Case 55.—G. W—, died, aet. 73. Epileptiform convulsions.

Testicle. —Not sectioned.

Thyroid. —Vesicles large, epithelium flattened. Very few interstitial
cells.

Pituitary.—Pars anterior: Cells mostly basophil. There are many
small vesicles enclosed by cubical epithelium, some of which contain
homogeneous neutrophil colloid. Many cells show vacuoles in their
cytoplasm. Pars intermedia: There are several very large colloid
vesicles containing neutrophil colloid. Pars posterior: Neuroglia net¬
work less dense than usual. Contains hyaloid bodies and pigment
granules. No invading cells from pars intermedia.

Thymus. —Not examined.

Suprarenal. —This organ is very large. The cortex shows an
extremely advanced stage of degeneration ; the nuclei stain well, but
the cytoplasm appears as a network of fine threads with large spaces.
Some cells show less advanced changes, and in these the cytoplasm is
markedly granular. The medulla is affected to a less extent and some
parts stain well.

Liver. —Chronic venous congestion. Early fatty degeneration of cells
of zones of hepatic vein.

Case 54.—M. E. H—, died November 27th, 1916, set. 39. Broncho¬
pneumonia following status.

Ovary. —This organ consists of more or less cellular fibrous tissue
in which are a few corpora fibrosa. The blood-vessels are surrounded
by very thick fibrous walls. The cortical zone is less cellular than the
central portion. No follicles are seen.

Thyroid. —The vesicles are of medium size, and are more or less
uniform and filled with eosinophil colloid, except in some instances
where the epithelium has proliferated and filled the vesicle. There is a
slight degree of interstitial fibrosis and multiplication of interstitial cells.
The vesicular epithelium is cubical.

Pituitary. — Anterior lobe: Eosinophil cells predominate, with here
and there nests of basophils. There are numbers of vesicles containing
eosinophil colloid. Many cells contain large blood pigment granules.
Pars intermedia : There are several vesicles containing eosinophil
colloid. The lining epithelium is very much flattened. Pars posterior :
There are very few hyaline bodies. No pigment granules and no
invading cells are to be seen.

Thymus .—Not examined.

Suprarenal. —The cortex shows a slight degree of degenerative change.
In many cells clear spaces having appearance of vacuoles are seen. The
medullary cells contain much blood pigment, and in some are found
homogeneous eosinophil globules.

Liver. —Shows early fatty degeneration and infiltration.

Case 53.—S. J. M—, died May 25th, 1916, set. 57. Exhaustion
after series. Fits began at 16.

Ovary. —This organ is small and intensely sclerosed. The sub-
capsular layer consists of interlacing bundles of spindle cells, whilst the
centre of the organ is occupied by large, faintly-staining masses of
fibrous tissue with a few septa represented by fibroblasts (hyaloid

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bodies). The blood-vessels are surrounded by immensely thickened
fibrous walls. There is no evidence of follicular tissue.

Thyroid. —The colloid vesicles are mostly small and separated by
proliferated cellular tissue. The vesicular epithelium is cubical.

Pituitary. — Pars anterior: In subcapsular regions eosinophil cells
predominate and vessels are distended; the central cells are chromo¬
phobe with a few basophils. Pars intermedia : There are a number of
small colloid vesicles. A few eosinophil cells are seen passing towards
the pars nervosa. Pars posterior: A number of eosinophil hyaline
bodies are seen in the meshes, and yellow pigment granules are also
present in considerable numbers.

Thymus. —Not sectioned. Probably not found post-mortem.

Suprarenal. —This is firmly attached to the kidney with only the
fibrous renal capsule between the two organs, though in places this is
absent and renal tubules and columns of suprarenal cells are seen inter¬
mixed. In some places in the suprarenal tissue small spaces lined by
cubical epithelium are found; some are filled with a homogeneous
neutrophil substance whilst others are empty. These, perhaps, repre¬
sent aberrant renal tubules. The suprarenal cells stain well except in
one part, where in the subcapsular region degenerative changes are in
evidence.

Spleen. —Capsule is thickened and there is vascular sclerosis and
waxy degeneration.

Liver. —Shows an advanced stage of fatty infiltration.

Case 51.—H. D—, died October 7th, 1916. Status epilepticus;
set. 50. Has had fits since two years of age.

Ovary. —Shows extreme degree of fibrosis. There are several large
corpora fibrosa, and no Graafian follicles can be seen.

Thyroid. —Not examined.

Pituitary. — Pars anterior: Chromophobes predominate. Pars inter¬
media : There are no colloid vesicles. Pars posterior : This portion is
more cellular than usual, but no hyaline bodies or invading intermedia
cells are visible.

Pineal. —There are numerous small particles of lime.

Thymus. —There are numerous islets of true thymus tissue containing
Hassall’s corpuscles, scattered amongst fatty areolar tissue. The type is
regenerative.

Pancreas. —The alveolar cells are normal, but there are very few islets
of Langerhaus.

Spleen. —The vessels are sclerosed. There are small haemorrhages in
evidence.

Suprarenal. —The cortical walls show a moderate degree of degenera¬
tion ; the medullary cells contain much pigment.

Case 52.—M. M—.died June 15th, 1916, set. 50. Lymphadenoma.

Ovary , thyroid , and pituitary. —Not sectioned.

Thymus. —Vascular gland tissue is present, containing many Hassall’s
corpuscles. The type is probably regenerative.

Suprarenal. — Post-mortem changes present—skrinkage of cortical
columns and cloudy swelling of cells.

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44 EPILEPSY AND THE DUCTLESS GLANDS, [Jan.,

Spleen. —Interstitial fibrosis ; large amount of granular pigment;
chronic venous congestion.

Liver .—Shows an extreme degree of fatty infiltration.

Case 50.— C. H. B—, died August 12th, 1916, aet. 40. Suddenly,
in a fit. Fits commenced at 34.

Testis .—Not examined.

Thyroid. —The vesicles are small and irregular and do not centain
much colloid; the lining epithelium is cubical and appears to be
actively proliferating, so that in places there are masses of cells. The
intermedial tissue is increased. The blood-vessels are congested.

Parathyroid. —This is attached to the above section and is 3 mm. in
length by 2 mm. in breadth. Apparently it shows no abnormality.

Pituitary. — Pars anterior: Eosinophil cells in excess. Pars inter¬
media : No colloid. Apparently there is an extensive effusion (of
lymph), which in parts has a fibrillar structure, whilst in others it is
granular; in it a few red cells may be seen, but no vessels or fibroblasts.
In places cells of pars intermedia appear to be forming a layer. Pars
posterior: Large numbers of darkly-staining intermedia cells are
streaming out into this portion. Masses of pigment granules are to be
seen in some numbers—the appearances suggest that they are derived
from the invading cells.

Thymus. —Represented by numerous small collections of lymphoid
cells in fatty areolar tissue. Hassall’s corpuscles are present. The
gland tissue is very vascular, the capillaries being large and thin-walled.
The type is regenerative.

Suprarenal. —The cortical cells exhibit degenerative changes—though
the nuclei show up well the cytoplasm appears merely as a network or
has a granular or vacuolar appearance. The cells of medulla stain
well, but even amongst these the cytoplasm has a vascular appearance.

Case 31. —W. S—, died suddenly November 1st, 1916, aet. 25.
Aorta small. Thymus very large. Onset of fits at 15.

Ovary .—This organ consists of fibro-cellular tissue, which in places is
extremely vascular. Only one small follicle is seen in the section.

Thyroid and pituitary. —Not examined. Pineal. —Normal.

Thymus. —This is apparently of retrogressive infantile type. The
thymus tissue contains numerous Hassall’s corpuscles \ there are also
lime particles.

Suprarenal. —Appears normal.

Pancreas. —Cells are shrunken. Very few islets seen.

Spleen. —Shows numerous small haemorrhages.

Case 48.—C. E. P—, died August nth, 1916, suddenly, aet. 22.
Fits commenced at 15.

Testis. —Apparently normal. Interstitial cells are present.

Thyroid and pituitary. —Not examined.

Thymus. —This is a large organ of persistent infantile type. There is
much gland tissue with numerous Hassall’s corpuscles. The blood¬
vessels are large and thick-walled.

Suprarenal. —Both cortex and medulla show degenerative changes.

Pineal. —Contains some particles of “ sand,” otherwise normal.

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1 9 1 8.] BY GUY P. U. PRIOR AND S. EVAN JONES. 45

Case 21.—C. A. R —, died February 27th, 1916. Status. A£t. 41.
Fits since 2 years of age.

Ovary. —This organ is small, and consists almost entirely of cellular
fibrous tissue. Only one small Graafian follicle is seen. There are
several corpora fibrosa, some in the early stage of formation being com¬
paratively cellular and containing spiral capillaries. The arterioles
have thick walls, while the capillaries are very large and thin-walled.

Thyroid. —The alveolar spaces are large and the lining epithelium
moderately flattened. In places there are masses of proliferated inter¬
stitial cells.

Pituitary.—Pars anterior: Cells are shrunken and are mostly
chromophobe, though there are considerable numbers of eosinophils.

Pars intermedia: There is one vesicle lined with cubical epithelium
and containing basophil colloid. Within another space lined with
cubical cells is seen a mass of pink-staining material broken up by
numerous round cells. About some of these cells are more or less
clear spaces having a faint reticular appearance. Pars posterior: There
are no invading cells. A few hyaline bodies are seen.

Thymus. —There are numerous foci of gland tissue with many Hassall's
corpuscles.

Suprarenal. —Both cortical and medullary cells show poorly-staining
cytoplasm ; the change is more marked in the former.

Liver. —Shows advanced fatty degeneration.

Pancreas. —The acinar structure in parts is lost, so that the gland has
the appearance of an adenoma. The islets of Langerhans stain faintly,
and in the cell nuclei mitotic figures may be seen.

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46 EPILEPSY AND THE DUCTLESS GLANDS, [Jan.,

R£sum£ of Changes Found in the Endocrine Glands.

Gonads .—Constant changes of the nature of obliterative fibrose are
present in the female, but there are no corresponding changes in the
male.

Ovary .—The ovaries were examined in five of the six female patients.
Microscopically they appeared shrunken and atrophic. Histological
examination revealed constant and advanced changes. In all cases the
organ was extremely fibrosed, the stroma being made up of fibro-
cellular elements whose appearance resembled that in a fibroma. In
areas the cellular elements had almost completely disappeared and the
tissue stained faintly—these are the so-called corpora fibrosa. In two
instances small Graafian follicles were seen, but were absent in the
others. The arterioles were surrounded by relatively very thick fibrous
coats, while the capillaries were thin-walled and large. These changes
must be taken to indicate a great deficiency in the activity of the
ovaries.

Testis .—Of the eight males the gonads were examined in four, and
in only one of these was a definite pathological change evident; this
was in “W” 20, a case of dystrophia adiposa genitalis, whose testis
showed a deficiency of interstitial cells.

Thyroid Gland .—Two types were recognised on histological examina¬
tion. In one the vesicles were large and lined by flattened epithelium,
whilst interstitial cells are few in number. In the other the vesicles
were relatively small and lined by cubical epithelium which appeared
to be proliferating, and there were large numbers and masses of inter¬
stitial cells. From the resemblance to the appearances seen in the
thyroid in exophthalmic goitre, the latter type may be considered to
represent an active phase, whilst the other represents a quiescent state.
Of the eight males, the thyroid was not examined in one case ; of the
other seven, four were classified as quiescent and three as active. Of
the six females the thyroid was examined in three, in two it was of
active type, in one it was of quiescent type.

Parathyroid.

The gland was not specially examined, but in one case 50 “ B ” (20)
in which it was cut with the thyroid, no pathological changes were
evident.

Pituitary .—No constant changes were found, although there were
frequently seen indications that suggested that the gland was over
active in some cases.

Thymus .—The thymus was present in five out of eight males and
in four out of six females. In some cases it was as large as the palm
of the hand, whilst in others it was only recognised on section of the

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Case No. 59.—Chart showing amount of urine'passed, its specific'gravity,
the amount of phosphates and chlorides in grammes per cent, in
12-hourly specimens, and their relations to epileptic attacks.

Fits thus O. Equivalents in form of tremors thus-.

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48 EPILEPSY AND THE DUCTLESS GLANDS, [Jan.,

mediastinal fatty tissue. Two types were recognised : (1) The persistent
infantile type has the macroscopic and microscopic appearance of the
infantile thymus; this was present in two males and three females.
(2) The regenerative type—in this the thymus tissue was recognised
microscopically, and appeared in islets of true thymus tissue embedded
in fat—this was the case in three males and one female. In all cases
the glands were extremely vascular.

Suprarenals. —Almost constant changes were found in the gland.
The cortical cells failed to stain at all well; usually the nuclei stood
out well, but the cytoplasm was coarsely granular or represented by a
fine network enclosing clear spaces. It is difficult to determine whether
the change is degenerative or merely exhaustive, but the fact that it is
most advanced in cases that have died of status points to the latter
conclusion. The medulla, as a rule, shows the change but slightly.
In one series the granularity of the cortex was present in an advanced
degree in six males and one female, moderately in one male and
three females, and absent in one male and two females.

Pancreas. —In several cases in which the pancreas was examined it
was found that the islets of Langerhaus were few in number. In a
further series of five epileptics, three males and two females, whose
endocrine glands have been recently examined, the following changes
were found.

Gonads.

Testes. —In two cases there were fibrotic changes affecting chiefly the
basement membranes of the tubules. Ovaries : In one case advanced
fibrosis was present, in the other the ovaries were not examined.
Thyroid: In one male and two females the type was active, in two
quiescent. Pituitary : Changes indicating unusual activity were present
in two males and two females. Suprarenal: In all cases there was
vacuolation of the cortex. Thymus: Active thymus tissue was present
in three males and one female; in one male the type was persistent
infantile, in the others regenerative.

Chemistry.

We, in a former paper (31), pointed out the chemical changes in the
blood and urine that we had observed to occur before and after epileptic
attacks. Since then we have in a certain number of cases made examina¬
tions of the urine twelve-hourly instead of every twenty-four hours, and
have in this way found some of the changes more accentuated. In a
twenty-four-hourly specimen of urine the pre- and post-epileptic effects
often become confused. We have also in one case examined the blood
twice daily, and in this way found the changes before a fit more pro-

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1918.] BY GUY P. U. PRIOR AND S. EVAN JONES. 49

nounced. To repeat, shortly, the changes we formerly stated or have
since found to occur are :

In the urine, before a fit or series: An increase in the calcium
excreted; a fall in the amount of phosphates excreted; a fall in the
amount of chlorides excreted. The calcium change varies in different
patients, some habitually excrete little or none, and in these no change
is observed. The change in the phosphates and chlorides, more especi¬
ally the former, is, with an occasional exception, constant.

In the blood, before a fit or series : A fall in the degree of alkalinity ;
a fall in the leucocyte count. The coagulation time, which we formerly
thought was shortened before a fit, we have since seen in some cases
lengthened, and in other cases the change is so variable as to be no
guide. The calcium blood index was also variable, sometimes being
high and sometimes low.

After a fit or scries there is in the urine: An increase in the amount
of phosphates excreted, which in some cases greatly exceed the inter-
fit interval amount; there is also a rise in the amount of chlorides
excreted, but this is not so marked or so consistent, and occurs earlier
than the phosphatic rise.

In the blood after an attack there is found : An increase in the
number of leucocytes; a shortening of the coagulation time; a rise in
the degree of alkalinity; a rise in the calcium blood index.

We have also noted in many cases previous to an attack that there is an
increase in the amount of urine passed, which in some cases habitually
amounts to from roo to t3o oz. per diem, falling during a series or after
an attack to from ro to t5 oz., this last being of much higher specific
gravity than the former. We claim that by examinations of the urine
twice daily and daily examinations of the blood, we can, in the majority
of cases, foretell an epileptic attack, in some cases a day or two before,
in others only a few hours before.

The indications we find of greatest use, and subject to fewer excep¬
tions than the others, are the change in the percentage of the phos¬
phates and chlorides excreted, and the change in the leucocyte count;
the other indications we have named are useful confirmatory points but
are subject to more variation ; all these are subject to much alteration
by other influences than the epileptic attacks.

We believe that in many cases before an attack there is an increase
in the amount of calcium excreted, in all a diminished amount of phos¬
phates excreted, with generally a fall in the amount of chlorides. Can
these changes in any way directly or indirectly be connected with the
epileptic attack ? We think they can. It is stated that calcium is for
the most part excreted as calcium phosphate, that phosphorus is mostly
excreted as the sodium or calcium salt, and that the chlorides are
mostly excreted as sodium chloride. There being an increase in the
LX IV. 4

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50 EPILEPSY AND THE DUCTLESS GLANDS, [Jan.,

calcium excreted, together with a fall in the phosphates and chlorides,
we think this might be taken to show that there is a retention of sodium.
Sabbatani (32) has stated that the surface of the brain is rendered more
excitable by the application of sodium, and less excitable by the applica¬
tion of calcium salts. Substances that precipitate calcium heighten the
excitability of nerve (33). Falta states that common salt given to children
suffering from tetany brings about, full anodal hyperexcitability (34).
Epileptics are known to improve on a restricted salt diet, but has the
benefit that follows a saltless diet been attributed to the right cause ?

In some cases before an attack there is a lengthening of the coagula¬
tion time, which may mean a diminished amount of fixed calcium.- In
female epileptics attacks are commonest at the time of the menstrual
period, when the coagulation time is lengthened and there is an increased
loss of calcium. We think that these changes all point to a lessening
of the calcium in the tissues and a retention of sodium, and that the
bad effects of sodium chloride on epileptics may be due rather to the
sodium than the chloride. Both the amount of calcium and phos¬
phorus excreted by the utine are greatly influenced by food and drugs,
e.g. magnesium sulphate will increase the amount of calcium eliminated
by the bowel and diminish that passed by the urine, lime will diminish
the amount of phosphorus passed in the urine and increase that passed
by the bowel (35). Until the faeces have been examined daily as to the
quantity of these salts excreted, and the relation of the amount to that
lost by the urine and to the epileptic attack, it is not possible to state
the effect of these salts on the disease. We have endeavoured to abort
attacks that we have foretold, by increasing the phosphates excreted, by
creating a leucocytosis and increasing the calcium blood index and
shortening the coagulation time, but so far with only partial success.
Nuclein will cause a leucocytosis, and it is stated that it will cause an
increase in the amount of phosphates excreted. Calcium injected sub¬
cutaneously will cause a shortening in the coagulation time and an
increase in the calcium blood index; it is said to diminish the amount
of phosphates excreted by the urine and to increase the amount elimi¬
nated by the bowel. We have often observed after its use a high
leucocytosis. We used nuclein, thinking that its action might be similar
to that of thymus extract, with the additional advantage that it can be
subcutaneously injected.

Case 35. — A female patient, to whom we gave injections of nuclein
every third day, had previously averaged 20 fits a month; for the first
month on this treatment she had no fit; at no time before had her
record been less than 11 attacks a month. During the second month
of this treatment her average returned to its former level. We dis¬
continued the treatment for several months, after which interval we
gave her nuclein per os every alternate three days. For the first month,

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1918.] BY GUY P. U. PRIOR AND S. EVAN JONES.

51

while taking this, she had 8 attacks, all at the time of her menstrual
period, being her lowest record with the above exception. The con¬
stitutional effects of the fits were less than usual. For two more
months this treatment was continued, but without benefit, except that
the after-results of the attacks were rather less.

We have given injections of nuclein in a few isolated cases, when the
patients have told us that they were about to have an attack and the
attack has not taken place. It is impossible to draw any conclusions
from these results, but they are suggestive, and the action of this drug
in epilepsy is worthy of study. If our idea as to sodium retention is
correct, it is possible that nuclein might do good by promoting the
excretion of sodium phosphate, and the leucocytosis that it causes may
help to ward off the attack.

Case 45 is the one in which we have tried nuclein most freely, and
is the case in which we have continually endeavoured to abort attacks.
This is a case of great interest, and is worth some remarks, we having
made daily, or twice daily, observations on him for nine months. He
came under our care in October, 1916, with but little as to his past
history and only six months of his fits, which varied from 4 to 20,
giving an average of 8^ attacks a month. He is a happy, good-natured
imbecile, tet. 35, and said to have been an epileptic since childhood.
Preceding a fit, for from a few to twenty-four hours, he has intense
general clonic-muscular spasms, during which he is quite conscious,
will talk rationally, and attend to his wants. It is while in these attacks
that he will have the typical haut mal fits, the clonic spasms afterwards
easing down for about half an hour, when they will return and con¬
tinue if not treated for from thirty-six to forty-eight hours, ceasing
gradually. These attacks will, if not interfered with, recur with fair
regularity about every ten days ; if postponed by treatment the tendency
is to recur at a shorter interval. We have charted the observations
made upon this patient, and we think have prevented the haut mal
attacks by treatment at the time we expected them to occur, but have
not been so successful with the accompanying attacks of spasms; but
we think we have at times postponed them, and have lessened their
severity. It will be seen, by reference to the chart, that this case shows
a decided fall in the phosphatic excretion before an attack and a marked
rise afterwards, that the quantity of urine excreted rises greatly at the
time of the attack and falls after. There is a pre-fit fall and a post-fit
rise in the chlorides excreted. The calcium excretion in this case is
always low, seldom more than a trace, and is not sufficient to bear any
direct relationship to the attacks. His blood changes for the most part
are such as we have stated to occur.

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5 2

EPILEPSY AND THE DUCTLESS GLANDS,

[Jan.,

Epitome of Treatment.

Case No.

Treatment.

Gland.

Number of
months.

Monthly average
no. of tits.

2

K. Br.

Nil

12

41

Ca. Cl. et Br.

Nil

9

«3

Idem

Suprarenal

2

IO

3

Nil

Nil

5 1

110

Ca. et Br.

Suprarenal

3

9

Idem

Thymus

3

48

6

K. Br.

Nil

12

l6

Ca. et Br.

Thymus

l6

8

5

K. Br.

Nil

12

27

Ca. et Br.

Nil

4

'5

Idem

Thymus

9

14

7

Nil

Nil

3

20

Various treat-

ment

—

9

24

Ca. et Br.

Parathyroid

5

12

'9

K. Br.

Nil

4

35

Ca. et Br.

Nil

3

3°

Ca.

Didymin

3

25

Ca.

Pituitary

*

33

Ca. et Br.

Didymin

6

17

20

Nil

Nil

5

33

Ca. et Br.

Nil

s

28

K. Br.

Nil

12

22

Idem

Suprarenal

6

17

39

Nil

Nil

6

100

Ca. et Br.

Nil

1

3°

Ca. et Br.

Parathyroid

8

17

Idem

Suprarenal

2

38

40

K. Br.

Nil

12

IO

Ca. et Br.

Parathyroid

IO

3

22

Nil

Nil

5

l 8

K. Br.

Nil

4

13

K. Br.

Parathyroid

3

18

Ca. et Br.

Parathyroid

5

9

23

Nil

Nil

6

21

Ca.

Thyroid

1

34

Ca. et Br.

Suprarenal

3

Idem

Thymus

4

8

Ca.

Suprarenal

3

7

Ca. et Br.

Nil

4

3

24

Nil

Nil

0

9

Ca. et Br.

Nil

6

3

Idem

Thymus

4

2

2S

Nil

Nil

7

18

Ca.

Nil

3

10

i

Ca. et Br.

Thyroid et

Thymus

4

9

Idem

Thymus

5

7

29

Nil

Nil

7

10

Ca. et Br.

Nil

4

10

Idem

Thymus

13

7

3 °

Nil

Nil

4

15

Ca. et Br.

Nil

8

9

1

Idem

Suprarenal

5

4

1

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1918 .] BY GUY P. U. PRIOR AND S. EVAN JONES.

53

Conclusions.

Among statements and results which are apparently absolutely con¬
tradictory and opposed, is it possible to co-relate these more than
confusioned actions ?

We have seen that epileptiform convulsions, according to various
authorities, may occur with apituitary, hypo- and hyper-thyroid, hypo-
and hyper-suprarenal and aparathyroid conditions. All these glands
play an important part in the calcium metabolism. In apituitary,
hyperthyrord, hyposuprarenal, and aparathyroid affections, there is an
increased loss of calcium from the tissues. If this salt has the influence
that we think in the causation of epilepsy, this may be found to be the
common ground upon which all these glands act. In over-action of the
suprarenals there is a calcium retention, which makes it difficult to
explain how an over- and an under-action of this gland can both cause
convulsions. If an over-action of the suprarenals should be a factor
in the causation of the phenomena it may be through these glands
that the thyroid, pituitary, and parathyroid act, as thyroid secretion
stimulates the suprarenals to action, and the cortex of the suprarenals
hypertrophies in apituitarism, and there is an ill-understood relation¬
ship between the parathyroids and the suprarenals. The subject is
full of difficulties, and probably not at present capable of explanation.
That the ductless glands have some part in the production of epilepsy,
and that their extracts may be beneficial in this disease, we think is
proved. But, except in cases of apituitarism and marked cases of
aparathyroid ism, it is not possible to give definite indications as to
which gland will be useful in any given case. One can only be led by
general glandular symptomatology.

Our thanks are due to Dr. Oliver Latham for kindly preparing, and
cutting of, and advising as to the sections ; and to Mr. R. C. Dent for
much help in forming the tables upon the action of the glands.

References.

(1) Allbutt's Medicine, vol. viii.

(2) Bell, W. Blair.—“ General Function of Ductless Glands in
Female,” Lancet, April, 1911.

(3) Falta, W.— Diseases of Ductless Glands, second edition, p. 336.

(4) Schafer.— The Endocrine Organs, p. 111.

(5) Reference in Endocrinology, vol. i, No. 1.

(6) Ibid.

(7) New York Medical Journal, 19x6, ciii.

(8) New York State Journal of Medicine , 1916, xvi.

(9) Falta, W.— Diseases of Ductless Glands, p. 182.

(10) Paton, D. Noel.— Regulators of Metabolism, p. 186.

(11) Know, H. A.—“Research in Epilepsy,” New York Med.
Journ., 1917, cv, p. 406.

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54 MUTISM IN THE SOLDIER AND ITS TREATMENT, [Jan.,

(12) “ Epilepsy : A Metabolic Disease,” Journ. Mint. Sci., January,

1917.

(13) Bell, W. Blair .—Sex Complex , p. 54.

(14) Sajous, C. E. de M.—“The Theory of Internal Secretions,”

The Practitioner, February, 1915, p. 180.

(15) Ibid., p. 181.

(16) Thursfield, H.—“Status Lymphaticus,” Clinical Journal,

June 10th, 19x5.

(17) Barr, Sir J.—“Lime Salts in Health and Disease,” Brit. Med.

Journ., 1910, ii, p. 829.

(18) Turner, W. A.— Epilepsy, 1907, p. 195.

(19) , (20) Paton, D. Noel .—Regulators of Metabolism, p. 1 1 7.

(21) Schafer.— The Endocrine Organs, p. 47.

(22) Bell, W. Blair.— The Sex Complex , p. 19.

(23) Schafer. — The Endocrine Organs, p. 134.

(24) Falta, W.— The Ductless Glandular Diseases, p. 362.

(25) Cotton, Carson-White, and Stevenson.—“Pathogenesis and
Treatment of,” New York Med. Journ., 1916; Ref. Endocrinology,
vol. i, No. 1.

(26) Bell, W. Blair .—The Sex Complex, p. 185.

(27) Ibid., p. 182.

(28) Ibid., p. 190.

(29) Bell, W. Blair, and Hicks, P.— Brit. Med. Journ., i, 1909,

P- 592 .

(30) Ludlum and Carson-White.—“ Thymus and Pituitary in
Dementia Prsecox,” Amer. Journ. of Insanity, April, 1915.

(31) “ Epilepsy : A Metabolic Disease,” Journ. Menf. Sci., January,

1917.

(32) , (33), (34) Falta.— Ductless Glandular Diseases, p. 195.

(35) Martindale and Westcott .—The Extra Pharmacopoeia, 1915,
vol. ii, p. 246.

(36) Schafer .—The Endocrine Organs, p. 56.

(37) Waller, H. E.—“ The Use of Hormones in Children’s Diseases,”

The Practitioner, February, 1915. t

(38) , (39) Falta, W .—The Ductless Glandular Diseases, p. 147.

(40) Auer, Murray E.—“ Sensory Phenomena in Epilepsy,” Amer.

Journ. of Insanity, January, 1916.

Mutism in the Soldier and its Treatment. By Colin McDowall,
M.D., late Capt. (Temp.), R.A.M.C., Ticehurst House, Tice-
hurst.

Many varieties of functional disturbance are found in men enlisted
for the present war, and not the least interesting is mutism. In a
hospital set apart for the treatment of nervous disorders many cases of
complete loss of speech are met with, and these may be divided con¬
veniently into three main categories as follows : Mutism arising in the
field, in hospital, and previous to participation in active service.

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55

Loss of speech occurring in the field is nearly always due to close
proximity to the explosion of a shell or mine. The man is frequently
blown into the air or knocked over and buried, but this is not always
the case. Men have described to me how one shell after another fell
near them in rapid succession, and though not close enough to inflict
any physical injury, yet the mental effect was so great as to produce a
state of complete helplessness and subsequent loss of voice through
fear. The men can tell when a shell is near them by the sound pro¬
duced as it travels through the air, and some have described the sensa¬
tion of being thrown up by a shell explosion. One patient, a warrant
officer, said that he felt as if he was being distended with air. On the
other hand, many can give no details of any kind. It would appear
that the main effect of shell explosions in one’s immediate neighbour¬
hood is to produce a highly emotional state. It is not to be wondered
at that men under heavy shell fire experience many emotions. They
know only too well what a shell can do, for they have seen what
shells have done, and they can judge to a certain extent if a shell is
about to fall near them. They cannot say how near, but the uncertainty,
danger, and noise put what they call “ the wind up them.” That is the
soldier’s expression for an emotional state characterised by fear.

It is not so easy to prove how great a part emotion plays in the produc¬
tion of mutism in those cases in which a man is violently thrown into
the air or is knocked over by concussion. The actual explosion lasts
only a minute fraction of a second, but the mental effect, if the victim
retains his consciousness, must be intense. That he has no recollection
of the explosion in no way disproves that he was momentarily conscious
of it. On admission, at any rate, these subjects of mutism exhibit many
signs of extreme emotion due to terror—tremor often generalised, rapid
breathing, marked corrugations of the forehead, and a restless, shifty
manner. There is another type of case in which dulness, apathy, and
depression are the leading features, and this type is most frequently
observed when deafness is a superadded symptom. These cases are
of such frequent occurrence that they will be referred to again.

At a home hospital it is almost impossible to obtain reliable histories
with details of the onset of the patient’s trouble, and men are only too
ready to attribute their condition to shell-shock, though subsequent
inquiry may fail to furnish any evidence. My belief is that mutism, as
seen in soldiers, is due to various causes, but all of an emotional
character, and once a condition of speechlessness has been produced
this state is prolonged by the inability of the man to overcome an
inhibition, and thus regain the control of a voluntary mechanism which
he does not understand. In most instances ignorance, and in many
indifference, prolongs the trouble.

The symptoms accompanying mutism are not invariable, but the

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point of most importance is the condition of the respiratory apparatus.
Frequently a case cannot hold his breath for more than twelve or fifteen
seconds. The respirations are rapid and shallow. The man is unable
to take a deep breath, and he cannot blow out a match a yard away.
The volume of breath on powerful exertion is only poor. Such is the
condition in a typical case, and it does not appear to matter how long
he has been ill, as cases of six or seven months’ duration have exhibited
the same respiratory signs. This description, however, needs some
qualifications. If a man is on the point of recovery his respiratory
troubles are by no means so marked, and in the cases of home troopers,
and indeed in all cases in which emotion could not be assigned as a
causal factor, the respiratory disturbances are not present. Other, but
not invariable, accompaniments of mutism, are inability to coughi
whistle, and put out the tongue—the latter a suspicious indication of
a not straightforward case. Some patients are unable to arrange the
lips correctly for the production of certain sounds, and the tongue does
not strike the teeth when an attempt is made to produce dentals. On
recovery all have a certain amount of hesitation in their speech, and
absence of this impediment must be considered a suspicious sign.
The recurrence of mutism after some weeks and even months is quite
common, and here, again, the emotional character of the cause is very
evident.

The first series of cases will refer to mutism occurring in the field.

No. 62, an N.C.O., set. 23. No history of previous nervous disorder
or heredity. A clerk who enlisted in the second month of the war,
he did little training, but was chiefly employed in an office. He
went to France, and on the way up the line had to fall out twice with a
weakness in the legs. He was in the trenches one month. They were
shelled out of their first line of trenches, and retired to the second. He
was told that he was buried, but he cannot remember anything about
it. He lost his speech and hearing, and could not see with the right
eye. His hearing returned in two days; a month later when he came
to Maghull he was mute, but two days afterwards he spoke. He was
lying in bed half asleep when someone bumped against the side of his
bed. He uttered an ejaculation. Three months later he went home
for the day, and as he got out of the train he saw another N.C.O., a
great friend of his, who he thought had been killed by the same shell
that blew him up. Naturally he was much surprised and hurried up to
greet him. He put out his hand and said “ How ”... but could
say no more. He continued to be mute for ten days, but suddenly
recovered his speech when he replied “ Good morning ” to my saluta¬
tion. He was very tremulous and speech was indistinct. The tremor
quickly disappeared, but the stammering persisted for three months.
Shortly afterwards he again lost his speech. He was incorrectly accused
of having removed some writing paper from an office, and again he
became very tremulous and his speech faint and hesitating.

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57

Such a history is quite a usual one following shell-shock and burial.
Hearing returns before speech. The recovery of speech was spontaneous
and could not be attributed to medical treatment. The circumstances
attending the recurrence of mutism is interesting as demonstrating the
relation to the obvious stimulation of the emotions. The unexpected
meeting of the man he thought was dead, and the unfounded accusa¬
tion of pilfering, were not the only painful factors acting upon him, as
he had a family trouble about which he sought my advice. The sub¬
sequent history was uneventful, and there have been no relapses. His
neurasthenic state has greatly improved. Here, then, we have a not
quite simple case of shell-shock, for he had in addition an irritating
mental factor, and when this was removed the risk of relapse dis¬
appeared. Although it is not usual to find such complications in
mutism, the possibility of their existence should not be overlooked.
Shell explosion of itself is sufficient to produce loss of speech, but under
proper treatment a simple case speedily responds. When relapses do
occur, or suitable treatment proves unsuccessful, the whole mental field
should be sifted and the sources of irritation removed.

No. 54, private, set. 21, went to France in February, 1915. On
April 23rd he was blown up by a “Jack Johnson.” He remembers
hobbling away, but discovered that he was very shaky, and that he
could not speak; but his memory of the shock is not very clear. When
examined three months later he had no tremor, was mute, and could
not whistle or cough. He passed out of my hands, but returned six
months later looking very well and healthy. He was happy and
cheerful, but still quite mute. He had various ill-defined pains : “ his
heart felt like a bruise,” “ there was pain at the angle of the jaw,” etc.
Breathing exercises were at once begun. He whispered clearly in
twenty-four hours, and could phonate loudly in two or three days. He
was discharged to his depot, and did quite well for a few months,
when on saying good-bye to a draft that was on its way to France, he
found himself giddy and upset, and his voice became whispering and
feeble. He was readmitted to Maghull, and regained his voice in a
few days. In this case it may be interesting to mention that a few
months before war broke out this man was working on a submarine.
He accidentally made contact with the electrical apparatus and received
a violent shock. He lost his speech on this occasion for three hours.
It is therefore possible that suggestion had something to do with his
attack of mutism following shell-shock. The only other point of
interest is the long continuation of the functional disability—he was
dumb fully nine months. When first he regained his speech he talked
only during inspiration. This condition I have not uncommonly seen
in other cases. It appears to me probable that he could have recovered
the power of speech sooner if he had made a determined effort. Men
have come under my care suffering from various functional troubles
after they had passed through numerous hospitals with little or no
improvement in their condition. They had often been told “ you will
get well now; this will be your last hospital.” This is no doubt very

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sound suggestive treatment, but when not successful it becomes highly
discouraging by repetition. So it is not difficult to imagine how
heartily sick of hospitals these poor fellows become. They have no
intelligent conception of their illness, no one takes the trouble to explain
it to them, and so they drift on, tired of trying to bring back a faculty
the simple rudiments of which they do not understand. But let them
get into a hospital where the atmosphere is entirely different, and where
they will come under new experiences, then they may be induced to
make a stronger and possibly final effort. So far as my experience goes,
nothing is easier to cure than mutism, and no class of case responds
more readily to proper environment. For this reason they are always
welcome in my ward. One recovered mute infects another with con¬
fidence and hope, more especially if the treatment adopted in each case
is the same, and simple enough to appeal to the patient’s intelligence.

Another man went to France after a year’s training, and five months
later was blown up by a shell. He says that he lost consciousness for
a time; he found himself the same evening in a dressing station, but
he could not speak, and his hearing was imperfect. Fie was trembling.
After five weeks his hearing had become normal. When he came
under my observation he had been dumb for six months, excepting
that he had been heard to say “ Dash ” when he burnt his fingers,
about a month before I saw him. Under the usual treatment he spoke
loudly and with only very slight hesitation after an interview of about
quarter of an hour’s duration. It should be noted that in this case the
patient could hold his breath tolerably well, and his breathing was not
rapid. After recovery I suggested to him that he could have talked
sooner if he had wished, and he admitted that he had not made a great
effort to get well. He was happy in hospital, and having got quite used
to dumb show the loss of speech had not been a great inconvenience.
In fact, he had got into a groove, and was content to remain there.
This type borders on the malingerer. In several respects he was rather
an inferior man ; a barman in civilian life, rough, uneducated, rather
cunning, but at the same time dull and lacking in initiative.

No. 69, private. He was buried by a shell. “ This is what has been
wrote to me; I don’t remember.” He was unconscious for six hours,
and then found that he was deaf and dumb. After five weeks the
hearing returned to one ear. He came to Maghull seven months after
the shell explosion. This was his eighth hospital in England. When
questioned as to what treatment he had had he answered, “ I had really
no treatment, only experiments,” although in various hospitals electricity
and anaesthetics had been tried. He regained his speech for three days
in a previous hospital after a game of cards, but when he came to
Maghull two months afterwards he was quite dumb, and in a very
perverse frame of mind. He professed himself heartily tired of hospitals,
and had no faith in himself or any medical man. Under the circum¬
stances it was thought prudent to leave him alone, and allow the
hospital atmosphere to produce in the patient a more readily receptive
mental attitude. Three nights later during sleep he was heard to call
out loudly, “Take the wire off.” He was dreaming of the events
immediately preceding the shell explosion. He spoke to the nurse
who waked him. The next day he spoke, but only on inspiration. He

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could fully expand the chest, and hold his breath for twenty-six seconds.
For permission to quote this case I am indebted to Capt. Reeve.

I have included this example of mutism relieved during a dream,
because, though not unusual fora mute to speak in a dream, on regaining
consciousness he usually becomes silent again. Dreams are occasionally
the cause of men losing their power of speech. One case lost it eight
times, always as the result of the same dream. On each occasion he
woke up agitated, breathless, sweating, and speechless.

Another example of deaf mutism occurring in the field may be given.

No. 60, aet. 19, a shipyard worker, of fair education (Standard VII.)
Since childhood he had a lisp. No heredities. Within three weeks of
arrival in France he was blown up and completely buried by a shell.
He remembers the shell coming, but when dug out he was deaf and
dumb. He also remembers being carried away. He was in a French
base hospital for some months, and then in one at home for a month.
He was able to whisper during the latter period, but could not hear.
He again lost his speech by bumping into a man in the street. When
he first came under my care he appeared very dull and stupid ; the lips
were kept open, but the complexion was florid and healthy. Treatment
along the usual lines was adopted. He heard the raised voice almost
at once ; a few minutes later he could hear a whisper. His speech then
received attention and he spoke almost at once, and at the end of
twenty-five minutes he left the room with perfect hearing and only very
slight hesitation in his speech. This case is probably an example of the
type referred to by Lieut.-Col. Myers when he deals with the stuperose
condition associated with shell-shock. The man looked very dull. A
sudden noise produced an immediate blinking of the eyelids. I wrote
on a piece of paper “You can hear”; but he shook his head and
appeared quite indifferent to his position. He was then given a mirror
and instructed to look at my eyes as reflected in it. The unexpected
noise was repeated, and he saw his own eyelids react.

Such an experiment naturally raises the old problems. Was the man
able to hear before ? Is this condition the result of prolonged stupor ?
Was he a malingerer? Why did he not hear much louder sounds
before ? All these questions, excepting malingering, are very difficult
to answer. I do not consider these men malingerers. Some patients
describe how they heard sounds, but were unable to distinguish them,
as they all felt like vague rumblings. These men do not realise that
this is hearing. They are not accustomed to describe things accurately,
they take or leave things as they find them ; and if they cannot hear
properly they are rather inclined to think that they cannot hear at all.
Our patient had had a ralher long railway journey the day before I saw
him, yet he denied that he had heard the train moving or anything else,
and I am prepared to accept his statement. His mental condition was
distinctly one of apathy, and he appeared to be quite indifferent to

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external things, and wholly lacking in initiative and energy. Now that
he has recovered his facial expression is entirely altered.

The second group of which I desire to speak comprises those who
develop mutism in hospitals after return from overseas. This group
nowadays exceed the former, and this is no doubt due to the fact that
treatment is undertaken in special hospitals in France.

No. 104, a private in the R.E., married. He went to France in
October, 1915, and was partially buried by a shell at Christmas, 1916.
He was very shaky after the explosion, but would not report sick.
Next day he was worse, and, although advised to do so, would not
leave his company as his younger brother was in it. However, the
following day he was obviously so unfit that he was sent to hospital.
He could speak and hear. He returned to light duty, and then
obtained leave to go home for ten days. Two days after arrival
there one of his children became ill and died the same day. An
inquiry was held, as it was thought that the cause of death was cerebro¬
spinal fever, and it was suggested that he had brought the infection
with him. He was accordingly sent to an isolation hospital. He lost
his speech suddenly as the result of “thinking.” Two months later he
came under my care. He was mute, the head was shaking, and there
was marked tremor of the arms and legs. He was very emotional and
depressed. He could hold his breath for fifteen seconds only. His
efforts to blow out a match were unsuccessful, and he made facial con¬
tortions when urged to increased efforts. The breathing was improved
by demonstrations, and then the sudden artificial contraction of the
abdominal muscles, applied in the middle of a long expiration, pro¬
duced a sound. He was very pleased, but became highly emotional.
Next day he whispered, and on the following day he spoke, but with a
very bad stammer.

This is a fairly typical example of mutism occurring as the result of
strong emotion. We have, firstly, the shell explosion ; next, the home¬
coming ; later, the tragedy of his child’s death ; and lastly, the sugges¬
tion that he might have been the cause of infection. The fact that
in the first instance he refused to leave his brother is evidence how
strongly family affairs entered into his life.

No. 62, a private, tet. 24, single. He had been in France for eighteen
months and seen a good deal of fighting. In August, 1916, he was
wounded through the right side of the face, the bullet passing across
the floor of the mouth, and making its exit in the side of the neck. The
tongue was not injured. At the same time he received two other
wounds, and when lying wounded, a shell exploded close to him,
covering him with earth. When invalided to England he was able to
talk, but not loudly. He was returned to his depot, and his voice
became quite strong again, but shortly afterwards it began to fadeaway,
and ultimately he became mute. He said that he received no treatment;
the desire to treat him was not absent however, as the experiment of

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throwing a bucket of cold water over him when he was in a hot bath
was unsuccessfully tried.

When first seen at Maghull he was an anxious-looking man; his
respirations were 24 to the minute ; he could cough but not whistle, and
he complained of a “feeling in the chest as if it were too tight.” The
day following treatment he whispered, and the next day he spoke but
with a very bad stutter. Why the voice disappeared completely is not
easy of explanation, but one can readily understand how a man,
wounded very close to the organ which, according to popular idea, is the
principal apparatus of speech, might readily become mute. Pain
itself would make speech difficult, at least for a time. Probably the
return to his depot brought back all the old associations, and he was
unable to overcome the resulting inhibition.

It would be easy to multiply examples of this kind, but one only
need be given, an instance of deaf-mutism.

No. 85, private in the A.S.C., married, seven children, of whom five
are in the Army. He gives his age as 48, but looks older. After
working in France a year as a transport worker, he developed a “bad
cold,” and went into hospital. His work had been too much for him. His
speech left him apparently as the result of coughing. Gradually his
hearing became more and more affected until he seemed to become
quite deaf. The man added : “ I am nearly fifty now, and that was the
age when my father became stone deaf.” When seen he was apparently
a deaf-mute. He could cough loudly, but not whisper, nor could he
make a satisfactory effort to use his lips in the formation of sounds, and
could not lip-read at all. In appearance he was very depressed and
helpless. He gave a history of having been in the trenches, but not
specially exposed to heavy shell fire. In a month after his transfer to
England he spoke in hospital. He stated that he could not hear
properly, and could not carry on any form of conversation because of
the impairment of hearing. He was sent home on ten days’ leave, and
on his birthday his speech suddenly left him, and the deafness became
absolute. When examined two months later at Maghull the breathing
was normal. After treatment he whispered in twenty-four hours, and
two days later speech was normal. The following day he could hear a
sudden noise, and recovery followed very quickly.

There are a few points in this case which may be noted. The
speech was perfect before the hearing, and this held good for both
occasions of his speech recovery. The very clear influence that sugges¬
tion played in the causation of his deafness is interesting. Lastly, the
condition of his respiratory apparatus was normal. He had not been
shell-shocked ; apparently he had not been subjected to any disturbing
emotions; but, as he said, “ The work was too much for him.’* The
special sense which had been his father’s weak spot was adopted by the
son as that offering least resistance.

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As to mutism occurring in soldiers without active service my experience
is very limited. One man became speechless following an attack of
bronchitis. He had suffered from aphonia before the war, and was a very
neurotic subject with a bad heredity. In another case mutism developed
after a boil on the face. Both these men were members of the R.A.M.C.
No doubt they had heard a great deal about mutism, and probably had
seen some cases in hospital. Neither showed anything unusual in
breathing, and I have little doubt that the second man was not genuine.

This brings me to the subject of malingering. No one who has seen
much of functional nervous cases will dissent from the aphorism that
before any treatment is adopted malingering must be excluded. In
mutism the opportunity for the malingerer is immense. A man may be
genuine at the beginning, then suddenly discover that he can speak,
but maintain his former silence; or he may simulate dumbness from
the beginning. Deafness may also be simulated, but the task is more
difficult though not impossible. A much commoner form of shamming
is aphonia. Such a man, after months in hospital, was “cured ” by one
day’s strict isolation.

No. 70, N.C.O., set. 30, reservist and ex-policeman. He was called
up at the outbreak of the war and went through all the earlier fighting.
At Christmas, 1914, he was blown over by a shell. The last thing he
remembers is the approaching of the shell. He became deaf and dumb.
A few weeks previously he had lost his speech as the result of shell
explosion, but he never left the trenches, and his voice returned. This
is the man’s own account. In France he had a variety of treatment;
he was placed blindfolded close to a big gun when it was fired, and he
had electric treatment and anaesthesia in hospital. He was admitted
ultimately to Maghull. He could hear but not speak. He went to
Liverpool with another soldier, and was the centre of attraction to a lot
of people. His companion could talk, and was evidently soliciting
sympathy by showing him off in the street. A detective, suspecting that
begging was going on, asked for an explanation. This was accepted
as satisfactory, and the same day our patient overstayed his leave, and
when next seen was talking to a woman. Unfortunately for him the
detective who had previously spoken to him was passing at the time
dressed in mufti. He spotted our patient as the man who, a few hours
previously, he had been told was deaf and dumb, and promptly arrested
him. I saw him next day, and he gave the history of the events
leading up to his arrest. He said that he met a woman and they had
a quarrel; that she struck him on the chest; that he exclaimed “ Oh,”
and at the same time his hearing returned. In the police court I had
to admit that such a thing was not impossible, and so the man returned
to hospital. Seven days later, for no apparent reason, his speech and
hearing again left him. He said that his neck seemed to swell out. A
few days later he again overstayed his leave and was arrested by the
police. In the police-station, when being searched and his money taken
from him, he said “ Money.” He returned to hospital and came under
my charge. He was apparently unable to take long breaths or inhale

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cigarette smoke. Treatment was persevered with for a week with no
improvement. Strict isolation was begun, and within an hour he
whispered, and next day phonated perfectly. He explained that he
had had to “keep pushing the apple down.” When urged to make an
effort to speak he had complained of pain in the larynx.

It is probable that the first stage of his condition was genuine. It
is certain that after his return to hospital the loss of speech and hearing
was simulated. The fact that he was apparently unable to take a long
breath and was unable in my presence to inhale need not be regarded
as contrary to the diagnosis of simulation, as he was commonly seen by
others to inhale cigarette smoke.

It is difficult to give any satisfactory explanation of mutism and
deafness. I have already said something about the former, but nothing
about the other. Deafness corresponds to functional anaesthesia. It
seems to be produced by a mental stimulus sufficiently powerful to
deaden the central area for the reception of sounds. Functional deafness
may engraft itself on a passing organic condition. Labyrinthine con¬
cussion is a recognised condition. Functional deafness is somewhat
analogous to the state of amnesia frequently met with in soldiers
returning from overseas. I have seen two instances where the amnesia
persisted after the deafness was cured. No doubt cases seen at an
earlier stage would show the alliance of the two conditions more clearly
and more frequently. The loss of memory is an unconscious effort to
blot out the horrors of the patient’s past experience. Probably in much
the same way, deafness is a successful but involuntary means to shut
out the present. Then ignorance, lack of self-confidence, and initiative
maintain the disability.

The forms of treatment of mutism are endtess in variety. My own
may be briefly described as follows : The patient is asked to take a long
breath. He is then told to hold his breath ; he fails, but very frequently
persists that he succeeded. I then give him a cigarette which he is
asked to inhale, when the patient at once discovers that he is incapable
of holding his breath. He learns, possibly for the first time, that his
respiratory apparatus is at fault. Exercises to promote correct breathing
are then undertaken. The most important point is to obtain a good
volume of breath without hesitation on expiration. He is asked to blow
out a match at increasing distances ; then to breathe freely, trying to
say “Ah ! ” at the same time ; then to sigh the sound “ow,” and later
the sound “ ou.” Three long breaths and three sighs, together with the
correct mouth formation, produce the sentence “ How are you”? Once
deep breathing is established, a sudden squeeze of the abdominal wall
will produce phonation. The immediate effect will be a display of
emotion. Tears are frequently the precursor of speech. As soon'as a
man can whisper faintly but sufficiently for others to hear I bring in

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another patient or a nurse to show the patient that he can now be
understood. The following day the same process is repeated, and as a
rule the man will talk freely'after the third day. The method of suddenly
squeezing the abdominal wall has already been described in a French
journal, but I have lost the reference.

Deafness is also dealt with on simple, common-sense lines. The
patient is seated in a chair and holds a small mirror in his hand. I
stand behind the man and instruct him to look at my eyes reflected in
the mirror. After a suitable interview a sudden noise is made without
any movement on my part. The patient will blink and the mirror will
render him conscious that he has moved his eyelids. He is also
conscious that the movement is a proof that he can hear. The whole
performance is simplicity itself, and it appeals to the man’s common
sense and he is convinced, against his inclination in some cases.

In both these simple methods the principal agents are common sense
and re-education. Lip-reading and the deaf and dumb alphabet should
never be allowed.

Clinical Notee and Cases.

A Case of Porencephaly. By H. E. Bond, M.D., Dip.Psych.Med.

(Cantab.), L.R.C.P. and S.(Edin.).

The subject of this paper, R. I. M—, was admitted into the Jamaica
Government Lunatic Asylum on April 13th, 1914, with a history of
epilepsy. She was a well-developed woman, ret. 37, with a right-sided
hemiplegia ; the right upper limb was flexed at the elbow, wrist, and
finger-joints, a very limited range of movement being left. The
muscles of the limb were quite wasted. The lower right limb was
equally affected as regards wasting and limitation of movement. She
could neither spit nor whistle, and saliva was continually dribbling
from her mouth. She was suicidal but not dangerous. Previous
history: There was no instrumental delivery at birth. She started to
have fits when sixteen months old. The paralysis was noticed at that
time, and she attended school for a period, but, owing to the severity of
the fits, had to be taken away. No one of her relatives had been insane.

During her stay in this institution she had fits periodically and
suffered from recurrent attacks of pellagra. Apart from these she
enjoyed fairly good health. For six months prior to her death there
was a complete absence of fits, but she, however, gradually began to
get very thin and emaciated, and had to be confined to bed up to the
day of her death—September 2nd last.

Post mortem examination revealed the following : The skull was very

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thick, dense, and heavy ; the dura mater thickened, fibrous, but not
adherent to the calvarium ; the pia-arachnoid opaque and cedematous ;
brain, there was a notable disproportion between the two sides ; right
hemisphere, simple convolutional pattern, congested, no wasting; left
hemisphere, simple convolutional pattern, pale, general wasting; sec¬
tion, from the anterior to the posterior pole there was a well-marked
cavity containing straw-coloured fluid which was not turbid. When the
fluid was let out the cavity was smooth, there being a complete absence
of the basal ganglia or any other vestige of brain matter. Lying across
the floor of the cavity were remnants of the choroid plexus. There
was an excess of cerebro-spinal fluid. The brain weighed 895 grm.
Examination of the cerebellum, pons, and medulla showed nothing
abnormal. No morbid changes calling for special note were found in
any of the other viscera.

For permission to publish particulars of this case I am indebted to
Dr. D. J. Williams, Medical Superintendent.

Some Notes on the Case and Post-mortem Examination of a
Microceplialic Idiot—Absence of Corpus Callosum. By G. N.
Bartlett, Medical Superintendent, Exeter City Asylum.

E. G—, a female, was admitted in October, 1904, set. 14.

Her general development and stature were much below normal, her
height being recorded as 4 ft. 6i in., her weight 5 st. 2 lb., the circum¬
ference of the head 18 in., and the other cranial measurements as
correspondingly small. Her vocabulary consisted of a few words and
phrases and some bad language, and her speech was a very indistinct
drawl. Her movements were clumsy, and her gait a shuffle but stable
enough to allow her to knock another patient down. She had a double
squint and was more than usually degenerate and repulsive in appear¬
ance, especially as facial contortions were common, and the mouth
usually open and dribbling. She proved herself uneducable, even as
regards her personal habits, and quite dependent, and in a short
description her uncontrollable temper only need be mentioned; an
exhibition of screaming, swearing, kicking, biting, scratching was forth¬
coming on the slightest provocation. Her habits were very dirty and
destructive, and her table manners were repulsive.

In 1909, ulceration at the angle of the mouth was recorded and
regarded as syphilitic, but there was no amelioration under prolonged
treatment. She was always thin and anaemic, and subject to digestive
troubles due mainly to her habit of bolting food. Suspicions of tuber¬
culosis of the lungs and lesions of the spinal cord, aroused from time to
time by her condition, were dispelled by negative examinations, and
there was no apparent change in her movements and powers of

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co ordination up to the time of her death in October, 19x7, at the
age of 27.

The post-mortem examination revealed complete absence of the
corpus callosum, a condition unsuspected during life, as in some other
recorded cases of this rare abnormality. (I regret time prevents a study
and paraphrase of the literature on this subject.)

Other conditions found were microgyria in the occipital and frontal
regions of the brain, and internal hydrocephalus, the lateral ventricles
being enlarged out of all proportion to the size of the hemispheres, and
the grey and white matter much attenuated. The remarkable smallness
of the brain and other organs is shown by the appended weights. The
kidneys were lobulated, and there was broncho pneumonia in both
lungs.

Weights.

Encephalon .

Right hemisphere .

Left hemisphere .

Cerebrum . . . .

Pons and medulla .

Heart.

Right lung ....
Left lung ....

Liver.

Kidneys ....

870 grm

380

»

335

»

8S

u

20

>1

140

II

235

>1

355

640

If

65

>1

Occasional Note.

Reform in Lunacy Law-

At the November Meeting of the Parliamentary Committee it was
resolved to form a sub-committee to consider the amendment of the
existing'Lunacy Laws. This sub-committee has since been formed,
consisting of twelve members, including the chairman and secretary of
the parent committee, who will also act in these respective offices for
this sub committee. It has already commenced its labours by a critical
investigation of thc'important legal changes advocated in the Appendix
of the Status Report, which report, as our readers are aware, was adopted
by the Association at its Annual Meeting in July, 1914. It is now more
than a quarter of a century since the last principal Lunacy Act came
into operation, and although many amending measures have since been
presented to Parliament, no further progress has been made. It is
hoped that public attention has been awakened by the mental cases

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resulting from the war, and that during the era of reconstruction that
must inevitably follow when peace is finally declared, if not before, a
more enlightened opinion may prevail which may lead to better
provision being made for the treatment of certain types of mental
disorder. The admission of voluntary boarders to County and Borough
Asylums, for instance, should no longer be a stumbling block, and
some alternative method should be devised with proper safeguards for
dealing with cases of temporary or unconfirmed insanity ; and above
all, exists the desirability of the establishment of psychiatric clinics
whether as separate hospitals for mental disorders or by the allocation
of special wards in general hospitals for these cases. Much has been
written on this subject, and we call to mind the valuable introductory
address of the Emeritus Lecturer in Psychiatry at the Middlesex Hospital
Medical School, which appeared in our Journal for January, 1915.
Whether such clinics can be contrived on a voluntary basis or by subsidy
from the State, and whether some limited form of legal detention should
be granted for cases that have overstepped the border-line of insanity,
are matters that require careful consideration. Many of our members
have no doubt pondered over these problems, and it would be of
advantage to the sub-committee referred to if they would state their
experience of defects in the present system of dealing with patients
suffering from mental disorders, and how in their opinion these defects
may be remedied. The Chairman or Secretary of the Parliamentary
Committee would be grateful to receive such communications. Although
the war while it lasts must continue to absorb our energies, nevertheless,
it is incumbent on us to see that our speciality keeps in the van of
progress, and the present time does not seem inopportune to give this
matter of amending the Lunacy Laws our immediate attention.

Part II—Reviews.

A Text Book of Insanity and other Mental Disorders. Second
Edition. By C. A. Mercier, M.D., F.R.C.P., F.R.C.S. Pp. xx
+ 348. London: George Allen & Unwin, Ltd. 1914. Price
7 s. 6 d. net.

The second edition of this illuminating volume appeared at the out¬
break of the war, and we regret that, owing to the exigencies of the
times, the review of this publication has been so long delayed. Its
size is about half as large again as that of the first edition, which,
perhaps, the medical student will deplore, but the author acknowledges
in the preface that the considerable additions he has made are intended
for those who devote themselves to the special study of insanity.

The introduction, excellent as it is, remains unchanged, as does also
the chapter on the Causes of insanity. The chapter on Conduct con-

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tains an account of those activities which other authors usually include
in a preliminary discourse on psychology. In this portion there is also
no alteration except the insertion of a fresh paragraph on the subject
of the reproductive instinct. The chapter on Mind completes Part I,
which is entitled “The Institutes of Insanity.” This interesting
chapter, which has been much amplified and entirely remodelled,
should be carefully read by every thoughtful student. Dr. Mercier has
arrived at the conclusion that psychology as taught in the ordinary text¬
books is of little use in the elucidation of insanity. He laments the
fact that the results of introspection have never been collated with the
phenomena of disease, and he now endeavours to make an advance in
this direction. Following Hughlings Jackson’s doctrine of evolutionary
levels of the nervous system he has sketched out a fourfold division of
grades or levels of Mind. He mentions five primary mental faculties
that may become disordered, viz., Desire, Volition, Feeling, Thought,
and Memory, but he increases these to seven by considering Feeling
and Thought in their subjective and objective aspects. The four
evolutionary levels apply to six out of these seven faculties—Memory
not being susceptible to such levels. In this scheme which Dr. Mercier
has devised there are, therefore, twenty-five compartments to be
enumerated in which mental disorders can be mapped out. By Sub¬
jective Feeling the author means feeling of pleasure or pain graded as
crude, euphoric, resthetic, and moral, and by Objective Feeling the
residue that remains of compound feeling when pleasure or pain is
abstracted and removed, classed in levels as sensation, emotion,
resthetic, and social. By Subjective Thought Dr. Mercier introduces
the consideration of self-estimation, which he says has not received
recognition before and which is so often disordered in insanity, the four
grades being physical, mental, possessive, and moral. By Objective
Thought he refers to processes of reasoning as regards the environment,
the evolutionary steps being perception, caution, ingenuity, and wisdom
or prudence. The levels for Desire are racial, selfish i, selfish ii, and
social, the levels for Volition being trivial ends, sub-subordinate, sub¬
ordinate, and main ends, whilst Memory is discussed as a whole and on
a different basis. Fora due appreciation of these levels and the various
disorders to which these sections of the primary faculties are subject
the reader must refer to the lucid descriptions given in the book. His
attention is particularly directed to the differentiation of mental dis¬
orders that may be regarded as sane from those that occur in insanity,
as the title of the book implies. Dr. Mercier has tabulated these
arbitrary divisions of Mind diagrammatically and suggests that blank
forms should be used, so that disorders can be indicated thereon by
shading, and he exhibits specimens accordingly. Probably some asylum
medical officers have already made use of these forms in their routine
work.

Part II is headed “Forms, Types, and Kinds of insanity,” and
begins with Classification, a subject on which the author is an acknow¬
ledged expert. He has followed a strictly logical method which has
involved, in place of the double series—Forms and Varieties of insanity
—which appeared in the first edition, the advent of a third series, viz..
Types, /.<?., acute or chronic insanity—with sundry subdivisions. Forms

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of insanity—and here Dr. Mercier treats of insanity as the symptom—
consist of disorders of the several faculties, but always with affection
of the highest level of thought which renders the patient unable to
recognise the disorder of which he is the subject—according to the
author’s teaching. Kinds of insanity refer to insanity the disease,
meaning thereby the whole group of correlated disorders from which a
patient suffers and that can be traced to a single agent. Insanity the
disease includes insanity of undevelopment as well as insanity of disso¬
lution, and the last-mentioned is then divided into two categories:
Symptomatic and Idiopathic, the former being dependent and the latter
independent of any bodily disease so far as is known. This we
acknowledge to be an important step in classification and the further
subdivisions are both practical and sound. It is to be remembered,
however, that this table has to be used in connection with the Forms of
insanity and Types of insanity already mentioned. It may be noted
that General Paralysis is regarded as symptomatic insanity, and that
Alcoholic insanity may be symptomatic or idiopathic as the case may
be. Whether the tripartite nature and many subdivisions of this
classification will render it too cumbrous for the average student
remains to be seen. The delineations of each individual class of the
three series are brief but excellent, some of them are rewritten, and
there are a few new importations, such as the insanity of Childhood,
Traumatic insanity, and Sequelar insanity.

Part III, which deals with the Legal Relations of insanity, opens
with a few fresh paragraphs of a practical nature, and has also the
provisions of the Mental Deficiency Act, which has come into opera¬
tion since the first edition was published.

The book is one that every asylum medical officer should study. He
will not fail to recognise its systematic and orderly arrangement, to
which fact is attributed the absence of an index. The psychology that
is presented to him is plain and concise and the definitions are clear
and acceptable, whilst logic at last reigns supreme in the difficult task
of the classification of insanity. To refer to a few points of special
interest he is asked to learn to discriminate between euphoria (elation)
and exaltation, between dysphoria (misery) and abasement, to gain a
due appreciation of the levels of thought, to observe the outgrowth
of suspicion from an exaggeration of caution, and to regard morbid
suspicion as lying at the root of stubbornness (or resistiveness). The
author pays particular attention to this last-mentioned disorder, which
he considers an invariable sign of deep insanity and although clinically
differing widely from, in his opinion, is essentially allied to paranoia.
Dr. Mercier deals in a somewhat novel manner with the faculty of
memory, which, he points out, is not only concerned with recollection
of the past but with remembrance of future events ; paradoxical though
he acknowledges this to be, it is, however, true. Inasmuch as the
author restricts the term dementia either to a type or a kind of
insanity he uses the word “anoia ’’for the weakmindedness and defective
conduct which every case of insanity exhibits in some degree.

Most of us are in thorough accord with the doctrines of Dr. Mercier,
whose writings have done so much to enhance the scientific status of
psychiatry in this country. There may be a few points that some of us

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do not quite see eye to eye with him in this book. For instance, the
impression is left that there is, perhaps, a tendency to extol the influence
of thought at the expense of feeling in the interaction of these con¬
stituent elements of mind, especially when we consider the beginnings
of insanity. Can we subscribe to the view that a person is sane whose
intellect is unclouded but whose feelings are deranged and prompt to
insane action although self-control still exists but threatens to give
way ? Again, is not the person rightly regarded as insane throughout
whose instability is revealed by hallucinations or delusions which are
from time to time relatively sane or insane—his normal insight being
alternately present and absent ? Such cases occur to us when we think
of the shading in Dr. Mercier’s diagrammatic forms. Further, we can
recall patients suffering from obsessions, from morbid hesitation and
vacillation, possessing full recognition of their disorders, yet requiring
certification to promote their recovery. That disordered conduct is
the earmark of insanity no one will deny, and it could not be other¬
wise seeing that our actions are but the outward expression of the
mental mechanism within us. Surely this has been fully recognised by
authors in the past as well as by the legislature, but all the same we
owe a debt of gratitude to Dr. Mercier for his special work on this
matter—a summary of which this book contains. One word more—the
reader must not hope to find in these pages any reference to sub¬
conscious mental activities or for any support of the newer terminology
such as dementia pnecox or maniacal-depressive psychoses, and he
must not be surprised to find a decided antipathy towards the Freudian
psychology. But with these brief comments we heartily commend the
book as one of the highest value and we feel assured it will be read by
everyone who takes an interest in mental science, and it should rank in
the foreground amongst text-books for students and practitioners of
medicine.

Alfredo Niceforo, I Germani: Storia di un’ Idea et di una “ Razza. ”
Rome: Societal Editrice Periodici, 1917. Pp. 88. Lire 3.50.

For many years before the war the Pan-Germanic idea of a
“ Germanic race ” of tall blonde dolichocephals, assumed to be the
noblest race in the world, the creators of civilisation, a race which had
already been infiltrated into the finest figures of all European countries,
and which was destined to dominate all countries, had secured con¬
siderable vogue. Naturally this vogue was mainly confined to Germany,
and even in Germany was not accepted by most serious investigators.
The original pioneer was, indeed, a distinguished Frenchman, Count
Gobineau, although in his mind it was a much wider, vaguer, and more
fluid idea thap it became later, and the most thorough-going champion
of the idea at the present time is a Teutonised Englishman, Mr. H. S.
Chamberlain. To-day this idea has become familiar to many who
never before heard of it, and the author of the present little book sets
himself, in a popular style but a scientific spirit, to combat it.

Prof. Niceforo, well known as criminologist, anthropologist, and
sociologist, is very well equipped for his task. Pie always keeps close
to facts, and his tightly-packed footnotes on every page show how well

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he possesses the literature of his subject. Moreover, he reveals a
quality which to-day is rare; he is able throughout to preserve an
atmosphere of calm scientific discussion; he never once indulges in
the slightest vituperation of his opponents or even depreciation. It is
unnecessary to remark how greatly this adds to the force of his
arguments.

Gobineau, with his rather vague idea of a special fair race which had
created civilisation, had not specially identified it with the Germans.
Durand de Gros (again not a German), who furnished another germ for
the myth to work on, also had no eye on the Germans when he made
the interesting observation that the inhabitants of towns and the higher
social classes are more dolichocephalic than the dwellers in the country
and the lower social classes. But a few ingenious and Chauvinistic
German scholars put together these ideas and facts, and proceeded to
argue that it is the German who represents this fair dolichocephalic
aristocratic race, the creators of civilisation, even outside Germany by
their migrations into other lands (it is argued, for instance, that Dante
and all the leaders of the Italian Renaissance were really Germans by
name or in physical type), and destined to dominate the world.

In the course of his little book Prof. Niceforo convincingly demon¬
strates the fallacies and confusions on which this Pan-Germanic myth
has been built up. Even if we choose to consider the fair dolicho-
cephals as the most exalted type of men, they are not specifically
German ; they are found all over Northern Europe, from Ireland to
Russia, and constitute what is now commonly called the Nordic race.
They are not even a majority, but only a small minority, of the popula¬
tion of Germany, which is mainly constituted of a very different race,
the men of the brachycephalic so-called Alpine type. How little
claim the Germans possess to be specially identified with the dolicho¬
cephalic race is shown by its existence long before there were any
Germans. In Neolithic times all Europe was peopled by dolicho-
cephals, and it seems probable that originally the fair dolichocephals
of the North were of the same stock with the dark dolichocephals of
the South (now commonly termed the Mediterranean race), from whom
they became differentiated by the influences of the northern climate.
On these and the other points raised by the Pan-Germanic myth the
author writes clearly and concisely, not attempting to force the argu¬
ment at points where doubt still exists. His discussion is probably the
best and most competent within brief compass yet published.

Havelock Ellis.

La Psichiatria Tcdesca neUa Storia e tiell'Atlualitii [ German Psychiatry
in History and at the Present Day\ By Prof. E. Lugaro.
Florence: Tipografia Galileiana, 1917. Pp. 357.

When the social history of the last thirty years of the nineteenth
century and of the first twelve of the twentieth comes to be written, the
slavish credulity with which the fiction of the mental superiority of the
German peoples was accepted by other and nobler nations will astonish
the student. We are too close to the period, and many of us still
suffer too much from the obsession, to be able to judge the phenonemon

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fairly. Yet Prof. Lugaro’s book goes a long way to put us in the
position of the future historical student. It places in the full glare of
the limelight the work of German scientists stripped of self assertion,
takes it at its real value, and compares it with that of other labourers,
European, American, and Japanese in the scientific field. It helps us
to view ancient and recent events, personalities, discoveries, and labours
in their true perspective, and it honestly gives credit where credit
is due.

The keynote of the book is that thought is universal. “ If to the
word thought is given its proper signification, that of the work of the
intellect, it is evident that to speak of ‘ German thought ’ (or that of
any other nationality) is to speak nonsense. There is no such thing as
German thought, there cannot be, because thought does not recognise
nationality.”

“ Correct thought is the conscious image of reality, therefore it can
only be one. Error, the spurious product of thought, may be multiple,
particular, regional, individual. In that which they have of the essential,
the correct, and the true, Chinese thought and European thought are
identical. Also, apart from every historical connection, the thought of
the Egyptians, of the Hindoos, of the Phoenicians, of the Greeks, of the
Romans, of the Italians of the Renaissance, and of modern Europeans
follows schematic lines of continuous and harmonious development.”

After a few pages devoted to preliminary considerations, the author
proceeds to sketch the history of the birth and progress of psychiatry
from the earliest times to the present day. He touches on the origin,
development, and reformation of asylums for the insane, and as the
story unrolls itself, the reader observes, perhaps with astonishment, how
in all these matters Germany has lagged woefully behind other nations.

The Professor then passes on to a review of some of the chief mental
disorders, roughly dividing them for the convenience of study into
psychoses having an organic basis, and those which are functional,
allowing, of course, for much overlapping. He points out how little
of our knowledge of these conditions and of their treatment we owe to
the Germans in comparison with what we owe to labourers of other
nationalities.

Afterwards he studies in detail the work of Griesinger, Krafft-Ebing,
Schiile, Arndt, Meynert, Ziehen, Wernicke, Kraepelin, Freud, Adler,
Specht, and Miinsterberg.

The writer’s exposition of Freudism is a model of clearness. He
shows us Freudism stripped of metaphysics, and Freudism stripped of
metaphysics is a feeble affair. He warns the practitioner of psycho¬
analysis of the dangers and pitfalls which beset his feet.

A considerable portion of the latter part of the book is devoted to
the consideration of some general questions concerning the anatomy
and physiology of the nervous system, and of the opposition with which
many of them have been received by German scientists. The Professor
rather apologises for what he considers a digression from the original
plan of his book, which was intended to be a historical and critical
examination of pure psychiatry, and of the work done by the Germans
in that field. But the reader willingly excuses the digression, for it
gives him the opportunity of studying certain physiological problems of

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the greatest interest both to the physician and the alienist as expounded
by a master of clearness and perspicuity.

The last section of the book is devoted to the consideration of the
“ German method,” and of Imperialism, one might almost say militarism,
in German science, in German universities, and in German teaching
generally. From a historical point of view this section is of the greatest
importance, for it reveals with what subtlety and craft, with what
methods worthy of a petty tradesman, the German scientist has wormed
himself into the false position which he has occupied for so many years
in the world of thought.

Generally speaking, the book must be considered as a historical work,
but frequently the physician and the pathological anatomist overcome
the historian, and present us with miniature clinical pictures which
arrest the attention from their vividness, and with thumbnail sketches
of morbid conditions remarkable for suggestiveness of detail. In places
the seriousness of the subject is relieved by a play of irony, which is
seen, perhaps, more than anywhere else in the descriptions of the
individual work of the leading German scientists ; for example, in the
pages devoted to the consideration of the theories of Theodor Meynert,
who “places his clinical study of mental diseases on the solid pedestal
of anatomy,” and immediately drifts hopelessly away into more or less
pure psychology.

For the English reader, what is most pleasing in Prof. Lugaro’s book
is the generous homage he pays to English work. Look at the long
line of English physicians and alienists, from Sydenham to Clouston,
whose names he quotes ! Does it not fill one with honest pride? And
it is not to the honoured dead alone that he refers. As one reads the
pages of his book, one realises that for clinical research and experimental
work Englishmen still living stand second to none.

But the writer does not forget the other great schools of the world.
He metes out praise as unstintingly as it is well deserved to those of
his own country, to those of France and America, and to the modern
Spanish schools, particularly to that of Barcelona. Lugaro is just also
to the Germans. Where they have done honest work he credits them
with it. But where they have stolen other people’s ideas without
acknowledgment, and where they have robbed others of the fruits of
their labours, he holds them up to the derision of the world as thieves
and plagiarists.

In conclusion, it is to be said that the book is remarkable for the
enormous amount of information, both historical and scientific, which
it contains, it is well printed, and it is provided with indexes, which are
complete and useful. J. Barfield Adams.

Automatic S/eep (Le Sommcil Automatique). By Dr. Georges Boyer.

Paris : Alfred Leclerc. Pp. 92. 1914.

The first fifty-two pages of this contribution to the pathology of sleep
are devoted to a somewhat extended consideration of certain aspects of
normal and abnormal psychology, which serve to pave the way to the
study of the particular symptom indicated in the title.

Chapter I is occupied by the consideration of automatic as con¬
trasted with voluntary activity. It includes a study of the historical

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development of the term “ automatic,” a r£sum<! of the meanings which
have been attached to it, and an enumeration of the various psycho¬
logical phenomena which are associated with an act or thought to which
the term “voluntary” can rightly be ascribed.

These preliminary considerations enable the author to detail the
various grades and types of automatism, from a simple reflex to a com¬
plicated reaction of defence, and to demonstrate how each of these acts
lacks certain psychological elements which differentiate it from a volun¬
tary activity. He then devotes attention to pathological automatism
both in the sphere of thought and action, dividing abnormal automatic
acts into three groups, according as to whether the disorder is one of
inhibition, consciousness, or personality. The chapter concludes with
a schematic presentation which serves to classify the various phenomena
grouped under the term “ automatic.”

The next chapter deals with the relation of sleep and the will. The
author develops in detail the conception, with which the name of
Claparede is especially associated, that sleep is a positive function, a
positive act comparable with other acts which the will directs, and not
merely a passive function or negative state, a kind of abdication of the
higher powers of mind. He shows that, in normal circumstances, sleep
does not occur apart from the will of the individual; its usual rhythm
can be modified by the will, and the will is also actually present, in a
lesser degree, during sleep itself. The hypnique function is not purely
physiological, it is not dependent solely on the lower centres, but
dependent on the control of the higher centres, as are co-ordinated
movements directed voluntarily to a certain end.

The two essential elements of sleep—muscular relaxation and
generalised attention—are both under the control of the will, and the
need of sleep, the preliminary state of fatigue does not determine, ipso
facto , the arrival of sleep, any more than hunger automatically leads to
the act of eating. Sleep is thus a positive act, a consent, an act of
will, and like voluntary thought, a mental disposition, an attitude.

The author reserves the term “automatic sleep” to that condition in
which patients affirm that their sleep is unnatural, that they are sent to
sleep, mesmerised, hypnotised, forced to sleep, and so on. The two
essential characters of this symptom are its involuntary nature, and the
fact that it is ascribed to external agency. It is explained as a disorder
of sleep itself, in the same way as an hallucination is a disorder of
perception. Like an hallucination it obtrudes itself against the will,
it ceases to be under the control of the personality, and it becomes
a phenomenon'which the patient regards as due to an external agency.

It is certainly of interest to bring this symptom into line with other
morbid phenomena, but to merely lay emphasis on the fact of dissocia¬
tion would seem to be somewhat inadequate as an explanation. The
cases cited are evidently instances of dementia prsecox, and the
delusional interpretations in regard to sleep are no more than one
manifestation of the whole morbid picture. A further analysis would,
no doubt, reveal more than the mere fact of automatism ; it would
suggest the underlying mechanism and reveal theabnormal trends which
find expression in this particular way.

While in this respect the treatment of the main theme is somewhat

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superficial and unconvincing, the essay as a whole is an interesting
example of the French school of psychology. Perhaps its chief interest
and value lie in the emphasis which is laid upon the important relation
between sleep and the will. This aspect of the psychology of sleep is
of considerable clinical importance, and it deserves full recognition and
study. The want of sleep in neurasthenic and psychasthenic patients,
a symptom often so prominent, is often no more than a want of confi¬
dence, a lack of will-power in respect to sleep. It is one expression of
a general inability to perform acts under the control of the will. For
this chapter alone, as well as the general discussion upon auto¬
matism and volition, the book well repays attention.

H. Dkvine.

The Ideal Nurse. By Charles A. Mercier, M.D., F.R.C.P
F.R.C.S., etc.

Although delivered some eight years ago in the form of an address
to the nursing staff of the Retreat at York, this little brochure belongs
to that class of publications which time cannot wither nor custom
stale. Embodying, as it does, an ideal to reach which should be the
aim of all those who have adopted as their idle in life the nursing of
the insane, it at the same time gives practical instruction and guidance
as to how this object is to be attained. Nor is its use intended to be
limited to those only who are engaged in asylum nursing. It contains
matter which cannot fail to attract the attention of all those who
follow any branch of the nursing profession, and to afford help,
teaching, and encouragement to them in their daily work.

Some people have hands and no brains. Others have brains and no
hands. The fortunate ones have both. Perhaps in no case is this
more obvious than in that of the operating surgeon, whose success will
be proportionate to his possession of these two essential attributes.
But Dr. Mercier holds, and rightly holds, that the same is true as
regards the nursing avocation. The ideally endowed nurse is one who
has both keenness and agility of brain, and skill and dexterity in the
use of her hands. The first depends largely on heritage; one must
be born with it, and those who have it not are in nowise deserving of
blame. The last can be acquired ; and even persons who are naturally
slow and plodding in their mental operations by sheer hard work and
untiring perseverance can eventually become really efficient nurses.
In this connection Dr. Mercier puts in striking contrast cleverness and
capability. “A person who is not clever may make a first-rate nurse ;
but a nurse, however brilliantly clever, who is not capable is worthless.

. . . If you are not born clever, no amount of pains and study will

make you so ; but anyone may become capable by taking pains.”
Sympathy is another [prime essential. Someone has said that success
in the medical profession depends on one part knowledge, and three
parts sympathy. The same, no doubt, is true in the case of the
nursing profession. This consideration leads not unnaturally up to
what is practically a lay-sermon with i Cor. xiii as its text, St. Paul’s
well-known eulogy on Charity, which occupies almost the whole of the
latter half of the address, and is full of practical suggestions as to how

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to carry out in one’s life and work the principles enunciated by the great
apostle. It might well be designated the philosophy of loving-kindness,
a term which the preacher prefers to the Biblical word Charity.

Some of Dr. Mercier’s observations come almost under the category
of aphorisms, such as: The only way to learn how to do a thing
is to do it.—The intelligent worker is he or she who knows when
it is proper and necessary to break a rule. Rules are necessary
because workers are stupid.—Never, under any circumstances, attempt
to coax a patient by a lie.—Rejoinder and retaliation is a confession of
defeat.—I have spent a lifetime amongst the insane, and the most
salient result of my experience is that I never despair of a patient’s
recovery.

We can confidently recommend this little book—unique of its kind
—not merely to attendants and nurses, but to every one who is engaged
in the treatment of the insane. It might, with great advantage to both
nurse and patient, be carried in the pocket, and referred to with the
same regularity and constancy as that with which a priest peruses his
breviary. The principles there laid down should be known by heart,
and thoroughly assimilated, and every effort made to carry them out in
practice. The keynote of the address is encouragement, its motto
“ Sursum corda,’’ and we cannot conclude this notice more appropriately
than by quoting the inspiriting words which occur just at its close :
“When you watch the subsidence of excitement, the removal of
depression, the dispersion of suspicion, the gradual return to sanity ;
when you open the gates and say farewell, and bid God-speed to a
patient whom you have nursed through the valley of the shadow of death,
and raised out of the mire of tribulation ; when you send him home
clothed and in his right mind, and think of the load of misery you have
been instrumental in removing from him and from his family; you
taste a joy as refined and as pure as that of the angels of heaven over
the sinner that repenteth,”

The Third Annual Report of the Board of Control for the year 1916.

The third report of the Board, ordered to be printed on October
17th, 1917, is very much abbreviated as compared with the first. In
Appendix A there are only nine tables instead of twenty-four, and in
Appendix B only five instead of fourteen.

This economy of printing is no doubt justified by the state of war,
but it could be wished that similar care had been exercised in matter in
which the saving, instead of amounting to a few score pounds, would have
amounted to so many thousands. The want of these tables reduces the
report to a stereotyped repetition of the baldest facts and renders any
attempt at criticism or interpretation almost impossible.

The decrease in the number of the notified insane is again a striking
and interesting phenomenon, opening the door to much speculation in
regard to the influences producing this result.

The actual decrease for the year 1916 was 3,159, the total 134,029 on
January 1st, 1917, being less by that number than at the commence¬
ment of the year under review. The number on January 1st, 1915
(the highest recorded) was 140,466, and if the average annual increase

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of the preceding decade had continued, the present year would have
opened with 144,968, or 10,939 niore than the actual number.

The total decrease on the two years, therefore, is 6,437, and this
result has been brought about by decrease in the admissions, those in
1915 and 1916 being respectively 2,055 an d 2,527 less than in 1914,
together with the increase of deaths, which in 1915 and 1916 were 2,157
and 2,376 more than in 1914. The recoveries were 305 and 648 less
in these compared years, whilst the discharged not recovered were
increased by 707 and 367 respectively.

The want of the usual tables makes it very difficult to follow out sati s-
factorily the incidence of these factors in the relation to sex, but there is
no doubt that the reduction is somewhat larger in the males. These
on January 1st, 1916, being 46 per cent, of the total insane population
as compared with 46^2 per cent, on January 1st, 1915. On the other
hand, the decrease in the admissions for 1916 shows only a diminution
on those of 1915 by 17 per cent, for men as compared with 27 per cent.
for women (in actual numbers, 168 men and 304 women).

In the absence of the necessary facts only conjectures can be made
whether the stimulus and excitement of war has acted beneficially on a
number of persons who, under ordinary conditions, would have become
insane, or whether, as already suggested, the restrictions in the use of
alcohol have led to lessened intemperance and improved general
health, etc.

In regard to men, as the report points out, there are certainly a large
number who are being treated in hospitals and homes who will ulti¬
mately gravitate into asylums. When the actual facts become obvious
it is quite possible that the diminution will prove to have been larger
among women.

The increase in the number of deaths appears to have been largely
due to senile decay, in addition to a larger mortality from phthisis.

The drain of attendants for military service has been met every¬
where, the report shows, by employing female nursing in suitable wards
on the male side of asylums; as a result it appears that out of 5,289
attendants of military age over 3,000 have been called to the colours,
many of whom have been wounded or killed.

The voluntary boarder system has been threatened by an innovation
that might seriously impair its usefulness.

The report records that at the Bodmin Assizes, two men who pleaded
guilty to acts of gross indecency were bound over to come up for
judgment when called upon, provided that they agreed to go as “volun¬
tary boarders” to two provincial licensed houses. It is not astonishing
that the Board writes that this has caused them great anxiety or that
they have laid their grave objections to this procedure before the Lord
Chancellor and the Home Secretary.

That these persons can be considered as “voluntary boarders ” does
not seem possible to a non-legal mind. It is not stated whether the
boarding—whether voluntary or not—was for any fixed period ; whether,
for example, forty-eight hours’ residence w'ould be sufficient to comply
with the Judge’s direction ? or whether, on the other hand, if a fixed
period of boarding, say six months, was required. In the latter case it
would approximate to a sentence for that period. Neither is any

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indication stated whether the hoarding period should be determined by
the medical authority of the licensed house or by the boarders them¬
selves, or by the judicial authority.

The further question arises whether any licensed house would
voluntarily receive Such persons, or whether they, if designated by the
Judge for that purpose, would be bound to receive them.

The proposition certainly seems an impossible one : and it must be
hoped that the learned Judge will himself see this.

The total average cost per head for maintenance for all asylums
showed a further increase of 6f d. per week on the previous year; and
this appears to be a moderate rise in relation to the increased cost of
food, etc.

Mental deficiency care would appear to be progressing as satisfactorily
as war conditions will permit. The report speaks highly of the valuable
help of voluntary associations in the supervision of defectives. The
Brighton Guardianship Society is specially cited as an example. The
number of mental defectives on the register of the Board are: January ist,
1918, 6,836, of whom nearly 6,000 were in certified institutions; but
this does not include a very large number, who are at present cared for
by the Education and Poor Law authorities, as well as many others not
yet dealt with in any public way. 1

The training of teachers and attendants on the mentally defectives
is receiving the attention of the Board, and the hope is expressed that
the next annual report will contain an account of a practical and
inexpensive scheme for this purpose.

During the year eight certified institutions were established. The
reports of the visits by the Board to the various institutions are given
in full, and contain a considerable amount of information interesting to
those specially concerned in the administration of the Act.

As stated at the outset, there is little in the report affording a basis
for critipism, and in the present stress of work thrown on the Board,
it would be unfair to expect any of the new departures in the treatment
of the insane, which we may hope may be dealt with when the country
again enjoys the opportunities of progress afforded by a lasting peace.

Part III.—Epitome of Current Literature.

1. Physiological Psychology.

The Nature of Mental Process. {Psychol. Rev., May, 1917.) Carr,
Harvey.

The author proposes the view that the mental functions with which
psychology is concerned are in reality psycho-physical and at times
neural, and that psychology must attempt to comprehend these functions
in their entirety. That is to say that psychology must not be content
to deal with the conscious and subjective elements of psycho-physical
events, leaving their neural correlates to physiology, but include within
its domain all the neural events involved. This, Carr points out, is
unorthodox as a definition of the scope of psychology, but is entirely in

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harmony with the prevailing biological point of view. The new defini¬
tion of the mental permits a restatement and solution of the mind-body
problem more in accordance with common sense, the distinction of
mind and body being regarded as “ merely a distinction of two systems
of organic function.”

Carr remarks that the subjective conception of mental process con¬
stitutes an inadequate tool for the physician who attempts to comprehend
physical disorder. To diagnose a case as “ purely mental,” and to give
the impression that it could not in any way be stated in neural terms,
is “a crude and preposterous conception.” But, unlike Watson and
other critics, Carr is inclined to put the blame less on medicine than on
psychology. Medicine has merely accepted current conceptions set up
by psycholQgy, which has introduced into medicine old philosophical
problems regarding the relations of mind and body. These old problems
vanish at once if we assume that the disordered mental functions are in
reality psycho-physical events.

This psycho-physical conception of mental process, the author claims,
offers a mediating point of contact for the two extremes of subjectivism
and behaviourism. It permits mental processes to be studied from
the standpoint of immediate experience, or of objective observation, or
of clinical data. It differs from subjectivism by allowing an objective
method of approach. It differs from behaviourism by admitting that
the study of conscious data can give much useful information.
Behaviourism, logically defined, includes the whole field of organic
function. But psychology should be content with a more modest
programme, still allowing a place beside it to biology and physiology.
The parallelism of mental and physical still remains as a working
hypothesis, but it is the total activity that becomes the object of study ;
the dichotomy involved is not one of process but merely of method of
approach.

There are no immutable boundaries between sciences. A science
must take up whatever is pertinent to its primary interest. If mental
acts are a means of organic adjustment they must be studied. If neural
events are an essential part of the act, they, too, must be included.

Havelock Ellis.

2. Clinical Neurology and Psychiatry.

The Voltaic Vertigo Test in Epilepsy \Le Vertigini Voltaiche tiegli
Epilettici\ (Rivista di Patologia e Nervosa e Meniale, October ,
1917.) Bono la. Dr. F.

In epilepsy, the writer remarks, vertigo, as a subjective state, occurs
rather frequently, either as the aura or as a symptom.

The vertiginous sensation represents an illusion of the failure of
our static relations with our surroundings ; a momentary suspension,
in other words, of that complex of the sensations of the orientation of
our body which is furnished to us principally by stimuli transmitted to
us from the semicircular canals and the vestibule, and secondarily by
visual sensations.

The very important part played by the semicircular canals and the
vestibulein our static sense is proved by observing either the results

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of direct stimulation of these organs, or the failure of specific reaction
when they are imperfect. In fact, the compensatory movements
(nystagmus, rotation, and inclination of the head), which are observed
in men and animals undergoing the tests of rotary vertigo and of
voltaic veitigo, are not observed in animals deprived of the semicircular
canals, nor in men suffering from profound lesions of the labyrinth.
The vertiginous sensations which are put in evidence by the rotary
tests (Barany), or by tests in which the galvanic current is employed
(Babinski), have, therefore, origin in an irritation of the semicircular
canals, an irritation which translates itself objectively by the compensa¬
tory movements referred to above, and which Ewald has demonstrated
to be of a purely reflex origin.

The nervous terminations in the semicircular canals and in the
vestibule are stimulated in the ordinary way by displacements of the
endolymph, and these stimulations are perceived by us as alterations
of our position in space. In the case of rotary vertigo, the vertigo is
also produced by movements of the endolymph ; in the case of voltaic
vertigo by the current; and in the case of the vertigo, which accom¬
panies inflammatory conditions of the internal ear, by the propagation
to the nerve of the pathogenic stimulus ; in all cases the nerve responds
to the stimulus by its own peculiar form of irritability, which is trans¬
lated in its sphere of cortical projection by the sensation of movement,
of vertigo. Experiment has demonstrated that the character of the
vertiginous sensation varies with the localisation of the stimulus in the
different semicircular canals and in the vestibule.

The commonest and safest methods of experimenting on the vestib¬
ular labyrinth are the test of rotation, and that of the voltaic vertigo
of Babinski. The writer prefers the last, because it is easier and more
sensitive than the'other, and because the results are more sure, more
constant, and more demonstrable. The technique is as follows : The
electrodes (of 2 to 3 cm. diameter) are applied in front of the tragus,
and the circuit is closed. If the labyrinth be normal, with a current
of from 1 to 4 milliamperes, there is an inclination of the head con¬
stantly towards the positive pole, whatever be the direction of the
current, a sensation of vertigo more or less intense, and often a rotary
nystagmus directed towards the negative pole. If the current be
increased, there is also an inclination of the whole body towards the
positive pole.

If there are bilateral vestibular lesions, there is an exaggeration
of resistance which may reach to 15 or 20 milliamperes, and may
even surpass them, there is a remarkable delay in the appearance of
the vertiginous sensation, there is a failure of the inclination of the
head towards the positive pole, which is often replaced by a move¬
ment of the head backwards or forwards, and there is an almost constant
failure of nystagmus. If the lesion be unilateral or chiefly on one
side, one observes a constant inclination of the head to that side,
whatever be the direction of the current. Also, after the test of voltaic
vertigo, one often observes alterations in the test of the index of
Barany, and lateral deviation of the body during walking, reactional
movements caused by the cerebellum under the influence of labyrinthic
excitement.

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After devoting some paragraphs to the most recent views of the
anatomy of the vestibular nerve, its origin, and connections, the writer
proceeds to speak of the results of his experiments.

The test of voltaic vertigo was applied to thirty-two patients suffering
from so-called essential epilepsy, and in five cases opportunity was
taken of repeating the experiment within six hours of an epileptic
attack.

The writer employed the following as control cases.

Three patients suffering from cranial injuries without osseous
lesions, but who suffered from epileptiform attacks and vertiginous
sensations.

Two patients suffering from convulsions of a clearly Jacksonian type.

Two suffering from unemic intoxication with convulsive attacks.

Twenty soldiers, sixteen of whom suffered from attacks of what the
writer has elsewhere described under the name of “ convulsive states
of neuropathies,” and four of whom suffered from typical hysterical
convulsions.

The test in the control cases gave the following results:

(a) In two of the three patients suffering from cranial injury there
was a remarkable increase of the vertigo, and a very great resist¬
ance to the appearance of the compensatory movements, accom¬
panied in one by a constant inclination of the head to the right,
and in the other of the head backwards.

(b) In the two urcemics and in the two patients suffering from
Jacksonian convulsions (without any sign of intracranial injury) the
vertigo was normal.

(1 c) In the cases of the sixteen soldiers suffering from organic
convulsive attacks, but not epileptiform (convulsive states of
neuropathies), the sensation of vertigo was rather accentuated.

(d) In the four hysterical cases the vestibular reaction was
normal.

With regard to the thirty-two epileptic patients, the writer gives a
very careful account of his observations, which are arranged in seven
categories. Briefly, it may be said that in no case was the reaction to
the voltaic vertigo normal. In the epileptics with a vertiginous aura,
the vertigo was very much stronger than in the other subjects. In the
hours immediately succeeding (within six) an attack the voltaic test
produced a sense of vertigo much less accentuated than at a later
period. In no'case did the voltaic test produce an attack of epilepsy.
It may be added that none of the thirty-two patients presented any
alteration of any importance of the cochlear labyrinth or any other parts
of the ear.

The writer considers that the alterations, which he has observed in
the vestibular labyrinth of epileptics, are very difficult of interpretation.
They may be interpreted as phenomena of pathological hypo-excita¬
bility, materialising, perhaps, in sclerotic processes, which the writer
can only associate with the disequilibrium of the blood-pressure and
that of the cerebro-spinal fluid so frequent and so serious in epileptics.
This disequilibrium, through the communications existing between the
cavities of the labyrinth and the intra-arachnoid spaces, and through
the vessels of the membranous walls of the labyrinth, may have a
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dangerous conlre-coup on the delicate terminations of the crests and
acoustic maculae of the vestibular nerve, and go a long way to produce
the sclerotic processes, of which very likely the alterations of the
voltaic vertigo are the exponents.

J. Barfield Adams.

Emotional Hysteria \E 7 stcrismo Emotivo\ (Annali di Nevrologia,
Anno xxxiv, fuse. 3.) D’Onghia , Dr. Filippo.

At the commencement of his paper the writer draws the reader’s
attention to the fact that Neri did not meet with any of the ordinary
phenomena of hysteria among the 2,000 survivors of the earthquake at
Messina whom he examined.

Very often, he remarks, hysterical manifestations are caused by
trifling emotions and even every-day annoyances. The lady, who will
fall into convulsions on account of some miserable quarrel with her
husband, will very likely the next day, when something really tragic
occurs in her life, find all the energy that the situation requires, and
will put aside her hysteria.

An earthquake occurs unexpectedly. Frequently it arouses an
individual from his sleep, and permits only of one thought, that of
saving himself. Nothing artificial can prevent the accomplishment
of this one aspiration. It is not possible that the nervous energy,
which is absolutely necessary to the organism at that supreme moment
of peril, can remain useless in a paralysed limb which prevents the
individual from saving himself, or in a tongue dumb and silent, which
prevents him from crying aloud for assistance. *• It is not possible,
above all, that another personality, an inferior and encumbering person¬
ality, should substitute itself for, or overcome the first and true
(personality) and subdue it.”

“ War, on the other hand, and especially the war of to-day, is such
that the nervous resistance of the individual is put to a very hard
proof.”

“ During the long hours in the trenches, with limbs cramped by the
uncomfortable position and suffering from excessive cold or excessive
heat, when the surrounding silence is only broken by the distant roar
of cannon and the nearer rattle of musketry, by the groaning of the
projectiles of the former and the whistling of the bullets of the latter,
and finally, by the moans of a comrade, who, while moving to satisfy
some need, has been wounded to death by some invisible enemy
sharp-shooter, that is the time and the manner in which the nervous
tendencies of an individual acquire consistency and colour. And
when, at an ill-omened moment, the cannon thunders louder, and the
roaring is followed by a howling that shakes and overturns everything,
what marvel that this latent tendency, this potential neurosis, I might say,
is translated into an actual neurosis ? ”

“ Here, also, the danger is imminent, and no one, unless he be in
the fulness of health and strength, can sustain it; but, contrary to
what happens in an earthquake, the neurosis itself may be the means
of the salvation of the individual, by bringing about his removal to the
rear.”

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“ The idea, I know, is neither new nor strange; but meanwhile it
seems to me that it may be the fundamental point of the question,
that it creates a true psychological contrast between the survivor from
an earthquake and the soldier in a war. It is the pathogenesis itself
of hysteria which offers us the explanation of the phenomenon.”

“ Each one of us possesses two personalities which, in normal con¬
ditions, co-operate harmoniously in our conservation and in our well¬
being—consciousness and subconsciousness. In hysteria the second
sometimes usurps authority over the first, and causes the well-known
morbid manifestations, which may succeed in encumbering the life of
the patient. But when the actual existence of the patient is menaced,
the two personalities recover themselves and unite their energies in
common defence. We all know that hysterical symptoms, previously
rebellious to every form of treatment, disappear iu the moment of
peril; the paralytic recovers the movement of his limbs, the dumb
regains his speech, the blind his sight, etc.”

“ But if these morbid manifestations, which previously constituted an
obstacle to the free activity of the patient, can become, in some con¬
tingency, useful and beneficial to him, the subconsciousness does not
hesitate to reproduce them, feigning, I might almost say, for its own sake,
a set of morbid symptoms, which may be the only means of saving the
individual by removing him from the place of peril.”

“ Then the conclusion to which we must come, will be, I believe,
rather different from that at which Babinski and Dagnan-Bouveret
have arrived; that is to say, it is not so much the intensity or the
quality of the emotion which determines the appearance of the symptoms
of hysteria as the conditions in which the emotion is produced, and the
utility, more or less, which the individual may derive from the neurosis
which his subconsciousness charges itself with placing on the scene.”

The paper is illustrated with reports of a few cases in which hysterical
symptoms manifested themselves amongwounded soldiers. Dr. D’Onghia
explains the paucity of the cases because, being attached to a field
hospital, few such came under his care, as patients suffering from nervous
and mental diseases are removed as soon as possible to hospitals in the
second line. J. Barfiei.d Adams.

The Mechanism of Paranoia ( Journ. of Nerv. and Ment. Dis. April,
1917.) Abbot, E. Stanley.

The author points out that cases diagnosed as paranoia have rapidly
diminished during the past half century. Before that period the mere
presence of delusions was often considered sufficient justification for
the application of this label. But in 1904 Kraepelin estimated the
proportion of cases of paranoia as only 1 per cent., and by 1915 had
still further reduced it. Abbot believes, however, that there will
remain an irreducible minimum of cases showing elaborated delusions
with the absence of all other symptoms except such as are wholly
secondary. After describing such a case in detail he considers the
mechanism of such cases generally.

Man has to adapt himself to the variations of his environment. To
do this he must reason about it. The more accurately he reasons

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about it the more successful, other things being equal, will his
adjustments be. There are three ways in which he may fail :
(1) He maybe ignorant, as we all are, more or less; (2) he may be
mistaken; (3) he may be prejudiced, and apt to associate feelings
that are unjustified, or too intense, or both, with certain groups of new
ideas, so that when the ideas come into his head the train of thought
is determined by the associated feelings, as we may see among politicians
who regard politicians of the opposing party as a set of scoundrels. It
is this association with feelings which makes prejudice so much more
persistent than ignorance or mistake. Prejudice may even grow and
become complex, as we may see in many anti-vivisectionists in whom
embryonic delusional systems are found.

This mechanism of prejudice is the mechanism that is operative
in all true paranoia and fully accounts for the psychosis. The apparent
beginning of the psychosis is usually always an episode which arouses
several strongly toned affects. These affects predispose the patient to
see effects where there were none, to see causality where there was
only coincidence, to take possibility for probability, or even actuality,
and to ignore inherent improbabilities, or even impossibilities. But
this is the mechanism of prejudice.

In ordinary normal life prejudices are limited and do not tend to
become elaborated or extreme. It will probably be found that there
is an unbroken series of cases extending from the simple unelaborated
prejudices such as we all have, through the cynic, the optimist or the
pessimist; then the anti-vivisectio/iist and some other ardent reformers;
then religious exhorters and extreme anti-Catholics; then founders of
religious sects; then unrecognised paranoiacs in private life; finally
those whose anti-social acts bting them into the asylum.

The more intimately personal the subject matter of the systematised
delusion is, the stronger, the more durable, the more difficult to uproot.

Paranoiacs do not tend to become demented, any more than people
with prejudices. Kraepelin mentions a patient ?et. 90, who had been
a paranoiac for forty three years but was not demented. Abbot believes,
however, that the delirium may continue to grow, and that the patient’s
judgment and reason diminish in relation to his delusional system, while
remaining good in relation to other matters. His deterioration—unlike
what is seen in all other dementing psychoses—is only in the line of his
delusional evolution. This fact, Abbot believes, is consistent with the
mechanism he has outlined. Havelock Ellis.

3. Sociology.

Criminology and Social Psychology. ( Medico■ Legal'J,ourtt ., April , 1917.)
Schroeder , T.

The author, a well-known New York lawyer, desires to promote
“a genetic, synthetic, and practical criminology.” It should also be
a general social psychological method, but he considers that it is in a
prison it may best be begun and worked out. First comes classification.
On the basis of a physical examination all curable physical evils must
be discovered and relieved at the outset. Then the subject is to be
turned over to the psychological laboratory, and if there are any defects

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which may be regarded as congenital removed for special training, and
if he is morbidly inefficient, sent to a suitable psychiatric institutions.
Among those now remaining in the prison will be found the important
group of recidivists who are physically and mentally little below the
average level. These require careful study, for they are symptomatic
of general psycho-social disorder, and demand a sympathetic under¬
standing. In dealing with them, “ the newly conceived need for
reforming the convict and restoring him to society replaces in our
interest the older idea of punishment.” The secret of the social
inadequacy of these criminals is largely to be found in their emotional
attitudes, and therefore Schroeder urges the importance of a psycho¬
analytic department in every prison laboratory. If sexual taboos and
ignorances are found influential in determining the emotional impera¬
tives which lead to anti-social conduct, it becomes necessary “to establish
a technique for the conscious reconditioning of the desires, so as to
make them progressively more mature; this should be a deliberate
part of the working programme of a prison laboratory.” Beyond this
is the possibility of a higher synthesis in unifying the measures for the
improvement of all our educational systems, so that we may advance
to the discovery of the factors in social psychology which determine the
criminal mind.

There are other methods which could be efficiently applied in prison.
Thus, for instance, a technique might be developed for class instruction,
aiming to discover and eliminate emotional conflicts, and to adapt the
desires to more mature aims. This involves a new sort of sex education,
dealing with emotions rather than with physical factors, and is a kind of
hygiene also needed outside prisons. As, indeed, we approach the
treatment of criminals with a larger vision, we shall find ourselves
anxious to help them, not alone for their own sakes, but in a still
higher degree as symptomatic products of unhealthy and infantile
stages in our psycho-social development as a whole. In learning how
to deal w’ith the criminal we are learning how to deal with society.
We select the criminal in the first place simply because the so-called
normal psyche can best be studied in its exaggerations. The criminal
must in future be studied with the desire to find out what is immature
or inefficient in the human factor of his larger environment. Thus it
is that criminology leads on to social psychology. We have to “under¬
stand and acknowledge the criminal tendencies in ourselves.” Some
day, the author believes, we may perhaps be able to eliminate from
healthy members of society all those impulses to anti-social behaviour,
only a small fraction of which are now penalised, and which may be
manifested even in our desire to inflict punishment. In these and
similar ways a prison psychological laboratory may be performing a larger
social service, even while merely carrying on effectively its own special
work. Havelock Ellis.

4. Asylum Reports for 1916.

Bethlem Royal Hospital .—The report of this institution is less
curtailed than most of the annual reports, and it contains much
interesting reading. Bethlem is fortunate in having started life some

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hundreds of years ago with a correct definition as the “ Hospitium
mente Captorum Londinense.”

Most of us entirely approve of the name hospital, but probably few
approve of the reason for the name, and under no condition could the
existing legal definition, based as it is upon the financial condition of
the patient, be held as wise, good, or valid ; it seems to us a very serious
defect in the existing Lunacy Act that it should implicitly hold the
view that because a man is poor he should be deprived of any privilege
whatever to which a slightly richer man is entitled, and that the
historically unpleasant name, of Greek derivation, of institutions for
the treatment of mental disease, should be specially reserved for the
poor—and that because a man is poor he is not allowed to place him¬
self under treatment for mental disease when he himself feels he
requires it. Few medical superintendents can have been in office
long without feeling this hardship of the poor, suffering from mental
affliction. Those institutions for mental diseases that have assumed
an unofficial title of a more pleasant kind have invariably, we believe,
discovered that a new and better atmosphere is created, which is
much appreciated both by the patients and their friends : moreover,
the name itself has some effect in inducing relatives to part with their
patients at an earlier date—and thus the patients come under treatment
more readily; for instance, in Bethlem we find that 76 per cent, of the
patients are admitted within six months of the declared inception of
the disease; whereas, taking at random two county asylums, the pro¬
portion varies between 29 and 45 per cent. only.

Dr. Porter Phillips makes some wise remarks on the subject of
future research :

“ I feel that I must again repeat, as I have done on former occasions, that for
the physical basis of the actual causation in the greater majority of these cases,
we must, in future, exert all our energies in the direction of biochemistry, and, to
some extent, to psycho-analysis ; with regard to the former suggested research I
would like strongly to recommend that when more favourable opportunities
present themselves, a pathological chemist be appointed on the staff of this
hospital.”

As regards causation, we note that alcohol was not a very promi¬
nent factor, and that masturbation was considered to be the principal
factor in producing mental disease in two cases; but Dr. Porter Phillips
agrees with most other mental specialists in holding the opinion that
the war has played but a small part in the aetiology of mental disease.

The recovery rate for the year under review was 59'3 per cent, on the
direct admissions, which compares very favourably with former years,
but, of course, is not in any way comparable with other institutions for
the treatment of mental disease, which have to receive all types of
cases.

The causes of death include one due to senile dementia and one
due to dementia alone—a somewhat unusual form of classification.

Beds , Herts , and Hunts. —Dr. Fuller has been fortunate in having
been able to get carried out more structural improvements than is
generally to be expected during war time, and most of these were
urgently necessary for the convenient and proper administration of the

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kitchen and stores, the more so as this institution has been generous
enough to receive on the usual terms patients from the two temporary
military hospitals established at Thorpe and Napsbury.

The admissions for the year were somewhat lower than what is
regarded as normal for the contributing area, on account of agencies
which appear to be common to all such institutions during the present
stress. Amongst the admissions, the leading aetiological factor was
considered to be moral, including domestic worry and adverse circum¬
stances (and here we note that the older classification of causes is used
in the letter-press, and the newer in the table), which appeared to be
potent in nearly 27 per cent, of the total cases, and in twenty-three cases
out of 149 this particular form of stress was deemed to be the principal,
essential, or chief factor. Heredity takes only second position as the
aetiological factor in about 21 per cent, of the cases admitted, and
alcoholic excess accounts for a little over 9 per cent.

The recovery rate was 42^4 per cent, on the direct admissions, and of
these recoveries it is particularly noteworthy that one case >s indicated
of recovery after a mental illness of nearly fourteen years, a case which
might fairly give cause for serious thought to a Divorce Commission
contemplating drastic reform in case of mental disease in one or other
partners in marriage. Amongst the recoveries another interesting case
occurs of recovery in a male general paralytic, and in this connection it
would be interesting to know whether this was a case really yielding to
active treatment by some of the newer remedies administered intra¬
venously or intramuscularly, since we know that this treatment is in so
many cases quite disappointing in such advanced cases of lesions of the
nervous system and, so complete and deceptive are the remissions in
these cases, that the greatest caution is necessary in deciding that
recovery has actually occurred in any given case.

The mortality for the year was 11 per cent., and of the total number
of deaths 36 per cent, were due to some form of tubercular disease.

In the midst of all the troubles and administrative anxieties of an
overcrowded and understaffed asylum, and all the other difficulties
incidental to war time, Dr. Fuller was unfortunate enough to be hampered
in addition by several puzzling and elusive cases of, fortunately, isolated
foci of enteric fever and diphtheria.

Essex County (a) Brentwood. —Dr. Turner continues his very valu¬
able record of the clinico-pathological and pathological work during
the year, and it is to be hoped that this work, which represents the
skilful and detailed observations of a highly-trained clinician and
pathologist, will at some later date see light in a different form more
accessible to pathologists generally. The work as reported is in itself
so condensed that it hardly lends itself to review in an adequate form
in the space at our disposal; a few points, however, may be referred to.

Sclerosis of one or other (in one case both), cornu ammonis. This
was found in the proportion of 37*5 per cent, of males and 36 per
cent, of females suffering from epilepsy, chiefly in the congenitally
defective.

As regards his continued observations on the presence or otherwise of
the sulcus lunatus and the stripe of Gennari, Dr. Turner remarks that—

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“ These results do not lend much support to the idea that a greater stretch of
stripe on the external surface of the cerebrum and the presence of a sulcus
lunatus are signs of degeneracy."

Subdural haemorrhages were noted in only one male case, and they
occurred in no single case of general paralysis (male or female). Pachy-
meningeal haemorrhages certainly appear to be less commonly found at
post-tnortem examinations than they were years ago, and the reason may
be attributable to some change occurring in the course of the disease.

As regards the presence of gliosis, the findings of which Dr. Turner
shows in a table, he draws the following conclusions:

“ These results, drawn from this year's findings only, are quite in accord with
those of previous years. So that speaking from the study of a fairly wide field of
cortex—from a large number of cases—there does not seem to be any warranty
for the statement so frequently repeated in text-books, and generally given on the
authority of Alzheimer and Mott, that gliosis is a pathological feature charac¬
teristic of dementia praecox.”

Colloid bodies, which are so commonly seen in certain types of
cases associated with degenerative changes, he found in a peculiar
form, observed chiefly in cases of Korsakow’s disease. This consisted
in the deposition of an enormous number of these bodies in the imme¬
diate neighbourhood of the vessels in the white matter at the tip of the
temporal lobe.

The pathological report contains much more that is both interesting
and valuable, and excerpts, taken at random, give but a poor idea of the
amount of work involved and the extreme and minute care taken in
this laboratory ; the report should, however, be read by all interested
in the pathology of mental disease.

The recovery rate calculated on the direct admissions was 21 6 per
cent., which suggests that Dr. Turner uses great discrimination in the
use of the word recovery in mental disease. The death-rate was
17 per cent, on the daily number resident, and of the deaths about
12 per cent, were due to pulmonary tuberculosis.

The administration of the institution must have been during the
past year no light task, seeing that ninety-nine members of the staff of
all kinds have joined the forces, and this includes departures from the
medical and clerical staff, one head attendant, two head nurses, and an
assistant matron. We should like to congratulate Dr. Turner on
maintaining his high standard of work under such difficulties.

Essex County ( b ), Scveralls. —Dr. Turnbull feels, like many under
similar circumstances, some of whom have even entirely suppressed
their annual reports for the duration of the war, that it is difficult, and
perhaps out of place, to present a report at any great length, but
deplores the difficulties of administration under the conditions, in which,
as he says : “ The normal routine of asylum life has to be modified daily
in process of adjustment to altering circumstances.”

Having already suffered from the invasion of the military at an early
date, his difficulties then became acute in finding accommodation for
the influx of patients from Napsbury, Wandsworth, and Norwich City,
amounting to 429 in all. How this was met is told in the Commissioners’
report:

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“ Owing to the arrangement that had to be made in order to receive additional
patients from other asylums it has been found necessary to use one of the wards
on the male side for female patients, and to accommodate the displaced male
patients a new ward has been formed containing thirty-nine beds. An annexe to
this new ward has also been contrived by using the committee rooms and offices
on the first floor over the main entrance as day-rooms and dormitories, etc.”

The Commissioners’ report also contained some interesting sugges¬
tions. It is somewhat extraordinary to read recommendations in the
case of an asylum so recently built as this of “ outside staircases to west
ward on the femak^side and 13 ward on the male side, which at present
have no second exits for use in case of fire.” And, again, as regards
the recommendations of the provision of verandahs attached to all the
hospital wards, it seems difficult to understand why they are not com¬
pulsorily embodied in all original plans nowadays, so that they would
form part of a coherent scheme, rather than adapted excrescences of
modified convenience ; in addition, committees are apt to resent being
instructed to add what are called essential structures to institutions
almost immediately after the original plan is completed.

The admissions for the year numbered 724, including transfers, as
mentioned above, and the percentage of recoveries on the direct
admissions was thirty, the death-rate being as low as 9^5 per cent., the
deaths from tuberculosis not being high.

Dr. Turnbull, like many others, has not been able to escape the
penalty of overcrowding, which showed itself in the form of an out¬
break of scabies, and latterly of enteric fever.

In the financial portion of the report it is noted.-’that, under the
heading “ Other payments,” the details of which are set out in full, an
item occurs showing payment of “ fees for recertification of patients.”
Assuming that this refers to “ lapsed certificates,” it appears to establish
a principle previously in doubt, and one frequently not admitted by local
government auditors.

Royal Eastern Counties' Institution , Colchester .—The report of this
institution shows an excellent record for the year. The average daily
number resident was 498, a considerable increase, in part probably due
to the incidence of the Mental Deficiency Act, and the greater activity
of local authorities in these matters, 86 cases having been received
during the current year under review; of these only 18 were under 10
years of age, and the average age was as high as 14^ ; it seems a pity that
the more educable of these should not come under the care of the
authorities at an earlier age seeing the excellent training facility here
provided. An idea of the mental standard and qualities of those
admitted is shewn by the classification which Dr. Turner gives :

Twenty-two high-grade cases.

Seventeen fair and promising cases.

Nineteen not promising, not containing material that may be improved
with education.

Twenty-eight hospital patients incapable of education.

Giving the satisfactory proportion of some 67 per cent, capable ot
benefiting by the training school.

The above form of classification has the merit of being intensely

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practical and indeed necessary, but one must confess that reading the
report from a medical point of view one would like to hear some details
of the fundamental types of idiocy and imbecility in each group.

Great praise is due to Dr. Turner for the personal and detailed care
in which the cases are graded for educative purposes, a matter which
requires a considerable degree of knowledge and experience. The
following extract concerning the working of the Peckover schools and
shops portrays something of the plan adopted :

“Undoubtedly we have striven to keep the school work and methods of training
up-to-date ; we have adopted new ideas wherever they seemed good, though it
must be confessed the new ideas are sometimes only old methods revived or in a
little different dress. The children who go to school are divided into four classes,
though each class is subdivided at least once. In the upper classes ordinary school
subjects are taught in the morning, combined with plenty of practical object-
lessons and drill, and in the afternoon all classes do some kind of manual work.
Girls and boys are mixed in the same class for the morning subjects. This has
enabled us to grade the different patients much more evenly than if the boys and ’
girls were kept in separate classes. A particular patient can be thus placed in.the
class to which he or she belongs by reason of their mental abilities, and no attention
need be paid to the question of sex. For the afternoon session the patients are
again regraded, some of those who are in the first class for manual work may be
much lower for ordinary school subjects. The lower classes take manual work
both morning and afternoon. Some of the teaching in these classes is very
simple, but one is often surprised at the results. I have had a large number of
blocks and bricks of all sizes and various shapes made in the carpenter's shop.
These have been painted different colours, but each colour has been made as bright
as possible. One of the drawbacks to the Montessori apparatus in my opinion is
the absence of any bright colouring. There is nothing to strike a defective
child’s imagination. Any patient who improves sufficiently is at once put into a
higher class.”

That this education results in an improvement of real practical value
is shewn by the following paragraph from Dr. Turner’s report :

“ The work in the training shops has fortunately gone on throughout the year
without interruption. I have already mentioned how much the institution is
indebted to the carpenter's shop for the furnishing of the new house on East Hill.
The wood-carving shop has suffered more than most of the shops. Suitable wood
canhot be obtained, and even if it could, people are not disposed to buy articles
which may be called luxuries. Many of the best wood-carvers have been drafted
into other shops where the work is more strictly utilitarian. The brush shop has
turned out many hundred more brushes than in any previous year. In addition
to private orders the brush contracts for two large asylums have been obtained,
and the shop has had to work at high-pressure throughout the year. All the frocks,
suits, and uniforms required for clothing the patients and staff have been made in
the institution, as well as the greater part of the underclothing for the patients.
We have been enabled to do this, because the girls’ workroom now contains a
large number of higher grade young women, who do good work in this way. When
the new workroom is built we ought to make and repair everthing that is wanted
in the way of clothing. The number of jerseys, stockings, and socks knitted on |
the machines has increased by nearly 100 per cent. Five thousand five hundred
pairs of boots have been repaired in addition to the new boots made. The mat
shop has had plenty of work throughout the year. The excellence and durability
of the mats made by the patients is now so well known that there are always
plenty of orders. The basket shop is not so well known, and we could put through
more orders than we receive for baskets and hampers. The elder girls have been
of great assistance in the laundry, and have enabled us to do without that increase
in laundry staff which would otherwise have been necessary; indeed, the number
of paid hands in the laundry is now one less, than when the number of patients was
half the present figure. The farm has had an excellent year. The value of the

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farm to the institution is very evident at the present time, and more land would be
a great advantage, not only from the point of view of supplies, but because it
provided good work for the stronger patients.”

Both the ordinary death-rate and the tubercular death-rate was
comparatively low.

City of London .—This report, like so many more, is so seriously
curtailed that a great deal that is generally interesting in it fails to
come under review.

This institution has given accommodation to a considerable number
of patients from Napsbury and St. Luke’s Hospital, but nowhere do we
find Dr. Steen complaining of overcrowding, nor in the report is there
any sign indicating a condition prejudicial to the general health of the
community; indeed, except for a small outbreak of influenza, the year
under review appears to have been remarkably free from .epidemic
disease. Forty-five members of the staff were absent on military service,
but the remainder of the staff appear to have risen to the occasion
demanded of them, and the Committee are able to express their high
appreciation of their work.

The admission rate for the year was 169, but owing to the absence
of the aetiological table there is no information as to causation. The
average for the previous ten years was 143, and the previous five years
was 135 ; there was, therefore, some enhancement in the admission rate
for the year, though Dr. Steen clearly is of opinion that the war and its
concomitant conditions do not at present, at any rate, produce any
appreciable effect on the community in this direction.

"To sum up: there are so far no evidences that there has been any increase in
insanity during the past two and a half years, and it is highly probable that there
has been an appreciable decrease,”

and this is the conclusion gained from a perusal of most of the asylum
reports in the country.

The recovery rate for the year was $2'$ per cent., and the death-rate
as low as 7^4 per cent .; the usual death-rate, however, of this institution
is lower than the average of the counties generally, which we understand
Dr. Steen attributes partly to the excellent Site and subsoil, partly also
no doubt to the very extensive use of the verandah system.

In the farm balance-sheet, we note that although “ cartage done for
the asylum ” is represented, and “ value of pig-wash ” is charged for,
for some reason there does not appear to be any charge made for the
labour of patients, which in many institutions, at certain times of the
year particularly, is an important item, and in these days of increased
wages still more so. It is difficult to assess this really accurately on
account of its fluctuating quality and quantity ; it is generally considered,
however, that an approximate estimate should be made to give greater
correctness to the farm account for comparison with non-asylum farm
accounts.

Borough of Middlesbrough .—The Borough admissions for the year
1916 were 66, which showed a decrease of 13 as compared with the
previous year; the total direct admissions were 83 and the indirect 6,
and from a table shown by Dr. Geddes, the proportion of certified

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insanity of the poor class, to the population of the Borough, has risen
from 1 in 517 in 1894 to 1 in 408 in 1916, the population itself having
risen from 75,532 in the former year to 125,718 in the latter.

The recovery rate is stated to be the “ very satisfactory one of 49^4 ”
calculated on the direct admissions. It is very remarkable to notice in
the different annual reports what each medical superintendent regards
as a satisfactory recovery rate; at the one end of the scale we find
Dr. Whitwell referring to 158 as a satisfactory recovery rate, and from
this, through the whole gamut, culminating in a recovery rate of 50
per cent, and over. The question really is, are we to do our best to
achieve a scientific standard to represent recovery in mental disease, or
are we to accept the lay or legal view, namely, that a man is recovered
when he appears to be, according to the understanding of the uninitiated ?
The public, though they may be stupid in the matter of mental disease,
cannot help noting the large number of “recoveries” that are con¬
tinually coming back to asylums (for instance, in one series of asylums
during a period of sixteen years the returned “ recoveries ’’amounted to
nearly 30 per cent.), and the result of these observations made by the
public is that many of them are beginning to think that they are quite
as well able to form an opinion in this matter as the mental expert. On
the other hand, we have the remarkable and curious fact that according
to the existing Lunacy Law there is not anything called “ recovery ” of
poor (pauper) patients, but only according to Sect. 83, of patients in
hospitals or licensed houses. Again, it is very seriously implied by that
Act that after all, the final court of appeal as to a man’s mental con¬
dition is not the doctor but the layman. If, then, we are to accept the
idea that a man is recovered, the moment he has ceased to be certifiable,
not only by the doctor but by the layman (Sec. 38 (6) b ), then a high
recovery rate is not only inevitable but dreadful; but if we are to accept
the undoubtedly more scientific, and probably more correct, view that
though many patients appear to the uninitiated to be well mentally,
much fewer really recover, then the high recovery rate must go, and the
low one rule, which to some people would seem appalling.

The death-rate for the year was 10 3, and the deaths included one
unusual case from shock following the reduction under an anesthetic of
a dislocation of the hip-joint sustained in an epileptic fit.

County of Salop and Borough of IVenlock .—Although the dissolution
is now complete between the counties of Shropshire and Montgomery
so far as mental disease is concerned, the Asylum at Bicton still
continues to receive Montgomery cases, the current receptions under
contract at 21 s. per week and some of the residual cases at 14*. per
week, it seems probable that the general increase in cost of everything
will shortly render the latter figure untenable from a business point of
view. The number of patients at present in the Asylum, owing to the
dissolution of the Counties, is practically the same as obtained thirty
years ago, as is shown in an interesting table of the population move¬
ments since the year 1876 Dr. Hughes also shows the ratio of the
insane to the population in the various contributing Union areas taking
the 1911 census as a basis, from which it appears that the more purely
agricultural areas, such as Drayton for instance (1 in 588), tend to have

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the smaller proportion of mental diseases; this seems to suggest the
absence of that serious depletion of the country for the supply of the
urban areas, which sometimes occurs. The borough of Shrewsbury
shows the highest ratio, namely i in 280, the corresponding figures for
England and Wales being at present 1 in 266.

The admission rate for the year was lower than usual; owing, however,
to the great reduction in the statistical tables, and as in other asylums
the general volume of the report, there is nothing to be gleaned as to
the relative value of the causative conditions in operation. The recovery
rate was 4i - 4 per cent., calculated on the direct admissions, which must
be regarded as a high one from an institution which takes every kind
of case without selection. The death-rate is remarkably low, namely,
8 9 on the average daily number resident, 17 9 per cent, being due to
some form of tuberculosis.

Dr. Hughes is to be congratulated on the loyalty of his subordinate
staff who so readily assumed the extra work thrown upon them by war
conditions, since he is able to report that married men, artisans, and
tradesmen willingly and readily consented to take turn to sleep in the
asylum if and when necessary, artisans and tradesmen in addition
volunteering to undertake ward duties after their working hours, an
unassuming and useful form of patriotism which might to advantage be
emulated in other walks of life.

Warwick County. —Dr. Miller received during the year 224 patients
of both sexes, from Rubery Hill, Hollymoor, and Northampton Asylums,
which had been converted into temporary military hospitals ; the normal
number, for which accommodation is provided, is not shown in the
report, but it is readily seen that this great influx caused considerable
overcrowding, which had indeed already been in existence, as it was
referred to in the report of the previous year. At Warwick County
Asylum they are unique to some extent in having such a considerable
area of covered airing-court which they were able to use successfully as
a dormitory for male patients, ninety patients having been comfortably
housed there for the past one and a half years. Tiie great diminution
of the staff (seventy-six of whom are on military service), together with
the sudden great increase of patients, necessarily, as in other similar
asylums, limited the freedom and liberty of the patients, though judging
from the very satisfactory and healthy state of the farm account, the
patients must have been fully employed in farming operations, and
Dr. Miller was even able to assist neighbouring farmers by the loan of
patient labour.

Amongst the admissions we note there was a larger proportion than
usual of congenital cases ; this is a thing which is disappointing to most
medical superintendents, who had hoped that with the advent of the
Mental Deficiency Act they would have been relieved of this particular
class of patients for which they, as a rule, have no suitable accommodation,
and for whom they have no means of training. It is, of course, true
that under present circumstances the provisions of the Mental Deficiency
Act cannot be carried out, and to all intents and purposes it is in
abeyance, but in many counties the medical superintendent of the
county asylum is not in such close touch as he should, in our opinion,

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be with the Mental Deficiency Committee, whose official adviser, we
believe he undoubtedly ought to be (and sometimes is). The result is
that the Mental Deficiency Committee in some cases deliberately and
of intention takes advantage of Sec. 30, ii, of the Act, to shirk any
responsibility of dealing with cases that have been touched by the Poor
Law, although in the summary of the report of the Royal Commission
upon the Care and Control of the Feeble-minded it is definitely stated
that “ we have come to the conclusion that intervention by the Poor
Law in the case of mentally defective persons should be based on the
principle that such persons are suffering from mental incapacity,” and
in the Mental Deficiency Act it is clearly intended that the county
asylum should not be utilised for the disposal of inconvenient imbeciles
in the workhouse, since provision for their removal or transfer occurs
in Sec. 16 (II) to an institution for defectives. Unfortunately, however,
under Sec. 341 Lunacy Act, 1890, the term lunatic means “idiot or
person of unsound mind,” and thus unless proper direction be given
to the actions of Mental; Deficiency Committees when the Mental
Deficiency Act comes into actual being and force, there would appear
to be a possibility (if nothing more) of a repetition of some of the defects
of the Lunacy Act of 1890, in that the poorer class of cases will be
deprived of opportunities of education and treatment to which they are
justly and rightly entitled. Warwick County Asylum has already resident
200 congenital cases.

The total admissions for the year were 230, and as to. causation,

“ stress either sudden or prolonged ” is assigned as the cause of the
attack in a large percentage of cases, though owing to the necessary
shortness of the report there is no table to show whether this was
regarded chiefly as a principal or contributory factor. Alcoholic excess as
a factor of either kind only occurred in a little over 5 per cent, of the
admissions. The recovery rate was 33 per cent, on the gross number of
admissions. The two largest factors in the death-rate were senility and
tubercular disease, the latter accounting for 19-8 per cent., and of this
Dr. Miller observes:

“ The deaths due to tuberculosis and pneumonia are more numerous than in
previous years. This will no doubt be found to be the case in all overcrowded
asylums. There has been much inevitable overcrowding in this asylum, a factor
which in my experience has had marked influence on the incidence of the diseases
mentioned, and our dietary has of necessity been considerably reduced, which also
has no doubt tended to diminish resistance in constitutions already enfeebled and
prone to disease.”

Royal Edinburgh Asylums , Morningside.

There is much to be learned from the Scottish institutions as regards
the grading of patients, so that a man may not necessarily become what
is called “ a pauper ” from the mere fact of losing his earning power
through mental disease, any more than he does by entering a public
hospital for bodily disease, unless in fact he really is poor to the degree
of practical destitution. Thus at Morningside we find accommodation
for private patients providing their own clothing at a sum as low as
15*. 4 d. per week, for intermediates at ic)s. 9 d. per week, and rate-paid
at i6r. id. per week, and it is certain that many of these former classes
in an English county would of necessity be classed as rate-paid or—

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unfortunate word—pauper patients. Moreover, in order to maintain
these figures as low as possible, consistent with the high cost of living,
the Board of Managers resolved to suspend in the meantime the opera¬
tion of the Sinking Fund, so far as repayment of debt is concerned, and
to increase the rates of board only to such an extent as to provide an
income sufficient to meet ordinary expenditure. But Morningside is
fortunate in having excellent charity and benevolent funds for the
assistance of the less fortunate. On these, however, in the year under
review so great was the call that the expenditure exceeded the
income.

The total number of cases admitted during the year was 424. Owing
to an unfortunate printer’s error in Table I it is not quite dear exactly
what proportion of these were first admissions, but approximately 344 is
the number, therefore the figures do not show any increase of insanity
in the contributing area.

On the subject of aetiology, Dr. Robertson speaks strqpgly of alcohol
as an exciting cause amongst the admissions for the year, but concludes
from the figures that during the year under review there has been
slightly less drinking to excess amongst men and slightly more amongst
women, but, on the whole, less than during the past few years.

" There is no doubt whatsoever that the amount of alcoholic insanity admitted
has been decidedly less since the war began than in previous years, and there is no
evidence in the statistics at my disposal that women since then have been drinking
more.”

This is an observation of considerable importance, having in view the
great prevalence of loose statements on this subject and especially
calling to mind the fact that the above result has been achieved in an
area which has not been under that strict Government control which is
said to produce such beneficent results. Syphilis seems to have been a
definitely determined cause in 14.7 per cent, of the cases of insanity
occurring amongst men.

“ In other words, one in every seven men suffered from irrecoverable insanity
produced by a preventible cause and by a very curable disease, provided that the
remedies which medical science has discovered were made use of at an early stage
by those who became infected with it. At last, however, something is to be done
for its organised treatment. I would impress upon the public bodies concerned
that they cannot do too much. The return, so far as the prevention of this
incurable form of insanity is concerned, would not be immediate, for it does not
develop as a rule till twelve years after infection, but in the end the country will be
amply repaid for all outlays, whatever these may be. Leith provides a higher
percentage of this form of insanity, in comparison with its population, than any
other district in Scotland, and Edinburgh comes third on the list. The Inverness
district, including the northern counties, comes last, with only one-eighteenth of
the percentage, at the head of the list.”

In the retiological table we note that the older form of the Medico-
Psychological Association is used, so that the convenient term “etio¬
logical factor ” with all its latitude is replaced by the more exacting
phrase “ probable cause.” There are several interesting points in this
table, to two of which we would draw attention, namely, a case of
mental disease in which the “probable cause” assigned was mastur¬
bation as a predisposing factor, and another of cancer of the breast, in a
similar relationship. By predisposition, one generally means not really

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a cause but an initial and sometimes innate condition resulting in less
resistance to a stress which we may call exciting or precipitating ; pre¬
disposition to an end is thus a state of equilibrium of less stability than
normal, but of varying degree. It is not, therefore, easily conceivable
that an act such as masturbation, or a condition such as cancer of the
breast, should be a predisposing cause; in each case there must have
been a chain of events preceding them, of which this particular event is
but a terminal incident of comparatively small import. Such incidents
may, of course, be terminal factors, or in the one case a mere symptom
—whether they ever rank as “ predisposing causes ” is certainly open to
doubt.

Dr. Robertson gives some well-timed and temperate remarks on the
subject of spiritualism and its relation to mental diseases ; he regards
the publication of Raymond as lamentable, a view accepted by many,
and shows how dangerous spiritualism may be to those of neurotic
temperament.

" 1 would remind inquirers into the subject that if they would meet those who
are hearing messages from spirits every hour of the day, who are seeing forms,
angelic and human, surrounding them that are invisible to ordinary persons, and
who are receiving other manifestations of an equally occult nature, they only
require to go to a mental hospital to find them. It is true that the modern
physician, by a long study of these phenomena, has come to regard them as
symptoms of! disease, and has renounced the doctrine of possession by spirits,
though it had, the double merit of simplicity and of antiquity to support it. If
honest mediums do exist who hear inaudible messages or feel communications
without words, or see forms invisible to others, the mental physician accustomed
to ‘symptoms’ is inclined to regard their ' gifts’ as being, if not morbid, at least
as closely related to the morbid, with no element of anything ‘ occult ’ about
them.

“ I desire to warn those who may possibly inherit a latent tendency to nervous
disorders to have nothing to do with practical inquiries of a spiritualistic nature,
lest they should awaken this dormant proclivity to hallucinations within their
brains. I have known such a person who had lost her son following the procedure
in vogue at present, under advice, first hearing of him through mediums, then
getting into touch with him herself and receiving messages from him, some as
impressions and others as audible words, then increasing her circle of spiritual
acquaintances and living more for her spiritual world than for this, to the neglect
of her husband and household, till finally God conversed with her in a low musical
voice at all times, and confided His plans for the future to her. I would ask
spiritualists where in this case does spiritualism end and mental disorder begin ?
Do they overlap ? Dcf they exist ? Or is there such a state as disordered mental
function at all ? Or is it that spiritualism was wholly absent from the case ?

“ While inquiries into spiritualism sometimes lead to insanity in the predisposed,
I have found more frequently that to persons suffering from the simple forms and
early stages of mental derangement, the theory of spiritualism has a great fascina¬
tion. It is simple—a child can understand it—indeed, it is the explanation of the
primitive savage for all the actions produced by the mysterious forces of nature.
When, therefore, a person suffering from the early symptoms of insanity hears
imaginary voices, or experiences strange feelings and impressions, he finds in
spiritualism a ready and a comforting explanation of these phenomena, and he
becomes interested in the subject. However injurious spiritualism may be to these
persons in retarding recovery, it would be wrong to say that it was the cause of
their derangement.”

In another book on spiritualism recently published (The Dangers of
Spiritualism, Raupert), we notice that several of the cases there set out
in detail were obvious cases of crude mental disease familiar to all
mental students.

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Of the admissions, the melancholic form of manic-depressive insanity
was predominant, the difference in the proportion of the cases in different
areas is very marked, and appears at present inexplicable. Another
noteworthy feature in the admissions is the somewhat large proportion
of cases of “ infective-exhaustive ” insanity (presumably confusional
insanity), namely sixty-four in 424 admissions.

The recovery rate for the year was 30 per cent, calculated on the
admissions. In some quarters much capital has been made out of the
fact that, on the figures as published of mental disease, there has been no
increase in the recovery rate during the past fifty years ; we would go
still farther, and claim that there has been an actual diminution in the
recovery rate, as shown in statistics, for this period, as almost any
asylum tables will show. The fact of the matter is that our knowledge
in these matters has increased, and we are now better able to
differentiate between true and false recovery than we have ever been,
and instead of the deduction being that the study and knowledge of
insanity has not progressed, the deduction should really be that it is
because the study and knowledge of mental diseases has progressed,
that the recovery rate, as shown by statistics, has not increased or even
become lower. In the tables before us, showing the history of the
annual admissions since the opening of the asylum, it seems clear that
in the earlier years, some forty years ago when the recovery rates soared
to 48—55 per cent, on the admissions, a large number of these cases
were made up of non-recovered cases ; in one year the relapsed cases
formed 38 per cent, of the total admissions, and in the preceding forty
years they formed 31 per cent., while in the year under review they only
formed 23 per cent. While discussing the subject of recovery rates in
mental diseases over a period the very pertinent question might with
justice be asked, has the recovery rate in any disease of the nervous
system increased greatly in the same period ? The answer is in the
negative, but there are keen and earnest men working at both nervous
and mental disease, and those who cavil at results have forgotten
Tennyson’s line : “ Science moves but slowly, slowly, creeping on from
point to point,” and clamour for immediate and dramatic developments.
As regards the “ ill-considered advertisements for subscriptions for
hostels,” which disfigured a well-known daily paper, Dr. Robertson
makes some sound remarks ; we ourselves challenged each statement
in the paper as it was published, and were perhaps to some extent
responsible for their modification in the later issues.

“ In connection with the care of neurasthenic but not insane soldiers, I observe
ill-considered advertisements for subscriptions for hostels, which are doing a
public disservice by contrasting unfavourably the useful and excellent work done
in asylums, in the advocacy of their own schemes. Practically all asylums in this
country have large farms, gardens, and grounds attached to them, yet there
recently appeared the suggestion, by a suppressio veri, that ‘work on the land’ is
the distinctive feature of these places. There is no antagonism between hostels
and mental hospitals, as both varieties of establishments are necessary for appro¬
priate cases, and, so far as I know, no case of neurasthenia only has been sent to
an asylum. The converse, however, does not hold good, for a neurasthenic officer
recently sent to a home found the patient on one side of him suffering from
convulsions, and a deranged patient making trenches of his bedding on the other.
He would rather have been in a well-appointed mental hospital provided with
ample resources of every kind and good classification."

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Both the ordinary death-rate and the tubercular death-rate were low
for the year.

Roxburgh District .—We miss Dr. Carlyle Johnston’s hand in this
year’s report, and regret that his unsatisfactory health compelled him to
resign an office which he had held with great credit to himself and
marked advantage to the institution under his control for thirty-one
years. We hope that the removal of his responsibilities will allow him
to regain his health and enjoy his well-earned pension for many years.

The admissions for the year numbered seventy-one, a somewhat
lower admission rate than that of recent years, which Dr. Steele points
out is largely due to the diminution in the civil population by the opera¬
tion of the Military Service Act. Of these admissions twenty were re-
admissions consisting of patients who had mostly been intermingling
with the ordinary community for periods varying from one year or less
up to thirty-five years.

As to aetiology, alcoholic cases do not appear to assume large pro¬
portions, and in no case is this regarded as a predisposing factor.
Adolescence and senility Dr. Steele regards as predisposing causes, an
attitude we are strongly inclined to think may be the correct one if this
nomenclature is used, but in one case senility is regarded as an exciting
cause, and this is due doubtless to the dilemma in which the former
tables of the Medico-Psychological Association continually landed us,
which is avoided by the use of the terms “ principal ” and ‘ contribu¬
tory,” which are more elastic, and give more latitude in apportioning
the relative values of the factors in causation.

Dr. Steele, like most other Medical Superintendents, speaks with
considerable caution as to the effect of the war and its concomitant
conditions on the production of mental disease in the community.

“ The admissions included two soldiers from the Army. The question as to
what influence the war is having on the causation of mental disease is a difficult
one, and cannot be satisfactorily answered until the number of men who have
become insane whilst on active service is known. The likelihood is that there may
be some, though possibly not a very marked, increase in the numbers of the
mentally affected. It seems only reasonable to expect that some men of a neurotic
temperament and with hereditary predisposition, who, under the comparatively
quiet and uneventful conditions of peace, might have avoided a mental breakdown,
may succumb to the physical and mental strain of service in the field.”

The recovery rate for the year was 3o - 9 per cent. The mortality rate
was 107 per cent, of the average number resident, and 20 per cent, of
the deaths were due to some form of tuberculosis. Amongst the deaths
we note the case of a female patient between seventy-five and eighty
years of age in whom the cause of death assigned was purpura, we assume
this was not a case of true purpura, so rare at such an age, but a case
of cachectic purpura, so common in senile debility, but so rarely the
actual cause of death.

Glasgcnv Royal Asylum , Gartnavel. —The number of patients resident
in this institution shows but little increase at the end of the year com¬
pared with the number at the commencement, in fact, the average
number resident has only shown minor fluctuations for many years back.
The admissions for the year were slightly higher than in the previous year,

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which was, however, an unusually low one. There is a very striking
difference in different asylums in the United Kingdom in the proportion
of male and female cases, and various explanations are given of this in
different areas. Dr. Oswald points out, firstly, that the male admissions
to Gartnavel have always been fewer than the female; and, secondly, that
the excess of females over males, both in admissions and in “ number
remaining,” applies only to private patients :

“ for in the rate-supported class the admissions of males to the asylums of Scotland
in 1915 was considerably in excess of the females, and at the close of 1915 there
were four hundred fewer women than men resident. The difference is to be
explained by the fact that the man is usually the bread-winner, and when he
becomes ill there is no one to support him as a paying patient, whereas in the case
of a woman becoming mentally affected she can be maintained, for a time at all
events, by her wage-earning relatives.

“ Apart from this class distinction, the admissions into all Scottish asylums in
1915 show that insanity was nearly equally divided between the sexes, the increased
frequency of general paralysis and alcoholic insanity in men being balanced by the
greater number of women who suffered from melancholia, or who broke down at
the climacteric period."

That some slow-acting agency is gradually producing variations in the
type of mental disease occurring in the community is clearly shown in
many cases, though its varying degree is very striking in different areas,
and it would appear to be a corollary to the proposition that evolutionary
changes are occurring in the race type, and its mentality, and on this
subject Dr. Oswald remarks :

“ It is believed by some that mental disorders are changing in type, and that
states of depression are becoming more common, and states of mental excitement
less so. Acute mania—excluding that due to general paralysis or alcohol—is
certainly now less frequently met with, and, among the poor at all events, melan¬
cholia, due often to an impaired physical condition, is the most common of all the
psychoses. Among the educated classes delusional insanity is, however, very often
the form the illness takes, and such cases are among the most troublesome of all
to treat.”

Of the causes of insanity amongst the admissions for the year, the
largest single cause appears to be alcohol ; with or without the addition
of predisposing causes it accounted for 14 percent, of all the admissions.
Stress of various kinds is regarded as the “determining factor,” with or
without predisposing cause added, in another 14 per cent., and here Dr.
Oswald explains that in cases where more factors than one seemed to
operate, he tabulates the illness as being due to the cause which, having
regard to all the circumstances, he believed to be the determining
factor. The table of causes which he shows is somewhat different in
arrangement to the older form of that adopted by the Association, and
an improvement on it—it is doubtful, however, whether the new table
of etiological factors would not be better for showing the probable
relationship in the etiology when more than one factor appears. We
certainly confess to some diffidence in accepting without qualification
or modification the view that senility and adolescence are in themselves
the causes of mental disease, since it argues that the effect of the inci¬
dence of the adolescent period and that of senility is to produce mental
disease, a somewhat difficult thesis to hold.

The death-rate was the unusually low one of 5'3 per cent, on the

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average number resident, and the tubercular disease death-rate was
practically negligible.

Aberdeen Royal Asylum .—It is probable that there are greater possi¬
bilities of refinements in classification of patients in some of the Scottish
Asylums than exists in the majority of English County Asylums; the
fact that this institution of a total population of 885 at the time of
writing has four distinct divisions, namely,—Main Institution, Hospital,
Elmhill House, and Daviot Branch is evidence of this, and possibly the
relatively larger number of female nurses employed in the male division
compared with the average English County Asylum is thus explained.
Possibly also national temperament and type of case affect this question.
In many parts of England, however, at the present time there is to be
found a greater difficulty in filling female than male vacancies on the
nursing staff, owing to reasons that are frequently called patriotic, but
are more commonly financial and social.

“There have been many changes in the nursing staff, caused, for the most part,
by the war. Every endeavour has been made to release men for military purposes,
and, as far as possible, to replace them by female nurses. There are now sixteen
nurses in the Male Division, occupying such positions as are considered prudent
and desirable. For long it has been found that, with the aid of male attendants,
they are admirably suited for the care of the sick, infirm, and debilitated patients.
The unfortunate circumstance is that, at the present time, the limit to this system
has been reached in this institution.”

The admissions for the year, both private and parish, show a decrease
of five in the former case and forty-one in the latter, but, in spite of this,
Ur. Reid points out that the admission rate is the second highest since
the opening of the District Asylum in 1904, and the incidence was
highest between the ages of 40 to 55.

As regards causation, alcoholic intemperance does not appear to form
a prominent factor, and syphilis occupies a similar position. In the
aetiological table we notice with some interest that puberty and senility
are regarded chiefly as factors of an undeterminable position as regards
importance, while adolescence is frequently promoted to the position of
a predisposing cause. The difficulty of correctly placing these factors
in their proper relationship is very great, as is shown in report after
report—it seems safe to regard them as contributory factors without
necessarily committing oneself to their degree of potency in each case.

Of the deaths, tuberculosis of all kinds showed a death rate of about
11 per cent., and it will be remembered that in previous reports Dr. Reid
has on occasion shown extremely low tubercular rates, which he attri¬
butes to the extensive use of the verandah system, and free exercise in
the open air in all weathers.

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NOTES AND NEWS.

IOI

Part IV—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly Meeting of the Association was held at No. ii, Chandos
Street, London, W. i, on Tuesday, November 27th, 1917, Lieut.-Colonel David G.
Thomson, M.D., R.A.M.C. (President), in the chair.

There were present: Sir George H. Savage, Sir R. Armstrong-Jones, and Drs.
T. Stewart Adair, Fletcher Beach, David Bower, A. Helen Boyle, James Chambers,
Maurice Craig, R. H. Cole, A. W. Daniel, J. F. Dixon, T. Drapes, R. Eager, J.
H. Earls, C. F. Fothergill, A. Hume Griffith, N. Lavers, T. S. Logan, M. E.
Martin, A. Miller, A. W. Neill, Bedford Pierce, J. G. Porter Phillips, J. N.
Sergeant, G. E. Shuttleworth, R. P. Smith, T. E. K. Stansfield, James Stewart,
R. C. Stewart, C. M. Tukc, H. Wolsley-Lewis, and R. H. Steen (Acting Hon.
General Secretary).

Present at the Council Meeting : Lieut.-Colonel D. G. Thomson, M.D., R.A.M.C.
(President), in the chair, Sir Robert Armstrong-Jones, and Drs. T. S. Adair, A.
Helen Boyle, James Chambers, R. H. Cole, Thos. Drapes, R. Eager, J. G. Porter
Phillips, J. N. Sergeant, G. E. Shuttleworth, T. E. K. Stansfield, H. Wolseley-
Lewis, and R. H. Steen (Acting Hon. General Secretary).

Dr. Bedford Pierce attended on the invitation of the President.

The following sent communications expressing regret at their inability to be
present: Drs. C. C. Easterbrook, J. G. Soutar, John Keay, E. W. White, N.
Lavers, H. T. S. Aveline, G. D. McRae, C. A.Crichlow, W. R. Watson, and A. N.
Boycott.

The minutes of the May meeting were taken as read, they having already
appeared in the July number of the Journal, and signed as correct.

The President said he had to inform the meeting that a Special Meeting of
the Council was held on September 20th for the purpose of appointing a Treasurer.
At that meeting the Council, acting within its powers, appointed Dr. Chambers,
of Roehampton, to be the Association’s Treasurer, in place of the late Dr. Hayes
Newington.

Before beginning the actual business it was his painful duty to report to the
meeting the deaths, tragically enough on the same day, of two of the great pillars
of this Association—Dr. Hayes Newington and Dr. Urquhart. Both died shortly
after the last Quarterly Meeting. In the ordinary course it would have fallen to
his duty to pronounce a panegyric on the work and worth of those two deceased
members, but, opportunely, in the October issue of the Journal of Mental Science,
there appeared an excellent account of the careers of both. Under those circum¬
stances he did not propose to detain the meeting with any long story of the life’s
work of those two men : it was well known to all those present, and he felt that
any words of his would be but feeble, and could not in any way supplement what
had been so well said in the articles referred to. He asked the meeting to pass,
by upstanding, a resolution of condolence with the families of Dr. Newington and
Dr. Urquhart, which he formally moved.

The vote was passed accordingly.

In addition to those two gentlemen, death had laid its hand heavily on other
members, and these losses were equally sad and deserving of sympathy. The first
was that of Dr. William Graham, who was Medical Superintendent of Belfast
District Asylum. Any of the members who were at the British Medical Associa¬
tion meeting in Belfast some years ago, and who visited the asylum at Purdysburn,
would know what valuable and splendid work Dr. Graham did there. The tragedy
of his somewhat premature death was described in the British Medical Journal,
p. 674. His death was the sequel of an accident, which happened while he was
still in the prime of life and energy.

Another of the deaths was that of Col. James Hyslop, D.S.O., who was Deputy
Director of Medical Services of the Union of South Africa. He died at the
Sanatorium, Pietermartizburg, on October 5th, at the age of 60. He also was
known for the general good work which he did in the South African States, and

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for his special work in the asylum at Pietermaritzburg. He moved a resolution of
condolence with the relatives of those deceased members.

This also was carried by members upstanding.

The following gentlemen were duly elected members:

McIvek, Colin, Capt., I.M.S., M.R.C.S., L.R.C.P., c/o Messrs. Grindlay
& Co., 54, Parliament Street, S.W.

Proposed by Drs. J. G. Porter Phillips, W. H. B. Stoddart, and R. H.

Steen.

Wright, Maurice B., Major, R.A.M.C., M.D., C.M.Edin., Mental Specialist,
Eastern Command, 118, Harley Street, London, W.

Proposed by Drs. J. C. Woods, Maurice Craig, and R. H. Steen.

Dr. Adair and Dr. Sergeant acted as scrutineers.

The President said a letter had been received from Dr. David Orr, of Prestwich
Asylum, expressing the regret of himself and his co-author that neither were able
to attend to present their paper in person, as they were unable to leave in con¬
sequence of emergency war work. Dr. Devine, a colleague of Dr. Rows, would
present the paper.

Paper.

Dr. David Orr and Major R. G. Rows, R.A.M.C.: " Further Observations on
Experimental Toxi-infections of the Central Nervous System ” (with lantern
illustrations). (See p. 18).

The President expressed the thanks of the meeting to the authors for having
made the Association privy to the important work they were carrying out in this
domain of pathology.

Sir George Savage said he would like to suggest that when important and
intricate scientific contributions, such as this one, were presented to the Associa¬
tion at its meetings, it would be a great advantage—certainly it would be to him—
if a precis could be circulated beforehand.

The President expressed his agreement with what Sir George Savage had
said. The suggestion wotdd be carefully considered by the Council, and he did
not doubt it would be acted upon. It was a common practice in societies which
were doing scientific work, and he did not see why it should not be followed by
this Association.

It only remained for him to thank Dr. Orr and Major Rows for their contribu¬
tion ; they kept the Association up to date with researches, and members could
imagine the zeal and energy with which they were pursuing their work, at this
time when everybody was working so strenuously.

NORTHERN AND MIDLAND DIVISION.

The Autumn Meeting of the Northern and Midland Division was held by the
kind invitation of Dr. Jeffrey at Bootham Park, York, on Thursday, October 25th,
1917.

Dr. Jeffrey presided.

The following seventeen members were present : Drs. M. A. Archdale, J. G.
Blandford, A. J. Eades, J. W. Geddes, F. P. Hearder, T. Herbert, G. R. Jeffrey,
W. S. Kay, R. McD. Ladell, T. W. McDowall, H. J. Mackenzie, H. D. MacPhail,
S. R. Macphail, B. Pierce, M. L. Rowan, J. B. Tighe, and T. S. Adair, and one
visitor, Dr. C. S. Lowson.

Several apologies for non-attendance were received.

The minutes of the last meeting were read and confirmed.

Drs. McDowall, Pierce, and Street were unanimously re-elected to form the
Divisional Committee for the ensuing year.

Dr. Bedford Pierce gave some notes of an interesting case he had had under his
care of a patient with a peculiar periodicity, being to all intents and purposes
insane one day and sane the next. This condition was kept up for a long period—
the patient finally left the asylum. She came back at a later date, but on this
occasion had lost the periodical character of her insanity.

The question of rationing in the asylums, and the present difficulties in the way
of obtaining satisfactory food supplies wasthen generally discussed and considered.
A good many different experiences were given both as to the results of using a

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diminished allowance of bread and as to the difficulty of obtaining and using
satisfactory substitutes.

A very interesting meeting was terminated by a hearty vote of thanks to Dr.
Jeffrey for so kindly welcoming and entertaining the members.

SOUTH-EASTERN DIVISION.

The Autumn Meeting of the South Eastern Division of the Medico-Psycho¬
logical Association was held at the Springfield War Hospital, Beechcroft Road,
Upper Tooting, S.W. 17, at 2.30 p.m. on Thursday, October 4th, 1917.

The following members were present : Drs. D. Bower, J. Chambers, M. D. Eder,
J. H. Earls, C. F. Fothergill, E. G. Fearnsidcs, A. H. Griffith, S. f. Gilfillan, H.E.
Haynes, H. J. Norman, N. Oliver, G. E. Shuttleworth, R. H. Steen, R. Worth,
and J. Noel Sergeant (Hon. Div. Sec ).

Major Worth took the Chair.

The minutes of the last meeting were read and confirmed.

Dr. Fearnsides was unanimously elected an ordinary member.

The date and place of the Spring Meeting were left to the discretion of the
Secretary.

Major Worth was elected a member of the Divisional Committee of Manage¬
ment in place of Dr. R. P. Smith, who had intimated his inability to act.

Major Worth called upon Dr. Fearnsides to read his paper on “ Neurasthenia
and Shell Shock," and then read his own paper on “ The After-care of Shell Shock
Cases.”

A short discussion followed, in which Drs. Eder, Fearnsides, Sergeant, Steen,
and Worth took part.

At this stage the members availed themselves of the tea which had been
hospitably provided, and carried on the discussion in a more informal manner,
after which a brief clinical exhibition of some interesting cases terminated a most
enjoyable and instructive meeting, for which the gratitude and thanks of the
members are due to Major Worth.

SOUTH-WESTERN DIVISION.

The Autumn Meeting of the above Division was held, by the kind permission
of Dr. MacBryan, at 17, Belmont, Bath, on Friday, October 2Gth, 1917, at 2.30 p.m.

The following members were present: Dr. Aveline, Lt.-Col. J. R. Benson, Drs.
Lavers, MacBryan, MacDonald, Nelis, and the Hon. Div. Secretary, Dr. Bartlett.

Dr. MacDonald was voted to the chair.

Letters of regret for non-attendance from Drs. Devine and Soutar were read.

The minutes of the last meeting were read and confirmed.

Dr. Bartlett was nominated as Hon. Divisional Secretary, Dr. Aveline kindly
expressing his willingness to undertake the duties should Dr. Bartlett be called for
military service.

Drs. Aveline and MacBryan were nominated representative members of Council.

The place of the Spring Meeting (April 26th, 1918) was left in the hands of the
Secretary for arrangement.

The decease of the Treasurer, Dr. Hayes Newington, was recorded with regret,
and comment made on the great loss thereby sustained by the Association. The
Hon. Secretary was requested to convey the deep sympathies of the members
present to his sorrowing relatives.

Dr. Bartlett reported and made comments on the case and post-mortem exami¬
nation of a microcephalic idiot, the chief point of interest being the absence of the
corpus callosum.

The institution in asylums of Lord Devonport’s scale for flour, meat, and sugar
provided an interesting discussion, in which all the members present participated.
The following points were discussed : (1) the exceeding of this scale in the case
of flour only as regards the patients’ dietary; (2) the best methods to prevent
waste in institution catering; (3) the value of the saving effected by the substitu¬
tion of the flour used over and above the allowance by other cereal foods ; (4) the
difficulties arising in catering for the staff; (5) the staff diet scale published in
asylum reports, and how far this is binding on asylum authorities; (6) the right of

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the staff to claim the full pre-war issue on this scale ; (7) the comparison of the
cost of the reduced rations with the full pre-war issue on which the value of
emoluments for superannuation purposes was fixed; (8) the right of the staff to
claim a diet, equivalent in value to the amount fixed as board emolument; (9) the
grounds on which permanent increases in salary and war bonuses had been gene¬
rally given, and to what extent the reduction in food was thereby compensated ;

(10) the payment of a weekly sum of money in lieu of the rations deducted, as at
present conceded in some asylums, and the basis on which this sum is computed ;

(11) the making up of the deducted diet with available substitutes, and so forming
an acceptable and variable diet, as already favoured by some asylums. It was
generally agreed that if all waste could be stopped there would be little, if any,
need for rationing. The principle of fixed allowances was not considered as con¬
ducive to economy. There was a concensus of opinion that the fresh difficulties
created through forced changes in the administration of institutions have produced
troubles of an unexpected character, and considerably added to the cares and
anxieties in the successful administration of asylums. Further, the different
methods of dealing with the difficulties associated with the introduction of rationing
the staff have not tended towards a general or ready acceptance of the many earnest
and well-intentioned endeavours to meet and cope with unforeseen troubles. Apart
from any question of right (which could only be determined by a test case) it was
thought that the all round increase of wages fairly met any reduction in the
dietary, and, further, it had to be remembered that the question of rationing
applied to everyone.

SCOTTISH DIVISION.

A Meeting of the Scottish Division of the Medico-Psychological Association
was held at the Edinburgh War Hospital, Bangour, on Friday, November 16th,
1917 -

Present: Lieut.-Col. Keay, Major Hotchkis, Capt. Laurie, R.A.M.C.; Drs.
Dods Brown, Crichlow, Carlyle Johnstone, Kerr, Mackenzie, G. M. Robertson,
Ferguson Watson, and Dr. 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 loss which the Association and the Scottish Division
had sustained since last meeting through the death of Dr. A. R. Urquhart, formerly
Medical Superintendent of Murray's Royal Asylum, Perth. He stated that Dr.
Urquhart had taken a very active part in the affairs of the Association, having been
President in 1898, co-editor of the Journal of Mental Science, and Divisional
Secretary for Scotland for several years.

It was unanimously resolved that it be recorded in the minutes that the members
of the Scottish Division of the Medico-Psychological Association desire to express
their deep sense of the loss sustained by the death of Dr. A. R. Urquhart, and
their sympathy with his relatives in their bereavement, and the Secretary was
instructed to transmit an excerpt of the minutes to the relatives.

The Chairman also suitably referred to the great loss which the Association
had sustained through the death of Dr. H. Hayes Newington, a former President,
and Treasurer of the Association since 1894.

It was unanimously resolved that it be recorded in the minutes that the
members of the Scottish Division of the Medico-Psychological Association desire
to express their deep sense of the loss the Association has sustained by the death
of Dr. H. Hayes Newington, and their sympathy with his relatives in their
bereavement. The Secretary was instructed to transmit an excerpt of the Minute
to his relatives.

The minutes of last Divisional meeting were read and approved, and the
Chairman was authorised to sign them.

Apologies for absence were intimated from Lieut.-Col. Thomson, President of
the Association; Majors Eager and Stansfield ; Capts. Stewart Campbell and
Steele; and Drs. Yellowlees, Fraser, Easterbrook, Alexander, Tuach Mackenzie,
and Shaw.

The Secretary submitted a letter of acknowledgment received from the

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relatives of the late Dr. Turnbull, thanking the members of the Division for their
kind letter of sympathy.

A letter was also submitted from Dr. Carlyle Johnstone thanking the members
of the Association for their kind expressions towards him on his retirement from
the Medical Superintendentship of Roxburgh District Asylum.

The business Committee was appointed, consisting of the nominated member
and the two representative members of the Council, along with Drs. Carlyle John¬
stone, Maxwell Ross, and the Divisional Secretary.

Drs. L. R. Oswald and J. H. Skeen were nominated by the Division for the
position of Representative Members of Council, and Dr. R. B. Campbell was
nominated for the position of Divisional Secretary.

The members were then conducted over part of the hospital by Lieut.-Col. Keay.
The orthopaidic workshops were first visited, when an opportunity was given to
seethe various ways in which incapacitated soldiers were being trained in useful
forms of employment. The electrical department was next visited, when Major
Rankine, Officer in Charge, explained the various forms of treatment, etc. Lieut.-
Col. Stiles then gave a most instructive and interesting demonstration of various
nerve injuries caused by wounds, explaining the surgical methods which had been
successfully adopted to overcome many nerve lesions.

A vote of thanks to Lieut.-Col. Keay, Lient.-Col. Stiles, and Major Rankine for
the great trouble which they had taken to make such an interesting and successlul
meeting, concluded the business of the meeting.

After the meeting the members were kindly entertained to tea by Lieut.-Col.
and Mrs. Keay.

IRISH DIVISION.

The Autumn Meeting of the Irish Division was held on Thursday, November
1st, 1917, at the Royal College of Physicians.

Members present: Dr. J. O’C. Donelan, Dr. Drapes, Dr. Gavan, Dr. T. A.
Greene, Dr. Mills, Dr. Rainsford, Dr. Rcdington, Dr. Rutherford, and Dr. Leeper
(Hon. Sec).

Dr. Drapes having been moved to the chair, the minutes of the previous meeting
were read and signed.

Letters of apology for unavoidable absence were received from Dr. Hetherington,
Londonderry, and Dr. Greene apologised to the meeting for the unavoidable
absence of Dr. Nolan of Downpatrick.

A ballot for the election of two new members was next proceeded with, and
Dr. Redington was appointed scrutineer.

The Chairman declared that Dr. Christopher Costello and Dr. Vincent C.
Ellis, Assistant Medical Officers of Portrane Asylum, Donabate, were elected
unanimously.

It was proposed and seconded that in future elections of members, the word
“unanimous” should be omitted in declaring thv.- result of the ballot.

The Secretary was directed to forward a resolution of condolence to Dr.
Oakshott, of Waterford upon the death of his only son, who fell gallantly
leading'his men in action at the Front.

Dr. Mills next read his paper on "Homicidal Impulse,” which produced a
most interesting discussion.

Dr. Mills said: I have chosen to speak on a subject on which there are wide
diversities of opinion, and the views I intend to express are based on accumulated
experience in the treatment of various insanities, and I will welcome criticism of
my view's, and hope to receive help and enlightenment therefrom. I regret that
pressure of other duties and pre-occupation of my time with the details of admini¬
strative work incumbent on my office have prevented me from presenting a
scholarly exposition of authorities, as is usually done when papers are read at
meetings of the Medico-Psychological Association, but I offer for criticism my
views as regards the alienation of patients suffering from what I call the homicidal
impulse. The class of cases I propose to speak of from personal experience are
those outlined in the following words of Bianchi, translated by MacDonald,
quoted from the chapter on “ Fixed Ideas and Obsessions ” :

“ We now come to describe another group of obsessions—the obsessive

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impulses. These are ideas which have a motor content, which present themselves
before the consciousness, and, either directly or through the law of contrast, exert
irresistible power of translating themselves into action. These are the so-called
impulsive ideas ; they are the reflex of identical precepts, or they arise through
contrast. Once they have reached the field of consciousness these precepts fix
themselves there, in open contrast with the sentiments and tendencies of the
subject.”

The foregoing quotation seems to me to provide an admirable synopsis of the
type of cases I am dealing with, but a very insufficient and unsatisfactory elucida¬
tion of the underlying motives. I have in mind some cases in which the dominant
obsession was towards sudden, impulsive, reckless, brutal, unprovoked violence
against others. The first was that of L. M—, who is generally pleasant, suave,
agreeable, good-tempered, and well-mannered, fairly well educated and intelligent,
and answering questions with a ready treacherous smile. He has lived for years
the institutional life of fellowship, if not comradeship, with others, and has
suddenly made attacks on them with a furious malevolence that the Anthropoid
might envy but could not excel. If it were not that help was forthcoming, one at
least of the protagonists would be in very much the condition in which Kipling
tells us that Bertrand and Bimi were found, and yet a few minutes afterwards he is
quiet and composed, wears the same treacherous smile, assumes the air of an
injured person, plausibly justifies himself by a series of explanations, and when
controverted on one point with great readiness adopts another, and maintains it
without regard to his previous explanation, and without any hesitation about lying
freely. The explanations generally take the form of an implied necessity for self-
defence, but when it is pointed out to him that he has never previously complained
of the individual whom he attacked, he laughs it off without remark. He has
killed a man, and shows as little remorse, grief, contrition, or regret at the act as
a spider would at the death of a fly. There is a certain periodicity about the
attacks which cannot be measured by time sequence, but their imminence is
recognisable by the attendants, who know by his increased restlessness, irritability,
and impatience that he is approaching the explosive period. His personal or
family history gives no clue to his obsession. There is an indefinite history of
sunstroke in England, admission to Lincoln Asylum, and discharge in three
weeks. I am unable to offer any explanation of his motives, but suggest it may
be an atavistic tendency to eliminate rivals. He has had at times persecutory
delusions and hallucinations of a transitory nature.

I recall another case, that of P. McG—, who was dull, depressed, and melan¬
choly for some time, but, after what may be euphemistically called partial
recovery, discovered that his mission in life was to kill a man. He exercised a
rare and refreshing judgment in the matter, and, though he said it did not matter
whom he killed, he invariably selected for attack a senile dement or imbecile.
One day he chose for his victim an imbecile friend of a very powerful patient, who
intervened vigorously and with marked effect. The extraordinary and unexplain¬
able result is that the impulse has disappeared, and he is now a useful worker, but
talks a jargon which requires skilled interpretation. I have no explanation to
offer of this case.

I quote another case, that of M. Q—. She belongs to the tramp class, is
without education, and of low intelligence. Her husband deserted her for other
women, which seems to have embittered her. She has many hallucinations of
sight, smell, hearing, and taste, and persecutory delusions. There is no evidence
of phthisis or syphilis, except the suggestive fact that of thirteen children eight
were stillborn or died of convulsions in infancy, and only two now survive. She
makes treacherous premeditated attacks, always with a certain amount of previous
planning, on other patients and attendants, and when questioned is always
unctuous and self-satisfied, and explains that she only acted in self-defence. She
is utterly devoid of any moral recognition of her position, and her only point of
view, which seems to determine her acts, is that of self-defence. When she begins
she goes out to kill heedless of the consequences.

Dr. Rainsford remarked that in private asylum practice, cases suffering from
homicidal impulse were rare. Formerly, in Bristol Asylum, he had seen a
patient who had made a murderous assault on himself. This was a case in which
no marked delusions seemed to have preceded the homicidal effort. He was much

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struck by the remarks of Dr. Mills, assigning as a possible cause of homicidal
impulse an atavistic tendency to a primitive state, and that the act was one of
involuntary self-defence.

Dr. Gavan drew attention to the fact that in many cases the patient’s homicidal
act was not caused by delusions and hallucinations. It seemed to be due to an
uncontrollable impulse. He had an experience of such a case in Mullingar
Asylum. The patient seemed to have no moral sense: he had burnt hay,
apparently in pure wanton mischief, and had suddenly made serious attacks upon
people.

Dr. Redington also spoke of cases of homicidal impulse. He stated that
observers had recorded cases in which an aura was present with a sensation of
thirst and burning at the pit of the stomach. These sensations in the patient
preceded the attack of homicidal impulse, and sometimes a patient himself gave
notice of the attack to the attendants, and begged to be specially looked after.

Dr. J. O'C. Donelan gave an interesting account of a case under his care,
where a soldier had suddenly seized a rifle and bayonet in barracks and run it
through a fellow comrade who was sitting at the fire. This man stated that he
had no clear knowledge of murdering his comrade, but he believed that such
was a fact, and he believed he saw somebody perpetrating the murder; he did not
realise that he himself was the murderer, but accepted the fact that he had killed
his comrade, because he was told he did it. This man had an epileptic sister.

Dr. Leeper stated that, in his opinion, genuine cases of homicidal impulse were
nearly always associated with masked epilepsy —epilepsie larvce. From the
wide experiences of those present of homicidal impulse, arising apparently
causelessly, and which no foresight nor knowledge that we possess would enable
one to foresee, it was impressed upon us of the constant dangers attending the
lives of those who dwelt amongst the insane.

Dr. Drapes stated that homicidal impulses, they all knew, were likely to arise
in epileptic, paranoid, stuperose, and maniacal patients. Stuporose patients were
particularly anxious ones, as from an apparently lethargic condition, the patient
suddenly became actively homicidal.

Other members having joined in the discussion, Dr. Mills thanked the meeting
for the very kind way in which his paper had been received, and for the discussion
which it had produced. He had in Ballinasloc Asylum, a remarkable case where
an old dement, for many years trusted as a harmless patient, had suddenly made
a most determined homicidal attack upon an inmate. In many cases no apparent
motive for this attack could be found to exist. This case seemed to be due to
the survival of some atavistic tendency which might have been common enough
in the Stone Age of humanity. It was not always possible to get any corroborative
history of epilepsy or insanity occurring in the patient's person or family.

A most interesting discussion on “The Alimentary System in reference to
Mental Affections’’ was opened by Dr. Rainsford, who expressed his surprise
at finding that there was not much helpful literature on the subject available;
and that the most interesting paper bearing on the subject was a paper by
Dr. Wm. Eustace, read at the Irish Division.

He said that Punch’s celebrated advice to the harassed wife inquiring how best
to manage an irritable husband—" Feed the brute ”—probably embodied more
psychological truth than was generally understood. Wc are all conscious of the
sense of bien ctre which follows on a good dinner, well digested, and of the opposite
feelings when faulty digestion interferes with the happiness which would otherwise
result. He had been much interested in a recent communication to the Journal
from Dr. Mercier on the “ Influence of dietary on various mental states.”
Dr. Mercier found that from a review of a number of cases of mental disorders
due to errors of diet, that—

(1) Deficiency of meat was a potent cause of confusion of mind.

(2) Excess of fat in diet caused severe headache, migraine, and general

mental confusion.

(3) Frequently excess of starch and sugar caused mental depression.

Dr. Rainsford was of opinion that toxremic conditions had their origin in the
large intestine, and that the toxins there generated were carried into the blood,
and thereby affected the higher nerve centres and so gave rise to various states
of mental disorder. He put forward as supporting this view, the beneficial effect

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he had observed from the administration of intestinal antiseptics, notably the liq.
hydrarg. perchlorid. (B.P.), and quoted various cases illustrative of this. He also
suggested that in many cases various delusions and hallucinations met with in
mental cases would be found on close examination to have a physical basis instanc¬
ing the delusion of having gone long walks in cases of peripheral neuritis, and of
rats in the stomach in cases of chronic irritative dyspepsia.

In epilepsy, Dr. Hughlings Jackson long since pointed out the benefit that
resulted from a salt-free diet. In a few cases it was found that a daily dose
of 5ii of salt notably increased the number of fits, and in some cases marked
diuresis supervened, up to 130 oz. of urine being passed in twenty-four hours.
It had been stated that where ingestion of salt was accompanied by marked
diuresis which was not compensated by drinking water a rise in protein meta¬
bolism occurred.

In Dr. Eustace’s paper, read at the Summer Meeting of the Irish Division,
1914, it was pointed out that auto-intoxication might occur in various ways:
(a) histogenic, (A) organopathic, (c) gastro-intestinal; and that under certain
circumstances toxins developed by microbes become excessive and get into the
blood-tract. Putrefaction of proteid gives rise to various organic poisons—indol.
phenol, and skatol—that the liver has a great destroying power, using up ammonia
and amino-acids forming urea, and transforms offensive aromatic products into
less offensive material.

The influence of various physical disorders on the course of a mental attack
was also dealt with, and cases were quoted showing the effect of the incidence
/of tubercle, pneumonia, and sharp febrile attacks generally.

Attention was drawn to a recent paper by Drs. Orr, Rows, and Stephenson,
on “The Spread of Infection by ascending Lymph Stream of Nerves from the
Peripheral Inflammatory Foci to the Central Nervous System,” in which it was
stated that experiments had shown that the infection of the lymph system of the
peripheral nerves caused an ascending neuritis which spread upwards to pass over
the posterior root ganglia and along the spinal roots to the cord.

In conclusion, Dr. Rainsford apologised for the very scrappy nature of his
remarks, but expressed a hope that succeeding speakers would find in them
something which, from their wide experience and knowledge, would suggest to
them thoughts which would illumine the discussion, and diffuse more information
on the subject.

The Chairman said they all owed a great debt of gratitude to Dr. Rainsford
for the able way in which he had introduced the subject under discussion, which
had elicited some valuable comments from the members.

Dr. J. O'C. Donelan mentioned the marked beneficial results to patients
by treatment with naphthaline. This substance acted as a powerful intestinal
antiseptic, and he had found it very useful in cases where there was intestinal stasis
and evidence of toxaemia in mental states.

Other members spoke in similar terms of the value of purgation and a course
of intestinal and antiseptic treatment, saline injections, and other means of dealing
with cases of insanity whose condition depended upon morbid states of their
alimentary system.

It was proposed by Dr. Rainsford, and seconded by Dr. Donelan, that the
best thanks of the Irish Division be tendered to the President and Fellows of
the Royal College of Physicians for their kindness in allowing the Division to
meet in the College, which was passed unanimously.

CORRESPONDENCE.

Royal College of Physicians,
Edinburgh;

December 17 th, 1917.

Sir, —We have the honour to transmit to you a Statement adopted by the Royal
College of Physicians of Edinburgh dealing with the question of the establishment
of a Ministry of Health.

The College was led to take up the consideration of this matter by the attention

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which has been recently given to it, and by the general interest aroused by its dis¬
cussion in the public press.

The opening paragraphs of the Statement explain the position the College
occupies under Royal Charter, and we would emphasise the fact that under the
privileges conferred by the Charter it is the duty of the College to consider
“any matters affecting the general interests of the medical profession and the
public.”

Acting on this privilege the College has considered the question of the establish¬
ment of a Ministry of Health, and has accepted the general proposition that it
would be to the advantage of the public health were the various existing health
agencies co-ordinated and brought under the supervision, control, and initiative of
a Board of Health, constituted on the lines suggested in the Statement, and pre¬
sided over by a Minister of State.

The only aspect of the question which leads to a divergence of view is as to the
desirability of proceeding with a scheme of such magnitude at this strenuous and
anxious time in the nation’s history, when the medical forces of the country are
largely disorganised. In the circumstances the prevailing opinion of the College
is that the establishment of a Ministry of Health ought to be postponed until after
the war.

We have the honour to be
• Your most obedient Servants,

William Russell, M.D.,
President.

A. Dingwall-Fordyce, M.D.,
Secretary.

Statement by the Royal College of Physicians of Edinburgh regarding the
Proposal to Institute a Ministry of Health.

The Royal College of Physicians of Edinburgh was erected by Royal Charter
granted by His Majesty King Charles the Second, 29th November, 1681, and
incorporated anew by Royal Charter granted by Her Majesty Queen Victoria,
16th August, 1861.

The Royal College has been, and continues to be largely concerned with
matters affecting the Health of the nation. It has taken considerable part in
developing medical science and practice. It is therefore particularly interested
in all proposals which have for their aim the erection of a State Department of
Health.

The Fellows of the College have given careful consideration to the subject. The
statement which follows is the outcome of deliberations, which had regard to the
great questions of Health and the urgent need of their recognition and effective
handling by the State. The standpoint of tho College is frankly medical, not
political or departmental.

The administration of Health measures has in the past been developed in
connection with a number of Government Departments, such as the Local Govern¬
ment Board, Home Office, Board of Education, Insurance Commission.

Each of the several Departments has worked within the limts of certain Acts
of the Legislature dealing with definite subjects and conferring definite powers.

The Health of the Community has received benefit from the work of the
Departments ; but the operations of the Departments have not attained that com¬
prehensive measure of success which the extent and gravity of the Health problem
demand.

As regards Health questions, the sphere of the several Departments is limited,
and, with increasing legislation, the overlapping which inevitably follows from
their separation becomes steadily aggravated.

A fundamental weakness lies in the fact that in none of the Departments con¬
cerned is the control vested in a Minister appointed primarily to deal with Health
problems.

From this division of interest and responsibility departmental difficulties are apt
to arise : policy in regard to matters pertaining to Health tends to become subject
to considerations of departmental jurisdiction : and the essential interest of Health
questions is liable to be obscured.

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Under the restrictions of the present system it has been impossible to evolve
concerted means for dealing with the complex and ever-widening problems of
National Health. Not until these restrictions are removed will it be possible to
attain effective and adequate machinery.

What is required is the creation of a Ministry which shall concern itself with
Health matters pure and simple, and to whose jurisdiction shall be transferred
from other Departments the operations of all existing enactments in so far as they
deal with Health.

This opens up another aspect of the question, namely, the immense extent of the
issues involved.

Existing Acts deal only with sections and fragments of the subject. A multitude
of conditions affecting Health are not included in the purview of the Acts, and
have hitherto been left untouched.

The Minister of Health must handle the whole problem. He must be concerned
not only with questions already dealt with by the Legislature, such as infectious
Diseases, Infant Welfare, etc., but also with fresh questions arising from time to
time, e.g., conditions causing or affecting forms of sickness and disease not yet
included within the operation of Health Acts.

Such matters are frequently brought to light in the work of the medical pro¬
fession. Beyond the treatment of individual cases by medical practitioners there
are large questions concerning conditions to which sickness is due. These are
certainly matters for a Ministry of Health.

To enable the Ministry to carry out its wide and highly complex functions, a
Board of Health should be constituted, and its members selected in such a way as
to ensure that the attention of the Ministry of Health would be directed to all
matters affecting Health.

The Royal College of Physicians of Edinburgh is, therefore, of opinion that it
is essential, in the public interest, that a Government Department should be erected
to deal exclusively with Health.

The Royal College suggests :

I. That the Department should consist of the Minister and a Board of Health,

of which the Minister should be Chairman and whose Members should be

elected on the ground of experience and interest in matters pertaining to

Health.

II. That the Purposes of the Department should be:

1. To administer the Health Acts.

2. To devise executive measures for dealing with Health problems not

hitherto defined by legislative measures.

3. To institute inquiries with a view to introduce measures for improving

conditions affecting Health.

4. To develop facilities for investigation of problems in Health and

Disease as they may arise.

III. That the Board should include three Groups of Members :

1. Administrative officials.

2. Laymen with wide experience of Health problems, or in the adminis¬

tration of hospitals and other health agencies, official or voluntary.

3. Medical members who have had experience in :

(а) Public Health Service.

(б) General Practice.

( c ) Special Clinical Departments, including Industrial Medicine.

(d) Medical Research.

(e) Medical Statistics.

In name and by Authority of the College,

William Russell, M.D.,
President.

A. Dingvvall-Fordvce, M.D.,

Edinburgh : Secretary.

6 th December, 1917.

r

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NOTES AND NEWS.

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ERRATUM.

To the Editor of the Journal of Mental Science.

Dear Sir, — In the obituary notice of the late Dr. Urquhart it should have been
stated that he succeeded Dr. William I.auder Lindsay in 1879 instead of, as recorded,
Dr. Murray Lindsay (a brother who was Superintendent of the Derby Asylum) in
1880. I am,

Yours truly,

Tipperlinn House, George M. Robertson.

Morningside Place, Edinburgh ;

January 12/A, 1918.

OBITUARY.

Julius Mickle, M.D.(Toronto), F.R.C.P.(Lond.)

To most of the present members of the Association it is only his name and his
connection with a standard book on General Paralysis of the Insane that remains;
but with him has passed away one of the senior members of the Medico-
Psychological Association. He was elected in 1871, and thus for forty-seven
years has been a member. He was Assistant-Physician, for short periods, to the
Derby and County Asylums, but his life's work was done at Grove Hall, Bow.
This was really a private asylum, belonging to Mr. Byas, that was taken over by
the East India Company for the soldiers and other employees of the Company,
and the experience of Dr. Mickle, therefore, was chiefly with old soldiers who had
served abroad. As a result of this experience he was specially interested in
brain disease due to syphilis, and to tropical conditions such as sunstroke and
arterial degeneration.

But before entering on a discussion of his work and his professional position,
one must look at him as a man. He was tall, soldierly in aspect, with a long
black beard. He was very formally courteous in manner, but distant, and not
given to any wide social life. His surroundings at Bow, in the East End of
London, to a great extent cut him off from general society, and he was a self-
contained man. His work and his duty tied him to the East End. He, however,
when called upon to preside at meetings, or even at public dinners, proved a
capable and genial host.

A most painstaking observer and recorder, one might say that he was rather a
fact-heaper than a philosopher. His power of extracting the observations and
records of work of others was most praiseworthy. His published works were
encyclopaedic ; anything that anyone had ever recorded on the subject he was
interested in was plainly set out by him. One result of this was that we had all
the facts, but one was left in doubt as to their bearings and as to the recorder’s own
opinion as to their relative values. This voluminous collecting of facts and
recording is well referred to by the late Sir John Bucknill in Drain. As I have
said, dignified and reserved, but with good power of control, he managed a rather
difficult body of old soldiers with ability and success. Yet he passed what one
would have thought was a rather unsatisfied life. He was unmarried, and, as far
as I know, had no special hobbies, and was not given to sport of any kind. He
was a general reader. He continued at Bow until the institution was closed ten
years ago, and then, for some years, he lived at Bayswater. But later his general
health failed and he returned to Canada.

Next as to his professional position. He was an M.D. of Toronto, and after
being a student at St. Thomas’s Hospital, London, he took the M.R.C.S. and
L.S.A., and in 1879 he became M.R.C.P. London, and in 1887 was elected as a
Fellow of the College. He was an active member of the British Medical Associa¬
tion ; he was Secretary to the Section of Psychology at the meeting in Liverpool
in 1883, Vice-President at Glasgow in 1888, and President at the annual meeting
in London in 1895, and again in Toronto in 1906, when he received the honorary
degree of LL.D. He was President of the Medico-Psychological Association in
1896, and was also President, later, of the Neurological Society. At each of these
he gave an important introductory address. He delivered the Gulstonian Lectures

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[Jan.,

at the Royal College of Physicians in 1888. From these facts it will be seen that
his work and position were well recognised by the profession.

And now to proceed to speak more in detail as to his life’s work. His name
will always be associated with his book on General Paralysis, which passed
through two editions, the second being a much larger and more complete study
of the subject than the first. It certainly was the most complete collection of all
facts recorded by English and foreign observers up to 1886. In a way, it is
bewildering from its completeness as to the opinions and observations of others.
His own observations and methods of study are fully given, and are invaluable
as a kind of dictionary of general paralysis of the insane. But one is left in
doubt, on many points, as to the conclusions which he himself had arrived at.
In this book he nowhere states that he has made up his mind as to the relationship
existing between syphilis and general paralysis, although, as I shall point out
later, he recognised that there was very strong evidence that it was chiefly
associated with a history of earlier syphilis in the patient. He gave, among the
causes of general paralysis, various pathological changes which he had met with
post-mortem. Thus, the presence of gummata and gummatous changes in the
membranes of the brain, the arterial degeneration also met with in these cases.
But the discovery of the spirochrete had not been made, and so the real pathology
of the disease was still not understood by him. The description of the various
symptoms is excellent, and one recognises them as the work of a careful and
accurate observer. He was always proud of being the first physician to associate
the cortical changes in the brain met with in general paralysis as evidences of
localisation of function. He very carefully recorded the localities of the cortex
of the brain to which there were adhesions of the membranes, and associated
them with the clinical symptoms observed. Later, I shall refer to the use
he made of these observations in a classification. He differs from most recent
writers, however, in his classifications, and I fear that at present we are not in
a position to make a natural system or order of classification of general paralysis.
I may take one or two individual instances of what I may call his meticulous
care in reporting the opinions of others while leaving one in doubt as Jto his
judgment and his experience. Under the head of the ophthalmoscope, he accepts
the tact that with ataxic symptoms there may be atrophy of the disc. He says that
the reports of the ophthalmoscopic observances in general paralysis seem to have
been extremely confusing, and he gives several pages bearing out these opinions.
He even quotes fully the observations of Sir Clifford Allbutt that have since
been hardly confirmed, as to the relationship between general paralysis and
changes in the optic discs. This one section in reference to the eye conditions
met with in general paralysis is a very good example of the infinite care which
he took in recording symptoms.

A very interesting chapter is on the pathology of the varieties which he
noticed, and he is particularly careful in guarding against the consideration
of the classification as being anything more than a classification of varieties.
He gives five different groups, and, briefly, one may refer to these from the
pathological side. I may say that with each group, besides the pathological
findings, he gives also the associated clinical symptoms.

The first group shows cerebral hyperasmia and softening, usually generalised,
but particularly affecting the cortical substance of the superior external, and,
to a less extent, the internal, fronto-parietal regions. The second group, atrophy
of the brain, much intracranial serum, ventricles dilated and much granulated,
gyri of the brain wasted, especially on the upper surface and at the frontal region,
the corresponding grey cortex being either softened or, occasionally, of about
normal consistence; watery and sodden, and at times a fair colour, even mottled.
Third group: The left cerebral hemisphere is much more diseased than the right,
and is atrophied, usually atrophy of the grey cortex. Fourth group: Lesions
which are more marked on the right side than on the left cerebral hemisphere.
The general description of the changes in the left hemisphere in the last group
is transferred to the right. Fifth group : There is local, reddish, occasionally pale,
induration of the cerebral cortex, sometimes of wide distribution in its lesser
degrees, more marked in the frontal lobes or their anterior portions, and
affecting either one hemisphere or both. The indurated part is usually atrophied :
the non-indurated is of ordinary colour, or pale.

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Each symptom of each variety of general paralysis is given in careful detail.

As to the causation, I have already referred to the fact that he looked upon
syphilis as a chief cause, not as the only one, and he gives dozens of contributing
causes, and he seems to consider alcohol as almost as important a cause as syphilis.
He was also in advance of his time in recognising that the early symptoms of
general paralysis may be functional, purely functional—that, in fact, they may be
hysterical or neurasthenic. And he gives good examples of how easily one may
be mistaken in relationship as to whether symptoms are due to functional or to
organic disorder. His contributions on brain syphilis, apart from general paralysis,
are very numerous, most of them appearing in Brain. In these he recognises
the mental symptoms associated with the various diseases of the different parts of
the brain, recognising the arterial degeneration, the thickening and inflammation
of the membranes, and the special inflammatory changes taking place in the cortex.
He gives many examples of the coarse gummatous changes which may be met with
in association with mental disorder and syphilis.

Besides his work in relationship with syphilis and general paralysis, he paid a
very great deal of attention to heart affections, or, perhaps one had better say, the
relationship of mental disorder to disorders of circulation. Under this head one
might place his Gulstonian Lectures, and one 1 would refer to the synopsis of these
lectures and the opinions which he formed that are given in Tuke’s Dictionary of
Psychological Medicine under “Mental Symptoms with various forms of Heart
Disease,” vol. i, p. 178. I must say that here again we have a most painstaking
collection of mental symptoms associated also with certain pathological changes,
but they are not by any means convincing as to the relationship between the two.
Besides the Gulstonian Lectures, he wrote on a possible relationship between
aneurysm and mental disorder, his experience of aneurysms being, as might have
been expected, rather common in the case of the soldiers from the Tropics. He
points out that in association with aortic aneurysm you might have insanity, or
mental disorder of one kind or another, which may depend upon morbid impres¬
sions from the mere size of the tumour; secondly, from alterations produced by
the tumour on the circulation; third, the effect of the compression of this tumour
on other organs. He found general hallucinations were common, also delusions
of annoyance and ideas of persecution, and it is not surprising that there was a
good deal of emotional disorder with hypochondriacal and melancholic symptoms.

Besides these subjects, he wrote also on katatonia, and he fully recognised the
relationships of katatonia to mental stupor, and his description is quite up to our
present knowledge.

Next I would refer to one of his largest contributions, and that was “ Atypical
Brains and their Relationship to Mental Disorders.” Here again, I think, one
sees one of the marked weaknesses of Mickle. He observed and recorded in the
most elaborate way variations in the convolutions which he met with post-mortem,
and he seems to associate them, very distinctly, with a theory of evolution. For
instance, one may put it in this way.- that a slightly atypical brain might represent
a more primitive state of mankind; that such a brain was typically primitive.
Another group of atypical brains represents accidental but defective development
—arrest, one may say, of development both physical and mental. Then he refers
also to what might be called reversion, so that some atypical brains rather resemble
the convolutional arrangement met with in lower animals. This latter classifica¬
tion or idea is so like the one which was propounded by Prof. Benedikt, of Vienna,
when he exhibited the brains of murderers from Austria, and pointed out how cer¬
tain convolutions resembled those that were to be met with in carnivora, that one
looks upon both his theory and that of Dr. Mickle with some surprise and amusement.

Dr. Mickle not only was a careful observer of pathological processes, he also
was a careful student of treatments. He had very strong views that digitalis was
about the best remedy that could be given in many cases of mania and mental
excitement. He wrote upon this subject, and he also wrote upon antifebrin in
cases of pyrexia.

In dealing with Dr. Mickle, one finds it absolutely impossible to cover all the
ground concerning the work which he did. But, to sum up. For progress in
science it is necessary to have, first, careful observation of facts; next, to have a
complete and accurate record of such facts and their truth established; last, and
highest, an arranging and philosophising on these facts, passing thus from positive

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knowledge into the possible, from the definite to the indefinite, which, later, is to
become more definite and a stage for further advance. Mickle was a careful
observer and a most indefatigable collector and recorder, but his collection of facts
was so general as to be rather a heap than an arranged group. He toiled, but he
hardly constructed. And now he has left very many valuable collections, from
which others may select. Born in a colony, living his life in the Mother-country,
when failing in general and mental health he returned to die in his home colony.

Bibliography.

Journal of Mental Science. —Vol. XVIII, "Temperature in G.P.” XIX,“ Digi¬
talis in Mania.” XX, “ Case of Ataxic Aphasia.” XXI, “Case of G.P., with
Autopsy.” XXIII, “ Unilateral Sweating in G.P.” ; " Syphilis and G.P.” XXIV,
“ Varieties of G.P.” XXV, " Syphilis and Mental Alienation." XXVI, " G.P.”
XXVIII, “ Cerebro-Spinal Localisation”; “G.P. from Cranial Injury”; “ Hallu¬
cinations in G.P."; “ Knee-jerk in G.P.” XIX, “ Tubercular Meningitis in Insane
Adult”; “Unilateral Sweating”; "Visceral Syphilitic Lesions in Insane free
from Cerebral Syphilis.” XXX, “ Pathological Specimens of Heart and Brains ” ;
"Rectal Feeding and Medication”; “Brain Disease of Traumatic Origin”;
“ Spinal Sclerosis following Brain Lesion”; “Cerebral Localisation”; XXXII,
“G.P. Digest”; “Abnormal Forms of Breathing.” XXXIV, “ Antifebrin in
Pyrexia ”; " Insanity in Relation to Heart and Lung Disease.”

Brain. —Vol. Ill, “Review on G.P.” V, “Blindness and Cerebral Atrophy.''
X, “ Syphilis and G.P.” XII, “Aortic Aneurysm and Insanity”; “ Katatonia.”
XIV, “Katatonia, with Autopsy.” XV, “Traumatic Factor in Mental Disease."
XVII, “G.P. Digest.” XVIII, “Syphilis of the Nervous System.” XXI,
“ Nervous Syphilis, Digest."

Hack Tube’s Dictionary of Psychological Medicine. —“Sunstroke and General
Paralysis,” “Temperature in General Paralysis,” “Association of Mental and
Cardiac Disease," " Pupillary Signs in G.P.I.,” “ Antifebrin,” “ Digitalis in
Insanity,” “Spinal Durhrematomata in G.P.,” “G.P. following Rheumatic
Affections,” “ Diagnosis of Post-febrile Paralysis,” “ Treatment of Acute Mania,”
“Traumatic Factor in Mental Disease.”

G. H. S.

William Graham.

Death, in these latter days, brings few surprises, it is with numbed emotions
that we accept the daily sacrifice of our best; yet, even thus environed, the swift
passing of William Graham seemed unbelievable. No personality was less
suggestive of mortality ; no man went his way less conscious of the suspended
sword. Independent, fearless, and untiring, he planned and worked without
thought of untoward interruption ; and as he lay on his death-bed he was meditat¬
ing, and writing of, large schemes of travel and research, to be undertaken when
his practical work for the insane should be ended.

William Graham was born at Dundrod, in the Co. Antrim, on November 25th,
1859. He was educated in the Queen’s College, Belfast; obtained the M.D.
degree of the old Royal University of Ireland in 1882, and became L.R.C.S. of
Edinburgh in the following year. Specialised study in London and on the Conti¬
nent resulted in his appointment in April, 1884, as Assistant Medical Officer at the
Belfast District Asylum. In the December of 1886 he was appointed Resident
Medical Superintendent of the Armagh District Asylum, being then probably the
youngest superintendent in the United Kingdom. The latter appointment owed
nothing to influence in high places. William Graham was selected on his observed
merits to fill a troublesome post; a choice which he more than justified.

The Armagh Asylum, under Dr. Graham, inaugurated in Ireland a high standard
of internal equipment, and when his ten years’ service there ended the inspectors
devoted more than two pages of their annual report to an enumeration of the
substantial and permanent improvements effected under his rule—a tribute as
well-deserved as it was exceptional.

In the autumn of 1897 he received further promotion, returning to the Belfast
Asylum as Superintendent, and there found ample scope for his large activities. The
Belfast Asylum was built in the year 1829 for 104 patients, and was subsequently

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enlarged to 400 beds, while at this time the asylum population had risen to over
700. To meet this pressure the Governors had recently purchased, but had not
begun to develop, an estate of 295 (now over 400) acres at Purdysburn, a few
miles outside Belfast. The new Superintendent saw his opportunity, and followed
it up with characteristic enthusiasm. His plans were accepted and liberally
executed by a progressive asylum committee, and the product is the Purdysburn
Villa Colony— nearly, but not quite, completed. For twenty strenuous years he
combined the duties of superintendent with personal supervision of every detail in
the construction of the new villa colony. This is not the place or moment for
any description of his achievement. The colony has been visited by many
members of the Association and is recognised as perhaps the best that has been
done for the insane poor in the United Kingdom. In recreation the doctor was
as energetic as in work. He took his rest on horseback, in the hunting-field, or
on the polo-ground.

No fitter memorial can be raised to William Graham than the continuation of
the colony as he designed it. Ireland, in these matters, has fallen somewhat back
in the race; and one hopes that, for example and encouragement, the original
design of the model villa colony will be worthily completed.

The. successful superintendent, the creator of the model villa colony, was
sufficiently well known, though he shunned publicity and made no bid for pro¬
fessional or popular fame. There was another William Graham whose acquaint¬
ance was made with difficulty ; not so much from conscious reserve on his part, but
because this other personality was accessible only in moments of comparative
repose, and such moments were rare. In his speculative moods he was the best of
companions and conversationalists; ready either to talk or to listen, and never
dogmatising. He was profoundly interested in every branch of psychology; his
study was of the mind in apparent health, as well as of the mind disordered. The
particular mental twists which determine humanity to its divergent opinions and
beliefs, aspirations and negations, were of unceasing interest. A man of few
prejudicesand no intolerances, he postulated no categories of the impossible or the
incredible. His attitude was consistently that of student and observer. An
evening of talk over the fire at Purdysburn House was a realisation of Stevenson’s
aphorism: “The tendency of all living talk draws it back and back into the
common focus of humanity.”

He was inevitably attracted by the theories of Freud, and put them on trial in
asylum practice, but the analysis practised by Graham did not conspicuously recall
the distinctive hypothesis of Freudism round which controversy has gathered. In
the early summer of 1914 he started on an expedition to the South Sea Islands,
“ to see,” as he put it, “ mankind in the rough.” The outbreak of war closed the
route to the South Sea, but he was enabled to view humanity in various develop¬
ment over a great portion of the globe.

During the last few months of his life he undertook additional responsibilities
as Lieutenant-Colonel in command of the new war hospital now occupying the
buildings of the old Belfast Asylum. The inevitable routine and clerical duties
were in many details uncongenial, but success, as usual, attended his true pro¬
fessional work, to the very great benefit of his soldier patients.

He died on November 5th, 1917. A slight accident had caused fracture of the
femur, and the sudden and unexpected end resulted from an embolism occurring
while he lay disabled. He was fortunate in his death. Pain he could have borne,
but not easily the gradual failures of old age.

“To believe in immortality is one thing, but it is first needful to believe in
life.”

William Graham “ believed in life.”

Dr. Henry Maudsley.

We regret to have to record the recent death of Dr. Henry Maudsley. Owing
to limitations of space an obituary notice of our late colleague must be deferred
till the April number of the Journal.

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I l6 NOTES AND NEWS. [Jan.,

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The following resolution was passed at the meeting of Council held on Novem¬
ber 27th, 1917:

“ That in the case of a Member of the Medico-Psychological Association on
Foreign Service who makes a request that his subscription should lapse during
such service, the Treasurer should report the name of the Member to the Council,
who should have the power to sanction this request."

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.

The Editors regret that owing to the great shortage of paper the size of the
Journal has to be reduced, the limit assigned being 96 pages, which, however, has
been unavoidably exceeded. For the same reason the entire text has to be printed
in small type.

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JOURNAL OF MENTAL SCIENCE, APRIL, 1918.

Henry Maudsley, LL.D.Edin.(Hon.), M.D.Lond., F.R.C.P.Lond.

Obiit January 24th, 1918. Editor of Journal 1862-1878.

President, 1871.

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HENRY MAUDSLF-Y, M.D.

[April,

V*

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he accepted Agnosticism, but he felt that although he had little use for
religion or faith himself, for others it might serve as a help. The
Bible, he says, does not teach science : it speaks of important truths
to man in a way he can best understand. It is the Infinite speaking to
the finite and adapting Himself thereto.

Personally, he was a handsome man, and he had a healthy amount of
conceit. In younger days he was carefully dressed, and scrupulously
careful of his hands. As he grew older, he allowed his hair and beard
to grow long, and he had rather the aspect of an aged prophet. To
the end his senses were keen and his movements active. As I have
said, he was critical, and he had a Gladstonian habit of using post¬
cards. I have a collection, which I have headed “ Maudsley’s Fire.”
I shall never forget some of these, in which he criticised either some¬
thing I had written, or some opinion I had given. As will be seen, he
led a life apart, though he belonged to the Reform Club, and, I think,
to the Savile; yet he was not a clubbable man. Though fond of Art,
he had no special taste, and, I believe, avoided one of the vices of
doctors with means—he was not a collector of anything. He had no
knowledge of, or interest in, music. He was fond of bowls as a game,
so I understand, but cricket was his great pleasure. I do not know
that, even in youth or later, he played in any great match, but for some
years, I think, he used to go up to Lord’s, where he was bowled at by
professionals. He went, when over seventy, to Australia, as he said, to
see the best of cricket in its best home. Anyway he attended matches,
and had a complete knowledge of players, both English and Colonial,
and of their peculiarities. Later, when he went to live at Bushey, he
used to drive a pair of horses. I believe that for some time he took
quite a Yorkshireman’s interest in horses.

He was a brilliant success as a student, but I remember his telling me
that he felt rather ashamed of winning medals and prizes, as they did not
represent real knowledge, but only accurate memory. He said he had
an unusual visual memory, and that if asked a question he seemed to
be able to copy the answer from the text-books. There is no doubt he
had a wonderful memory, and he was always ready with quotations
from Shakespeare, the Bible, and from certain poets. I do not think he
professed to being a Shakespearean authority, but he was a great lover of
his works. Early in the sixties he wrote a study of “ Hamlet,” main¬
taining that he was not insane; and in 1908 he wrote about
“Shakespeare in his own bringings-forth,” gleaning the history of
Shakespeare from his writings.

His literary style was very cultivated, and yet there was a fluidity
which relieved its rather long and formal sentences. I have no know
ledge as to his method of writing or correcting, but I should fancy he
was very careful and very painstaking.

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HENRY MAUDSLEY, M.D.

I 19

So much for what Maudsley appeared to the world. As to Maudsley
himself, it would be rash to give at present an opinion. That he was a
man of refined taste and crtical habit there is no doubt. That he had a
deep sense of tenderness, I think, is also true, but his political Radical
principles seemed to mask this, and I once told him he seemed to be so
absorbed in his love for humanity that he had no affection to spare for
the individual man. Asa result, he had very strong feelings in reference
to the treatment of the insane, and was very jealous of any return
to undue control being used over them. He was extreme in this in
some ways, and I had some rather sarcastic communications from him
in reference to forcible feeding. He maintained that it was hardly
ever necessary, and that it was degrading to the doctor and to the
patient. He fully recognised his independent opinion, and was not
always tolerant of opposition.

Maudsley was a home-lover, and I feel, with others, that if he had had j
children he would have gained, and that his sympathies would have
been wider. He was a close critic and careful student of current medical
knowledge, but very independent in his ways of expressing his opinion.

Next, I purpose considering him as an author. His first essays, as
far as I know, are to be found in the Journal oj Mental Science in 1859,
when Bucknill was editor. Bucknill called him then the young philo¬
sopher. He was only twenty-three. His first article was on “The
Correlation of Physical Forces,” being a review of Groves’ epoch-making
book, as well as a notice of some other books on similar subjects. The
review was a good example of Maudsley’s style and of his future lines
of thought. He began with a general abuse of the accepted ideas of
philosophy, pointing out the futility of wrangling about words instead
of following observed facts. He says: “Wretched mistaken man that
thou art! How long, how long wilt thou rest satisfied to concern thyself
with the heresy of phenomena when there is in actual existence essences
in the Universe? Science cannot be possibly rejected, and must be
accepted. It must be regarded as affording data on which to found the
investigation of the real and the spiritual, or by whatever other name it
is called. The enlightened mind conquers Nature by obeying her.
Conscious soul may forget; unconscious soul does not. Of all vanities
metaphysics is the vanity of vanities, and the study thereof is vexation
of spirit.”

In Maudsley, however, there was a religious feeling, though, appa¬
rently, great contempt for formal religion. He accepts Sterling’s state¬
ment that science is religion; all things are so. Nothing is irreligious
but by error and by ignorance. For what is science but truth, and the
knowledge we get thereby but a knowledge of the laws of Nature, which
are the ways of Providence ? A world of revelation, there can be no
finality, as there is no finality in knowledge.

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HENRY MAUDSLEY, M.D.

[April,

In a very long article on “The Genesis of Mind” he follows the line
of evolution, and is against there being any proof of any other than
simple natural processes to explain the development of consciousness,
of mind, and of intellect generally. He traces, in the lower animals,
the growth first of reflex nervous action, which passes gradually through
sensational to the highest ideational relationships to the environment as
4 seen in man. He is greatly influenced by Darwin, though, after his
usual manner, he suggests that Darwinism may, after all, be but a pass¬
ing phase of philosophy. Yet he fully recognises the gulf between
mind and matter. He is in opposition to many recent observers in
believing that acquired traits may be transmitted. The article is full of
many animal tales, some of which w'ould need a good deal of evidence
to accept. Man is endowed with a noble birthright; he must labour
hard to assert it, for it is by no means sufficient for him to open his
eyes upon the world, but absolutely necessary that he should look into
it. In 1864 he wrote a long article on “Considerations with Regard
to Hereditary Influence.” This is full of wise thought and epigram¬
matic teaching. Jn this we see still the influence of Groves’ article on
“Correlation and Conservation of Force,” there being, as he says, no
beginning and no end—all one continuity. Man has to learn that he
is but a link, and not the last link, in the mighty chain of the Universe.
He compares the union of the parents to a chemical, not to a mechanical
union, the results differing from both elements. One can only give
short extracts from, or references to, his article. He points out how
twin monsters may have different temperaments, though, of course, pre¬
cisely similar origin. It is a fact also, he says, that distinguished fathers
often have weak sons, while parents “ with restrained or contracted
expressions may produce strong children.” He thinks that by great men
society may gain, but the family may suffer. No mortal can transcend
his nature, and his present nature is by no means a present production;
it has descended from the past through the regular laws of development.
The destiny of man is innate in himself. He is strongly of opinion that
men given to great sexual indulgence will fail in mental vigour, and that
the intellectual man may very probably fail sexually; he is of opinion
that emotional disturbance may affect the quality of the semen, or the
nature even of the ovum, and hence affect the progeny. Temporary
mental conditions of the parent may affect the offspring. Here, as
elsewhere in Nature, we are taught the eternity of action of any kind —
that nothing perishes absolutely in the Universe, not even a gust of
passion. From normal heredity he considers morbid transmission.

In conclusion, then, it may be added that the supposition that defi¬
nite laws of organic combination do exist and determine the nature of
the individual as surely, though not yet as clearly, as the laws of
chemical combination determine the nature of a chemical compound,

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can afford no possible excuse for the selfish indolence of an inactive
fatalism. Rather is there imposed on everyone a very serious responsi¬
bility, seeing how much the destiny of coming generations is in the
power of the present generation. “ Neither the evil nor the good which
a man does is interred with his bones, and long after the individual has
gone to sleep posterity may be receiving the benefits of his virtues or
paying the penalty of his vices.”

In 1865 Dr. Maudsley reviewed several French articles on “Syphilis
and Disease of the Brain,” and in this article he gives his opinion on
the pathology of brain syphilis. It is noteworthy that it was twelve
years later that Dr. Julius Mickle, reviewing the work again of foreign
authors, came to much the same conclusion as that formed by Maudsley.
In this article he recognises the gross results on the brain produced by
syphilis—the syphilomata of the membranes and the vascular changes.
And he shows how external symptoms only in part represent the deep
disease, and that even the microscope cannot reach the bases. In the
cases of brain syphilis recorded we recognise typical examples of general
paralysis, and Maudsley recognisse that paralysis and dementia result
from syphilitic disease of the brain. But he admits that these symp
toms certainly do not depend upon the more coarse and visible changes
which are found either in the membranes or in the vessels. He recog¬
nises fully that parental syphilis may cause all forms of mental defect
in the progeny, although, of course, he did not know or recognise the
adolescent forms of general paralysis. Thus we find that, while recog¬
nising syphilis as a cause of many diseases, its intimate connection with
general paralysis and locomotor ataxy had not yet been made clear
to him.

I have, thus far, traced the early work of Maudsley, and now I can
refer our readers of the Journal of Mental Science to the numbers of the
Journal during which he was editor, when he and the late Sir Thomas
Clouston left very marked evidence of their distinguished editorship.

I feel that it is not for me, here at least, to refer in any detail to his
main literary work as represented in his books on the Physiology and
Pathology of Mind, on Responsibility and Conduct, on Body and Will,
on Natural Causes and Supernatural Seemings, as they will probably be
referred to by some other writer. I must, however, more fully refer to
his last works as evidences of the maintenance of all his powers and
grace to the very end. Without doubt he contemplated his end, as we
shall see in referring to his later writings.

His last publication, published at about the time of his death, was
Essays on Religion and. Realities. This is a very concise exposition
of his beliefs, and also the results of his life’s experience. His essays
on Old Age, Death, and Life are very clear expositions of his own
desires and conclusions. He certainly looked on death as a friend

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rather than as a foe. He writes : “ With all, Nature has the last word
to say, and says it alike to ants and men. They must learn to go into
the dark, without fear. It seems to be the right fulfilment of an
individual’s destiny upon earth not to trouble himself greatly about
what he can do, but to do what he can. Try as he will, no one can
elude the fate of his hereditary antecedents whose fixed bond and
silent memory are latent in him, and may, on the occasion of a fatal
evoking crisis of danger or other mental condition, show openly.
Implicitly in his nature the wills of his forefathers have silently acted
J from all eternity to make him what he is.” In searching for what life
is, he writes: “The potent influence is derived from the sun, which is
the light of life, as it always has been.” His sun-worship is distinctly
interesting, and is thus expressed : “ No duly instructed and competent
thinker has any difficulty in conceiving, on the contrary he easily
conceives, that the perpetual bombardment of the sun’s rays on a
nowise inert speck of protoplasm must excite and maintain its growth
and continue to do so in increasing proportion as it grows in bulk, just
as such bombardment makes the pear grow and ripen. The sun is
visibly the light of its life, as it is of all life, under its genial radiance.
In the Spring, when the warmer rays are felt, the tender grass shoots up,
the leaf puts forth its prophetic buds ; the fish in the pond rises from
its winter quiescence, the fly wakes from its suspended animation in the
crevice of the wall, the frog croaks in amorous cry from the ditch, the
bird pours forth its rapturous melody, and the young man’s and maiden’s
fancy turns pleasingly to thoughts of love. All Nature feels and with
one consent responds to its vivifying rays.” The whole essay is eloquent
and instructive.

Another essay, that might be called the essay on Pontius Pilate, is
devoted to Truth. This essay gives, in brief, Maudsley’s faith. It
shows his strength, his beauty of language, and also, I think, his
limitations. He makes it clear that Pilate represents all thoughtful
minds, and that there is no ultimate truth unless it rest in Nature deeply
hidden and hard to find. He, in his usual cynical way, laughs at the
religious beliefs of men as representing phases of evolution. As he
says, men invented, fear fashioned false fictitious causes to account for
ills which they suffer, and by servile worship hope to escape. He points
out how each so-called truth should be the stepping-stone only to the
next. “ Let man apply himself, with all reverence, to Nature, as much
of knowable Nature as he ever can know. There must always be avast
amount which he can never know, and thereafter rest in the quiet
conviction that he is thereby doing his best to justify his existence on
earth, even though that existence has been at last a vanity and often a
vexation of spirit.” He has very little sympathy, when referring to
religious matters, with the mystics. He describes them as knowing

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little or nothing of physical forces and their natural effects in an
inviolable system.

The last essay is on “ Pessimism and Optimism,” and a special
interest of this essay is that it first appeared in the Journal of Mental
Science for January, 1917, a very small addition having been made to
the article in the final production. He points out, pretty clearly, his
view that though in life and living there are miseries enough in the
world, yet, after all, there are compensations. He again points, in this,
to his longings for truth, and he recognises that truth is variable, and
that there is no such thing as a perpetual or universal truth. Truth, he
says, is a pleasant abstraction, avisionary, an ever-receding ideal to be
pursued, the particular truth changing from day to day. The pessimist
observes sincerely, thinks fully and feels deeply, unlike, in that respect,
the optimist, who is exultant in the joy of living, seeing lights available
for human guidance in the gloomy vale of tears, his faith the greater
and reason the lesser light. That is the still disputed and unresolved
question, which the optimist answers by inspiration of feeling, and the
pessimist, less confidently doubting, by the daylight of reason. A true
reflective optimism will surely demonstrate that life, rightly considered
and rationally governed, is not only worth living, but capable of
incalculable improvement.

And now, having laid before the reader an outline of Maudsley’s
literary products as exemplifying his opinions, I feel that, though this
has been done imperfectly, yet it has been done conscientiously, and
with a faint appreciation of the great man he was.

And so there passes from our sight a powerful and graceful influence,
one with deep human sympathy, masked, to some extent, by reasonable
cynicism. His influence was wholly for good, though one feels, with
all the poetry and beauty of his writings, there is a want of some
definite faith, as felt, I think, by himself when we read what he thinks,
that reason cannot reason about it, the fact cherished as a sacred
mystery, which can be only embraced by minds extraordinarily and
specially graced. Their intuition of feeling is, however, absolute
assurance. And so we leave his influence to spread, as were his ashes,
on the land he loved.

G. H. Savage.

The following notice has appeared in the British Medical Journal :

“ Henry Maudsley came of a yeoman family long settled in Yorkshire
near the border of Lancashire. He was born on February 5th, 1835,
the third son and fourth child of Thomas Maudsley ot Rome, near
Settle, Yorkshire. He attended Giggleswick School, but when twelve
or thirteen, at the suggestion of his uncle, Dr. Bateson, at one time

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medical officer of health for Southwark, he went as a private pupil to
Mr. Newth of Oundle, Northamptonshire. From there he matriculated
in due course at the University of London, and, again on the advice of
Dr. Bateson, was apprenticed to the apothecary at University College
Hospital, Mr. Clover, afterwards the well-known anaesthetist. His
career at University College and in the University of London was very
distinguished. He was the first in most class competitions, and carried
off ten gold medals; he also took the University Scholarship and gold
medal in surgery when he graduated M.B.Lond. in 1856. Still he was
not reckoned a diligent student, and often seemed to his teachers less
interested in science than in sport, becoming, indeed, an authority on
cricket. But his brilliant intellect carried all before it. At first he
thought of becoming a surgeon, and was house-surgeon at University
College Hospital to Mr. Quain ; afterwards he contemplated entering
the Indian Medical Service, and in order to fulfil the regulation requiring
candidates at the examination to have had experience in lunacy, he
took an appointment in the Essex County Asylum. This accidental
circumstance may be said to have determined his career, for after a
short period at the Wakefield Asylum he became, at the age of 24,
medical superintendent to the Manchester Royal Lunatic Asylum,
Cheadle, in 1859, an appointment which he retained until 1862, when
he went to London to try his fortune. He had already written some
essays, including one on “Hamlet,” which had attracted the notice of
Dr. John Conolly, who at that time was superintendent of Hanwell
Asylum; he had a small private asylum near by, and Maudsley was
resident physician there for a time, and afterwards married Conolly’s
youngest daughter. Soon after settling in London Maudsley was
appointed editor of the Journal of Mental Science. Two years later he
became physician to. the West London Hospital, Hammersmith. He
was appointed professor of medical jurisprudence at University College,
London, in 1869, and retained the chair until 1879. He early attained
success in the practice of his speciality, and contemporaneously became
well known as a writer, by a series of books which were not only of high
technical distinction but appealed to the more thoughtful section of the
general public. In 1866 he published his first large book on the
Physiology and Pathology of Mind , which has been described as epoch-
making. In 1874 he published a book on responsibility in mental
disease. Afterwards h® rewrote his early book, and issued it in two
separate volumes—the one in 1876, on the physiology of mind, and the
other in 1879, on the pathology of mind; this last volume reached a
second edition in 1895. In 1883 he published Body and Will , and in
1886 Natural Causes and Supernatural Seetnings, a book which reached
its third edition in 1897. Another book was Life in Mind and Conduct
(1902), and his final work, which may be said to embody the philosophy

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of his long life, entitled Organic to Human, Psychological and Sociological ,
appeared in 1917.

“ He became a Fellow of the Royal College of Physicians in 1869, and,
we believe, was at the time of his death, both by age and seniority, the
fourth on the list. He delivered the Goulstonian Lectures in 1870 on
body and mind. He received the honorary degree of LL.D.Edin. in
1884, and was an honorary member of the Medico-Psychological Society
of Paris, of the Imperial Society of Physicians, Vienna, and of the
Medico-Legal Society of New York.

“ His interest in the work of the British Medical Association is shown
by the fact that he was vice-president of the Section of Psychology at
the annual meeting in Newcastle in 1870, and president of the same
section at the annual meeting at Birmingham in 1872. In 1905 he
delivered the address in medicine at the annual meeting at Leicester.
This address covered a wide field and contained the germs of his later
book, for he looked forward then to the ultimate levelling of all artificial
partitions, to the recognition of inorganic, of organic, and of spiritual
nature as grades in a continuous scheme woven together by the golden
thread of evolution. But it also dealt in a philosophic spirit with the
practical problems underlying the prophylaxis of disease, for, specialist
though he was, Dr. Maudsley took care to keep himself acquainted
with all movements in medicine.

“Dr. Maudsley may be said to have retired from practice in 1903,
when he paid a visit to Australia for the purpose, as he said, of ‘ seeing
how cricket was played.’ He retained his mental faculties and the
clearness of his intellect to the very last, and had just finished the
revision of the proofs of a volume of essays. He had been failing in
health for some two or three months, but died peacefully in his chair on
January 24th after a few weeks of confinement to his house overlooking
Bushey Heath, not far from Harrow, one of the last of the untouched
heaths near London.

“We are indebted to Dr. F. W. Mott, F.R.S., for the following tribute
to Dr. Maudsley’s life and work :

“ By F. W. Mott, F.R.S.

“At the age of 30 Maudsley’s philosophical mind revealed itself to
the general public by the publication in the Westminster Review of a
remarkable essay on * Hamlet.’ He had been previously known to the
profession by a number of original articles in the Jour?ial of Mental
Science under Dr. Bucknill’s editorship, by whom he was nicknamed
‘the young philosopher.’ Is it not strange to know that he harked
back to his grandfather, who was notable in the countryside for his
sayings, sardonic and sarcastic, which had earned him the soubriquet of
‘the old philosopher.’ Henry Maudsley’s next most notable work was

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the Physiology and Pathology of Mind , published in 1867 ; and as early
as this he declared his aim to be—

“To treat of mental phenomena from a physiological rather than
from a metaphysical point of view, and to bring the manifold instruc¬
tive instances presented by the unsound mind to bear upon the inter¬
pretation of the obscure problems of mental science. Also to do what
he could to put a happy end to the inauspicious divorce between the
physiology and pathology of mind.

“I was informed by a very eminent physician that upon reading that
work when he was studying philosophy and law as a young man at
Oxford, he determined to take up medicine, and especially that branch
relating to disease of the nervous system. Thus the seed soon fell on
fruitful ground, and during the last generation Maudsley’s name has
been pre-eminent in all that pertains to mental science. Indeed, it
would repay the present generation to read his later separate works on
the Physiology of Mind and the Pathology of Mind, which are referred
to frequently by Charles Darwin and by Ribot, and many other great
contemporaries of his. William James, the author of Principles of
Psychology , recommended his students to read Maudsley’s Pathology of
Mind. One of the most interesting chapters I know, and from which I
have gained much valuable information, is on ' The emotions or affec¬
tions of mind.’ It is prescient and original in thought, and is particu¬
larly interesting at the present time when emotional stress is operating
on a large part of civilised humanity. One passage in relation to
modern conditions of shell-shock may be noted :

“ To all appearances a violent emotion may react as a strong physical
shock to the nervous system, for it may produce convulsions, fainting,
loss of sensation, paralysis of movement, deafness—exactly the effects
which a strong electric shock may produce. We have not then to do
with mysterious self-determining agencies; we have to do with pheno¬
mena which, complex as they are, will eventually receive a complete
analysis.

“In a copy of this work which he presented to me he said: ‘The
quotation-notes at the end of chapters might, at any rate, be interesting.’
These quotations and the references show his extraordinary knowledge
and wide reading in philosophy, whence he got the broad grasp of
science as applied to the physiology and pathology of mind, and how
he has analysed and woven these into his work in a most lucid and con¬
vincing way, so that it has become his own fabric, and not a patchwork
of ideas and thoughts of others.

“ The same might be said of his book The Pathology of Mind.
Responsibility in Mental Disease was another work which aroused a
great deal of attention, and was regarded as a standard book on account
of its practical application to medico-legal questions relating to insanity,

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HENRY MAUDSLEY, M.D.

I 27

crime, and responsibility. When I)r Maudsley was lecturer on medical
jurisprudence at University College, I well remember his coming in and
reading a case of mistaken identity from the Times , and commenting
upon it in a way that immediately attracted the attention of the students
by his originality, humour, and critical insight. His latest work, Organic
to Human , embodies his philosophy, which may be summed up in the
principle of unity of the human organism and its continuity with the
rest of Nature’s processes. Borrowing his own words, it may be said
that having done diligently the work which it came in his way to do for
a livelihood and fulfilled his life-function in the sincere utterance of him¬
self,\ Maudsley has left his philosophical and philanthropic work to the
fate of time and events, well knowing that when all is said—

“ Thought is the slave of life, and life the fool of time,

And time that takes survey of all tiie world
Will have a stop.

“ The Maudsley Hospital.

“Dr. Maudsley in 1907 communicated to me his desire to give
.£30,000 to the London County Council if it would build a hospital for
the study and treatment of acute mental cases. I mentioned the matter
to Sir John McDougall, who pointed out to me the desirability of such
a hospital being associated with the University of London ; conse¬
quently I drew up a scheme, and this was supported by Mr. Balfour
and Sir Arthur Rucker, the late principal of the university. The
offer was then communicated privately to the chairman of the London
County Council, and in December, 1907, Dr. Henry Maudsley put
before Mr. H. P. Harris, who was then chairman, his scheme for the
establishment of a fully equipped hospital for mental diseases in
London. Towards the cost of carrying it into effect Dr. Maudsley
offered to contribute a sum of ,£30,000. In a letter to Mr. Harris’
dated February 14th, 1908, Dr. Maudsley said that as a physician who
had been engaged in the study and treatment of mental diseases for
more than fifty years, he had been deeply impressed with the necessity
of a hospital whose main objects should be the early treatment of cases
of acute mental disorder, with the view as far as possible of obviating
the necessity of sending them to the county asylums ; the promotion of
exact scientific research into the causes and pathology of insanity,
with the hope that much may yet be done for its prevention and
successful treatment; and the provision of an educational institution
which should offer to medical students the opportunities of getting
good clinical instruction in a class of diseases of which under existing
conditions it is not easy for them to obtain a competent knowledge.
Dr. Maudsley’s gift was accepted, but much delay occurred before a site
was finally chosen at Denmark Hill, opposite the new King’s College

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Hospital. The following statement submitted by the London County
Council to the Royal Commission on University Education, 1913, as
to clinical instruction in special hospitals, may with advantage be
quoted from the final report of the Commissioners :

“ In addition to the advantages which it is expected will ensue to the
patients who are treated there, it is hoped that the hospital will prove
of great value in the dissemination of knowledge of mental diseases
and in the provision of systematic instruction in methods of treatment.
The proposal includes the provision of a department for pathological
research, which, it is suggested, would be accomplished most economic¬
ally by the removal of the staff and equipment of the Claybury
Laboratory to the new institution. It is hoped that this institution,
when in being, will be in close touch with the London University and
medical schools.

“ The hospital was not finished when the war broke out, but to the
4th London General Hospital, of which King’s College Hospital is
the nucleus, the London County Council not only handed over two
large Grove Lane schools, but in addition hastened the completion of
the Maudsley Hospital, the whole being placed in connection and
forming the Maudsley extension of the 4th London General Hospital.
For the past two years or more this has formed the neurological
section, and served as a clearing hospital, and for the treatment of cases
of shell shock and war psychoneuroses. It has already fulfilled a most
useful purpose, which, it is to be hoped, may be extended to the civil
population after the war is over. We only regret that Dr. Maudsley
did not live to see this practical application of his life work and
principles.

“ Some Personal Reminiscences.

“ In connection with the planning, building, and future objects of the
hospital, I had many opportunities of becoming personally and inti¬
mately acquainted with Dr. Maudsley, and I made frequent visits to
Bushey Heath. It was a great pleasure and intellectual treat to talk
with the grand old philosopher, and after dining and spending the
evening with him, 1 would come away sometimes humbled but always
mentally refreshed. No matter what subject we talked upon I always
learnt from him ; even upon technical matters of which I had more
knowledge and experience, I would find his keen, critical mind ready
to detect weak points in the argument, but his sound judgment seemed
intuitively to tell him when the facts were adequate to support a
proposition.

“To those who had not the privilege of knowing him intimately,
he might seem cynical and satirical, but beneath a seeming hyper¬
critical manner was a most kindly disposition. I cannot help thinking
that at times the tinge of pessimism which he generally showed was

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partly due to his having no children, and partly to an inborn trait; for
he told me that he believed a man may inherit two unblended tempera¬
ments, and that it was so in his case.

“ His knowledge of character, derived from long experience and
contact with men in all ranks of society in his professional capacity and
otherwise, made his conversation upon politics and social problems most
interesting and entertaining, for it revealed a keen insight into human
conduct, and the motives activating it.

“ He had a great love of Nature, and up to a few years ago he
worked industriously in his garden, but he had no taste for music ;
although he possessed the sense of rhythm, that of melody was lacking.

“Up to the very end he retained all his remarkable mental faculties,
and his memory was marvellous; for he would quote long passages
from the great authors and poets, and show that he still kept abreast
with the general principles underlying modern biological science.”

Part I.-Original Articles.

The Aetiology of Crime. By Charles Goring, M.D. B.Sc., Fellow
University College, London.

In a recent number of the Journal of Mental Science, Sir Bryan
Donkin contributes some important and interesting “ Notes on Mental
Defects in Criminals.” This is an important contribution, because, with
manifest sincerity, it criticises adversely an important modern idea : the
idea that Criminological Science, that all Social Science, must be built
upon facts, and facts only. And, apart from their general interest, these
notes are particularly interesting to me, because they refer, more than
incidentally, to my book The English Convict, wherein the validity of
arguments and conclusions depends entirely upon the study and logic
of facts whose value, for elucidating biological problems, Sir Bryan
would appear to discredit. For this reason may I be permitted to say
a few words in support of a position which has been formidably
assailed ?

As a method of biological research, Sir Bryan holds, or used to hold,
strong views on the subject of Biometry, which he would seem to regard,
at best as an intellectual fad, at worst as a troublesome expedient for
exploiting Biology in the interests of Mathematics. This prejudice,
which is not shared with many other informed thinkers, has always been
to me an unaccountable mystery, and I never read an article by Sir
Bryan without hoping to find therein some explanation which may clear
it up. In the present case I was not so disappointed as usual. On
p. 31 Sir Bryan states that “the complex environment which moulds

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the characters of men cannot be analysed or reasonably dealt with by
statistical handling ”; because, “ if it be true, as Dr. Goring has proved ”
—through the medium of Biometry—that the facts are as Biometry
shows them to be, “ it must follow that there would be little, if any,
reason for making efforts to reform law-breakers.” In other words,
since Biometry, by disturbing preconceived notions, may threaten the
stability of our institutions, the employment of biometric methods is to
be deprecated. But Criminology is not part of a propagandist move¬
ment for regulating conduct. It is a Science, critical of the ideas by
which conduct is being regulated. And to Science, whose sole object
is to derive truth inevitably from fact, any consideration, apart from
this single purpose, can have no claim to relevance.

In my Government Report the genesis and growth of the so-called
“criminal character” were examined by biometric methods, and the
conclusion was drawn that the factors conditioning them were to be
found more in the constitution of the delinquent than in his circumstances.
Sir Bryan replies that, if these findings be true, certain consequences
follow, and that, anyway, Biometry is not a suitable medium for
elucidating the problem in question. But I hope to show that the
sinister consequences affecting reform, so much dreaded by Sir Bryan,
are really illusory, and also that the systematic analysis of data, by
biometric or other statistical methods, is indispensable for judging
probabilities, for estimating existing tendencies, for measuring the
strength of associations, for obtaining, in short, that clear and well-
focussed vision of aetiological processes by which alone a prudent, just,
sympathetic, and efficient policy of administration and reform can ever
be attainable.

Let me examine in turn the more important arguments put forward
by Sir Bryan. The first point is contained in the statement already
quoted, which is to the effect that, if the truth of my conclusion be
admitted—that “the one vital mental constitutional factor in the
aetiology of crime is mental defectiveness ”—it follows as a self-evident
proposition that law-breakers must continue their misconduct, and that
efforts to reform them must be futile ! But, surely, it would be as
reasonable to affirm that when disease has a constitutional origin it
must, on that account, be incurable ! The conclusion, in a word, does
not follow from the premises. The premise from which we start is the
statistical fact that inferior intelligence is associated with law-breaking,
which, stated inversely, is the same thing as saying that superior
intelligence is associated with law-keeping. Consequently, if from the first
statement of the fact we permit the conclusion that law-breakers, because
of their lower intelligence, must go on breaking the law, we are bound
to conclude, from the second statement of the fact, that people of higher
intelligence must, by virtue of their quality, go on keeping the law—a

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revealed. Scientific prediction is only inevitable in certain conditions ;
and therefore must always deviate, and very often must depart entirely,
from predestination which is, ex hypothesis totally unconditioned. Thus
even in exact science, prediction, based on knowledge of causation, is
a very different thing from predestination, with its signs and portents of
inevitable and unavoidable destiny. In the biological sciences, which
are, and always must be, far from exact, the two are entirely dissimilar.
Here, one event, in a universal sense, rarely determines a second. The
search in this field is not for causes, but for tendencies or associations ;
and prediction, based on a knowledge of tendency, is again vastly
different from prediction, based on a knowledge of causes. In the first
place, its value lies not in application to individuals, but to individuals
en masse. In the second place, the process makes no pretence to fore¬
cast specifically the occurrence of individual events : fore-knowledge of
the definite probability of their occurring is all it pretends to provide.
In the third, last, and most important place of all, the accuracy and
legitimacy of prediction, based on a knowledge of association, depends
entirely on the conditions governing the association remaining con¬
stant. Because intelligence and crime are associated in conditions
pertaining to-day, we cannot assume that defective intelligence has
always been a source of crime; and we cannot predict that it will
remain so in changed conditions of the future.

It will be seen, then, that the criminological correlations upon which,
in my report, all conclusions were based, make no claim to rival, and
could never be twisted to correspond to, the soothsayer’s pretensions at
revelation; to which would be related the notion of individuals “com¬
pelled to continue their misconduct if not permanently coerced by
force”; or the doctrine, preached by Lombroso, of a “criminal nt "—
predestined from birth to do evil. Yet it is a profound mistake to
suppose that biometric prediction formulae, because limited in their
application, have little value. Legislation, social and economic organi¬
sation, the schemes of the actuary, all practical affairs whose aim is to
promote, protect, or materially better, not this or that individual, but
the people as a whole, may turn, as many of them have already profit
ably turned, to the prediction potentialities of Biometry. And my
criminological coefficients have no less and no more value than any of
these. Within the prescribed limitations, predictions based on these
will be definite, precise, and serviceable ; and a by no means unim¬
portant service is the knowledge they provide, not for paralysing, but
for promoting schemes of reform. For the aim of reform is not to
eradicate tendency ; it is to strengthen the will to overcome tendency.
It is not to effect a miraculous change of constitution by equalising
circumstances; it is to modify conduct by strengthening the will to act
decently even in the face of adverse circumstances. “ Man is master

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of man’s estate.” Despite of his circumstances, despite of himself, is
the theory on which reform is based. And whatever may be his
motives, proclivities, or leanings, however favourable or adverse his
circumstances may be, the criminal who gives up doing evil becomes
reformed. Certainly the subjects upon whom I made my inquiry were
habitual criminals ; and were, therefore, at the time of examination,
unreformed. But this fact does not prove that reform is futile; nor
does it necessarily demonstrate that future efforts at their reform will go
on being futile. All it shows is that, despite of education, constitu¬
tional tendencies have prevailed ; it tells nothing of the majority, whose
mean emotions, jealousies, suspicions, greed, intellectual defects, and
other constitutional tendencies and deficiencies have been overcome or
masked by education. To-day, we are grappling with only the rudi¬
ments of the problem, whose nature becomes more clearly revealed as
the relationship of habitual criminality with mental enfeeblement is
more strictly defined. How full of promise for the future may be
efforts in correcting „or diverting activities originating from feeble¬
mindedness, is shown by the effectiveness of regulations laid down for
the treatment of mental defectives in prison. No one would suppose
that the classing of a prisoner as weak-minded affects any miraculous
change in his constitution or character. Yet when so classed, the
immediate change in his conduct is indisputably manifest. Within my
experience a modern idea of the mental defective criminal as a soulless
husk of a man, without will, with capacity only for doing evil, unedu-
cable save for breaking the law, drifting aimlessly along a course of least
resistance always towards evil, a Frankenstein monster with every
human essential omitted—this imaginative portrait of the criminal
mental defective is a conception which, when contrasted with my
experience of the actual man, appears entirely detached from reality.
In my experience, the habitual criminal, even when classed as mentally
defective, and despite his low level of intelligence, is far removed from
the pathological imbecile he is often portiayed to represent; he has
capacity for useful activity as well as fordoing evil; he is amenable to
good, as well as to bad, influence; he by no means contradicts the
general truth that, to make a law-abiding citizen, two things are needed,
capacity and training. The existence of the habitual criminal to day
proves the failure of existing measures to reform all criminals ; but it
does not prove the futility of reform. What it does point is the urgency
of our immediate task : which is to find the appropriate penalties, dis¬
cipline, scholastic education, or other form of supervision and training
best adapted to mask the disabilities, and cherish the potencies within
every individual, for keeping their activities within the law, and for
playing a useful part in the world. For, when all is said, what are the
facts? We know that criminal action is largely due to lack of intelli-
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gence. We know that the most unintelligent activities can be diverted
into useful channels by discipline and training. We know that the
activities of actual mental defectives may be, and in fact every day are
being, diverted in prison—surely, to utilise again Sir Bryan’s quotation
from Dr. Samuel Johnson, “there’s an end on’t.”

The next point in Sir Bryan’s criticism is a statement to the effect
that it may be laid down in advance, as an a priori proposition, and
even despite statistical evidence to the contrary, that environmental
conditions must of necessity have a determining influence on crime.
Before proceeding to deal with this statement, I should like to say one
thing. I have never pretended that my systematic study of some
environmental factors was sufficiently exhaustive to justify a general
conclusion that crime is uninfluenced by any environmental condition.
My own statement was as follows: “ between a variety of environ¬
mental conditions examined and the committing of crime we find no
evidence of any significant relationship.” This does not claim to be a
last word on the matter. It does not claim that because some factors
are unrelated to crime therefore any relationship of this kind is, or must
be, non-existent. It does not deny that when other conditions come
to be examined, clinching evidence of existing relationship may then
emerge. All it affirms is that, in my own particular inquiry, no such
evidence had been discovered ; its only claim is that, until such evi¬
dence is forthcoming, judgment must be suspended. If evidence does
exist, let it be produced;. In the absence of evidence a mere rehearsing
of belief is idle. That Sir Bryan will sympathise to some extent with
the truth of these principles is revealed by his own statement: “ The
very posing of this question ”—whether the criminal 'is a product of
heredity or environment—“leads to irrelevant and unnecessary disputes
in many and varied fields ; and it lies at the root of great confusion in
much that is written on the causes of criminality.” With that statement
I heartily agree. And I also concur with the observation that “ many
grounds of literary dispute would vanish on the attainment of greater
precision in the meaning of the terms employed.” That is one reason
why Biological Science has profited enormously from Biometry, whose
characteristic feature is precision of terminology. As biological
problems have found expression through the medium of mathematical
symbols and formulas, less and less have they been centres of verbal
disputation and literary wrangling, which more and more have been
replaced by reasoned criticism, based on definite and stated grounds.
It has been said, as a merit of Mathematics, that they provide no scope
for dilletanti. Mathematics have the additional merit of replacing the
frequent vagueness of verbal expression by a symbolism whose meaning
is precise, unvarying, and always unambiguous. Moreover, when the
conditions of a problem are stated in, and reasoned about through,

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the terms of an algebraical formula, everyone knows precisely what is
being aimed at, and with what success the target is reached. This may
not appear a great gain ; yet, within its limitations, it is a distinct
advance on verbal disquisition and reasoning, which rarely convey the
same shade of meaning, and often transmit totally different notions,
to different people. Personally, I never had a clear and well focussed
vision of environment and heredity problems until I viewed them
through the medium of correlation and prediction formulae. And, cer
tainly, it is difficult to believe that the formula employed by me, with'
the facts and figures and 2 and-2-make-4 reasoning on which they
were based—all of which were published in my report—can have s o
obscured the issue upon which I was engaged, or have left its admitted
limitations so vaguely and indefinitely prescribed, as to justify the
following criticism : “ Even if, for the sake of argument, the validity of
methods employed and conclusions arrived at be assumed, it cannot
possibly be held that any significant proportion of the innumerable
influences that act on all men from infancy to age, for good or for ill,
and contribute so largely to the make-up of each of us, have been
eliminated by the inquiry we have been considering.”

I must confess I find this outburst of Sir Bryan Donkin astounding t
Surely no one could dispute that influences which act for good or ill on
all men, from youth to age, etc., must act similarly, for good or evil, on
all criminal men, whatever their age may be, whether they be in prison
or out of prison, whether they be reformable or incorrigible. For
instance, the existence or non-existence of food to eat, of air to breathe,
of a world to live in, of buildings that may burn, of people who may be
robbed, of institutions that may be defrauded, are, all of them, influ¬
ences for good or evil; and they are, all of them, influences on crime
and criminals: in the sense that without air to breathe there could be
no breathing criminals; without the influence of food no men could
live to become criminals; without material potentiality for committing
criminal acts, no crime could be committed. But in no rational, or
less equivocal sense, could these essential conditions of life itself, in
any of its manifold forms, be described as part of the force of circum¬
stances determining the particular form of being known as criminality.
Accordingly, we can assume that those circumstances which are indis¬
pensable for any form of human activity are not the particular ones
whose influence, Sir Bryan warns us, still survive my investigation.
What, then, are the influences to which he does allude ? If he has any
circumstances in mind, why does he not plainly specify what they are?
An unconscious answer to this question may, perhaps, be found in the
following statement of Sir Bryan : “The various factors that contribute
to the production of a criminal cannot be disentangled from the totality
of the complex environment which moulds the characters of men,” and

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this environment itself “ cannot be analysed or reduced to such items
as can be established, or eliminated, or reasonably dealt with by statis-
lical handling.” The reason then, for Sir Bryan’s reticence in this
important matter, is clear. He does not specify the conditions to
which he refers because, being unanalysable and irreducible to specific
items, they cannot be specified. But, in this case, these conditions, if
•existent at all, can have little practical significance for the criminologist.
Sir Bryan defines criminology as knowledge that “ may assist in the
formation of practical measures for the prevention of crime and the
treatment of criminals.” What practical measures, we ask, can possibly
result from the knowledge that crime depends upon circumstances
which, ex hypothesis are unanalysable and cannot even be nominally
specified ?

I think it is important to assert that the environmental influences
studied by scientific investigators, and the influences of environment
as envisaged by reformers, humanitarians, and other propagandists, are
two separate things which are often quite unrelated to each other.
The former are causes or associations, whose effects or strength, being
universal in character and variable in degree, can only be estimated
by investigation. The latter are incidents , whose effects upon indi¬
viduals, being self-evident, are not matter for scientific inquiry. The
humanitarian exclaims: “All individual men are influenced for good
or ill by the incidents of their environment.” “ Quite so ! ” replies the
scientist; “ that is an axiom which is presupposed by the investigator,
whose object is not to demonstrate a self-evident proposition, needing
no demonstration, but to search for a truth which only by investigation
can be discovered : viz., the varying extent to which, in the long run,
men are influenced for good or ill by varying the conditions of their
environment.” Thus every individual child is influenced in some way
by education. Yet, from this indisputable fact no one can assert, as
an a priori proposition and without inquiry, that failure in class or life,
or in becoming a law-abiding citizen, must necessarily, in the long run,
be due to lack of some particular form or degree of education, under
the influence of which success would be equally assured.

It will be seen, then, that in one sense Sir Bryan is right when he
s:.ys that “ the innumerable influences that act on all men for good or
for ill cannot be dealt with by statistical handling.” They cannot be
dv:alt with by statistical handling because, their effects being self-
evident, they are not material for any sort of scientific handling. For
Science is not concerned with the cataloguing of series of incidents
affecting the careers of individuals. The business of Science is to
discover causes ; and causation, as investigated in the laboratory, is
always the universal relation, which cannot be revealed by repre¬
sentation, however vivid, of particular incidents. That is to say, the

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causes there traced are not those affecting any one thing, but things in
general; they are not the innumerable incidents affecting for good or
ill individual lives; they are those general truths which are described
within that category of Science technically known as /Etiology.

I am, of course, aware that incidents affecting individual persons or
things are often described popularly as causes ; and, if it pleases people
to regard any incident as a cause, there is no reason why it should not
be called by that name: provided one is not misled into attaching
scientific value to the term. To describe thus particular events is
certainly justifiable ; because any event, however insignificant, is one
out of what Huxley described as “ the great series of causes and effects
which, with unbroken continuity, comprises the sum of existence.”
And to single out anyone event from a series and to attribute causative
value to that, may serve many a good or bad purpose. Thus, for the
sake of assuming responsibility, a mother might attribute to her own
negligence the cause of a child’s taking cold ; or, in order to transfer
responsibility, she might seek a causal agent in her nurse’s carelessness,
etc. The reasons for thus attributing a special value to particular
events may be excellent. But the causes there specified are unrelated
to the general truths of causation : no scientific treatise would refer
to a particular mother’s negligence, or to her servant’s carelessness,
when describing the retiology of cold in the head.

Let me illustrate my meaning in some of the foregoing remarks
with a case of murder which was committed by an epileptic, who was
also a licentious fellow, a heavy drinker, and who suffered from the
effects of syphilis. The crime was apparently a motiveless one; and
the plea put forward by the defence was that the prisoner committed
the act when in a transient state of epileptic unconsciousness. According
to the evidence, this was a just plea ; and consequently, for adminis¬
tration of justice, it was justifiable here to select the factor of epilepsy
from the series of causes and effects of which the crime was the
culminating episode, and to describe epilepsy as the cause of the
crime. This selection was justifiable, because its object was not to
advance scientific knowledge, but to show that at the time of the
offence the prisoner’s will was in abeyance, and his mind free from
guilty intent. To Science the selection of epilepsy, as the cause of
this particular crime, contributes nothing. That is to say, this repre¬
sentation of a particular relationship does not in itself increase our
knowledge of the general relationship between epilepsy and crime : it
is without value for purposes of prediction. For the scientific purpose
of predicting crime from a knowledge of epilepsy, the describing of
this man’s epilepsy as the source of his crime is of no more value than
would be the attributing of its cause to his alcoholism, his syphilitic
disease, his licentiousness, the fact that he carried a revolver, the fact of

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the stupidity of his victim, or an indefinite number of other factors.
For it is the sum of all these factors which was the real cause of the
crime; and when prominence is given to any one factor by describing
that as a cause, the existence of all the others, as an unvarying back¬
ground, is, as it were, assumed. The scientific problem of causation is
to trace how and to what extent two events, A and B ( e.g ., epilepsy and
crime) are connected in the picture, independently of its ever-varying
background ; and this is provided by the conception of association
which, in the biological sciences, replaces the physical concept of
causation. From data of the several conjunctions, namely, (1) A with
B ; (2) A without B ; (3) B without A ; (4) A and B both absent, we
measure the extent to which changes in the A event are followed by
corresponding changes in the B event. In other words, we find the
law that governs the relationship between A and B ; and the correlation
formula expressing it is a truly scientific statement, because, when the
tests of science are applied to it, it will be found to answer true. It
follows that the scientific problem of the influence on crime of the
force of circumstances is essentially a problem of correlation, which
can only be solved satisfactorily to Science in one way, namely, by
measuring the extent to which specifiable and explicitly specified
environmental conditions are correlated with crime. My own investi¬
gation consisted almost entirely in measuring these correlations for
several representative conditiofts which have been accepted as criminal
influences. And because the result was practically zero in almost
every case, I formulated my conclusion that iro evidence had emerged
from the investigation 4 o show that crime, to any appreciable extent,
was influenced by the force of circumstances. I then went on to trace
and explicitly define, in similar fashion, the influence of heredity on
crime : which brings me now to the third point of Sir Bryan’s criticism
of my work which I want to discuss.

I find Sir Bryan’s arguments, which refer to my biometric treatment
of the heredity and crime problem, evasive. He employs also, it
seems to me, unsubstantiated charges against the Biometric School.
I will produce these charges seriatim with my reply to each. The first
is stated in these words : “ The two diverse schools,” the Biometric
and Mendelian, “appear to be at one in placing a sharp dividing line
between inborn and acquired characters.” Now I am not competent
to speak with authority on behalf of Mendelian doctrine, but as a
biometrician I am in a position to say this : that the Biometric School
is not inclined to place sharp dividing lines between categories ; and it
certainly would not draw r one between such highly imaginative and
artificial categories as those described by authors as “inborn” and
“acquired.” Indeed, the case is just the contrary. For what are the
iffertntia which, in fact, do separate by a sharp dividing line the

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doctrine of Biometricians from that of their more ambitious, but
perhaps rather more confused, confreres, the Mendelians? It is this :
that Biometricians refuse, and always have refused, to recognise any
real existence in the unit characters, unit compartments, and sharply
partitioned pigeon-holes which are at the basis of Mendelian theory.
The characteristic feature of Biometric doctrine is that Nature distributes
her attributes in continuous quantitative series. The tall and the short
peas of Mendelians are not, according to Biometric teaching, specific
entities of one definite degree : there is a wide range of tallness in the
one variety, as there is a wide range of shortness in the other. And,
very similarly, Biometricians recognise no line of demarcation between
Albinos and those who are without the Albinotic character; or between
criminals and those who are without criminal tendency : Albinos and
criminals merging into their opposites by insensible gradations. To
accuse, then, the Biometric School of drawing a hard and fast line
between categories is, of course, a mistake.

Equally mistaken is the second charge against the Biometric School
of “ employing the terms 1 inheritance’ and ‘ reproduction ’ as synony¬
mous.” Nowhere in biometric literature, certainly not in my Report,
would these words be found used as if they were interchangeable.
Sir Bryan says that “ the Biometric School has made several elaborate
investigations into heredity questions and draws its conclusions from
large numbers of observations gathered and statistically studied.” This
is the fact. But what in each case has been the object of the investiga¬
tion, and what the nature of the observations ? In every case, without
any exception, they have been the tracing of ancestral resemblance from
data of ancestors and offspring. These investigations were inspired by
the genius of Sir Francis Galton, whose ideas of heredity, which have
been adopted by those carrying on his work, were defined in his Law
of Ancestral Resemblance : a title which speaks for itself as to the
meaning adopted of heredity. The title, at any rate, disposes of the
allegation that Biometricians confuse reproduction with inheritance,
which is a law of reproduction ; and the nature of the investigations,
referred to above, prove conclusively that to Biometricians the law of
reproduction called Heredity means one thing, and one thing only—
Ancestral Resemblance. I don’t maintain that these two notions are
never confused ; they frequently are. All I assert is that they have not
been confused in published works of Biometricians, whose refrain,
emphatic and unvarying, reiterates monotonously the fact that inherit,
ance means ancestral resemblance—nothing more and nothing less.
Nearly all misconceptions about heredity arise from an inability to
hear, or from refusal to listen, to the cardinal fact of this refrain.
Grasp this fact, and you will see, for instance, how stupid is the widely
spread misconception that inheritance of a character, such as criminal

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tendency, must nullify efforts at criminal reform. It is as foolish to say
that a criminal is incorrigible because he is like his criminal father, as
it would be to deny possibility of his reform because he is like any
other criminal who is not his father. For parental resemblance does
not imply annihilation of the human will, whose incalculable power
of conquest over tendency is at the source of all reform. I repeat:
the essential fact to be grasped is that heredity means nothing more
and nothing less than ancestral resemblance. Fix that fact well in mind,
and you have a key to many difficulties of the heredity question.
That is the sum and substance of Biometric teaching ; and, in the face
of it, to say that Biometricians treat of inheritance and reproduction
as if they were synonymous is manifestly inaccurate. .

The next charge is more difficult to repudiate because of the
ambiguity of some of its terms. Here it is verbatim : “ The Biometric
School place a sharp dividing line between inborn and acquired
characters; it employs the term inheritance and reproduction as
synonymous. Thus , the characters or qualities this School investigates
are found by them to be inherited or inborn ; and a reproduced quality
means, in fact, for this school a purely inborn and transmitted quality.”
Why the word “thus,” connecting this charge with the two preceding
ones? What is the meaning of this thusness which transfers respon¬
sibility to the Biometric School for an unthinkable conception of a
purely inborn and transmitted quantity? There are, of course, such
things as figures of speech ; and figurative language is often as useful
as, and is sometimes more illuminating than, literal speech. Yet the
expressions, “purely inborn character,” “transmitted character,” which
were probably not intended by their real authors to be interpreted
literally, are being used here as descriptive terms in a highly technical
subject; and figurative expressions, w'hen used technically, can only
perpetuate the confusion of thought that may have engendered them ;
and consequently, they would be studiously avoided by the Biometric
School, whose characteristics are clear thinking and precision of
language. Biometric descriptions refer invariably to facts of experi¬
ence ; Biometric investigation, as Sir Bryan admits, “draws* its
conclusions from large numbers of observations” which are the
recorded results of experience. Now, observation and experience show
us heredity not as a power for transmitting, or withholding transmission,
of any definite thing such as a purely inborn quality; they show' us
heredity as a tendency only : as a tendency to reproduce a more or less
approximate likeness of that thing. Accordingly, without calling upon
figurative expressions, the Biometrician is able to describe his experience
of heredity influence in simple, literal, and plain language, as the
observed tendency of every newly created being to develop the likeness
of those within, and the relative unlikeness of those without, his own

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line of ancestry. Descriptions of characters as “ inborn ” and “ acquired ”
are not only not employed, but they are studiously avoided, by
Biometricians. And in this studied boycott of figurative terms we
have the exact opposite of what Sir Bryan states to be the case,
namely, that the characters or qualities the Biometric School investi¬
gate are found by them to be purely inborn or transmitted qualities.

The fifth charge Sir Bryan brings against the Biometric School is that
“as regards heredity it necessitates no further assumption than that
sameness of reproduction in the case of a given quality implies sameness
of inheritance.” In apparent contradiction to previous statements, Sir
Bryan admits here that Biometric Science regards heredity as sameness
of reproduction, which is a different thing to reproduction, and might
mean the same thing as ancestral resemblance. The allegation, how¬
ever, now is that ancestral resemblance is always, without further
inquiry, assumed by the Biometric School to be due to one cause,
namely, the influence of heredity. The inaccuracy of this statement is
shown by the following passage from the Report of my biometric
investigation of the problem of heredity in its relation to crime : “We
only know that there is such a thing as Heredity by its effect in pro¬
ducing Ancestral Resemblance. The first step, then, when studying
the influence of Heredity is to obtain a measure of this resemblance-
It must be understood, however, that this estimation of resemblance is
only a first stage towards the solution of the heredity problem. Inherit¬
ance presupposes resemblance, but resemblance need not necessarily be
due to hereditaty influence. The first step, then, in the study of criminal
heredity leads only to the discovery of certain statistical facts of family
resemblance. These facts alone do not in themselves provide answers
to the wider questions they lead up to; these are, to what extent these
facts of family history are due to the inheritance of a constitutional anti¬
social disposition, or to what extent they depend upon the influence of
family contagion.”

This concludes the indictment against the Biometric School. The
remaining charges are directed against me and my particular biometric-
work. The first of them is as follows : “ Dr. Goring’s final conclusions
rest upon the conception that qualities or characters are either inherited
or acquired—either of a constitutional origin or produced by the force
of circumstances, and that it is possible to disentangle the influence
of heredity from a complication of environmental influences—which
illustrates the unfitness of applying biometrical methods to all branches
of biological research.” What the statement really illustrates is the
futility of criticising the application of a principle until the nature of
that principle has been definitely agreed upon and accepted. Were
Sir Bryan and I at one concerning the conception involved in heredity
problems, we should not possibly be at variance regarding the fitness of

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applying biometric methods for the solution of those problems. Now,
what precisely Sir Bryan’s conception of heredity may be I do not
know. He tells us something of what it isn’t—for instance, that heredity
is not the same as reproduction, but he nowhere states explicitly and
unambiguously what he conceives it to be. How widely and funda¬
mentally our respective conceptions must differ is revealed in the passage
quoted above. For no one, proceeding from a conception of heredity
as an influence tending to produce ancestral resemblance, could pro¬
fess to form an estimate of the extent of its effectiveness in any particular
case without investigating the matter statistically ; that is to say, without
making a statistical analysis of data recording the degree of resemblance
actually observed between ancestors and descendants. These data are
as necessary for estimating intensity of ancestral resemblance as were
observations on falling bodies essential for measuring the intensity of
terrestial gravitation. And as with the force of heredity, so with the
force of circumstance. The forces of heredity and circumstance are
both of them conceptions derived from experience of associations, and
the only way to measure precisely the strength of associations is by the
statistical analysis of data. But Sir Bryan implies that characters can be
differentiated as either inborn or acquired without investigation; that,
by some mystical process unexplained, character can be shuffled into
either one or other of these two compartments at sight. It is clear,
then, that when describing characters as influenced by the forces of
heredity and of circumstance, I am performing an entirely different
operation to that of Sir Bryan when he classifies characters as either
inborn or acquired. In other words, the conceptions of heredity and
environment on which my conclusions rest must be fundamentally
different from the conceptions of environment and heredity ip Sir
Bryan’s mind when he criticises those conclusions. And, in fact, that
our respective ideas of heredity and environment do refer to entirely
different realities is conclusively proved by a final pronouncement on
my work which Sir Bryan makes in reply to his own question, “whether
any conclusion of value bearing on the genesis of the criminal is likely
to be attained by the statistical methods Dr. Goring has employed ? ”
The answer is that no conclusion of value could be so attained, and
a verdict pronounced on the final conclusions I did reach by these
methods is that “ these conclusions are erroneous.” The conclusion
that crime is influenced by heredity is erroneous, because “the fact
that inborn capacities are necessary for the production of human
characters is accepted knowledge; no longer a hypothesis in need of
verification.” The conclusion that crime is not appreciably influenced
by the force of circumstance is erroneous ; because a notion that “the
human being, criminal or non-criminal, is the creature of his inborn
capacities alone has not been proved.” Could anything be more final ?

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Could anything settle more conclusively, once and for all, that biometric
research is a futile intellectual vagary ? Or else, that Sir Bryan’s notion
of the problem involved in the aetiology of crime is unsound at the
core? And, in pursuance of this latter contingency, I think a glance
at the introduction of my book will take us as far as this : That what¬
ever his own notion of the aetiology of crime may be, Sir Bryan has
completely failed to acquaint himself with the biometric conception of
that problem. For it will be seen immediately, from my description of
the criminal diathesis in the introductory chapter referred to, that “ the
hypothesis no longer in need of verification,” which Sir Bryan describes
as one final conclusion of my investigation, is, in reality, a postulate or
starting point from which that investigation proceeded. And it will
also be seen, from the same reference, that what Sir Bryan describes as
a second final conclusion of my investigation, namely, that the criminal
is a creature of his inborn capacities alone—this unthinkable notion
was certainly not a goal which that investigation set out to reach.

Let us try to get down to the fundamentals of a problem that can
provoke such complete misunderstanding. The first point, which is
abundantly clear, is that the mere existence of life, apart from the
form it may take or the characters that may distinguish it, the mere
fact of life itself must presuppose two things. First, the influence of
reproduction and development determining, through the germ plasm,
a continuity of organic growth between the generations. Second, a
range of environment within whose influence alone organic growth
can take place. These influences upon life are assumed wherever
any form of life is manifest. In the absence of either of them, or
rather in the absence of reproduction and development, and in the
presence of an environment extending beyond prescribed limits, organic
growth ceases, and existence comes to an end. It follows, therefore,
that questions connected with the formation of human characters, that
all questions of retiology, are in no way concerned with this fixed and
invariable influence of both girm and environment, which is obviously
indispensable for growth. In discussion of these questions there can
be no real difference of opinion on these elementary facts; and any
difference there may appear to be is one of expression only. As pointed
out by Prof. His “To think organic beings can be built up without
any environmental means is a piece of unscientific mysticism.” All
this, of course, is as simple as it is obvious; but it is a matter whose
importance cannot be over emphasised by statement and restatement
of the obvious postulate which I repeat: when investigating aetiology
problems, the facts of reproduction and development determining
growth within a fixed range of environment, have no relation or
reference of any kind whatsoever to our direct and immediate concern
which refers to the opposition between germinal and environmenta

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influences in determining not growth, but the particular way growth
takes place, and the particular kind of characters which are produced
as an ultimate result of growth. How is growth modified by varying
germinal influences? How are the ultimate effects of growth modified,
to what extent can they be stunted, or encouraged, or diverted, by
varying the degree or proportions of environmental influences? These
are the questions the investigator asks himself; and in seeking answers
to them, he naturally turns to the observation of the senses as the only
means for formulating a tfuly scientific reply.

In plants, and amongst lower animals, the possibilities of modifying
growth by environmental means are very great. Apart from effects
due to selective breeding, pronounced modifications in the growth of
fruit and flowers have been, and every day are being, produced under
varying conditions of temperature, nutriment, moisture, climate, etc-
As the result of treatment, the remarkable variability in the produce
of gardeners, working on the same material, is a matter of everyday
experience. But as we go up in the animal scale, the possibility of
thus modifying growth becomes more constricted; and the extent to
which results achieved are due to stock, or environmental selection,
becomes increasingly doubtful. Hence the innumerable questions
which arise. We know that for human physical development some
form of nutriment and exercise are requisite. The question is to
what extent, by taking thought—by prescribing this or that regime of
nutriment and exercise—a cubit can be added to stature, or muscular
development can be increased, or obesity reduced ? We know that
a tendency of human tissue to become diseased would be arrested by
eliminating any one of the conditions which are essential to the life
of human tissue. The question is to what extent, modifications, within
the range of conditions compatible with life, will arrest or encourage
the fruition of morbid tendencies: to what extent will over-crowding
insufficiency of diet, defective sanitation, increase tubercular tendency ;
to what extent will cod-liver oil, tuberculin, or open-air treatment
arrest it? We know that the criminal tendency is affected by the
“environmental influences which act for good or for ill on all men,”—
by all kinds of education or training, for instance. The question is
to what extent the degree of this character ultimately attained depends
on the presence or absence of some particular kind of training, or
some particular form of discipline : whether any one form of education,
as, for instance, primary, secondary, or reformatory school training,
or the education of the streets, or the educative influence of parental
example in a corrupt home, is more productive of, let us say, habitual
criminality than is any other specified form of education? These are
he burning questions that requiie answering, and that call for precise
answer, in plain language, from the expert sociologist; and from the

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nature of tlie questions it will he realised that no amount of reflecting,
of appealing to opinion, of referring to authority, of exercising
dialectical ingenuity, can possibly provide the convincing and indis¬
putable answers which are demanded, and which can only be attained
in one way: namely, by appealing to, and making the best possible
analysis of, experience. For what is the nature of the questions
referred to ? In every case it will be found that what these
questions demand is an exact measure of the relationship between
two variables. Consequently, for all practical purposes, problems of
setiology resolve themselves to this: as we modify one variable, what
is the observed effect on another variable ? In all their mental and
physical attributes, and morbid states, and conditions resulting from
these, how and to what extent, in all these ultimate results of growth,
do human beings change, as we vary the hereditary and environmental
influences which govern the growth of human beings? This is the
problem of aetiology which, it will be seen, in every case, is essentially
a problem of correlation. And how correlation between variables is
to be assessed, save through the medium of a correlation calculus, it
is not for me, as a biometrician, to say. It is incumbent on those
critics who condemn the biometric calculus for solving problems of
aetiology to supply that information.

In conclusion, I should like to point out that I do not discover in Sir
Bryan’s criticism any sense of the fact that the aim of my inquiry was
not to support speculation upon what, in ideal conditions, might con¬
ceivably be a source of crime, but to discover what actually are its
relations in conditions prevailing to-day. Because certain specified, but
entirely imaginative, adverse circumstances might admittedly increase
the production of habitual criminals, therefore habitual criminality is,
in fact, a product of adverse circumstances—this seems to be the burden
of a passage, which I cannot refrain from quoting, as an illuminating
commentary on Sir Bryan’s conception of the aetiology of crime. “ I
venture to think,” writes Sir Bryan, “ that most of us, including Dr.
Goring, would agree, even in default of a demonstrative experiment,
that most children and young persons from whatever stock they might
have sprung, could have their normal criminal diathesis so influenced
by neglect or positive training as to be actually and easily produced as
even habitual criminals of various kinds.” Let us admit that habitual
criminals might be produced in the conditions Sir Bryan lays down.
The admission would not affect the conclusions of my investigation ; it
would only restate a possibility which, in fact, that investigation did
assume : “ the possibility that environmental, as well as constitutional,
factors play a part in the production of criminality.” This possibility
is, and always must be, a matter for investigation : never for discussion.
Crime might be influenced by many circumstances; just as it might be

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146 RELATION OF ALCOHOL TO MENTAL STATES, [April

uninfluenced by many circumstances. Crime might be influenced if
doors were left unlocked, or if streets were no longer policed; it is
none the less uninfluenced by the circumstances I examined. Future
investigation may reveal many criminal agencies at work which are at
present unsuspected. But in the meantime, we need not let ourselves
be diverted, by such speculations, from established facts. These facts
were summarised in my conclusion which, despite of speculative criti¬
cism, still holds. It is that “between a variety of environmental
conditions examined, such as illiteracy, parental neglect, lack of employ¬
ment, the stress of poverty, etc., including the states of a healthy,
delicate, or morbid constitution per se, and even the situation induced
by the approach of deatl^ 1 )—between these conditions and the com¬
mitting of crime we find no evidence of any significant relationship.

(') At all ages of life up to fifty-five the death rates of prisoners are practically
identical with the general population rates.

The Relation of Alcohol to Mental States, particularly in regard to
the War. By Major Sir Robert Armstrong-Jones, M.D.,
R.A.M.C., Lecturer on Mental Diseases to St. Bartholomew’s
Hospital. (*)

I propose to deal with this subject in the light of present-day
experience and knowledge, reflecting, to begin with, the medical opinion
of to-day and afterwards that of the general public, and I propose to divide
my theme into two sections : Firstly, the evident meaning attached to
my title, viz., the different forms of mental abnormality resulting from
excessive drinking in the individual, and secondly, the different mental
states exhibited, or the different points of view adopted by the com¬
munity responsible for the methods of its sale and use, and, as a con¬
sequence, for the maintenance of public order. In dealing with the
latter section I shall pass in review the different legal measures that
have been adopted to control its sale and the various steps that have
been taken to safeguard the health of the people in connection with it.

The question of the effects of alcohol upon the human organism is an
important medical point, as well as being an interesting, economic, and
sociological one; for it has a concern with the vitality and with the out¬
put of work of the individual, as also with his relation to the State
which protects him and of which he forms a component part. As to
the use of alcohol in health all experiments are in accord, and it would
be useless to occupy space with a repetition of the results obtained.
Broadly stated, they are that alcohol stimulates the heart and circula¬
tion ; in other words, it increases the force and frequency of the pulse

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and the functional activity of the nervous system, but it tends also to
lower the temperature of the body, because it checks tissue changes. It
is evident, therefore, that we have in alcohol a drug which can afford
temporary relief in certain abnormal bodily states, but the very relief
afforded in one particular direction, viz., as a cerebral stimulant, doubles
the temptation to its frequent use, and as the body becomes habituated
to its action, and the dose has to be increased more and more, the habit
of frequent stimulation grows almost of necessity into drunkenness.
For this reason I am of opinion that no physician is ever justified in
prescribing alcohol for its purely soothing, stimulating, or narcotic
effects, and I have never used it, nor advocated its use, for the mental
conditions described as painful, emotional states; because I consider
its legitimate use to be for those extremely serious nutritional dis¬
turbances such as threaten the last moments of life, and in these
states I have known it to prolong the life struggle. Personally, I have
no sympathy under ordinary circumstances with the daily use of alcohol
by healthy persons who are not beyond middle life, and even such use
in health has moral and politico-moral issues which cannot be discussed
here; but under conditions of unaccustomed exposure to wet and cold,
when the extremities are numbed and have lost, or are losing, their
proper feeling, I have been informed by both officers and men from the
trenches that the “rum ration” has enabled these men to withstand the
continuous exposure to intense cold and wet. This fact is not in con¬
tradiction of the physiological experience already quoted, that alcohol
lowers the body temperature and has no heating power. It only means
that the chill of sudden exposure, the stiffness from benumbed extremities,
and the bronchitis that may follow are the result of cold, which drives
the blood from the skin and the general surface of the body to the
internal organs ; that as a consequence of long exposure the circulation
fails in the skin, the functions of which are suspended with the result
that the skin ceases to excrete the body waste normally carried out with
perspiration, and that these waste products are now thrown upon the
internal organs, which are already in a state of passive congestion. The
relief obtained is properly explained by the physiological effects of
alcohol, which maintain the increased circulation and keep the external
surface supplied with fresh, warm blood from the internal and engorged
bodily organs. The obvious danger of prescribing alcohol in health is
to induce intemperance, but it is only right to state that intemperance
is also often the effect of brain weakness and brain disease; indeed,
some writers have gone so far as to state that in practically all cases of
mental disease associated with intemperance, the latter is a consequence
of mental weakness and not the cause; a statement which is probably
less than half the truth.

In regard to alcohol, chemistry teaches us that alcohol is primarily

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a strong dehydrating agent. It takes away water from living matter,
and, as a fixed amount of water is a necessity for the life of healthy
protoplasm, this dehydrating action may prove to be highly injurious,
hence its effect upon living tissues is to cause a degeneration and decay,
which can be seen in the pyramidal or the essentially psychic cells of
the brain, with consequent loss of their function and with marked
intellectual degeneration when they are affected. The higher will power
is impaired, the will loses its grip, normal inhibition is removed so that
the person is easily tempted to other forms of indulgences, and we know
that the great campaign of the National Council for Combating Venereal
Disease cannot afford to disregard the connection between alcohol and
the social evil. I have seen young officers, barely twenty years of age,
whose army career has been ruined by drink and debauchery. The
disposition in those who drink to excess changes into querulousness and
impulsiveness; in fact, the most marked mental effect of excessive
drinking is the tendency towards the development of a hostile attitude
of mind, with the consequent liability to react furiously and intolerantly.
Alcohol attacks the hierarchy of the tissues, for it has a special affinity
for the nervous system ; there is a shedding by degrees of the most
highly evolved faculties ; there is a loss of prevision, an impairment of
the judgment, and a failure in the power of discrimination ; later on the
memory becomes affected, and no amount of reasoning is able to
persuade the person who has got into the habit of drinking to give it
up, even if it be clearly pointed out to him that he and the family
dependent upon him are being pauperised by it.

It is always very difficult to estimate the exact setiology of even the
most common diseases, but it is impossible to arrive at accurate con¬
clusions in regard to the causation of mental diseases ; yet, in connection
with alcohol, the Lunacy Commissioners, in their report for 1905, made
the precise and definite statement that alcohol, in their opinion, was a
“brain poison.” Whether it be justifiable to describe as a deleterious
poison an organic substance useless to the individual under ordinary
conditions of health may be a matter for legitimate differences of
opinion, but the Lunacy Commissioners made, in addition, the further
statement that, although some counties with a comparatively low rate
of insanity had a high proportion of cases admitted into asylutps with
a history of intemperance, there were other counties with a high rate of
insanity but with a low proportion of cases suffering from alcoholic
intemperance. Nevertheless, in those areas in which there is an asso¬
ciation of intemperance and insanity, there is found also the definite
association of intemperance and crime, which appears to justify the
inference that in those cases where there may be a high incidence of
intemperance, there will also be a high proportion of insanity and crime,
and it is the considered conclusion from the definite observation of all

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social workers that where there is intemperance there also are crime and
insanity. It is interesting to note that when statistics as to the causation
of insanity are taken over a series of years, the number of cases appearing
as caused by alcohol as well as by other causes show but little variation
from year to year, and it is computed that alcoholic intemperance may
correctly, and without any doubt, be attributed as the assigned cause of
insanity in no less than 20 per cent, of all males admitted into asylums,
and in no less than 10 per cent, of all the females ; and when the total
number of admissions for the last year of which we have record, viz. y
1915, was quoted as 8,600 males and 10,000 females, we can readily
see that alcohol was in one year responsible for over 2,700 cases of
mental disease in England and Wales, i.e., of persons who had to be
compulsorily detained against their will, and who, in consequence of
drink, were deprived of their social, civil, domestic, and financial rights,
and of whom, it may be observed, a number will continue under deten¬
tion for the remainder of their lives. It may be surmised that possibly
about 3,000 persons every year become insane through drink in
England and Wales.

I have referred to the difficulty there is in arriving at the exact factor
of causation in mental diseases, and as may well be appreciated in this
illness the patient himself is unable to assist the investigator, as, owing
to the clouding of his reason, the statements he makes are unreliable,
and further, the information vouchsafed by the friends does not help
to elucidate the cause, for the reason that they only relate such ante¬
cedents in the history as appear to them to bear upon the illness,
which are rarely either accurate or full; moreover, in many instances
the cause attributed by the friends only stands in some immediate
relation to tlie illness, and forms no true part of the cause; indeed, it
often has little or no connection with it, the real factor being some
inherited or acquired frailty or some weakness in the nervous co¬
ordination, which the friends have either minimised or overlooked or
have carefully attempted to suppress. So often is this the case, owing
to the stigma attaching to mental disease, that a studious effort is
made by all the relations to lessen the importance of a faulty family
history and to give prominence to trivial and unrelated factors having
no definite causative effect. From what I may claim to bean extensive
personal experience, I am more than ever convinced that in mental
disease there exists some locus resistentice minoris in the brain tissue,
which renders the individual more prone to be affected by circumstances
which in the healthy person would have less influence ; and, although
several antecedents may combine in the ultimate production of a mental
breakdown, it is logical to assume that any one of several causes may
be the immediate agent responsible for the final breakdown. In regard
to this much depends upon the so-called “immunity ” or the individual
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resistance shown by the person affected, and as we know, when several
persons are exposed continuously to the same infectious fevers, some
always escape and do not contract the infection, whilst others appear
to take the disease repeatedly and to suffer in turns from almost all
the other ills to which flesh is heir. No fact in biology is more
striking than the difference in susceptibility to disease conditions
exhibited by different persons and different races, or even by different
animals. It accounts for the very different symptoms produced by the
same dose of the same kind of alcohol upon different persons. We
know from medical experience how in regard to drink some persons
may break down from arterio-sclerosis, haemorrhage, and cerebral soften¬
ing, whilst others may suffer from interstitial changes in the glandular
structures, e.g., the liver or kidneys, whilst others again rarely suffer
from nervous or mental lesions at all, but they break down from more
gross tissue changes and become physical rather than mental cripples.

Drink in small doses is literally death to some persons, whereas
others tolerate it in large quantities, and the brain worker rather than
the manual labourer shows the least resistance to it. As we know, one
person may become morbidly irritable and quarrelsome, another may
be ludicrously affectionate, a third stupid, a fourth vain and boastful,
and a fifth silly, all these differences denoting differences of suscepti¬
bility to the same dose of the same kind of alcohol. The same
susceptibility to alcohol and to disease that is seen in persons is also
exhibited in the history of races, eg., the native races in many parts of
the world are comparatively insusceptible to yellow fever, to enteric,
and to malaria; and we know the same condition to exist in animals,
for dogs and goats are rarely tubercular, and rats, which are not
susceptible to anthrax, are only so after fatigue or when fed upon an
exclusively vegetable diet, which helps to render the blood alkaline, a
reaction which favours the growth of the bacillus; we know, again,
that tetanus, for instance, is never met with in fowls. These facts
demonstrate that there is a natural immunity or a natural insuscepti¬
bility on the part of certain races, individuals, and animals to certain
diseases which may in the same persons even vary at different ages, eg.,
as age advances, the immunity to diphtheria and to scarlet fever
becomes more marked and definite, and this immunity may be either
partial or complete. Precisely the same sort of immunity or insus¬
ceptibility as occurs in disease is met with in the use of alcohol, and we
are therefore unable to foretell the particular group of neurons likely to
suffer in any special case of alcoholic indulgence; nor can we foretell
the progress of the symptoms when a group of neurons has been
attacked ; all we can assert is that for every individual there is a spot
or place of weakest resistance which has been arranged for him through
natural selection and heredity. For long periods of time many of the

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different races have been exposed to alcohol, but the susceptible ones
have been weeded out, whilst the survivors transmit their insuscepti¬
bility to their descendants, and although this is an observed fact, yet
it gives us no physiological explanation of the greater immunity of the
insusceptible ones. It is possible that more proteolytic enzymes are
produced by the organs of one individual than by those of another in
order to destroy or to modify such a toxin as alcohol, with the result
that a greater immunity exists in one person than in another. Whether
the explanation of this phenomenon be afforded by the humoral
hypothesis, which ascribes immunity to the action of certain substances
existing in or generated by the body fluids; or the explanation be
afforded by the cellular theory of the more active phagocytic action of
the polymorpho nuclear leucocytes ; or by the cellulo-humoral theory
of the production of alexins or bacterio-lysins in the blood, cannot now
be discussed ; but it is a well-ascertained and an incontrovertible fact
that alcohol acts differently upon different persons, and this personal
equation of the individual should be taken into consideration not only
when discussing the symptoms of alcohol, but also when urging
legislation for the control of its sale. I have mentioned the subject of
immunity in order to show that whilst alcohol may be regarded as a
poison—and clearly in this particular what is one man’s meat is another
man’s poison—yet like many other poisons it can, under certain circum¬
stances, be of distinct service to mankind. I may say that I believe
the consensus of opinion among medical men in the present day is
that in many instances the use of alcohol is to some extent beneficial ;
but there is a strong section of the thinking public which realises
that alcohol is a lethal weapon which can work the most fell and deadly
effects, and that its general use therefore needs the most careful and
earnest control. We know personally from too many instances brought
to our notice that alcohol reduces energy, lowers vigour, diminishes
initiative, and paralyses enterprise, and therefore many persons abstain
from it altogether, and they use untiring efforts to prohibit its use by
others, and this through the highest motives, but it must not be
forgotten that total prohibition hreeds vices in regard to drugs, seda¬
tives, and anodynes. At the moment, the public feeling generally is
that under the control of the normal reasoning and moral faculties the
moderate demands of working men and women should be satisfied,
i.e., within strict limitations, which is interpreted by public opinion to
apply to its use at meals only, and only by those who find it helpful in
their daily work. It is often felt by those who watch events that the
logic of facts has to be carefully weighed against the sentiment of an
ideal, and if true progress in regard to temperance is to be encouraged
the watchword must be festina lente. However excellent the motives,
however firm the zeal, and unwavering the devotion, progress cannot be

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forced, and it cannot be pushed far in advance of public opinion. I
know how in regard to the control of the liquor traffic both feeling and
sentiment have run high and with regrettable consequences. It is
necessary in regard to this aspect of the question to take cognisance of
the state of feeling in all classes of the people, and at the moment
there seems to be an irresistible popular feeling against the complete
prohibition of alcoholic drink, which that great and useful movement
the “War-time Prohibition” or the “Strength of Britain Movement”
has already had to encounter; nevertheless it has achieved much
useful success in its educational campaign, for it has drawn special
attention to a social problem that has been too largely ignored. In
discussing this problem various aspects of the drink question come
under review, and the hygienic, medical, sociological, and ethical
aspects all come up for consideration.

In this paper I propose to deal exclusively with the mental
symptoms, viz., those that result from the influence of alcohol upon the
nervous system, and in discussing this aspect it may be appropriate
to state there is evidence that every psychological state has a correspond¬
ing physical state in the brain, for to every psychical process there are
special physical and chemical changes in the nervous substance
corresponding to it, hence the maxim, “to every psychosis there is
an appropriate neurosis,” which means that every mental act has its
appropriate physical correlation. This parallel relationship has been
demonstrated by observation and experiment; it is a joint conclusion of
psychology and physiology, and can be definitely supported by clinical
and pathological research. Different parts of the brain, as we know,
subserve different physiological functions; thus, one part is concerned
with vision, one with sensation, and another with bodily movements
and speech, yet the whole brain acts together, so that when these
various parts are affected by alcohol there occur visual and other
sensory illusions upon which are based delusions ; in consequence of
affections of touch there arise mistaken ideas and complaints about
electricity, machinery, hot irons, or the gnawing lacerations of wild
animals. It is sensory disturbances in particular which so often
originate delusions of persecution and the violent and impulsive retalia¬
tions associated with drink. There is no better ascertained fact in
medicine than that alcohol has a peculiar affinity for that part of the
brain which is connected with the “ muscular sense.” It destroys the
co-ordination of the fine sense which secures the equilibrium of the
upright position and that of the limbs, and, as we see in drunken¬
ness, it may bring about motor paralysis. Even before ordinary
sensation is affected, the muscular sense may be attacked, so that
engineers, delicate instrument makers, mechanics, type-writers, pianists,
draughtsmen and those who do fine work need to be especially on

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guard if their educated and delicate muscular sense is to be preserved
to them. It is our fine perceptions that give us the experience upon
which we act, and two classes of perceptions especially, viz., sight and
touch, have been very fully studied experimentally, and these are the
ones mostly affected by alcohol. In regard to touch, a composite
sensation, we know there are four distinct external receiving organs in
the skin—firstly, that giving the measure of pure touch ascertained by
the pressure on the skin of fine hairs mounted in wooden handles and
attached to a balance, then the pain spots indicated by pressing with
metallic points ; thirdly and fourthly, heat spots and cold, spots indi¬
cated by hot or cold blunt rods. In every instance is the response to
these varied by alcohol; the first to go is pain, the next heat and cold,
and the last pure touch. These are facts that can be demonstrated by
experiment, and are the same as occur when the nerve to the skin is
divided. In speaking of the mind as related to the brain, we realise
that its study implies a close investigation of the various senses which
are the avenues leading into the mind. Formerly the study of the
mind was limited to the field of introspection only ; but of late years
investigation has been carried into mental phenomena by means of
experiments, and these have enabled us to examine our sense percep¬
tions with much more accuracy and precision, both under normal
conditions and under the influence of graduated doses of alcohol.
It is usual to speak of the mind as composed of three types of con¬
scious activities, viz., cognition or the state of knowing; of feeling and
sensation ; and, lastly, of the will; the two latter being now grouped in
the subdivision of interest, but the will is the highest and essentially the
most human characteristic of the mind. Of the powers of the mind
memory is one of the most fundamental as well as the most im¬
portant, for without memory we should be unable to co-ordinate the
different states of consciousness and we should also lose our personality,
results which we see occurring after the excessive use of alcohol. The
facts which come into the mind to be grouped together by association
—like to like and unlike contrasted with unlike—remain endorsed
upon it through memory, and the main objects of education are to form
time-saving and correct associations. Discipline is a matter of associa¬
tion—a body of well-trained troops only needs to hear the first of a
series of orders to carry out the whole train, as one is linked to the
next by association. The power of constructing and carrying out trains
of thought by association is described as the power of apperception,
which is the focussing power of the mind, and it is this which is the
first to be impaired by alcohol ; it may be temporarily suspended or
it may be permanently destroyed.

There has been much confusion as to the use of terms in dealing
with the effects of alcohol, and the term “ alcoho ism ” has received

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widely different meanings. Mr. Leif Jones (President of the United
Kingdom Alliance) in an address to the International Congress at the
Hague, in 1911, used it as signifying the total consumption of alcohol
by a people; whereas others use it to imply the measure of mortality
from strong drink indicated by mental and physical symptoms leading
to fatal results and recorded in the Registrar-General’s statistics. The
most common effect of the excessive use of alcohol is drunkenness,
and the symptoms of this are too well-known to need description.
But there are three very different types of drunkenness ; firstly, there
is the periodic drinker or the dipsomaniac who imbibes freely and
deeply but at intervals only, and during these intervals he may abstain
completely; secondly, there is the person who literally soaks in alcohol,
who is hardly ever sober, and is the person described as the “habitual
drunkard,” who swells the police-court lists until, eventually, owing
to the progressive lesions and their lasting effects, his death is recorded
in the Registrar-General’s statistics as a case of alcoholism; and,
thirdly, there is the ordinary drunkard who drinks from pure
conviviality and only needs the congenial “ pals ” to spend all or most
of his money whenever he gets it and thus to lower his productive
efficiency. He is the typical Saturday night and .Sunday drinker, and
he almost invariably gets into the hands of the police and figures in
their statistics. It is this person who is the average worker upon
whom the State depends. Broadly speaking, neither alcoholism nor
drunkenness in its three forms of these terms signifies the amount
of alcohol consumed, although the statistics of drunkenness may be
the most reliable index. As we know there may be a considerable
consumption of alcohol with a comparative absence of drunkenness,
and for this reason it would be more convenient to regard alco¬
holism as a social disease of which drunkenness—whether of the
periodic, the chronic, or the occasional kind—is one of its forms. If
drunkenness may be taken as an index of the amount of drink
consumed, the number of deaths from cirrhosis, delirium tremens,
dropsy, or Bright’s disease may be taken as the index of the inci¬
dence of the social disease. It has been asserted by some critics
that a diminution in the numbers of cases of drunkenness may imply
even more rather than less drinking, because those persons who,
under the present restrictions, have a difficulty in obtaining alcohol,
may drink privately and secretly in their own homes; but this is
denied by all social workers, and is contrary to the observed experience
and the recorded inferences of all those who know the homes of the
people. Whatever importance or value we give to these terms, it
must be the question of immunity or the insusceptibility or the
vulnerability of the different organs of the body which is the
determining factor as to whether a case comes under the definition

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of occasional drunkenness or habitual drunkenness, or of alcoholism.
We here employ the term alcoholism to signify all the pathological
changes which result from drink and to include all the varying symp¬
toms whether mental or physical, and whether these occur in hospitals,
asylums, police courts or the private home of the individual. Alcoholism
must therefore be the total effects of the use of alcohol, of which
drunkenness is probably the most convenient if superficial indication,
and it is drunkenness, whether its effects be sensory, motor, mental, or
moral, which is the most common indication of excess.

Of the various forms of mental impairment caused by alcohol the
most dangerous because the most violent and impulsive is delirium
tremens , which occurs in one-fifth of all cases of alcoholism, and in
consequence of continuous alcoholic intoxication in those persons
who are liable to mental and sensory hyperaesthesia, and is associated
with extreme agitation, tremors, night hallucinations, and insomnia.
The symptoms are too familiar to be further detailed, but probably
thousands of these cases occur annually. Another form of mental affec¬
tion not uncommon among the civil population, although fortunately
rare among the military, is that of multiple neuritis associated with
mental symptoms, and commonly called Korsakow’s psychosis. It is
characterised by a loss of memory of a peculiar kind. There are gaps
in the recollection of past events, which the person fills up with events
that have never happened; these being suggested by some trifling
incident in the environment at the moment, and for this reason he is
said to lie shamefacedly, but this is only because the memory is a
blank and he is unable to retain impressions of his own statements,
causing a peculiar forgetfulness as to time and place—a loss of
orientation. There is .an impairment of that special retentive quality
of the nerve-cells by which the healthy brain is able to register the
images of past sensations, and by means of which thoughts may be
expressed in a clear, regular, and logical order. This form of loss of
memory is described as paramnesia , and is most indicative of alcoholic
indulgence. A third form of mental affection through drink is one
closely related to epilepsy, and this is greatly favoured by a head injury
or some predisposition to mental disease. It is accompanied with
sudden frenzy and fury, and is not infrequently associated w-ith
unconsciousness, and possibly also epileptic convulsions, but if these
are absent there is a marked “automatism” and a complete forget¬
fulness of what has previously occurred. In these attacks the person
may commit acts of serious violence, even suicide or homicide, and
there is an imagined hostility from his environment which calls for
resistance or retaliation; but this condition ceases entirely with
abstention from alcohol, although an immediate relapse may occur
when excessive drinking is again resumed, and it may be noted that

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this excess may be a very small amount of alcohol, as in these persons
there is a marked susceptibility to its effects. I have met these cases
repeatedly in civil practice, and also in the case of young officers who
have suffered from head injuries. A fourth form of mental affection
is an unrestrained excitement caused by the presence of vivid
hallucinations, and again it is the susceptible brain that suffers rather
than the normal person, for very little alcohol may produce these
hallucinations which are vivid and terrifying, and which may induce
a chronic delusional state from which there is no recovery. This
condition much resembles that of paranoia with delusions of sus¬
picion and persecution. It is essentially a chronic form. Lastly,
there is the state of terminal dementia, in which the mind gradually
fails until the mental wreckage is complete. Whether a case evolves
from slight mental confusion through the different mental states into
fatuity and dementia as the result of alcohol, must depend more upon
what has already been referred to as the peculiar susceptibility of each
individual rather than upon the quantity or the quality of the alcohol
imbibed. It is certain that all young persons in health are better
and fitter without it, as also all older persons with a neurotic family
history.

It may be correctly stated that there is much in common between all
the forms of mental disorder associated with alcohol. There is an undue
suspicion in all against their environment, and if delusions are present
they tend to be of a persecutory nature; even if they partake of a
grandiose character, there is frequently the suspicion that the victims
have been robbed of their rank, position, and wealth. Their
hallucinations mostly relate to sight and touch; imaginary objects are
seen moving, crawling, or creeping over them, and they complain of
being burnt, electrified or tortured; the memory is invariably affected
for recent events, although more correct for remote events, and their
actions are predominantly impulsive, purposeless, and unreflective;
they make imaginary journeys and relate what seem to be plausible
assaults committed upon them which they resent, and which they
intend to repay their fancied enemies with interest; lastly, there is
the invariable moral and intellectual deterioration shown by the
offences committed against public decency and against the amenities
and conventions formerly so corrrectly observed, so that the alcoholic
ends by becoming an object of reproach to all his former friends and
associates.

I have already referred to the impulsive and dangerous acts committed
by persons under the influence of alcohol. In some instances these
resemble the uncontrollable fury of epileptic mania, which, in my
opinion, is the most furious and savage violence that can be seen in
any individual, for it seems like a tornado of wild, impetuous, destructive

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rage. Under the influence of alcohol the most rancorous and loathsome
cruelties have been perpetrated upon innocent victims; the most bitter
hatred has been shown ; prudence and moderation and altruism have
disappeared under its influence. We have it officially recorded that the
most brutal excesses followed in the track of the drunken German troops
in Belgium and in Northern France. After they had emptied the cellars
of the French chateaux they ransacked the furniture and priceless
contents, and then lay upon the floors in stuporous semi-consciousness ;
whilst at Rheims they behaved with ferocious cruelly, and in the dug-
outs of the Somme battle our men found German officers hopelessly
drunk and filthy. The account of eight drunken German soldiers
returning from Malines is authoritatively quoted, and relates that when
a little child ran out into the street as these drunken Huns passed by
she was bayoneted by one of their number, slung up, and thus carried
away whilst his comrades sang. The organised cruelties and atrocious
outrages carried out by gangs of drunken German soldiers, the assaults
committed upon helpless women and children are an eternal disgrace
to the military forces of Germany and to those in authority over them.
The German medals struck to commemorate the foul murder of the
helpless passengers on board the “ Lusitania ” will for ever remain a
shame and a reproach to German honour, and drink has frequently been
the root of like actions. I have personally witnessed the mental break¬
down of innocent women from Flanders who were driven into madness
by the coarse savagery of German officers and men, whose animal
nature was set loose, and whose instincts and brutal desires through
drink w r ere no longer inhibited by the control of the higher faculties.
The horrors of German atrocities have already been fully and accurately
described with great moderation in the Bryce Commission’s Report and
other records. The German troops, as well as the higher commands,
have shown a most mad brutality, as well as a sordid love of malicious
destruction. They have delighted in spoiling anything beautiful and
irreplaceable.

I have already referred to the use of alcoholic liquor as an ordinary
article of diet, and I consider it a dangerous temptation to the younger
officers. The following extract from the letter of a young officer supports
my view. It is written from a divisional headquarters, “somewhere in
France,” and it runs as follows : “ It is very hard for the teetotaller out
here, as it is not safe to drink the water unless it has chloride of lime
in it, and this makes it taste simply foul. I am at present drinking
very light French beer, which is much better for me than w'hisky.
I am afraid the present way of keeping the mess bill will not work,
as they order cases of whisky and port, and the cost is shared by all
members whether they drink it or not.” This is a matter that needs
•the urgent attention of the authorities, for there is no reason to penalise

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the abstainer to save the pockets of those who are not. Abstention,
like the custom of drinking, is a habit, and it is imperative that young
men who are ready to make the extreme sacrifice for their country
should not be sacrificed on the road which is not the road to victory,
but the short cut to all the other vices. Quite different, in my opinion,
is the use of the “ rum ration ” in the trenches. I have spoken to
Army chaplains about this matter, some of whom are life abstainers and
have served in the front trenches ; these men speak of the value of
medicinal doses of alcohol against cold and wet and exposure, but one
and all condemn the estaminets , where the men are served with mixed
poisons having special intoxications of their own, yet all are labelled with
the indefinite name alcohol. The chaplains are naturally in favour of
the dry canteens, which many of them manage, but most of them are
in favour of permitting light wines, beer, and spirits during meals, if
only the estaminets could be considered by the commanding officers to
be “out of bounds,” and some of the chaplains are ready to buy and
sell drink at the canteens for the sake of the men, if their use is limited
to nieal-times and the estaminets are forbidden. That this matter is a
most difficult one will at once be acknowledged, and that there are
different views in regard to it is also natural. The two letters which
appeared in The Times on December 17th last show the different mental
states from which the critics view the present condition of things in
regard to alcohol. One of the letters is from Dr. Grenfell, C.M.G., of
Labrador, who is well known to members of this Society. He states
that the American soldiers show an absolute freedom from drunkenness
and a small amount of immorality, but when they get to England and
France “ they will get all the alcohol they want, and therefore also the
danger that comes with it.” In the same number of The Times , Mr.
W. T. Ellis writes that he has just arrived in London from Russia, and
his own impression, after fours days of observation, was in striking
contrast to the suggestion of Dr. Grenfell—a strong prohibitionist. Mr.
Ellis writes : “ I have yet to see a drunken soldier here, or one behaving
in any way that reflects discredit upon the Allied flags.” To the man in
the street the real truth must lie between these two extremes, and it is
interesting to reflect upon the mental state of the critics themselves. I
may add that during the whole of Christmas week, whilst going about
freely in London, I did not meet a single drunken person. As to the
effects of alcohol upon the mind we may repeat, firstly, that there are
the various degrees of mental confusion and motor inco-ordination
described as drunkenness, which are mainly of three types, viz., the
periodic kind, shown in the dipsomaniac, the more or less continuous
form seen in the habitual drunkard, and the occasional drunkard;
secondly, the state described as delirium tremens ; thirdly, the combined
condition of neuritis and psychosis; fourthly, the convulsive and auto-

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matic state; fifthly, that of chronic hallucinations and delusions, and
lastly, the terminal state of fatuity and dementia. It may be stated,
broadly, that all forms of mental affections brought on by alcohol or
associated with it may be subdivided or referred to one or other of these
groups. I am leaving out of this paper the fatal malady, general
paralysis of the insane, which, in my opinion, has a close, indirect
relation to alcohol. It is a mental and physical disease which affects
young men in the Imperial services, particularly the Army and Navy,
and out of the whole population possibly 1,000 men—these probably
of the best and most adventurous type—are destroyed annually. Side
by side with this is the mental and physical destruction of about 500
women from the same disease.

Let me now take the second section of my theme and briefly
refer to the mental states shown by those responsible for the sale
and control of alcoholic drink, which have ranged between a mild
endurance and extreme intolerance, and as we know the question of
drink is by no means a new one in this country; indeed, drunkenness
as the consequence of drinking is the oldest of the vices and has been
known in every country from very ancient times, whereas alcoholism
or the pathological conditions produced by alcohol is a development
of civilisation.

The statutory licensing of ale-houses began as far back as 1495,
but it was not until 1606 that—to use the words of the Act—“the
loathsome and odious sin of drunkenness ” was made a statutory offence
punishable by fine or confinement in the stocks. Throughout the
Middle Ages the provincial and the Diocesan Ecclesiastical Courts
exercised an active and strict jurisdiction in regard to moral correction,
and sternly punished the “infamous and offensive” sin of drunkenness.
Apart from special local legislation the early statutes of 1606 continued
until 1872 when the Licensing Act of that year made it an offence
punishable on summons by fine to be found drunk in any public
place or on any licensed premises. There was more activity in regard
to drink legislation during the seventies than in any consecutive ten
years before or after, and not until the Licensing Act, which came
into force on January 1st, 1903—as a result of a special Royal
Commission described as the Peel Commission—was there any
concerted effort made to diminish the number of public-houses
proportionately to the population. This Act made it a penal offence
for a person to be “ drunk and incapable ” on any licensed premises or
in any public place, and a drunken person if in charge of a child
under seven years of age became liable to imprisonment with hard
labour for the period of one month, and information in respect of
this offence, and even the arrest itself may be made by any person.
A special feature of this Act was the “ Black List,” a system by which

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the offender, if convicted for drunkenness four times in the same
year, may be either fined or sent compulsorily into a reformatory for
any period up to three years. The police provide photographs of the
offender (with details of previous convictions) to all licensed premises
and to all secretaries of clubs within the district of the Court, and
if drink is afterwards supplied heavy fines may be imposed upon those
who sell. This Act aimed at protecting the home, and it tended to
make it impossible for drunkenness to become the curse and ruin
of an innocent family, and in addition the Act gives power to control
the structural arrangements of all public-houses, so that no alteration
is possible without the consent of the licensing justices. The Act
was an effort to repress the abuse of alcohol rather than to restrict
the sober person; yet, since the passing of the Act and for several
years up to 1914, there lias been a gradual rise in convictions for
drunkenness of both males and females; the “ Black List ” also, in
spite of good intentions, has become a dead letter, so that although
there has been a steady diminution and reduction of public-houses—
partly by order of the licensing justices and partly also by arrangement
with the brewers—it was not an infrequent occurrence for County
Councils and other authorities as well as for local residents to petition
the licensing justices .to diminish the number of public-houses on the
ground that facilities to obtain drink not only increased the temptation
for people to drink but also encouraged the desire; the petitioners
feeling deeply that the class of the very poor should not be swelled with
continual recruits through drunkards and their families being brought
into them from all the other classes. Indeed, so serious had matters
become six months after the war through drunkenness, impairment
of health, loss of workmen’s time and general bad temper, where a
large population had congregated for munitions and other Government
work, that the present Prime Minister described the drink as a worse
enemy than the submarine, and in June, 1915, the Liquor Traffic
Control Board (with Lord D’Abernon as Chairman, and Mr. J. C. G.
Sykes as Secretary), was instituted by the Parliament of the people
under the Defence of the Realm Act, and it must not be forgotten
that the enactments and regulations of this Board have the force of
an Act of Parliament. This Board set to work at once with a definite
policy which was to stop continuous drinking and to modify drinking
at frequent intervals, especially during working hours, as these
indulgences were believed to be the root of most of the physical
and mental troubles and disabilities among workers, and the Board
hoped to discourage all drinking except at meals. The work carried
out by the Board in such areas as Carlisle and Enfield reads like a
romance, but it would have been probably impossible if Parliament
had gone to the country asking for the powers they have exercised.

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In Carlisle and Annan the Board have closed many of the public-houses
and some of the breweries, and have themselves taken over the enter¬
prises carried on formerly by these as well as by the wine merchants.
They have placed disinterested managers in charge of their houses, and
managers were not to profit by the sale of drink but only by the sale
of food; the hours of opening were restricted to those of meal time,
the sale of spirits was to be discouraged and none was to be issued
to those under eighteen years of age, and—a very important feature—
all drinks were permitted to be diluted. They have arranged for
entertainment and recreation to be provided for persons frequenting
their premises. They also have power to provide postal and banking
facilities for their customers. Moreover, they have arranged for their
own inspectors to visit and examine all premises and clubs within
their controlled areas in order to insist that the regulations are
carried out, and, lastly, they have established Sunday closing. It is
not fully appreciated by the public to what extent the regulations of the
Board have succeeded, but it is only short of marvellous to % realise that
these rules control thirty-eight millions of the population of this country,
and it may be surprising also to know that the Board have not acted
in a single instance without an application to do so being presented
by the local naval, military, transport or munition authority. May we
ask what results have followed the action of the Board ? Throughout
London and in forty towns with over 100,000 inhabitants, 159,000
convictions for drunkenness in both sexes occurred before the war,
whereas in 1916 these had diminished to 77,000, or less than one-half.
In London alone last year nearly 20,000 arrests were made by the police
for drunkenness, with “ incapability ” and disorderliness as qualifications,
and this number is less than half the number during the first year of
the war. In all the areas where the Board have exercised their powers,
the streets have become more decorous, the station platforms more
orderly, the people more tranquil and crowds less excitable; workers
have been healthier and their minds less irritable; there has been
more contentment among the mass of the people, they are more
reasonable and have got through more work. In addition, there has
been a reduction by one-half in the number of cases of delirium
tremens, especially in places where men collected in large numbers,
and many of them drifted through drink into the Poor Law Infirmaries.
The results in all areas have been perfectly astonishing although these
are only a few of the attainments of the Board, and these results have
been testified to by chief constables, medical officers of health, district
workers, nurses, and even by members of the licensing trade itself.
The police-court statistics have supported the statement made that
drunkenness among men and women has diminished by one-half.
Yet what do we find among some of the critics, viz., those who are

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described as extreme temperance advocates; persons whose whole¬
hearted efforts are said to be in the public interest, yet, who in regard
to the control of the liquor traffic, are “neck or nothing.” They offer
to the policy of the Board an uncompromising opposition, and in place
of the scheme of purchase and control so successfully carried out by
it, they advocate a scheme of total prohibition. They offer a flat
contradiction to the Board’s statistics, and to support their opposi¬
tion they urge that in spite of the restrictions generally imposed by
the Board, the fact that there has been a continuous increase since
the war cf expenditure on intoxicants—which was 12 per cent, higher
in 1916 than in 1915, and 24 per cent, higher than in 1914—and that
the amount of money spent upon alcoholic liquor in 19x6 was higher
than in any previously recorded year, and the highest yet recorded;
but this can be accounted for by the high price paid for drink, which
means that although the nation spent more, it drank less, and the
revenue received less money. These opponents also assert that if there
has been a diminution of drunkenness, which is not admitted by them,
there has been more private drinking, which is denied by all those
most competent to judge; or they state that the police have been more
lax in their supervision of drunkenness since the war, which is an
aspersion upon the police. What are we to think of the mental state
of persons who can direct such a virulent and vehement crusade against
the work of the Board of Liquor Control ? The following is the criticism
made in the leading article of The Times of December 26th (1917):
“The diminution of intemperance among women will not be welcomed
by those intemperate advocates of temperance who regard the total
prohibition of the liquor traffic as an absolute good in itself. Some
people seem actually to prefer an increase to a diminution of
drunkenness, because it is a lever for promoting their cause, and they
will criticise and deny the evidence quoted in the report of the Board,
viz., the fact that there has been a diminution of drunkenness as
shown by the average weekly number of convictions—which has fallen
from 700 in 1914 to 239 in 1917.” These specious critics assert that
police statistics are notoriously unreliable and that the fall in these
have been more than overbalanced by an increase in home drunken¬
ness, that public excess has been replaced by “ secret drinking,” which,
of course, is not the case. The local Carlisle journal’s reply to this
criticism reads as follows: “ The improvement (in Carlisle) is as
noticeable in the orderliness of the streets as in the official figures
of decrease in convictions for drunkenness, and to the citizens this
return to good order must be highly gratifying; and not only are
the numbers decreasing in comparison with previous years, but the
improvement still continues and is very pronounced.” Nor has this
hostility been limited to the work of the Board; one member of the

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Board himself has been the recipient of the most unmerited abuse
and contempt on the part of this extreme wing of the temperance
party. Nor was it long before their example was taken up by other
discontents. The Labour Council in Carlisle saw in Sunday closing
an interference with the workmen’s comfort and freedom, and they
naturally demanded a reconsideration of this matter by the Central
Board, with a request to return to the former hours of opening. The
whole matter was referred to the local Advisory Board which apparently
took the side of the Labour Council, but the Central Board very wisely
decided there was not sufficient reason to go back upon their decision,
suggesting that whatever determination was arrived at would always
give rise to some conflict of opinion. The matter is possibly not yet
closed because the Labour Council have decided to make further
representations, and it is earnestly hoped that the trouble started by
the extreme wing of the temperance party will not be the means of
stirring up labour troubles in Carlisle and elsewhere. In addition to
the complaints of the Labour Council there has arisen an acute opposi¬
tion from the Midlands, and again on behalf of the prohibitionists,
but apparently originating in an insignificant quarter.

It is quite well known that before the Central Board came into
being the policy of regulation and restriction under private ownership
had already received a fair trial throughout the country, but it is also
equally well known that it had reached its effective limits and some¬
thing practical and immediate had to be done. No one denies that
to the idealist temperance reformer—may we say not only to the mind
of the total abstainer—prohioition as an ideal has undoubted public
advantages over any system of State purchase, precisely as this has
merits that are immeasurably superior to the scheme of the improved
public-house, as it is called, advocated by the self-denominated True
Temperance Association; but the work of the Central Liquor Traffic
Control Board has by an overwhelming consensus of public opinion
advanced the cause of temperance; yet there has been this incompre¬
hensible attitude against its members and against its work, and more
incomprehensible still this attitude has been excited and fomented by
those who should have been its best friends. What is the pyscho-
logical explanation of such opposition? I am of opinion that this
intolerant exhibition of superiority deliberately shown by this extreme
section is based upon a form of egoism; it is a consequence of a
psychological self-gratulation and self-esteem which borders upon an
obsession, and is regarded by some authorities as pathological! Most
of us will acknowledge that all excellences require some comparison
to demonstrate their advantages, but when specious reasons are
advanced to support them and these are mingled with personal attacks,
then such criticism passes beyond the limits of legitimate argument.

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A person who argues from selfish ends and from a feeling of personal
superiority over others is very apt to dry up the wells of truth in order
to justify his standpoint. Nor is such a person contented to stand
alone, but, as we see in this instance, he courts the sympathy of others
—whoever they may be—and so long as his own views are furthered
he will even sacrifice his own sense of honour in his effort to bring the
opinion of society against his opponent and to throw discredit upon
his views. No form of hostile criticism is so unendurable to a sensitive
high-spirited nature as the disapprobation of his fellow-men and fellow-
workers, and it is a favourite device with the advocate of a weak cause
that he should not only excite public opinion against his opponent, but
also that he should heap upon him as much private contempt as
possible, with the sole object of forcing him through this vituperation
and scorn to modify his attitude, and this irrespective of the public
good. We have used strong words in criticising this conduct of the
extremists, and we know that this virulent and vehement opposition is
not supported by public opinion. Let us be thankful that in the best
interests of this country we have had a strong and energetic committee
that has created a great change in the habits of the people as a war¬
time measure. It behoves us to think of what is to happen after the
war is over. The period of demobilisation is going to be a serious
trial, especially to us who have to bring our brave men home from far
distant seats of war, and all our men will be returning to find things
very different from what they were. As Major Eccles said, “ scenes of
drunkenness will be a dishonour to a nation that has been fighting for
right and righteousness ” It is the duty of this Society to urge that
the best conditions for employment shall be provided for our damaged
men. There will be many difficulties after the war; there may be
destitution ; there certainly will be shortage of food and money. The
question of the control of drink must be one of the first considerations,
and are we giving it the amount of thought it needs? Our present
mental attitude is too apathetic, and if we do not awaken now we shall
be confronted with far greater menaces than we have hitherto faced.
At any rate, we can rely upon the standing example of what has been
achieved by this Board even during the stress of war.

(*) A paper read at the Society for the Study of Inebriety, January 8th, 1918.

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War Psychoses : An Analysis of 202 Cases of Mental Disorder

Occurring in Home Troops. 0 ) By Temp. Capt. D. K.

Henderson, M.D., R.A.M.C., Royal Victoria Hospital, Netley.

In June, 1916, a portion of the Lord Derby War Hospital was set
aside for the care and treatment of cases of mental disorder occurring
in non-commissioned officers and men of the British Expeditionary
Forces. In addition, it was found that at the home training camps,
and in soldiers doing garrison duty in India, Gibraltar, Sierra Leone,
and so on, numerous cases of mental disorder were from time to time
arising. As it was obviously impossible for general hospitals adequately
to care for such cases, the Lord Derby War Hospital, pending their
final disposal, was called upon to receive a certain number of them.
Other arrangements have now been made for more expeditiously dealing
with these cases, and in consequence none such are now received in
this hospital.

These Home Troop cases have, however, provided a valuable amount
of material for study, and have particularly brought forward the impor¬
tant question : Who should be recruited ? I shall not delay at this
point to discuss this question, but it will be taken up and dealt with
in detail in discussing the different types of mental disorder which have
arisen.

Seeing that these men had broken down during their military training
on home duty, it was conceived likely that they would never make
efficient soldiers, and consequently, irrespective of the type of mental
disturbance, the plan was adopted of discharging these men as quickly
as possible from the Army. With the great majority of the cases there
can be no doubt that, from the point of view of the Army, this was the
soundest policy to adopt; but, seeing that one had to deal with cases in
such an arbitrary way, one could not help but feel that greater care
should have been exercised in their enlistment. Or if, on the other
hand, it was felt to be an absolute necessity to enlist such men, then,
likewise, greater care might have been exercised in apportioning to them
the work for which they were best suited. It stands to reason that
when any large group of individuals is called upon to meet a certain
situation, no matter how simple it is, there will always be some who
either because of certain faults in the balance and adaptability of their
make-up, or because they are congenitally defective, or because of
already definitely developed forms of mental disorder, e.g., general
paralysis, chronic alcoholism, etc., will be unable adequately to meet
the situation. The consequence is that it would seem to be not quite
right, from the individualistic point of view, that a number of those
who break down should be summarily discharged or sent to asylums.

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The great majority of the men comprising this group were men who
had been called up under Lord Derby’s more or less compulsory scheme,
and the balance had been made up of those others who on account of
their age, or of some minor disability, were considered to be unfit for
active service abroad.

Apart from these preliminary and more or less general considera¬
tions, it may be stated at once that there did not seem to be any one
special type of mental disturbance to which these cases were particularly
prone, and here we had a heterogeneous group of individuals all
exposed practically to the same situation, but each of whom tended to
react to that situation according to his inherent or predisposed con¬
stitution. The cases were not clear-cut, but frequently showed a mixing
of symptoms, and formed a composite picture. Before going on to
discuss the individual groups it may be admitted quite frankly that in
several of these cases the formal diagnosis is quite open to question,
but owing to the vast number of cases passing through one’s hands, and
owing to the short time the majority of them were under observation,
this could hardly have been otherwise. After all, the labelling is not
the important thing ; it is much more interesting and stimulating to look
upon these cases as reactions to situations which could not be adequately
met. Roughly, however, these 202 cases have been differentiated as
follows :

Mental deficiency

. 61

Paranoid states .

. 8

Dementia praecox

• 43

Toxic-exhaustive insanity

• 3

Manic-depressive

• 24

Epilepsy with insanity

• 3

General paralysis

• 19

Organic brain disease.

2

Alcoholic insanity

■ t 7

—

Traumatic insanity .

12

202

Psychoneuroses

10

Mental Deficiency.

Sixty-one cases, or roughly 30 per cent, of the 202 cases, have been
included in this group. In considering these cases, the most striking
feature which has come to one’s notice has been the fact that the acute
symptoms which necessitated these patients being sent to hospital were
of an exceedingly transitory nature. That statement is best brought
home by saying that 45 of these 61 cases showed such a betterment in
their condition that in the course of a few weeks they were able to be
discharged to their homes; the remaining 16 were certified as insane,
and committed to mental hospitals. There would seem to be little
doubt, however, that, considering that the average period which these
patients spent in this hospital was approximately six weeks, a consider¬
able number more would have cleared up provided it had been possible
to treat them for a longer period of time.

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167

Alienists have not infrequently been reproached with looking upon
everyone as mad, and one becomes constantly and forcibly reminded
of this when it comes to saying whether or not a person is mentally
deficient. There are, of course, many cases which obviously to any one
are not “all there,” but there are very many other cases which it is
exceedingly hard to fairly size up. One would not complain nor
criticise provided one felt that just ordinary care had been exercised in
recruiting cases of mental deficiency for the Army, but where the defect
stares one so openly in the face, as in the great majority of the cases
included in the group which we have examined, then it would seem that
the time had come for reform to take place. In mental deficiency all
sorts of superimposed clinical forms may show themselves, but for the
purpose of this paper five main sub-groups have been differentiated as
follows:

(1) Mentally deficient, but without definite psychotic

symptoms ....... 34

(2) Dementia praecox-like states .... 8

(3) Manic-depressive-like states . . . . .12

(4) Impulsive, assaultive, suicidal states ... 4

(5) Acute hallucinatory states . . . .3

61

Mentally Deficient, but 7 vithout Definite Psychotic Symptoms.

All the 34 cases belonging to this group were so grossly abnormal
that it was undoubtedly a waste of both time and money ever to have
enlisted them. The great majority of them were simply feeble-minded
boys who were quite unable to adapt themselves to the stress of military
training, were unable to do their drill, understand commands, etc., and
in the course of their first few weeks’ training were sent to hospital, and
finally discharged. A brief report of a few of the most striking cases
is the best comment one could give :

(x) No. 12536, gunner, attached to R.G.A. (Signal School), aet. 30,
broke down within the first month of his training. He had been
admitted to the Rest Camp at Southampton “ because he said he was
forty-three years old.” He stated that he could not get the noise of
the buzzer out of his head, and the doctor who examined him diagnosed
the case as one of “ exhaustion psychosis,” and recommended a long
rest. On admission to this hospital he was found to be dull and stupid
looking, had a vacant expression, and all the appearance of a mental
defective. He stated that they had tried to teach him signalling, but that
he had utterly failed to comprehend it, and now wished to forget all about
it. When he left school, at the age of fourteen years, he had only reached
Standard III; he was unable to do the simplest calculations, could not
tell who was King, and had practically no realisation of current topics.

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In civil life this man had been a skilled machinist, doing Government
work ! How much better it would have been if he had been left at the
work which he was suited for, or else, if he had to be enlisted, surely he
might have been employed otherwise than in trying to learn signalling.
He was discharged from the Army and sent back to his former occupation.

(2) No. 26475, private, set. 27, had been seven months in the Army.
When admitted to this hospital he was dull and demented looking,
could not tell his regimental number, was somewhat suspicious, and
stated in an irrelevant way that he would refuse to sign any papers. He
was unable to tell when he had enlisted, or to give any satisfactory
account of himself. He did not know the day, but gave the month,
year, and place correctly. At school he had reached Standard III, could
only read and write with great difficulty, said that King Edward VII was
on the throne, and was quite unable to do the simplest calculations.
Physically, he had a low, broad palate, irregular, asymmetrical teeth,
microcephaly, and the whole general appearance of a defective. He
was committed to an asylum.

(3) No. 19607, private, set. 35, had been in the Army for about three
months. He was received from Litchfield Military Hospital, where he
was described as ill-nourished, of stupid appearance, gave vague answers
to questions, sometimes refused to answer at all, and gazed at the
ceiling. On admission he was found to be a poorly-nourished, defective¬
looking man who walked in a slovenly way, dragging his feet. He was
very dull and stupid, complained of headache, and could not tell how
long he had been in the Army. Apart from his general defectiveness
he did not present any special symptoms. He was committed to an
asylum.

(4) No. 37717 , private, set. 40, had been in the Army for four and a
half months. This man had been found to be quite unfit for his duties,
and on admission was unable to give any account of himself. He was
obviously a weak-minded individual. The following are samples of his
mental capacity : 3x9 = “ 18 ”; 6x4 = “45"; 2/6 in 15/- = “ 17 .”
Who is King? “The Prince of Wales is King now.” He was com¬
mitted to an asylum.

(5) No. 2633, driver, set. 29, had been in the Army for fifteen months.
He had always been nervous and complaining, and in 1914 had been
previously discharged from the Army “as unlikely to make an efficient
soldier.” At Connaught Hospital, Aldershot, he was dull and slow,
his mind appeared to be imperfectly developed, and childish. On
admission he was found to be simple and weak-minded, said the thought
of having to ride a horse made him feel badly, and that he had become
downhearted because he recognised he was not fit for his work. He
was returned home to the care of his friends.

(6) No. 5669, private, <et 19, had been in the Army for one month,
and in every way had been found to be utterly unfit. He could not
read or write, could not tell when or where he had enlisted, and his
usual reply to any question was: “ Father knows.” He had never
passed out of Standard I at school, and was really an imbecile. He was
sent home to the care of his friends.

(7) No. 36957, private, tet. 26, had been in the Army for five months.
He stated that shortly after leaving school at the age of ten years he had

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169

been knocked unconscious by a blow on the head, and following this he
had always suffered from headache and “bad nerves.” On admission
and during his stay he was quiet and orderly, but mentally he was very
defective, and made many irrelevant remarks. He was unable to do the
simplest calculations, and when asked who was King, replied: “ He is
our King, I hope, sir.” Physically, he had a marked cyanosis of the
extremities.

(8) No. 30390, private, aet. 20, had been in the Army for six months.
On admission here he was dull and stupid, said that his head seemed
to be on his mind, that it felt mixed up and numbed, and that it had
bothered him ever since a severe cycle accident which he received about
six months after leaving school. At times he said that his head would
get so mixed that he did not seem to know what he was doing, and at
Chatham he had gone to see a doctor because on a march he would
tend to go giddy. He had reached Standard III at school, and had
always done very menial work, never at any time earning more than
£1 per week.

These last two cases show very well the necessity for making careful
inquiry in regard to head injuries, and show the tendency there is for
head symptoms to reassert themselves as soon as a patient is subjected
to a strain that is too great for him to meet.

(2) Dementia Prercox like Stales.

Among cases of mental deficiency it has been a well-recognised and
long-accepted fact that frequently one meets with mute, resistive states,
or rather vague persecutory states which in a superficial symptomato-
logical way closely resemble the dementia praecox type of reaction. On
a closer analysis of such cases it is readily enough seen that the condi¬
tion has been engrafted on a mental defective make up ; furthermore,
that it is exceedingly transitory in duration, and frequently clears up on
a change of environment or on the lifting of the exciting strain.

(1) No. 24029, Private S. C—, set. 37, was admitted to D Block,
Netley, from Southampton Docks, where he had been employed on
labouring work. He is described as having been confused, and
admitted having attempted to take his life, because he said that people
had been taking him for a spy, and had been watching and following
him. He had definite delusions of persecution and had assaulted a
sergeant. On admission here he presented the same picture of suspicion,
and continued to express delusions of persecution, but these rapidly
passed away. He was of a very low type, was defective both intellectu¬
ally and morally, and at various times in his career had been convicted
of issuing base coin, theft, and burglary.

Another patient presented a dull, mute, catatonic, resistive state, but
his symptoms rapidly cleared up, and he was able to be discharged to
his friends.

The other cases corresponded to either one or other of the above
types, but they presented no special problems, and will not be further
referred to.

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(3) Ma?iic-deprtssive-like Stales.

Twelve cases belong to this group, nine of whom had spells of depres¬
sion and the remaining three showed periods of excitement. As has
already been noted in the dementia prajcox states occurring in mental
defectives, so also may it again be said here that the depressions and
excitements showing in this group of cases are on a much more superficial
plane than the true manic-depressive attacks and run a much more rapid
course. The matter is really best expressed by saying that the depres¬
sion or excitement is simply a mode of reaction towards a situation
which the patient cannot meet, and usually rapidly subsides when the
situation difficulty is removed. Symptomatically also the depression is
not of the slowness, sadness variety, but a rather more dramatic state
with outbursts of crying, restlessness, and agitation ; similarly, the
excitement is not so much in the nature of a jolly, elated, flighty,
distractible state, but rather an excitement characterised by obscenity,
irritability, and violent, assaultive outbursts. These points are well
illustrated by the following cases.

(x) No. 27878, Private R. F—, set. 39, had been four months in the
Army. At the Military Hospital, Lincoln, he was described as being
of low intellect, and as thinking that he was going to be killed On
admission he was dull and miserable looking, and could not give his
regimental number. He complained of his head getting into silly
“ sort of ways,” said that he had been worrying about his wife and boy,
and felt that he ought to be with them. He stated also that in civil
life he had had nervous depressed attacks, and came from a poor stock.
He spoke in a hesitating way, stuttered, said he had felt frightened,
and thought he was going to be shot, and had been quite unable to
adapt himself to the stress of military training. He was poorly endowed
intellectually, and made mistakes in doing simple calculations. His
father had been in an asylum, and his brother had committed
suicide.

(2) No. 29198 Private T. S—, set. 38, had been in the Army for
eight months. He was admitted to this hospital from Fort Pitt,
Chatham, where he had been diagnosed as a case of melancholia.
On admission he was in a tearful, depressed state, and when brought
into the examination room he inquired, in a frightened way : “ What
have I done sir, what have I done?” How are you? “I’m all right
(sobs ); I have always been like this—I can’t do anything with myself.”
The next minute he burst into tears in a pitiful way, and said he wished
that he was underneath the earth. He could not tell his regimental
number, nor when he had joined the Army, and did not seem to know
what his “ unit ” meant. In civil life he had never been capable of
doing any work, and his father had to take him to the recruiting office.
He could not tell the day, month, or year, and at school had never
been able to learn anything. He had the usual physical and mental
characteristics of an imbecile. His depression rapidly subsided, and
he was able to be taken home by his friends.

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(3) No. 6781, Rifleman W. J—, had been in the Army for three
months. He was received from Tidworth with the diagnosis of imbe¬
cility ; he laughed and grinned foolishly, was dirty in his habits, noisy,
and liable to fits of excitement. He had a simple fracture of his left
leg, which was in a plaster-of-Paris cast. On admission he was in a
noisy, destructive state, was dirty in his habits, and subject to outbursts
of violent excitement. He used the most filthy language imaginable, and
was constantly masturbating. His excitement rapidly simmered down,
and he was discharged to the care of his friends.

(4) Private J. S—, set. 36, had been three-and-a-half months in the
Army. In civil life he had been a fitter in the engineering trade, but had
been convicted about fifteen times for theft, burglary, assaults, drunken¬
ness, etc. Since joining the Army, he had spent the greater part of his
time in the guard-room, and several times had deserted. On admission
he was happy and elated, had no sense of his position, said that he
would like to go to France, but, first of all, would like to have leave so
that he might marry his sweetheart. He was sent to an asylum.

(4) Impulsive , Assaultive , Suicidal States.

The only case in this group which need be specially referred to is
that of a man who frankly enough admitted that he had threatened to
commit suicide as a means of leaving the Army.

No. 60544, Private G. H—, set. 20, had been in the Army for two
months. He gave a history of “ fits ” ever since the age of four years,
and stated that while he was in barracks he had had several “ fits ”; he
bit his tongue, had incontinence of urine, and his fits occurred at night
as well as during the day. At school he had only reached Standard III,
and since leaving he had never earned more than 3J. 6 d. per week and
food. A week or two after joining the Army he was sent to hospital
on account of his fits, and of trying to commit suicide. A few weeks
later he was found with a carving knife under his pillow, and later
admitted having done this purposely with a view to getting his discharge
from the Army. He could not read or write, and was sent to an
asylum.

A case such as the above might possibly give rise to considerable
discussion a6 to proper diagnosis and disposal, but where the mental
defect was so well marked it was felt that he could not in any way be held
tesponsible for his conduct.

The two cases showing acute transitory hallucinatory states had very
well-marked alcoholic histories, and the case with epilepsy was a well-
marked case of imbecility; these cases need no special comment.

In addition to what has already been said, it may again be stated that,
so far as our information goes, 12 of These cases had been previously
discharged—some several times—either from the Army or Navy ;
4 had previously been treated in asylums; 10 had made attempts at
suicide; 4 had had criminal records; one described himself as a con¬
scientious objector, and one was a sexual pervert.

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Dementia Prcecox.

Out of the 43 cases comprising this group 20 were able to be sent
to their homes, 22 were sent to asylums, and the remaining case was
transferred to another hospital. These statistics, small though they
may be, again simply go to show that certain types of individual would
be better not enlisted, not only because they quickly proved themselves
to be inefficient, but also because they are liable at any time to become
a very grave danger to their comrades. Many untoward accidents
happening on active service and during training would never take place
provided greater care was taken in regard to those who were enlisted,
and in apportioning men work for which they were suited. This point is
especially important in considering the dementia praecox type of case.
Their sudden, impulsive, homicidal outbursts are of a peculiarly
dangerous character. The following case is one in point:

(r) No. 6762, Rifleman G. YV—, aet. 27, while in camp on November
27th, 1916, suddenly attacked the man sleeping opposite to him, and
inflicted on him three severe wounds with his bayonet. He was
violently excited, stated that “voices’’had told him to kill the man,
and, later, said the voice had been the voice of God. This episode
took place only three weeks after he had been enlisted. On admission
to this hospital, he was quiet and composed in manner, but complained
of buzzing and “tick-tacking” in his head, and apparently for a long
time he had had the suspicion that someone had been wanting to do him
harm. In contrast to that idea, he used to comfort himself with
the thought that God was watching him, and after prayer he would
feel composed. During his first night in hospital, he became suspicious
of the orderly, told him not to play any games on him, and said that he
was experiencing peculiar draughts and noises. He had also visual
hallucinations. In reference to the homicidal assault above noted, he
stated that one night he heard a voice say to him : “ That man is your son
—kill him.” He then added : “ But I am all right now, doctor, when
I pray—these noises and draughts then go away—and I’ve got a son—
Amy got baby, but he is only a baby, and this was a man.” It appears,
however, that he has never seen his baby, that it was born out of wed¬
lock, and no doubt it was on account of these very reasons that the
homicidal assault was committed. His orientation, memory, grasp on
general information, etc., were all intact, but, throughout his hospital
residence, he was dangerous and impulsive, and was committed to an
asylum.

This case shows excellently how a man, who no doubt had been
suspicious and unstable in civil life, readily broke down under the stress
of military training, and in consequence his latent trends were brought
forcibly to the surface.

(2) No. 20740, Private A. S—, ret. 33, had only been three weeks in
the Army when he had to be admitted to the Military Hospital, Ripon.
He stated that as soon as he went to camp the men started to persecute

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him, pulled at his privates, poured things on him, etc. They took
money out of his letters, interfered with him in his sleep, and in various
ways tried to injure his health. Shortly after his admission to hospital,
he was able to readjust himself, and in a short time was able to go home
to his friends. This patient had been a bomb-maker in civil life, and
had been doing efficient work, while as a soldier he was worse than
useless.

(3) No. 33832, Private T. S—, tet. 37, on admission stated that for
twelve years he had been hearing “voices” which had been controlling
all his actions. It was a “nurse-maid who put the voices on him.”
This man, however, had served in the Army for seventeen months, but
about Christmas, 1915, he heard his thoughts being repeated aloud, he
was asked to sing and to do all sorts of strange things, and it was all
done by electricity. Such a case should never have been enlisted.

(4) No. 6615, Private T. G—, aet. 29, had been in the Army for two
weeks. While in camp he gradually lapsed into a semi-stuporous state
which lasted for three days, and this was succeeded by a rather elated
state, with fantastic, ill-defined delusions and auditory and visual hallu¬
cinations. On admission to this hospital he was dull and uninterested,
behaved in a strange way, wanted to shake hands three times with the
medical officer, and stated that he had worn boots without socks so as to
save his life. He admitted hearing voices talking to him, said that he
was a brother of Jesus Christ, and expressed many vague delusions. He
seemed dreamy and abstracted. His sister had been a patient in an
asylum. Previous to joining the Army this man had been doing satis¬
factory work on his father’s farm.

This case again serves to illustrate how an individual of a certain type
of make-up was quite unable to adapt himself to a situation, and on
account of certain predisposing factors developed a picture similar to
that seen in cases of dementia prrecox.

(5) No. 33085, Private A. H—, ret. 19, on December nth, 1916,
while undergoing detention for over-staying his leave, commenced to
have attacks of violence, alternating with periods of brooding. He
babbled about his past life, his petty thefts, his untruthfulness, and his
sexual irregularities. He had had asylum treatment in civil life. On
admission to this hospital he was in a semi-stuporous, resistive, catatonic
state, wet and soiled himself, and attempted to eat his excreta. He
maintained fixed positions, and did not respond to painful stimuli. He
had to be urged to take his food, was usually mute, but would have
periods when he would pray and blame himself for his past life. He
was transferred to an asylum.

(6) No. 2381, Private W. P—, set. 20, on July 20th, 1916, was sen¬
tenced to prison for 112 days for desertion. Two days later he cut his
throat with a razor and was placed in hospital. While there he became
strange in his manner, was dull, stupid, and refused to speak, was dirty
in his habits, masturbated openly, and was subject to sudden, unpro¬
voked, impulsive outbursts. On the night of his admission to this hos¬
pital he suddenly got out of bed and smashed a glass case in which the
•emergency key was kept. As a rule, he lay in bed in a state of stupor,

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was mute but sometimes mumbled the word “mother,” was dirty in his
habits, tended to retain his urine, and did not react to pin pricks.
Gradually, however, he made a fair recovery, and was discharged to his
friends.

(7) No. 6005, Private J. H—, set. 32, had been in the Army for about
five months. From November, 1903, to September, 1908, he had been
a patient in the Three Counties Asylum. He was admitted to this
hospital from Detention Barracks, Wakefield, where he had been under¬
going a sentence of eighty-four days for insubordination. He had had
two previous periods of detention of twenty one and fourteen days
respectively, also for insubordination. On admission to this hospital he
was rambling and inconsequential, frequently tended to answer quite
irrelevantly, and, mentally, was totally irresponsible. He was dull and
stupid, but no definite delusions or hallucinations could be elicited.

(8) No. 28686, Private T. S—, <et. 24, the first day he joined the
Army had been found incapable of duty. Soon after joining he deserted,
and for this offence was fined jQ 2. He was described as always having
been reserved and as never having made friends. On admission to this
hospital he had a sullen, vicious expression, refused food, and was resis¬
tive to all care and attention. He retained his urine, showed catalepsy
and flexibilitas cerea. On one occasion he made a sudden, vicious
assault on the corporal in charge of the ward. He was transferred to
an asylum.

In these last four cases no doubt there again might be a ceftain
amount of disagreement in regard to the diagnosis, and the first three
cases might be looked upon and considered as cases of “prison
psychoses”—that is to say, psychoses which arose in response to their
prison punishment. One can say, however, that all of these men were
of a type of make-up which specially predisposed them to a mental
upset, and in one of the cases, anyway, the punishment meted out
seems, to say the least of it, to have been hardly the proper way to meet
the situation.

Manic-depressive Insanity.

Out of the twenty-four cases belonging to this group, seventeen showed
attacks of depression, and the remaining seven attacks of excitement.
Out of the seventeen depressed cases twelve had made determined
attempts to take their own lives, usually by means of cutting their
throats.

It i» 4 nteresting to note that only three of these twenty-four cases had
had previous attacks of mania or melancholia, and, in consequence, it
might be said that these were really not true manic-depressive cases but
rather symptomatic depressions ; but the classification is not the impor¬
tant thing, and, for the sake of brevity, they have all been included in
the manic-depressive group. Owing to the rapidity of inflow' and
outflow of patients, we have had to content ourselves w'ith a very.

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sketchy account of the symptomatology, and in that respect no special
features have been prominent. The psychosis has been brought about
by a failure of adaptation, and no doubt in some cases enforced absence
from home, worry over domestic affairs, etc., were important contribu¬
tory factors. Two cases of depression admitted frankly enough that
their attempts to commit suicide were due to the fear of being sent on
active service, while another admitted that he took this means of
“working” his discharge from the Army.

Three of these cases are of sufficient interest to warrant their being
given in detail :

(1) No. 6784, Private F. H. B—, set. 24, had been called up on
August 8th, 1916. A few weeks later, while in camp, he became
depressed, wrote letters home pointing to “religious mania,” and seemed
to be afraid lest he should be sent to France. He was described as
self-centred and depressed, was full of ideas of unworthiness and wrong¬
doing, and thought there was no hope for him in this world or the next.
It was while in this condition on November 16th, 1916, that he attempted
to cut his throat with a pair of scissors. On admission he was depressed
and self-accusatory, said he had been eating too much food, had neg¬
lected his home, and had led a bad life. He answered questions
promptly, conversed coherently, stated frankly enough that he had made
the attempt on his life because he became frightened lest he should be
sent to France, and, in consequence, thought that suicide would be the
best way out of it. He had a good appreciation of time and place, his
memory was intact, and he had a good grasp on current topics. At
school he had been in Standard VII. Physically, apart from his cut¬
throat wound, there was no evidence of any abnormality. During his
stay in hospital he improved very greatly, and probably would have
made a complete recovery, but in the course of four weeks he was
transferred to an asylum.

(2) No. 51610, Private J. F. H—, set. 21, had been in a territorial
regiment since 1913. On October 15th, 1916, he made an attempt at
suicide by hanging. At that time he complained of a heavy feeling in
his head, and stated he had heard voices telling him to do away with
himself. On admission here he was able to give a good account of him¬
self, answered questions promptly and relevantly ; he complained of
dizzy feelings in his head and of his eyes being weak. His depression
had for the most part cleared up, and the auditory hallucinations which
he had formerly suffered from had practically disappeared. He stated
that his depression had been dependent on his being put on a draft for
France, he could not face up to it, thought it would be better to “ do
himself iti,” and in consequence made his attempt at suicide. He had
always been a nervous boy, subject to headaches, and his nervousness
and general unsteadiness had been heightened by a Zeppelin raid. He
had a good appreciation of time and place and his memory was excellent.
He had never had any previous nervous or mental illness. He was
discharged and sent home.

(3) No. 22616, Private J. T—, tet. 40, had been in the Army for
about six months. This patient was received from the 1st Northern

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General Hospital, Newcastle, with a history of having, on October 30th,
1916, attempted to commit suicide by strangulation. He was tried by
court-martial, but apparently (we have no record) was adjudged insane.
Ten years previously he had been hit on the head by a “ spinner,” and
since that time had been subject to headaches. On admission, he was
mildly depressed, complained of headache and dizziness, and said that
at times he felt dazed. At first he denied all remembrance of having
attempted his life, but stated that he had become depressed on account
of a misunderstanding with his wife. Later he admitted that the diffi¬
culty with his wife had played a very secondary role, and that he had
attempted suicide simply because he wished to leave the Army. There
was no evidence of any delusions or hallucinations. He had a good
appreciation of time and place and his memory was excellent. He had
been married for ten years, had four children, and by occupation was a
steel worker. Physically, there was no evidence of any gross disease.
He was able to be discharged to his home.

The above three cases may be considered together, as they all tend to
bring up the same question, viz .: How far should these men be held
responsible for their actions ? Should they be held as having done
wrong knowingly, and be punished accordingly, or should they rather
be pitied and discharged ?

Legally, I suppose, they would be held guilty of having committed a
crime, but, on the other hand, one has to recognise that they had been
put face to face with a situation which, constitutionally, they were quite
unable to adequately meet.

A case which was much more “ pathological,” and where there was
no question of the determination to take his life, was the following :

No. 6114, Private P. G—, ret. 35, had been in the Army for eight
months. In civil life he had been a professional musician. On Octo¬
ber 9th, 1916, he was admitted to the Military Hospital at Catterick,
suffering from a self-inflicted, penetrating gun-shot wound of the left
chest. For about eight weeks previous to this, he is described as having
been nervous and depressed. On admission to this hospital he was in
an exceedingly depressed, miserable condition; he whined and cried,
and constantly reiterated that he was not fit for the Army. He moaned
aloud, kept the other patients awake at night, was restless and sleepless,
and had to be forced to take his food ; on one occasion he had to be
tube-fed. Apart from his agitated, apprehensive, and depressed state he
showed no abnormal features, had no hallucinations or delusions, had
a clear appreciation of time and place, and an excellent memory. He
stated that when he first enlisted he had been in the band, bufr in July,
when the band was disbanded, he was transferred to the infantry. Ever
since that time he had been nervous and depressed, the work was very
uncongenial and trying to him, and he lived in constant dread of being
sent abroad. It was undoubtedly on this account, and because of
the feeling he had that he would prove himself a coward, that in despera¬
tion he attempted to take his life. For the first few weeks following his
admission he showed some improvement in his physical condition, but

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he continued to be exceedingly agitated and depressed, and even
although assured time and again that he would probably receive his
discharge, he continued to be obsessed by the fear that he again would
be marked “ fit ” and shot for cowardice, as people would not realise
how his nerves paralysed him. His father had died from delirium
tremens, and his mother from some form of “creeping” paralysis, but
he himself had never previously had any treatment in either hospital
or asylum. He died suddenly one night about one month after
admission.

In a case such as the above, one could not have any doubt in regard
to the sincerity of the man. He was a married man, with three
children, who had held a steady position in a well-known London
orchestra, and he had enlisted voluntarily. The strain of military train¬
ing, the idea of being put on a draft and sent abroad, and the thought
of leaving those who were near and dear to him was more than his con¬
stitution could stand, and hence the breakdown. Such a man certainly
could not, or at least should not, be held responsible for his crime ;
the pity is that attempts should be persevered in to make such a man
an efficient soldier when obviously it was going to be just so much time
wasted. It is a case such as this—and there must be many of them—■
that makes one assert, and reassert that the Army should, in any case at
the large training camps, have some one who is capable of carrying out
a satisfactory mental examination of such patients. It not only would
be a humane thing, but also, economically, it would well repay the
State.

In regard to the cases showing maniacal symptoms, nothing special
need be said.

Dementia Paralytica.

Nineteen, or nearly xo percent ., of home troops examined were typical
examples of this disease. Thirteen of these were transferred to asylums,
four were taken home against advice, and two died. Eleven of these
nineteen cases had exhibited mental symptoms within the first six
months of enlistment, so it is reasonable to suppose that, if a satisfactory
mental examination had been carried out, the probability is that some
of these men would never have been enlisted.

Surely, it is important that the recruit should be subjected to a
mental examination. If his feet, or his heart, or his lungs are affected,
and still he is enlisted, then he alone will suffer, but if his mind is
affected, especially with such a disease as general paralysis, he will
not only be a very grave danger to himself but also to all his associates.

Several of the most striking cases may be quoted :

(1) No. 127166, gunner, aet. 41, had been in training for one month.
He was admitted from Newcastle, where he had been diagnosed as

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“ Delusional Insanity.” On admission, he was found to be a quiet,
pleasant-spoken, plausible man, who said he had a brother-in-law called
Horatio Nelson, that his wife’s maiden name had been Jessie Nelson,
and that his wife’s family was related to that of Lord Nelson (all of
which was a delusion). He had a feeling of well-being, was very self-
satisfied, but otherwise he did not express any grandiose delusions.
His memory was defective, he made mistakes in doing simple, serial
calculations, and he had no appreciation of the serious nature of his
disorder. Four years previously, while engaged in civil work he had been
invalided from India. While in the Army, he had been subject to
“ weak turns,” and was quite unfit for his work. Physically, he had
unequal, irregular, Argyll-Robertson pupils; his speech was slurring
and sticking; his tendon-jerks were exaggerated; tremors of hands,
tongue, and facial muscles. His Wassermann reaction was positive,
both in his blood and cerebro spinal fluid.

(2) No. 8113, Private A. I—, aet. 33, had been in the Army for four
months. For twelve months previous to his enlistment, he had, accord¬
ing to his friends, been mentally affected. He was admitted from
camp, where he is stated not to have known his regiment or company,
to have been slow and slovenly, unable to understand the simplest drill,
and to have been thought to be mentally deficient. On admission he
had a feeling of well-being, and did not realise that he was ill in any
way. He gave the year as 1907, and had an exceedingly poor memory.
Physically, he showed all the classical symptoms of general paralysis.
He was transferred to an asylum.

(3) No. 45771, Private W. B—, set. 37, had been in the Army eleven
months. On November 14th, 1916, he was admitted to the Military
Hospital, Seaforth, where he was diagnosed as suffering from general
paralysis. On admission he was in an excited, megalomanic state,
stated that he was General B—, that he was the head of the nation, a
millionaire, etc. He had no realisation of the serious nature of his
disorder. Physically, he had Argyll-Robertson pupils, absent tendon-
jerks, slurring speech, and tremors of tongue, hands, and facial muscles,
His Wassermann reaction was positive with blood-serum and cerebro¬
spinal fluid. A letter received from a physician who had attended him
for two years previous to his joining the Army, in part stated : “ For
two years previous to his joining the Army, he presented symptoms of
locomotor ataxia (his acceptance for service was doubtless an oversight).
In the early part of last year (1915) he had a cerebral attack.”

(4) No. 232333, Private A. H—, aet. 39, had been in the Army for
one month. His wife stated that for eight weeks previous to his
enlistment he had been mentally disturbed, but, irrespective of her
protest, he was recruited. On August 25th, 1916, he was found
wandering about Liverpool in a lost condition, and was quite unable to
give any account of himself. On admission he was in an elated, over-
talkative state, was dirty in his habits, and noisy and disturbing. He
refused to co-operate satisfactorily, but his memory was definitely defec¬
tive, and he had no insight. Physically, his pupils were unequal and
irregular, his right did not respond either to light or on accommodation,
his left did not respond to light, but accommodated; his speech
did not show any disorder; his tendon-jerks were exaggerated, but his

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left knee-jerk was more exaggerated than the right; tremor of hands
and tongue. He was transferred to Armagh Asylum.

(5) No. 3027, Private K—, set. 37, had been in the Army for sixteen
months. Since January, 1915 (he was admitted to this hospital in
November, 1916) he had had five crimes against him for being
slovenly, late on parade, etc., but still his disease passed unnoticed.
Later he developed absurd grandiose delusions, said that he owned all
the motor cars in the world, that he was the King of England, etc.;
and by the time he was admitted to hospital he was in a very demented
condition. He exhibited all the classical physical signs, suffered from
retention of urine, and died in the hospital.

Such cases show only too clearly the gravity of the problem which
has to be tackled, and it does not require much imagination to think
of the many other cases many of whom have been sent on active
service, and no doubt have been placed in positions of responsibility,
Surely it does not require much time to examine the pupils and tap the
knee-jerks, and yet how frequently it is omitted ; often, may be, when
anomalies are present they are either not interpreted at all, or else
are misinterpreted.

I append two tables which speak for themselves:

Onset of Mental Symptoms Following Enlistment.

1

Mental Def. Dctn. Prafc. Manic-dep.

G.P.I.

Under 1 month in Army .

, Over l and under 3 months

Over 3 and under 6 months

Over 6 months and under 1 year
Over 1 year ....

i

10 7 3

12 4,4

20 17 2

H 59

8 to 6

5

1

5

2

6

1

61 43 24

1

19

Final Disposal of Cases.

1

1

Asylum.

Home.

Hospital.

Duty.

-

Died.

Total.

Mental defectives

16

45

61

Dementia pnecox

22

20

1

—

—

43

Manic-depressive

4

«7

I

I

I

24

General paralysis

13

4

'

2

J 9

55

86

2

I

3

147

1

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Alcoholic Insanity.

Seventeen or approximately 8 per cent, belonged to this group The
great bulk of these cases were men who for many years had been
chronically addicted to alcohol, and who shortly after joining the Army
developed acute, transitory delusional states with ideas of persecution
directed against their comrades, but rapidly clearing up under hospital
conditions. A few showed acute hallucinatory states with fear reaction,
one was a case of delirium tremens, and one a case of mania with an
alcoholic colouring. There was nothing about any of the cases to
warrant any detailed description of them.

Traumatic Insanity.

It is a well-recognised fact that a severe head injury either in the
nature of a concussion or a fracture, often carries in its train a transitory
or permanent series of mental symptoms not infrequently changing
the whole character of the individual. In some of these so-called
traumatic cases it is, however, at times difficult to see the connection
between cause and effect, and not unnaturally if a patient who at any
time has had a head-injury ever develops mental symptoms, the
tendency is for the head-injury to be held partly responsible, even
although no symptoms supervened until many years later. In such
cases it is often exceedingly difficult to see the connection between
the injury and the mental symptoms, but nowadays sufficient cases
have been described to constitute a definite entity known as traumatic
insanity. The following case shows clearly the close relationship
between a head-injury and the development of a mental disorder:

(i) No. 4546, Private T. W—, set. 26, had been in the Army for
three months, when on April nth, 1916, he met with a serious
accident, and was unconscious for about fourteen days. He was
admitted to hospital where he was described as suffering from
concussion, and symptoms of great cerebral irritation. On the sub¬
sidence of these symptoms, there was a total loss of memory; he
did not know his name, nor his regiment, nor where his home was,
nor any details of his accident. A gradual improvement took place
in his condition, but he had been in hospital ever since, and was
transferred to this hospital to be “ boarded ” rather than for any acute
mental symptoms. On admission he was quiet, conversed rationally,
but complained of persistent head pain. He had an amnesia for events
immediately preceding the accident, and for the accident itself, and
for fourteen days afterwards he was more or less unconscious. He has
never regained any memory for that period while in this hospital, he
had a clear realisation of time and place, his memory and retention
were good, and except for his complaints of persistent and severe
headache, always aggravated by exertion, he was in good condition.
Physically, he had hyperactive tendon reflexes.

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In the next case, the connection between the injury and the mental
disturbance is not nearly as clear, and complicating factors are present.

(2) No. 5837, Private F. O—, aet. 21, had been in the Army for
ten months. On November 2nd, 1916, he was admitted to this
hospital from Colchester Military Hospital where he had been since
October 14th, 1916, suffering from neuralgic pains in the head. His
history stated that in April, 1916, he had fallen from the top of a
hut on to the ground, injuring his head. He was stunned and dazed
for two days but did not lose consciousness. While in the hospital
at Colchester, he was excitable, restless and depressed, and peculiar
and irrational in his manner and conversation. He described the
pains in his head as being so severe that at times he felt he would
like to shoot himself or throw himself out of the window, and on
the night of October 26th, he did attempt to strangle himself. On
admission to this hospital, he complained of headache, and of feeling
depressed, irritable, and sleepless. He was quite coherent, was able
to give an excellent account of himself, had a correct appreciation of
time and place, and a good memory. He stated that he had always
been a nervous, delicate, sensitive boy, and when nine years old
suffered very greatly from an otitis following diphtheria. Ever since
that time, he had really suffered with his head. While training, he
found the drilling and marching too much for him, and usually had
to get his comrades to help him with his kit. On account of this,
he was given clerking work to do at Divisional Headquarters, and
apparently was quite happy, but when a re-arrangement was made the
patient was ordered to rejoin his regiment. It was just at this time
that he again began to suffer from pains in his head, and reported sick.
Physically, he had hyperactive tendon reflexes, and a rapid pulse of
110 per minute.

In this case, then, we have several eetiological factors all of which may
be said to play a certain part. In the first place, the history of dipth-
theria with ear trouble and headache following, the stress of training,
and the head injury. It seems to me that all the above factors have
been exceedingly important; but perhaps the most important factor of
all is the psychological one, and by that I mean that here we had a boy
who found the stress of military life too hard for him, who was quite
happy as long as he was doing work which was congenial to him, e.g.
clerking, but when ordered back to his regiment he began again to
suffer from headache, depression, etc. The case seems to exemplify
very well one type of “defence” mechanism, and would immediately
bring up the question as to whether such a case should be looked upon
as malingering. The patient himself, however, was altogether too
honest to be so classed ; he was constitutionally, physically, and mentally,
not equal to his military duties; his defence was for the most part
unconscious, and at all times he stated that he would be willing to try
again to do his bit, if it was thought advisable to try him.

LXIV. 12

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In the following cases the head injury was more remote in time from
the development of the mental disorder.

(3) No. 2466, Private H. V. H—, aet. 27, had been in the Army for
six months. He was admitted to this hospital from the Military
Hospital, Ripon, where he had been since August 24th, 19x6. In 1912
he had been pulled from a waggon, fell on his head, and is said to have
sustained a fracture of the base of the skull, was unconscious for a
period of twelve hours, and bled from his nose and ears. Following
this on several occasions, his wife had stated, he had become dull and
irritable, and had wandered away from home in a dazed kind of way.
At Ripon one night while in the hospital he suddenly jumped out of
bed and attacked the sentry. Next day he declined the most of his
food, stating that it was poisoned; but on the following day he
Again seemed to have regained his normal condition. On admission
(January 16th, 1916), he complained of sharp shooting pains in his
head, but he was quite clear mentally, was cheerful enough, and had
no hallucinations or delusions. While in camp, he said that he had
been told that one night he had tried to do away with himself, and
another time he was found with nothing but his shirt on at a place
several miles distant from the camp. He had no recollection of the
episode at Ripon Military Hospital, but says that he was told that he
had nearly strangled one of the guards. His relatives have all stated
that up to the time of his accident he had been a strong, healthy, active
man who had never ailed in any way. He realised himself that there
had been a change in his disposition, he was much more excitable and
irritable than ever previously, and he experienced an almost constant
feeling of tightness in his head. He has also noticed that he cannot
read for long because the words all tend to run together, and to
become blurred. Physically, he had tremors of tongue and hands, and
exaggerated tendon jerks.

In this case there would seem to be no manner of doubt but that
this man’s disability was entirely due to his former head injury, the
stress and excitement of military training simply acting as a determining
or aggravating factor.

(4) No. 83648, Gunner J. L—, tet. 39, had been in the Army for
seven months. This patient was received without any notes accom¬
panying him. On admission, he was found to be dull and depressed,
complained of pain across the top of his head, and of what he called
“ loss of mind.” He stated that three years previously, when working
in the pit, his head had been split open; he was unconscious for about
ten minutes, had to have five stitches in his wound, and was off work
for three months. Since that time he describes himself as having been
irritable and cantankerous, suffered from headache and dizziness, and
w r as afraid to touch alcohol because it seemed to go to his head at once,
and he would become so dazed that he did not know what he was
doing. On tw r o occasions he was punished for absenting himself without
leave, but he was unable to give any account of these “wandering”
spells: one time he was away for twenty days, and during that time

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183

could not tell where he had been, or what he had been doing.
Intellectually he was of a poor standard, and in addition, he had been
worried and depressed about being away from his wife. Physically, he
showed no special disorder.

In this case, also, the head injury seems to have been the principal
factor in the production of this man’s psychosis. The mental picture
is quite characteristic of traumatic insanity. The worry over leaving
home and the stress of training must, however, be reckoned as powerful
contributory agents.

(5) No. 456, Rifleman J. N—, set. 46, had served through the South
African War, but while in South Africa had fallen from his horse,
sustaining a depressed fracture of his skull. He was invalided from the
Army, and a few months later in Ireland, probably as a result of
alcohol, he developed an excited, suspicious, delusional state, was
certified as insane, and committed to Omagh Asylum, where he
remained for three years. At the outbreak of the present war he
re-enlisted, and had been doing garrison duty in India. He cannot quite
explain what happened to him ; he thinks the heat must have affected
him, but the last thing he remembers is drawing his pay on June 23rd,
1916, and from that time on he has an amnesia up until the end of
September, 1916. It appears from the history that in June he had
become excited, expressed delusions of persecution, threatened to shoot
his officers, and apparently was tried by court-martial for striking an
N.C.O. He denies remembrance of any of these episodes. On admission
to this hospital he had practically regained his normal condition. He
told how following his head injury an entire change took place in his
character, he became irritable and cantankerous; if he took drink it
sent him mad, and on this account he had frequently got into trouble
with the civil authorities, and also had lost his stripe. Except for his
period of amnesia his memory seemed to be intact. Physically, he had
a small depressed fracture of the vertex of the skull.

In this case, then, we have a man who fourteen years previously had
sustained a fracture of the skull, the symptoms of which reasserted
themselves owing to the stress of military service and the hot climate
of India.

Psychoneuroses.

Belonging to this group are ten cases, nine of which were anxiety
states, and the other was a case of the nature of a conversion hysteria.
In practically all of these cases a one-word labelling was out of the
question, but all of them in common were sensitive, highly strung
individuals who, face to face with a situation which normally they could
not meet, developed certain nervous symptoms which completely in¬
capacitated them. In these cases it was found that a change to a
suitable hospital and general care and attention were sufficient to cause
a betterment.

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184

(1) No. 38900, a private, on September 12th, 1916, was admitted to
the Military Hospital, Pembroke Dock, with the following history :
“ While in a state of great nervous excitement he inflicted on himself
a skin-deep wound of the neck. He complained of intense frontal
headache, and seemed in a dazed condition.” On October 16th, 1916,
when admitted to the Lord Derby War Hospital, his condition had
quieted down, he was feeling better, was sleeping well, and felt that
he was getting a grip on himself. He had enlisted in May, 1916, but
from the first Army life had not suited him, he was depressed by it,
and the way his N.C.O.s treated him grated on his nerves. At times
his head would feel dizzy, it was impbssible for him to collect himself,
at nights he was restless, felt he could not contend with it all, and in
consequence attempted his life. He was correctly orientated for time
and place, he had a good grasp on current topics, and realised his
condition. He had come from a poor stock, had always been nervous
and sensitive, and greatly devoted to his mother. His father had died
before he was born. When asked about getting married he replied
that so long as his mother lived—“ she has done so much for me ”—
he would not think about it.. Physically, he was very shaky and
nervous, had coarse tremors of tongue, facial muscles and hands and
hyperactive tendon reflexes. In the course of a few weeks he made a
complete recovery, and was discharged home.

The following case, which was diagnosed as one of conversion
hysteria, was as follows :

No. 247412, Private F. N. T—, ret. 25, had been in the Army for
three months. He was admitted to this hospital from Fort Pitt,
Chatham, where he had been diagnosed as a case of general paralysis.
He stated that ever since joining the Army he had been out of sorts,
he had been nervous and dull, and when questioned he had to be
urged to answer. He had not done any drills, etc., but all along had
been employed in the mess-tent. He was taken to hospital on account
of difficulty in walking, and on admission he showed a condition of
astasia-abasia, and when brought to the office refused to stand or walk,
but was dragged sliding along the floor. Otherwise he showed no
special symptoms, his memory and general grasp on things were ex¬
cellent. Physically, no signs of general paralysis, nor yet of hysteria,
apart from the astasia-abasia, could be demonstrated. Following his
admission to the hospital, a rapid improvement occurred in his con¬
dition, his nervous symptoms entirely disappeared, and soon he was
just as well as he had been.

Whatever one likes to call such a case, there can be no doubt that
here was an unstable type of individual, who was quite unable to adapt
himself to the exigencies of military life, and in consequence broke
down.

Paranoid States.

All of the eight cases belonging to this group were men well on in
middle life, the average age of the group being forty years (youngest

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thirty-four and oldest fifty). The majority of them were men who
had formerly been in the Army, who for one reason or another had
been previously discharged, but who re-enlisted when the present war
broke out, or shortly afterwards. These men had been employed on
guard duty or at labouring work, but the stress proved too much for
them, they were unable to adapt themselves to their situation, developed
ideas of persecution, and also auditory hallucinations which were
usually referred to their comrades. Some of these patients admitted
alcoholic over-indulgence, and no doubt the development of their
persecutory ideas was largely caused by this factor. None of the
cases have seemed sufficiently noteworthy to warrant special mention.

Toxic-exhaustive Psychoses.

All of the three cases in this group showed transitory mental dis¬
turbances which had entirely cleared up by the time they were admitted
to this hospital.

Epileptic Insanity.

No. 32504, Private T. J. D—, set. 28, ever since the age of twelve
suffered from epileptic fits. He is described as always having been
childish, irritable, and quarrelsome. In 1915, he had been discharged
from D Block, Netley, on account of epilepsy, but he re-enlisted again
in January, 1916, and in May was sent to India. In July, in India, he
had three epileptic fits, and on October 31st was boarded at Quetta as
a case of epileptic dementia. During his Army career he had had
many crimes recorded against him for being drunk, for bad language,
for not complying with an order, and for striking a superior officer. On .
admission to this hospital, he was noisy and troublesome, defied the
sergeant in charge of the ward, and had to be put in a single room.
He was of poor mentality, had difficulty in comprehending simple
questions, and had an exceedingly poor memory. Physically, there was
no evidence of any gross disease. The case was then a clear one of
epileptic dementia, who most certainly should never have been sent to
India.

Another case which could not be quite so easily diagnosed was as
follows:

No. 5980, Private L—, tet. 22, had been in the Army for four
months. He had been taken to the Military Hospital at Pembroke
Dock with a note from a physician certifying that he was suffering from
epileptic mania, and that he had had epilepsy ever since childhood.
On admission here, he stated that he had been feeling quite well until
August 9th, 1916, when on a route march he started to feel badly, and
had to fall out. Since that time he had never felt right, and had
suffered from terrible headaches. He remembers getting excited, and
jumping into the river at Haverford West, and for several hours did not
remember anything until he came to himself in hospital at Pembroke

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Dock. He gave a history of having “ fainting fits ” since boyhood, but
there was no history of an aura, of tongue-biting, or bed-wetting, etc.,
and, from the description, one could not be sure whether the case was
one of true epilepsy. Furthermore, during his hospital residence he
had no such attack. Mentally, he was quite bright and intelligent,
took an interest in what went on around him, and eventually was able
to be discharged home.

Organic Brain Disease.

These two cases were men of forty-two and forty-eight years respec¬
tively, with thickened blood-vessels, complaints of headaches and
dizziness, and the general picture of arterio-sclerotic brain disease.

Conclusion.

It is almost unnecessary to dilate further on the array of cases which
has been reported. They have been presented with one principal
object, viz., to draw attention to and to emphasise the fact that more
care should be exercised in enlistment. It stands to reason that a man
who is mentally enfeebled would be much more liable to break down
than a healthy man, and in consequence if such a man is enlisted then
undoubtedly the Government must accept all further responsibility for
him. The Government have recognised that obligation, and it is
gratifying to know that the man who breaks down during training on
account of “ certifiable insanity ” is regarded as pensionable when there
is definite evidence to the effect that he was insane at the time of
enlistment; even those who have had one previous attack of insanity
are regarded as pensionable. Such is no more than justice, but it
would seem to be possible to prevent a great many of these men
from ever entering the Army provided certain hereinafter stated pre¬
cautions were taken. To meet this difficulty in some degree various
psychiatrists of standing have been appointed to various commands
throughout the country to inquire into such cases of suspected mental
disorder as might be brought to their notice. There can be no doubt
that such a step is one in the right direction, but the whole matter is of
so great importance that one cannot but wonder whether the means
taken are sufficient to meet the difficulty, and whether some additional
steps ought not also be taken. It is probably true that the majority of
recruits are drawn from the large industrial centres, and, therefore, it
would seem feasible that someone capable of making a satisfactory
mental examination should constitute one of the recruiting medical
officers in such a centre. Cases in any way doubtful could at once be
referred to this authority, and no doubt arrangements could easily be
made for this officer to see and examine cases occurring in out-lying
districts. Such a person should also have power conferred on him to

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recommend the branch of the service for which the recruit would be
most suited, and his opinion should be regarded as final. It is readily
admitted that many cases of mental defect and of chronic states of
mental illness could well be employed in the Army, but such persons
should be given work for which they are suited—work, that is to say,
of a purely mechanical nature, where no special initiative would be
required, and unsuitable cases could be prevented from going on active
service. By so doing the State would not only acquire a set of men who
would do useful work but also, it is reasonable to suppose, that fewer
men would break down, and in consequence the State would benefit by
having less expense in the evacuation of cases, and less expense in
regard to hospital treatment and pensions.

The cases which one should be chary of accepting are those who are
grossly defective, those who in civil life have shown definite neuropathic
traits, and those who have previously suffered from serious head injuries.

The argument advanced against all this is to the effect that special
mental examinations would take a great deal of time, that expense
would be entailed in employing specialists, and that possibly some who
would make good soldiers would not be passed as fit by the mental
expert. No doubt such statements in certain instances would prove
true, but it would seem to be a much sounder policy to run the risk of
losing a man or two than to enlist Tom, Dick, and Harry irrespective
of their mental status.

My excuse for these remarks is that the number of nervous and mental
cases on our hands is now assuming large proportions, suitable accom¬
modation and treatment for such cases is always and increasingly diffi¬
cult to obtain, and, furthermore, prevention is always better than cure.

At the beginning of the war no one had any realisation of what an
important problem the care and treatment of our nervous and mental
cases was going to be, but as the war has progressed we have come to
know how urgent the matter is. An index of the state of affairs with
our Army may be gathered from the fact that in the United States Army
in times of peace mental disorders in all their forms are responsible for
one-fifth of the total discharges of enlisted men.' This does not include
discharges for neurasthenia and hysteria. The discharge rate per 1000
was 2‘64, tuberculosis in all its forms coming next with a ratio of 1 '56
per 1000. “During the mobilisation of the regular troops and militia
on the Mexican border last summer and fall, mental disorders again led
in the causes for discharge.” In a recent number of the Journal
of Mental Hygiene , an editorial on Psychiatry in War comments as
follows: “We must recognise the great practical importance of pro¬
viding in the organisation of military medical units in peace and war
adequate facilities for treating mental disorders. Such facilities include
provision for the observation of suspected cases, special arrangements

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for transportation from posts in advanced zones to those at military
bases, and facilities for effective treatment at such bases. . . .

Recovery in mental diseases depends very greatly upon the promptness
and efficiency with which treatment is received. . . . Such treat¬

ment can only be carried out by physicians and nurses skilled in mental
disorders.” No one, I am sure, could question any of the above
remarks, and the sooner we, as a nation, come to realise that it is of
the utmost importance to tackle this problem of nervous and mental
disease occurring in the Army, the better it will be for the Army, for the
State, and for our national peace and security. While yet in the midst
of war it may seem a far cry to think of days of peace; but when peace
does come, it will be of value to have some plan and organisation in
readiness for dealing with mental cases. The majority of men joining
the Royal Army Medical Corps do so within the first year after gradua¬
tion in medicine, and, in consequence, the great majority—if not prac¬
tically all—have no knowledge of psychiatry except what they have
acquired as medical students. If, then, our Army is going to be a really
efficient Army, the authorities should recognise that it would be sound
policy to select men who have shown an aptitude for psychiatric work
or who have an interest in it, and give these men facilities for special
training. Just as the welfare of our soldiers is now being looked after
in regard to venereal diseases by the establishment of clinics presided
over by specially trained men, so also a group of men could and should
be trained in mental diseases, whose business it would be to prevent
the enlistment of those who would be “unlikely to make efficient
soldiers,” and who, in case of mental illness, would be adequately
trained and equipped to deal most effectively with it. To again empha¬
sise what has already been said, it is suggested :

(1) That cases showing mental deficiency, neuropathic and psycho¬
pathic traits, and giving a history and showing evidence of severe head
injury should, for the most part, be rigidly excluded from the Army.

(2) If it is necessary to recruit a certain number of these individuals,
then it should be definitely ruled that under no circumstances should
they be permitted to go on active service; such men should be given
suitable work at home or at the base in France.

(3) To effect the above objects it is suggested that a certain number
of mental specialists should be appointed to the recruiting boards, and
recruiting medical officers generally should he given definite instructions
to pay attention to all cases of probable mental defect or disorder, and
refer such cases to the expert.

(4) At the large training camps there should be one mental specialist
whose business it would be to examine recruits, and to have those
obviously unfit immediately rejected—once and for all—from the Army.

(5) It is only by adopting methods such as the above that we will

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ever come to grips with the wastage occurring in our Army due to
nervous and mental disease.

(’) These cases were all studied at the Lord Derby War Hospital, Warrington,
Lancs.

Evolutional Progress in Psychiatry : A Plea for Optimism. By
Hubert J. Norman, M.B., D.P.H., Capt. (Temporary) R.A.M.C.,
County of Middlesex War Hospital.

I.

Human perfectibility, or even entire social amelioration, appear with
the passage of lime to recede into a yet further distance ; and, whilst
forming subject-matter for academic discussion and for visionary imagi¬
nation, they hardly come within the range of practical politics. With
them, as with disquisitions about the hereafter, there has been a
tendency to allow “ other worldliness ” to obscure the necessity for
doing our duty here and now, and letting the distant future take care of
itself. To those who object that this view is a sordid, or at least a
selfish one, it may be answered that if we observe the Golden Rule—if
even we practise but a negative virtue by refraining from doing evil—
we shall yet make for the desired goal, possibly as rapidly as those who,
their eyes fixed on that distant point, fail to observe the obstacles which
lie immediately in their path, and who have, again and again, to arise
bruised and disheartened by their stumbles and disappointments. It
may indeed be that their aims are but illusions, mere figments of the
fancy, impossible of realisation. “Uniform and universal knowledge,
social salvation and sovereign goodness, a golden age to come excelling
a past golden age, a Paradise regained in lieu of a Paradise lost, in fact,
a kingdom of heaven on earth or elsewhere, are not yet matters with
which the sober-minded scientist can grapple 1 ; ” and nescience can
only formulate them in phraseology which lacks verisimilitude even to
those who utter it. It is doubtful whether the projectors of ideal
commonwealths would have desired to have been themselves inhabi¬
tants thereof; even if they had had the will it is certain that they would
not have had the ability to carry it into effect. Much of their work is
perchance energy misdirected, and the words of Milton may be applic¬
able to others as well as to him of whom he uttered them. “Plato, a
man of high authority indeed, but least of all for his Commonwealth, in
the book of his laws, which no City ever yet received, fed his fancie
with making many edicts to his ayrie Burgomasters, which they who
otherwise admire him wish had been rather buried and excused in

1 Organic to Human , by Henry Maudsley, p. 129, London, 1916.

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the genial cups of an Academick night-sitting.” It is no use, as he
further remarks, “to sequester out of the world into Atlantick and
Eutopian politics, which never can be drawn into use, and will not
mend our condition ; but to ordain wisely as in this world of evil.” 1

It may be said that this is an inauspicious opening to any essay which
is entitled “A Plea for Optimism,” and that, moreover, the time is in¬
opportune when the majority of the human race are concentrating their
attention on the best methods whereby they may destroy one another.
Yet optimism in respect to any matter may be permitted if it can be
proved to be reasonable ; and the bitterest strife has an ending—even if
the cessation be but the product of exhaustion, and, therefore, only
sufficient to allow of recuperation for another outburst. Is there, then,
foundation for hope of still further advancement in our knowledge
respecting mental disorders ? And may we believe that we shall yet
improve our therapeutic methods ?

A consideration of the progress made in science generally, and of
psychiatry in particular, appears to warrant us in adopting an attitude
of reasoned optimism. A brief historical survey may, therefore, be
permitted, and an endeavour made to substantiate the claim herein
advanced.

II.

It is only within very recent times that an attempt has been made to
investigate mental disorders along those lines which have led to such
successful results in other directions. For centuries it has been held
either that they were due to some Divine infliction whereby demons
were allowed to enter into and to afllict the body of the unfortunate
sufferer, or they were produced by some disorder in a hypothetical
“mind,” which acted upon the brain and body, but which could not
conversely be influenced by them. In both cases there was obviously
no likelihood of research into physical substructure; and, indeed, it is
only slowly that, even at the present time, the belief is beginning to
prevail that it is necessary patiently to investigate the brain if any satis¬
factory conclusions are to be reached in psychology and in psychiatry.
Even though relatively immense strides have been made in other
branches of medicine by these methods, mental disorders have been
left for the most part severely alone—so potent has been the influence
of theological and metaphysical ideas. And now, when the relatively
few workers have done so much already to illuminate the dark recesses
of our knowledge of the brain and its functions, the reproach is
often uttered that in psychiatry—the Cinderella of the sciences—research
has lagged behind. “ Only ignorance of the solid accomplishments in

1 Areopagitica, Arber's reprints, pp. 49 and 51.

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this field which recent years have brought forth, or inability to estimate
their worth, can be responsible for the repetition of this complaint.”
Thus wrote Feuchtersleben, in 1844, of the often-repeated objection
that the study of psychiatry had been “ all too sadly neglected ” and that
alienists were, therefore, “ still groping in the dark.” The retort may
surely be made that it is only beginning, and that in due course—with¬
out inferring any disparagement of the aspect of the sister-sciences—we
may hope to see as sure, if not as speedy, a transformation as Cinderella
experienced. But the fairy god-mother will have to make sure that she
does not omit to touch the researchers with her golden wand ! In
other words, it is necessary to provide adequate funds for the
purpose in order that it may not continue to be said that the person
who devotes himself to research is worse off than if he had directed
his energies along more commercial, more remunerative, channels.

The progress of ideas regarding insanity has not been an uninterrupted
one. It may, indeed, be staled that movement has been rather in
cycles. A period characterised by quite primitive conceptions is
followed by one of considerable enlightenment, and this, again, gives
place to darkness and ignorance. There is, however—or there appears
to be—with each succeeding phase a wider diffusion of knowledge, and,
at the same time, an increasing accuracy in regard to details. It is this
more minute research, made possible by the invention of instruments of
precision and by refinements in chemical methods, which is tending to
differentiate the present period from all preceding ones. It is becoming
increasingly more possible to investigate the fundamental structure of
the Universe than ever before. Opinions and hypotheses may be dis¬
puted, controverted, perchance; facts are ultimately—except to the
Berkeleyan !—convincing. It is in this respect that we may be said
to have made our chief advance since Hippocratic times—in this,
and in the substitution of other conceptions to replace the humoral
pathology.

Prior to the Hippocratic period, there was one in which the hypo¬
thesis of supernatural influence held chief sway. A consideration
of the evidence contained in the Old Testament makes this clear.
Ideas of this kind, however, arose in much more primitive times.
It appears likely that, even in the savage mind, as a result of the
evil-doings of his aggressive neighbours, conjoined with the influence
which dreams would almost inevitably exert, the idea of some super¬
natural force might easily arise. There is no evidence that a belief in
actual beneficent or maleficent deities arose suddenly. Only by slow
degrees and by gradual accretions of knowledge could such well-
defined beliefs, as, for example, that of the personification of Good and
of Evil in the form of Ormuzd and of Ahriman, come into being.
Indeed, such a differentiation implies a precedent development lasting

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for unnumbered centuries; and it is probable that the dawning
belief in extraneous, supernatural powers was one which looked upon
the inscrutable power as a maleficent one. No matter, however, in
what manner the belief was acquired, once established it was natural
to ascribe to the influence of this power anything which passed the
more or less limited comprehension of man. Thus strange and awe¬
some happenings in the human body, such, for example, as epileptic
fits or outbursts of maniacal fury, were set to the account of some
mischievous demon or of some provoked deity. In some form or other
this has been one of the most persistent and widespread of beliefs. From
the time of Saul’s mental derangement even down to the present it has
been accepted as a satisfactory cause of mental disorder. We are
told that because of Saul’s sad dereliction of duty—he had failed to
carry out the Divine command to slay utterly certain of his neighbours
—“the spirit of the Lord departed from Saul and an evil spirit of the
Lord troubled him ’’l 1 David, who was of an ingenious turn of mind
and full of expedients—as his method of dealing with that obstacle of
his, Uriah the Hittite, goes to prove—narrowly escaped the fate of
many innovators when he endeavoured to allay the king’s fury by means
of music!

As among the Jews so in ancient Greece the belief in irritated
deities as the prime movers in the production of mental disorders was
the one which held sway. Hercules, for example, was pursued by the
anger of Juno; and she it was who afflicted him with epileptic fury.
Euripides has described dramatically the outbursts to which he was
subject, and how, in one of his homicidal attacks, he slew his wife and
children. 2 Orestes, Ajax, and Meleager were smitten in a similar
manner; while the daughters of Proetus, King of Argos, were also
rendered mad, but in their case the administration of hellebore counter¬
acted the Divine wrath !

A remarkable period of enlightenment began, however, to dawn in
the sixth century b.c. Pythagoras, physician as well as philosopher,
initiated the movement which produced in the following century that
illustrious thinker, Hippocrates. The Pythagorean school directed its
attention chiefly to what may be described as prophylactic methods.
By means of careful regimen they sought to bring about health of the
body and soundness of the mind. Music was used by them also as a
therapeutic method in dealing with cases of insanity. With the advent
of Hippocrates (460-377 B.c.), medicine was for the first time set upon
a rational basis. Instead of devoting his time to web-spinning and

1 1 Samuel xvi, 14.

: In the Bacchce Euripides gives a further illustration of the same Divine anger.
Bacchus produces madness in Agave, the mother of Pentheus, because of her
opposition to worship of him.

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phrase-mongering he set himself to the task of observing accurately
the symptoms of disease and of constructing from the facts thus col¬
lected a practical science of medicine in contradistinction to the airy
imaginings which proved so satisfactory to the majority of his pre¬
decessors—to say nothing of many of those who have come after him.
This was sufficiently remarkable in regard to disease in general; but
that he should have attained to the conception that mental affections
could be included among bodily disorders is, indeed, amazing. That
he should have been able to postulate such beliefs and live is an
exemplification, too, of the tolerance which existed at that time in
Greece. “ I am of opinion,” wrote Hippocrates, “ that the brain
exercises the greatest power in man. This is the interpreter to us of
those things which emanate from the air, when it happens to be in a
sound state. . . . And by the same organ we become mad and

delirious, and fears and terrors assail us, some by night and some by
day, and dreams and untimely wanderings, and cares that are not suit¬
able, and ignorance of present circumstances, desuetude and unskilful¬
ness. All these things we endure from the brain when it is not
healthy.” 1 In the same way Hippocrates dismissed as fanciful the
idea that epilepsy was a manifestation of Divine interference. It had
been called the sacred disease ; but it was, he said, no more Divine
than any other form of disorder.

In such early times, when knowledge was confined to the few and
when even civilisation was narrowly circumscribed, views similar to
those held by the Hippocratic school were unlikely to obtain any wide
acceptation. Even those who were capable of understanding his
teachings were for the most part too prejudiced to be influenced by
them. The links between function and structure had not been dis¬
covered. Nor was it possible with the methods then available to
demonstrate the nexus between the two. Recourse had to be had to
theory in order to explain what took place. The humoral pathology
was the result. It might have been true; but, even if it were so, its
truth could not be demonstrated. Yet there were adherents of the
new learning who strove to carry on the lamp of knowledge. Asclepiades
(circa 80 b.c.), Themison, Soranus (circa 95 a.d.), and Caelius Aurelianus
not only maintained the Hippocratic tradition, they substituted the
hypothesis of a vital force —the excess or defect of which brought
about the symptoms described—for the humoral theory. They simpli¬
fied and made more precise the descriptions of various morbid mental
states; and this was also a characteristic feature of the writings of
Aretaeus. 4 In regard to treatment there was an equal advancement.

1 Hippocrates, Sydenham Society’s edition.

* “ Son plus grand titre de gloire est d'avoir laisse des diverses formes d’ali^n-
ation mentale, et notamment de la manie et de la melancolie, des descriptions

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When one reads the teachings of Soranus—as embodied in the
writings of Caelius—it seems almost incredible that for about another
seventeen hundred years the darkness of ignorance could have pre¬
vailed in this respect. Not only does he set forth rules which are to be
followed in dealing with the insane as to diet, the necessity of procuring
sleep, proper accommodation, and so forth, he deprecates the harsh
methods advocated by others, notably by Celsus, who even suggested
castigation, chains, and deprivation of food in order to subdue
lunatics. 1

This period of enlightenment practically ended with the second cen¬
tury a.d. Galen was the last physician of distinction, then, who
carried out the teachings of the Hippocratic school. In his writings
we find again that modernism of tone which contrasts so strongly with
the almost primitive ignorance of the majority of those who came after
him. It was not so much a reactionary movement which overwhelmed
the rational teachings of the Greek school but rather that the waves of
Greek culture fell back impotently from the rocks of tradition and
prejudice which resist at all times by their sheer inertia the impact of new
ideas. Yet was this teaching not altogether without avail. Vandalism
and bigotry did not succeed entirely in eliminating the writings of those
early teachers, and in the course of time they found again pupils who,
undeterred by the odium which they ran the risk of incurring, absorbed
their doctrines and gradually built a superstructure of modern know¬
ledge upon the foundations therein laid down. It has been well said
that “ the crowning glory of the Grecian epoch was the recognition once
for all that whatever the determining or contributing factors or their
manner ot operation, madness is not a manifestation of supernatural
power but a disease, and not only a disease, but a disease of the brain ;
and that physical symptoms commonly accotnpa?iy the mental ones, both
being alike traceable to natural human causes .” 3 When we consider the
amount of medievalism which still characterises much present-day
writing on matters psychological we cannot sufficiently wonder at the
enlightenment of those far-off times. Almost may we say with
Browning that—

" Those divine men of old time,

Have reached . . . each at one point

The outside verge that rounds our faculty.” 8

d'une exactitude et d’une verity remarquables,” Rtlgis, Precis de Psychiatrie (Paris,
1914), p.8.

1 It is only just, however, to note that these were not the main methods advo¬
cated by Celsus. He also formulated wise and excellent rules for the treatment
of the insane.

‘ “ Some Origins in Psychiatry,” by Clarence B. Farrar, Amer. Journ. of
Insanity, vol. lxiv, No. 3.

3 Cleon.

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195

Progressive medical science was not, of course, confined to Greece
and to Rome. Among the Egyptians, for example, a considerable
advance was also made, and the thirst for knowledge led them to
observe and even to experiment. But culture generally was limited to
but a small part of the globe. Beyond that part were the vast masses
of the uncultured. Among them it was not possible for the culture of
the Greeks to spread until a period of intellectual probation had elapsed.
In the first place, they would absorb most readily the simpler ideas of
a more primitive culture, such as that of the Jews, tinging them at the
same time with the emotional colouring produced by difference of race
and of climate. So it came about that rational concepts were stifled,
or nearly so, by the supernaturalism of the early Christians, who, be it
remembered, were carrying on directly the traditions and the beliefs of
the Jews. The New Testament emphasises and reiterates the teach¬
ings as to demon-possession. And this possession is not restricted to
human beings, as witness the episode of the Gadarene swine. But
whereas in the olden time the lunatic might roam comparatively un¬
molested among the tombs—“wander through the soothing cypress-
groves in the moonlight or lie under the shading palm in the
noontide heat,” now gradually he came to be regarded not so much
as one in “the guardianship of God,” 1 but as a miserable sinner,
who harboured demons and who required exorcism or more drastic
measures to rid him of his affliction. For the mad and for the half-mad,
such as many of the witches, the Dark Ages were approaching Not
that they were invariably badly treated. Cures were attempted by means
which were not inhumane, but certainly for the more troublesome
lunatics there was short shrift. Not even froifi the science of medicine
—such as it was—could they look for much comfort. In this country
in Anglo-Saxon times disorders of this kind and, indeed, diseases in
general were treated—so far as drugs were concerned—by means of
potions of appalling nauseousness. 3 For centuries the chief criterion
of therapeutic potency seems, indeed, to have been the unpleasantness
of the compound and, in addition, the number of components, so that
a list of the ingredients in a prescription in the olden times resembles
nothing so much as the nomenclature of a modern synthetic drug.
Even those who had sufficient independence to break away from the
accepted beliefs were not able to make any appreciable advance beyond
the limits of the Greek school. Chief among these were Alexander of
Tralles (a.d. sixth century) and Paulus ^Egineta (a.d. seventh century);
and the Arabian physicians, Rhazes (a.d. 850-923) and Avicenna
(a.d. 980-1037).

1 A History of Penal Methods, by George Ives, p. 77, London, 1914.

3 For examples, Oswald Cockayne’s interesting volumes in Leechdoms, Wort-
Cunning, and Starcraft may be referred to, London, 1864.

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III.

Throughout the Middle Ages, and, indeed, even until the end of the
seventeenth century, belief being for the vast majority of the people
fixed, there was little likelihood of any advance. There were, so to
say, simply variations on the same tune. The change of view', if any,
was rather in the direction of aggrandising the part played by the Devil
and of diminishing the influence of the Deity. Instead of the insane
being afflicted and, therefore, objects of pity, they were harbourers of
demons, perchance even agents of the Devil himself, and, consequently,
deserving of treatment by the most drastic means. As belief became
more gloomy and as the laws enacted to suppress the crimes of sorcery
increased in their rigour, so did the troubles against which legislation
was directed become more widespread. Epidemics, such as the dancing
mania, afflicted many ; and witchcraft increased to an amazing extent,
if we are to believe the accounts of the chroniclers of the time.

The amazing thing is not that such beliefs should have obtained so
wide an acceptance, but that, once so firmly established, rational
thought should ever have been able to dispossess them. It does not
appear to be bv any conscious effort that such a change is brought
about, but rather that, in the course of time, constantly recurring
stimuli tend to modify the nervous system in such a way that in the
end it becomes able accurately to comprehend what is influencing it,
just as, when the sun rises, objects which had appeared shadowy, indis¬
tinct, even ghostlike in the gloom, gradually become clearly outlined.
So it w'as that the ideas which characterised the Greek school could not
arise among the Northern nations until w’hat has been called the period
of intellectual probation had been traversed. This took a matter of
some sixteen hundred years.

Towards the end of the sixteenth century several thinkers had come
to realise that many of the beliefs then almost universally held were
erroneous and pernicious. It was in regard to the witchcraft delusion
in particular that an advance began to be made. Men like Reginald
Scot, in his Discoverie of Witchcraft (1584), and the German physician,
John Wier, in his De Pmstigiis Dccmonum (1563), were among the
first to preach a more reasonable doctrine. But theirs were almost
voices in the wilderness. The weight of opinion, theological and lay,
w r as against them. Nevertheless, it was a beginning of the rational
movement in thought which has gradually dispossessed the cruder
superstitions. Yet there have always been men of acute intellect who
have championed the cause of superstition ; and even down to the
present time there appears to be no belief, however illogical or unbased
on fact it may be, which need lack advocates. Harvey was bitterly
opposed when he promulgated his doctrine : and in these later days

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Pasteur had a hard fight ere he won credence for his theories. So the
“ possession-theory ” in regard to the insane maintained its ground even
when enlightenment had apparently spread very widely; and even in
our own day it is not difficult to find those who uphold this view.

Throughout the seventeenth and most of the eighteenth century there
was little amelioration in the condition of the insane ; and this state of
affairs naturally went along with the theoretical opinions which were
still maintained. The need for providing for their accommodation
did not become very pressing until with the growth of population
there was a considerable increase in the number of insane. The
drastic measures adopted against the more troublesome lunatics by the
civil powers, and against those unfortunates whose symptoms made
them incur the odium of theological opinion, tended to restrict their
numbers still further. A good many, however, were allowed to pere¬
grinate the country without let or hindrance : and the wandering
“Tom o’ Bedlam” was a not uncommon figure. When the time
arrived for buildings to be provided for housing the insane it was
rather with a view to restricting the movements of the troublesome
ones than with any idea of curative treatment. “ About the middle of
the eighteenth century . . . grim and sombre circumvallate buildings
began to be erected 1 for this purpose. They were but prisons of
the worst description. Small openings in the walls, unglazed, or,
whether glazed or not, guarded with strong iron bars, narrow corridors,
dark cells, desolate courts, where no tree nor shrub nor flower nor
blade of grass grew. Solitariness, or companionship so indiscriminate
as to be worse than solitude; terrible attendants armed with whips
. . . and free to impose manacles and chains and stripes at

their own brutal will; uncleanness, semi-starvation, the garrotte, and
unpunished murders—these were the characteristics of such buildings
throughout Europe.” 2 The lot of the wandering lunatic or even that
of the others who were cared for privately was for the most part
preferable to being immured in such drear and comfortless holds.

It would be unfair, however, to those who were responsible for this
state of affairs not to note in passing that the conditions under which
the insane lived were more than equalled in their misery and squalor
by the habitations provided by the community for criminals. Howard
published his State of the Prisons in 1780, and even a glance at that
epoch-making volume is sufficient to convince any unprejudiced reader
of the dreadful callousness exhibited towards the prisoners, and of the
insanitary—not to say filthy—manner in which they were lodged.
Such things were characteristic of the times; though, even all these
things considered, the condition of these unfortunates was no worse

1 History of Venal Methods , Ives, p. 84.

■ Conolly, Treatment of the Insane, London, 1856.

LX IV. I 3

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than that of similar classes on the Continent. Indeed, in France up to
the lime of the Revolution the state of the honest peasant was, in
some districts, little belter. Arthur Young speaks, after his journeyings
throughout that country, of the “extent and universality of the
oppression under which the people groaned ”and he found still
rampant the blighting effect of tyrannical feudalism.

The reaction against these iniquities was, however, beginning. Con¬
temporaneously in France and in England two men were initiating
the movement which has led to the betterment of the condition of the
insane. It was during the height of the French Revolution that
Pinel was advocating and carrying through his reforms in regard to
the treatment of the insane : and in 1793 he achieved his purpose of
freeing the patients at Bicetre from their chains. In England William
Tuke, appalled by the condition of things in the York Asylum, deter¬
mined to found a home for the insane where they would be treated
with humanity. The result was the “ Retreat,” the building of which
was started in the year 1792.* Although amelioration may be said to
have been continuous from this time onwards in certain places, it w’as
long before it became generalised. In an official Report published in
1815.it is made evident that even in London itself the condition of
the insane was almost incredibly bad. 3 Bethlem Hospital was, according
to the evidence published in that report, one of the worst offenders;
and if this could be so in London itself, where inspection and super¬
vision might be carried out with some degree of thoroughness, it is
easy to imagine the state of affairs in the provinces. On the other
hand, it is to be noted that the fresh impetus which was about to be
given to the movement for the more humane treatment of the insane
came from a provincial town.

By the year 1838 Dr. Gardiner Hill had gradually introduced the
system of non-restraint into the Lincoln Asylum; and, only a little
later, Conolly brought about a similar improvement at Hanwell. They
demonstrated that those measures were practicable which many other
men looked upon as Utopian : and experience has tended to justify
their wisdom and humanity. Yet there were not a few who continued
to oppose these methods; and there are still some people who look
upon Hill’s suggestions as counsels of perfection. But in the main the

1 Travels in France during the Years 1787, 1788, 1789 (“On the Revolution in
France”), by Arthur Young.

a “ La tentative de Pinel ne fut pas isolde. Au meme moment des efforts
analogues s’op^raient sur d'autres points. D£jk Daquin, en Savoie, avait pr£che
la meme doctrine humanitaire dans une sphfere plus modeste, tandis que Chia-
ruggi, en Italie, publiait, en 1794, son Traite de la folie en general et dans I'espece,
ou il consignait les rdsultats des ameliorations obtenues par lui k Florence,”
Regis, Precis de Psychiatrie, p. 17.

8 Report and Minutes of Evidence on the Madhouses of England, London, 1815,

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followers of Hill and Conolly dominate opinion at the present time.
The inherent brutality of mankind—so strikingly exemplified in recent
times—does not, however, readily give up repressive measures; and
for a while after the Hill-Conolly epoch the strictures contained in such
books as Hard Cash received justification. Such measures have become
nowadays the exception instead of being the rule; and instead of being
countenanced, they are discouraged not only by law but, what is perhaps
more important, they are strongly deprecated by general opinion.

IV.

All this is a substantial advance, and for the immediate well-being of
the insane population it is of paramount importance. But there has
gone along with this a movement in scientific thought which is of even
greater value. In the words of one of the reformers in the treatment of
the insane : “ Derangement is no longer considered a disease of the
understanding, but of the centre of the nervous system, upon the unim¬
paired condition of which the exercise of the understanding depends.
The brain is at fault and not the mind.” 1 That is, quite succinctly, the
opinion which, in spite of more or less fantastic reactions towards the
metaphysical specula;ions which have so long been predominant, is
steadily becoming more and more widely received. Enunciated by
Hippocrates it was yet too sane and rational to find acceptation during
later ages when nescience and mysticism prevailed, and when the im¬
probability of a doctrine was all the more cogent reason for believing
in it. This doctrine is, however, merely a restatement of the Hippo¬
cratic dogma ; and if it rested on no more experiential basis than it
did in his day it would be as difficult to meet the objections of the
cavillers at the present time as it was then. Even though the number
‘of those who have studied the minute structure of the brain and the
localisation of function in different areas is comparatively small, yet the
results obtained have given invaluable support to the theory that mind
is merely the name applied to the functioning of certain parts of the
nervous system. Every year brings fresh evidence to prove that the
dictum, “ no brain, no mind,” is true beyond all dispute. 2 Physio¬
logically and pathologically the results point in the same direction. It
is not to be expected, however, that the majority of people will readily
become converted to such a belief. It has not, superficially, the
picturesqueness of the theory that the mind is a vague something which

1 W. A. F. Brown, What Asylums were, are, and ought to be, p. 4, Edinburgh,
1837 -

* “ Indeed, it is impossible to conceive how any mental action, however subtle,
can occur without a corresponding change in the brain-cells.” The Origin and
Nature of the Emotions, by Geo. W. Crile, p. 121.

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plays like a will-o’-the-wisp 1 somewhere in space and therefrom descends
upon the individual to whom it has been allotted ; nor docs it make
any appeal to the mystical and emotional. But to those who have to
deal practically with minds in disorder it is an inspiration to further
effort and research. When we realise that these morbid conditions are
due to disease or disorder of the nervous substratum we can at once
direct our attention to finding out where the trouble lies, and, if possible,
rectifying the disorder or curing the disease.

It is not infrequently said that the results of all the work done towards
ameliorating the condition of the insane and in other lines of treatment
has made little difference in the recovery rate. Those who make such
statements would do well to remember that psychiatry as a scientific
subject is practically in its infancy. It is only in very recent times—as
has been pointed out—that even a beginning has been made. When
the overwhelming importance of the subject is considered, the number
of those who have undertaken research and investigation is very small
in comparison with those occupied with medicine in general. Various
factors have conduced to this undesirable state of affairs. There can
be no doubt that many have been deterred by the belief that insanity
is a condition in which any hope of therapeutic success is illusory.
They have felt that in diseases of the chest or the eyes, for example,
certain structures are affected, and that the morbid condition may,
therefore, be attacked. But in regard to insanity, there is simply the
intangible “ something ” which does not respond to any of the ordinary
methods of treatment. Even now, when those engaged in the study of
psychiatry are beginning to realise that this is not so, there still remains
this lingering belief in the public mind ; and fresh strength is given to
that belief by the various reactionary movements which arise from time
to time, and which, aided by newly-coined terminology, obscure the
issue. We look back to the time of Harvey and contemplate with
amusement the theories of his opponents with their “ vital spirits ” and
similar refuges of ignorance ; but how many are there nowadays who
hold practically a precisely similar belief in the matter of mental pro¬
cesses ? They have retired with their “ vital spirits ” to the last citadel—
the “mind,”—and there defend themselves with all the valour of enthu¬
siasm rather than of reason. But the researches into such a condition
as, for example, general paralysis of the insane, have done more to
undermine their defences than any amount of theory could possibly do.
In it the assumption that a definite causal factor would be found has
been justified ; and when Noguchi discovered the spirochiete of syphilis
in the brains of patients suffering from this disease a shrewd blow was

1 Even the will-o’-the-wisp is less nebulous than the metaphysical mind. It
might be better to call it the Nothingness—using, of course, the capit which
gives an appearance of reality without necessitating any further explanation.

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given to what may be designated the “ vital-spirit ” school. Here was a
condition in which was seen a wonderful variety of mental symptoms,
yet these were brought about by the influence of the syphilitic organism
or its virus on the brain-cells ! Surely, the inference is justifiable that
in other forms of mental disorder there may be some organism at work,
or the derangement may be due to some other physical factor which
disorganises temporarily or permanently the functions of the nerve cells.
In any case, an impetus has been given to further research along the
same lines; for, from the practical point of view, more has been
achieved by such a discovery as this than by all the windy verbiage in
which the subject has been obscured.

If, as is not unlikely, some of the therapeutic methods which are being
directed against the causal factor in general paralysis of the insane prove
to be successful, the death-rate in insanity generally will be speedily
reduced, for this condition is responsible annually for quite a large
proportion of the total deaths among the insane. Glandular treatment
—or opotherapy—is likely to be extended ; and the results obtained by
the administration of thyroid substance already warrant hopefulness in
that direction. The introduction of artificial feeding by means of the
nasal or of the oesophageal tube has saved many lives that would have
otherwise been lost. Further developments in the treatment of epilepsy
may be confidently expected ; even now the bromides have proved of
undoubted efficacy in this disorder. Balneotherapy—an ancient usage
—has been employed more extensively. The open-air treatment of
insanity has given beneficial results. Electricity in various forms is now
made use of. New hypnotic and sedative drugs have proved of utility
in many cases. Treatment by suggestion has given rise to good results
in certain forms of mental disorder, according to some observers ; and
the same may be said of the psycho analytic method associated with
the name of Freud—though there is still much discrepancy of opinion
in regard to this. 1 The nursing of the insane has been improved.
Those who take charge of them have to undergo special training;
and the general change which has taken place in the attitude
adopted by the public towards the insane is reflected in those who
occupy this important position in relation to the mentally disordered. 8

1 “ From hysteria psycho analysis was applied to other groups of psycho¬
neurotic disorders, first to morbid obsessions and impulsions, then to all sorts of
psychic disorders, including various forms of insanity, though it may be doubted
whether it has worked out as well in any of them as in hysteria, and in the severe
forms of mental disease, as Freud himself has pointed out, it is helpless.” Havelock
Ellis, Journ. of Mental Science, October, 1917, p. 542.

a The nursing of male patients by women has been successfully adopted in a
number of asylums; and there can be little doubt but that an even more extensive
use will be made of their services, especially in view of the exigencies of the
present time.

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Pathological and physiological research have advanced our knowledge
of the structure and function of the nervous system very greatly. This
is particularly so in the matter of microscopic investigation, where
higher-power lenses have made it possible to see intimate details and
changes which were before only inferential. Experimentally it has
been “proved conclusively that whether we call a person fatigued or
diseased, the brain-cells undergo physical deterioration accompanied by
loss of mental power. Even to the minutest detail we can show a direct
relationship between the physical state of the brain-cells and the mental
power of the individual—that is, the physical power of a person goes
pari passu with his mental power.” 1 Many others have come to the
same conclusion, and it may safely be anticipated that further investiga¬
tion will confirm and amplify the results already arrived at. The find¬
ing of micro-organisms in the brain—as, for example, in general paralysis
of the insane—has been rendered possible by the use of the modern
methods of investigation, and the discovery of other noxious organisms
may throw light on the hitherto obscure aetiology of certain mental
disorders.

Pathological findings and the observation of the symptoms and pro¬
gress of cases have made it possible to classify more accurately the
various forms of mental disorder. In this respect the suggestions put
forward by Kraepelin have had much influence. But the more the
subject is investigated, the more difficult is it found to adopt at present
any one of the classifications already promulgated. The differentiation
of mental disorders which has already been achieved warrants, however,
the hope that in this direction also a further advance may be made.

V.

The theory of evolution has gradually been found to be of wider and
wider application, and in regard to mental processes, and, consequently,
of mental disorders, it has immensely assisted in bringing about enlighten¬
ment. Darwin, Wallace, Spencer—but, in the matter of mental evolution,
Spencer in particular—have initiated a movement which has steadily
progressed since their time. It has done very much towards under¬
mining the belief in a mind apart from organisation. Their theories
are being carried to a logical conclusion which, it is true, they may not
have anticipated; but it appears to be inevitable that all those who
look at the matter broadly will, in the end, come to see that mental
processes show a progressive complication which goes along with in¬
creasing complexity of organisation. The work of Huxley, of Romanes,
and of Haeckel—to mention no others—has helped to make this
clear in regard to normal mental processes and from the integrative

1 The Origin and Mature of the Emotions, by G. W. Crile, p. 121.

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point of view. 1 But just as confirmation is obtained from such an
inductive method, so from the consideration of disintegration of the
nervous system support is also obtained. In this case along with
deterioration in nerve-cell structure there is diminution of mentality.*
Although various more or less specious arguments are advanced in
opposition to this, it tends to be more and more strongly confirmed
by observation ; and if more exact methods of testing mental capacity
were utilised, the truth of this statement would speedily become more
evident. No one has done more to illustrate this and to simplify the
evolutionary doctrine in its bearings on nervous processes from the dis¬
integrative as well as from the integrative point of view than Dr. Henry
Maudsley. His Physiology and Pathology of Mind (1862) may well be
looked upon as constituting an epoch in the study of psychology as
well as of psychiatry. For the first time he dealt comprehensively with
the subject from the devolutionary as well as from the evolutionary
aspect. Nor must the splendid contributions to research in nervous
disorder made by Hughlings Jackson be forgotten; and, perhaps most
noteworthy of all his conclusions, the statement that the most highly
evolved parts of the nervous system are the least organised, and, there¬
fore, that in processes of dissolution they most readily break down.
Also his researches in regard to epilepsy and convulsions, and his
theory that, in nervous disease, it is the uninhibited function of the
portions of the nervous system not yet attacked by the disease which
give rise to symptoms.

Evolution in regard to the nervous system is shown to be from the
simple to the complex, and there is at the same time a tendency towards
differentiation and specialisation; that is, although it works as a whole,
yet in different parts special functions are carried on. This is obviously
so in regard to certain portions, such as the autonomic system; and the
researches of, for example, Ferrier, Broca, Horsley, and Schafer, have
demonstrated that this holds good for the brain also—at least, in
respect of certain areas. The inference is fair that further investigation
will show that this process of specialisation has gone still further, and it
will be seen that the “silent” areas of the brain have definite functions
to fulfil.

Support for the evolutionary doctrine and for the theory of increasing
specialisation has been derived from the study of prehistoric man and
of living savage races. Progression from the simple to the complex has
taken place phylogenetically as well as ontogenetically—in the race as
in the individual. A narrrow outlook has appeared to negative this by

1 A clear and succinct account of mental evolution is to be found in The
Evolution of Mind by Joseph McCabe (London, 1910).

* “ Loss of the higher mental functions invariably accompanies the cell dete¬
rioration.” The Origin and Nature of the Emotions, by Geo. W. Crile, p. 125.

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pointing to the waxing and waning of different races ; but when a wider
view is taken, these vicissitudes are seen to be but as the advancing and
receding waves of an incoming tide. 1 TJie investigations of Tylor 2 3
and of many others show that certain simple ideas characterise the
thinking of primitive races, and that with increasing sociological com¬
plexity there is an ever-widening intellectuality. On the theory that
mind is a thing apart from organisation and uninfluenced by it, such
progressive intellectual differentiation is difficult to understand.

The intimate connection between criminality and insanity has become
more apparent of recent years. Therein also we may see an advance
and an improvement. It is now admitted by all who are competent to
judge that there are certain individuals whose mental defect precludes
them from observing satisfactorily the ordinary code of rules whereby
society protects itself from its anti-social members. These defectives
are of so poor cerebral organisation that education is ineffective to raise
them to such a standard of conduct as will fit them to take their place
as useful citizens. The irresponsibility of the definitely insane has been
admitted from the legal point of view ; but in regard to the mental
defectives—especially those with moral defects—the matter is difficult,
and opinion is, therefore, variable. It is beginning to be realised
that many who are apparently sane and responsible are yet not so ;
and, accordingly, the inutility and wastefulness of ordinary methods of
dealing with them is slowly becoming obvious. The application of
scientific tests of mental capability is replacing the haphazard method
which has been so common. It is being realised, also, that it is essen¬
tial that the prison medical officer should have a competent knowledge
of mental disorders, so that he may recognise some of the less obvious
troubles than “melancholy madness,” or “raving madness.”

The effects of the changes of opinion are already obvious. More
discrimination is being exercised in dealing with individual cases : and
in time as the community comes to understand its responsibility in
regard to the nurture of those whom social conditions have placed in
evil surroundings a still greater advance may be looked for. The old
illusion of the freedom of the will is not now so readily accepted as one
of the eternal verities. It is realised that there is a balancing of
motives and that the scale may be turned by adding to the weight of
one or other of these. Aggression or punishment of a vindictive nature
lend to arouse violent opposition or hatred; consequently they have

1 Whether there will or will not be an eventual reflux involving the whole of

mankind does not appear to affect the statement that generally there has been an
advance.

3 Primitive Culture, 1871. There has been much useful work done also in
regard to social psychology, as, for example, by G. le Bon, The Crowd, and The
Psychology of Revolution, and by McDougall, Social Psychology.

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failed to produce reformation or cure m the criminal or in the insane,
and they have almost entirely been discarded. The benefit has been
more widespread than is usually imagined. It has shown itself not
only in the condition of prisoners and of the insane, but also in those
who have charge of them : for brutality has an evil and degrading
effect on those who practise it as well as on those who suffer by it.

In this connection the work of Eombroso, in particular, has been of
value. However much his theories maybe criticised—and there seems
to be no doubt that he allowed his hypotheses too great a scope—he
has done much to arouse scientific interest in the criminal and the
defective. His investigations and those of other criminologists tend to
confirm the dictum enunciated by Sir Matthew Hale in the seventeenth
century that “ most persons that are felons . . . are under a degree
of partial insanity when they commit these offences.” It is early yet
to speak dogmatically on a subject to which attention has been directed
only in recent times and that, too, by comparatively few who have had
adequate knowledge both of criminals and of the insane. We may
hope, however, that the time will soon come “ when those morbid
mental processes which eventuate in anti-social acts will be made an
object of psychiatric attention.” 1

Another problem which has come under consideration and in which
it has been difficult to say definitely how much is due to moral defect
is that of sexual perversion. Where, however, formerly it was sufficient
to place such offenders under the ban of the odium thcologicum it is
now realised that the matter cannot be so easily disposed of. It is
seen, too, that this subject exhibits many aspects each of which requires
careful study. It remains for the future to discuss these questions
fully and frankly. Up to the present it has not been realised that—
scientifically considered—nothing is unclean and that everything in
regard to which we are in doubt has to be looked upon as a subject
for investigation. The difficulty has been—and probably for a long
time will be—to separate the scientific from the pornographic. It % is
something, however, that a beginning has been made ; and the writings
of von Kraffi-Ebing, 2 Havelock Ellis, 3 Bloch, 4 and others have already-
thrown much light upon an abstruse and difficult problem.

The application of the knowledge of morbid mental states to historical
and to literary subjects has helped towards a more complete under¬
standing of much that was obscure. It has been shown how the conduct
of, for example, certain of the Roman Emperors was the result of their
mental unsoundness ; how certain religious movements have been

1 The Causes and Cure of Crime, by T. S. Mosby, p. 68, London, 1914.

2 Psychopathia Sexualis.

3 The Psychology of Sex.

4 The Sexual Life of Our Times.

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initiated by men and women who were influenced by hallucinations
and delusions; and how, in literature and in art, much has been the
product of morbid mental states. The effects of certain bodily disorders
in producing irritability, cruelty, and even violence in ordinary domestic
life are understood by most people; but it has not been realised to
anything like the same extent that similar disorders occurring in men
of eminence have in certain instances altered the course of history.
From this point of view there remains very much still to be done ; and
the studies made, e.g., by Ireland, Maudsley, Cabanas, 1 show that much
may be anticipated from further investigations along these lines.

There is another aspect of the matter which may, however, be again
adverted to, namely, the financial one. In these days when economic
conditions have become less favourable to living the studious life, it is
necessary to take more earnest thought as to the means of subsistence.
Nor is it merely the question of a bare livelihood. Even the man who
is drawn towards scientific research is not necessarily inhuman, and he
may be deflected from the path which he had set out to tread by the
need of providing adequate means for the support of his family. He
knows very well that he cannot expect even moderate success from
the financial point of view if he devotes his time to research, so, unless
he is an enthusiast who is willing to sacrifice everything to his work,
he turns his attention to a more lucrative branch of the profession. 4
Nowhere is this more to be noted than in regard to cerebral research.
In the ordinary way when it is desired to obtain the services of
competent workers it is realised that adequate remuneration must be
offered. It is sound business; and from the financial point of view
it pays. It is admitted that there has been no stint in the matter of
expenditure in erecting asylums. How much has been set aside,
however, to provide for research ? And in how many cases have arrange¬
ments been made to have an adequately paid pathologist attached to
even the large asylums? It is practically left to individual effort;
and even then there is little encouragement given. Nor do asylum
appointments attract the best men. It is true that conditions have
somewhat improved of late years, yet much remains to be done.
Until this is rectified it is somewhat unreasonable to complain that,
though there is an immense field for research, so little of practical
value emanates from the medical officers whose lives are given up to the
care and treatment of the insane.

1 \V. W. Ireland, The Blot on the Brain, Through the Ivory Gate; Henry
Maudsley, Natural Causes and Supernatural Seemings, Body and Mind ; Cabanas,
Cabinet Secret de THistoire, La Nevrose Rcvolutionnaire, etc.

* There are, it is true, certain positions which would satisfy all but the most
exacting. The fewness of these only serves, however, to justify the present con¬
tention.

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There are those who will say that the association of scientific research
with financial considerations is a sordid one. It is a comfortable doc¬
trine for those whose means of support are ample and also for the tax¬
payer 1 ; but, as economic conditions become more stringent and as the
task of gaining the daily bread is, therefore, almost sufficient to absorb
the ordinary man’s energies, it is being more and more clearly realised
that the labourer is worthy of his hire, and, what is more important, that
he is not going to be deprived of it. Charity at the expense of others
is too simple a matter to have failed to be exploited in science as else¬
where.

Prophylaxis.

As much insanity is due to congenital defect or to the breaking down
of inherently unstable nervous organisations, curative measures in
certain cases are likely to prove inefficacious. Obviously, cure can be
looked for only in those cases where there is temporary interference
with nerve-cell structure, and where, prior to the attack, the brain has
been sufficient for the ordinary demands. Just as in the ascending
scale the brain of the imbecile cannot be brought by any form of educa¬
tion to such a stage of efficiency as will enable the individual to become
an average member of society, so, when definite deterioration has taken
place, it is impossible to rehabilitate the brain-cells. It becomes
necessary, therefore, to prevent, if possible, an undue strain being
thrown upon the unstable brain. For example, the child with inherited
instability may be apparently above the average intelligence during
school life. This being so, the intensive methods still too prevalent in
educational systems are brought to bear upon the child with the result
that the brain breaks down, and, it may be, primary dementia is
initiated. It may be said that a person so unstable is likely to be of
little use in life, but this is by no means proved. Certain cases which
have come early under care and which appear to exhibit undoubtedly
the symptoms of primary dementia, yet recover apparently completely.
In the same way with other forms of insanity, attention to the early
symptoms and the application of therapeutic measures may preclude a
more acute attack with its possible issue in permanent enfeeblement.
It is the prolongation of the period during which the morbid stimuli
act which brings about such deterioration that the brain-cells are unable
to recover; and the length of time required to bring about disinte¬
gration will naturally vary in different individuals, depending on their

1 “ Stretched in his marble palace, at his ease,

Lucan may write, and only ask to please ;

But what is this, if this be all you give,

To Bassus and Serranus? They must live.”

Juvenal, Satire VI (Gifford's Translation).

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208 EVOLUTIONAL PROGRESS IN PSYCHIATRY, [April,

powers of resistance. In the mental defective this resistance is so
slight that he is unable to withstand even the ordinary stress entailed
by social life, and he is therefore unable to conform to the rules which
the community has laid down.

These matters are being taken into consideration and some advance
has already been made. The Mental Deficiency Act has for its object
the segregation of those defectives who are anti-social in their con¬
duct, and who are likely to become—if no let or hindrance is inter¬
posed—the parents of criminals and of lunatics. Punitive measures
are simply energy misspent. Sterilisation is a method by no means
beyond criticism ; and, indeed, any form of treatment which tends to
link the medical man with the executioner starts with an initial dis¬
advantage.

Attempts are being made to bring the patient in the incipient stages
of an attack of mental disorder earlier under treatment. The out¬
patient system adopted at certain hospitals is a step in this direction,
hut can only be of value to a limited extent unless arrangements are
also made for in-patient treatment where this is necessary. The question
of certification will probably have to be discussed anew and a somewhat
wider latitude granted, especially where it is certain that proper care
and supervision will be provided. The exigencies of the present time
have done much to show that a less rigid system than the present one
in regard to early certification is within the bounds of possibility. It
was realised that some injustice would be done to soldiers who had
broken down mentally on account of the stress of war conditions if
they were straightway certified ; and special hospital accommodation
was provided for these men with the result that many who would have
been certified under ordinary conditions have not required certification.
If this holds good for them, then, surely, those who have broken down
under the stresses of ordinary social life—often far from inconsiderable
—may justly claim some such exemption. 1 The objection to certifica¬
tion may be entirely sentimental and it may in time be overcome.
In the meantime, Draconian edicts arouse irritation; and in such a
case as this, unless it can be shown that dangers to the community
or to the individual are likely to arise, compromise is indicated.

It is also necessary to induce the public to realise that the function
of the alienist is not chiefly in bringing about the segregation of the
patient—an idea unfortunately too prevalent—but in advising or
directing treatment as is done in other branches of the medical pro¬
fession.

1 The munificent gift made by Dr. Henry Maudsley, which has resulted in the
building of the hospital which bears his name, may be noted as a very practical
attempt to satisfy this need.

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Generally, a more comprehensive outlook in regard to the possi
bilities in psychiatry is needful—even among alienists themselves. In
the words of a recent writer, “This wider field of activity for the
greater psychiatry includes not only the recognised problems of insanity,
feeble-mindedness, and psychiatric states in general, but a large group
of phenomena, mostly social in their bearings, such as delinquency,
inebriety, prostitution, and various phases of delinquency and social
failure .” 1

Summary.

Even this brief survey may have sufficed to make it evident that in
regard to mental disease there has in recent times been a definite
advance in regard to the general attitude adopted towards the insane;
and this has resulted in a steady amelioration of their lot. Although
a retrogression took place after the classical period of Hippocrates and
Pythagoras this in turn was succeeded by the more enlightened epoch
initiated by Pinel and Tuke towards the latter part of the eighteenth
century. The progress of rationalism has tended to displace the
metaphysical conceptions which, assuming an extraneous mind, made
it easy to postulate the influence of other extra-natural influences.
From the sixteenth century onwards belief in demon-possession has
steadily waned; and along with this there has been a diminution in
credulity in regard to witchcraft and magic. The evolutionary doctrine
has been applied to nervous processes; and it has been seen that there
is uninterrupted progression from simple nervous reactions up to the
more complete reflexes which result in mind. The tendency towards
differentiation and the allocation of specific function to separate areas
—already noted in regard to the body in general—is seen to hold good
of the nervous system. Increasing complexity of social organisation
has been demonstrated by anthropological research. The study of the
relationship between insanity and criminality has made considerable
progress. Sexual anomalies and perversions are being scientifically
investigated. Results obtained from the study of morbid psychology
are being made use of to explain difficult problems in history. The
secretions of the ductless glands have received much attention, and
already the therapeutic results are such as to warrant the belief that
even more may be expected from that direction. Physiological and
pathological research have already yielded valuable results; and
the knowledge thus gained has tended to substantiate the assertion
that mental function is utterly dependent upon the condition of the
organic substratum. It is becoming possible to some extent to differ-

1 “The Broader Psychology and the War,” by Herman M. Adler, M.D
(Mental Hygiene, July, 1917, p. 364.)

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entiate between varieties of mental disorder; and this should proceed
even further when the methods of pathological investigation are more
able to reveal subtle changes. The discovery of the aetiological factor
in general paralysis of the insane has stimulated therapeutic effort
towards counteracting that dire disease. The prophylaxis of insanity
is yet in its early stages, but it is reasonable to expect that still more
beneficial results may be looked for.

Occasional Note.

Early Treatment of Mental Disorders.

The question of how best to secure early treatment for sufferers from
mental derangement has long engaged the attention of the medical
profession. It will not therefore, we premise, be out of place to scruti¬
nise some of the more recent pronouncements on this subject. And we
could not probably find a more appropriate text for discussion in this
connection than the little volume on Shell-Shock by Profs. Elliot-
Smith and Pear, a second edition of which has lately appeared, the first
having been rapidly exhausted. We welcome this fact as showing that
more or less general interest in this most vital and important subject is
being aroused, and we hope the demand will continue, although, as will
be seen, we have perused its contents with somewhat mingled feelings,
especially when taken in connection with an address delivered, since
the publication of the book, by Prof. Elliot-Smith at the Royal Institu¬
tion for Public Health.

The chief aim of the authors is to show that the early treatment of
mental disorders is an urgent public need. There can be little doubt
that this account of the treatment of sheli-shock under stress of war
conditions will go far to convince all who read it that similar provision
is required by civilians.

In July, 1914, less than a fortnight before the catastrophe of the war,
the Report of the Committee re Status of British Psychiatry was adopted
at the annual meeting of the Medico-Psychological Association at
Norwich. The foremost recommendation in this report was the estab¬
lishment of psychiatric clinics. Therein it is stated: “The evidence of
many authorities, who have practical experience of the value of treat¬
ment in the incipient stages of the illness, is conclusive that the exercise
of scientific care during the early phases of the mental disorder would
save many from such a complete breakdown as would necessitate certifi¬
cation and removal to an asylum . . . and therefore the Committee

regard it as essential that, in the large centres of the population, at any
rate, means should be provided to obviate the delay which now exists in
securing adequate treatment for mental disorders.”

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This book on shell-shock is written in support of this long-needed
reform. We read, p. 128: “For the relief of the mentally afflicted
amongst us, and especially for the prevention of insanity, it is our
bounden duty as a nation to take measures such as most civilised
countries have adopted long ago. For this purpose it is necessary that
there should be hospitals to which patients in the early stages of mental
disturbance can go, without any legal formalities, and receive proper
treatment from physicians competent to diagnose their troubles and to
give them appropriate advice.”

It is interesting to observe that the authors of this volume are neither
of them alienists or neurologists. Prof. Elliot-Smith is one of the ablest
and best-known anatomists of our time, and Prof. Pear is a distinguished
psychologist. But for the war, and the establishment of the military
hospital for functional nervous disorders at Maghull, near Liverpool, it
is doubtful whether this book would have been written. We note with
pleasure that it is dedicated to Major Rows (now Lieut.-Col.), whose
work at Maghull has been so strikingly successful.

As our readers are aware, Col. Rows was the indefatigable Secretary
of the Status Committee referred to, and it is a source of great satis¬
faction that in his present important position he has the opportunity for
carrying out some of the ideas he has had so long in mind. For there
is at last in being a “centre for teaching in which systematic instruc¬
tion” is given, accompanied by “ facilities for post-graduate studies,”
and where the army medical officer, at any rate, has “ the advantage of
working in a scientific atmosphere in an institution where he can see
treatment on the most modern lines, and where he can be assisted and
guided by men who have done and continue to do their share in inves¬
tigating the obscure questions connected with this science.” (We quote
from the Report of the Status Committee.)

Although the volume before us says hard things in reference to exist¬
ing institutions for the insane, we must admit that much of this is, as
the authors themselves state, but a paraphrase of the Status Committee’s
Report. We may instance : “ The most depressing aspect of the present
state of affairs is the comparative absence of all research ” (p. 117).
“ Nor, as yet, have many of the medical officers in our asylums sufficient
up-to-date knowledge of psychiatry to enable them usefully to co operate
with medical schools and the teaching staffs of the general hospitals.”
Moreover, the implication in the introduction (p. xr) is not pleasant
reading : “ The war has forced upon this country a rational and humane
method of caring for and treating mental disorders among its soldiers.
Are these signs of progress merely temporary ? Are such successful
measures to be limited for the duration of the war and to be restricted
to the Army ? ”

Most of us say things about ourselves and our shortcomings that we

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are apt to resent if said by anyone else. It is, therefore, not surprising
that criticism has been directed to this book in that it seems to do less
than justice to the devoted service of asylum workers throughout the
country, work frequently carried out under the most difficult conditions.
A careful study of the text makes it clear that the authors are not criti¬
cising the treatment of declared insanity so much as the system which
provides little or no treatment for persons on the verge of a mental
breakdown. They sum up the defects as follows : “ First and foremost
is the serious waste of time which almost invariably occurs before the
mental sufferer comes under medical care. This is due to a variety of
causes—all of them preventable. The chief is that, lying in the path
of patients who would voluntarily seek help, there is the insurmountable
obstacle of the asylum service and its restrictions. The men in the
asylum service, who have the opportunity of acquiring an intimate
knowledge of mental diseases, ar & forbidden to carry that knowledge into
the outside world for the benefit of the mental sufferer. If a patient,
suffering from a mental disorder in its earliest and easily curable stage,
should voluntarily go' to an asylum and ask advice, all that can be done
for him is to suggest that he should consult a medical man outside or to
recommend him to call and see the relieving officer. . . . In short,

all that the officials under our present system can say to such a man is:
‘Go away and get very much w'orse, and then we shall be allowed to
look after you ! ’ ” This criticism cannot be said to be unfair, though
the assumption that the early stages of mental disorder are easily curable
is, perhaps, over sanguine.

Although there is little in the book to which exception can be taken,
the public addresses of one of the authors appear to go further, and
may injure a good cause by over-statement.

The Manchester Guardian has reported an address delivered recently
by Prof. Elliot-Smith at the Royal Institute for Public Health w’hich
contains statements that seem to us exaggerated and deplorable. After
speaking of Conolly removing the iron fetters of Hanwell, the
report proceeds: “ To day the forces of ignorance and apathy were
responsible for the perpetuation of the vicious system which unneces¬
sarily inflicted upon thousands of English men and women every year
the more galling fetters of the asylum label and the stigma of madness.
Probably 50 per cent, of the patients admitted to British asylums to-day
would have been spared this ignominy ... if we had done as
many other nations had done long ago— i.e, provided facilities for the
skilled treatment of mental disorders in their early and curable stage,
an I so spared nearly 50 per cent, of such patients the fate of being
branded as madmen and being sent to an asylum.”

Making allowance for the condensation of a newspaper report, we
must take serious exception to two of the statements made. First, the

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implication that it is ignominious to be sent to a hospital for the insane
for treatment. Second, that 50 per cent, of the patients would be saved
from the stigma of madness by treatment in a special hospital.

Surely Prof. Elliot-Smith must know that however successful the
special hospitals may be, a large number of patients cannot be treated
to recovery in them, and will have to be transferred to a hospital for
the insane. And surely, it is cruel and reactionary in the extreme to
reproach the more grave cases with the “ stigma of madness,” and to
imply that they are something essentially different from those who
happen to recover quickly. The Medico-Psychological Association
has striven, since its foundation, to remove the reproach of lunacy, and
we cannot but regret to see it being emphasised in order to help
forward a needful reform in treatment. The assertion that 50 per cent .,
or nearly 50 per cent., will escape the fate of “ being branded as mad¬
men,’’ when considered in relation to the context, evidently means that
declared insanity will be prevented in half the cases. This is surely
too sanguine a view, and there are certainly no statistics available to
justify so sweeping a statement. We must not forget that it is the
disease itself which is serious, not what it is called, nor where it happens
to be treated.

The cause we have at heart cannot be advanced by statements which
must tend to create prejudice against institutions doing necessary and
most valuable work for the community, or by exaggerating the benefits
likely to be secured by reform. We are glad, however, that men eminent in
other branches of knowledge are joining hands with us in the endeavour
to promote improved methods of treating mental illness in its early
stages.

While we recognise the limitations of some of the supporters of this
good cause, who have not specially devoted themselves to the treat¬
ment of mental disorders, we venture to plead that future advocacy
may be free from reprehensible terms which betray a sad lack of
sympathetic appreciation of the feelings of the sufferers and of their
friends.

Part II.—Reviews.

Automatisms et Suggestion. Par H. Bernheim. Paris: Alcan, 1917.

Pp. 168. Price 2 frs. 50.

The problems of hypnotism will seem to many to-day to be ancient
history. Forty years ago, however, exactly the same storm raged
around hypnotism as now rages round psycho-analysis. On the one
hand were the enthusiastic champions of what seemed to them a newly-
discovered force full of immense possibilities ; on the other hand were
the adversaries who could find no language strong enough to express
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their condemnation. The storm has long since subsided. Neither the
champions nor their adversaries triumphed. Hypnotism and suggesti¬
bility were accepted, but in that acceptance they fell back into a posi¬
tion which, though assured, was seen to be quite humble and modest.

The veteran Prof. Bernheim, of Nancy, played a large part in the
settlement of these questions. By no means a man of brilliant genius
but endowed with a calm, common-sense, observant mind, he carefully
watched the pioneering experiments of Liebault and came to certain
conclusions. He was able to explain the phenomena as simply due to
suggestion, and he found reason to believe that the elaborate results
obtained by Charcot and others were in large degree artificially built up
by unconscious suggestion working on hysterical subjects. From these
conclusions he has never deviated.

In the present simply written little book his familiar results are pre¬
sented afresh with such slight new developments as he has since worked
out. Some of the views and definitions thus brought forward will be
regarded as personal to himself, but there is usually something to be
said for them. The book throughout shows that clear, calm vision
and unfailing sobriety of judgment which has always characterised the
author.

Bernheim refuses to believe that under the influence of hypnotism or
suggestion the subject is purely automatic, an unconscious machine,
acted upon by another’s will. The early chapters of the volume aie
devoted to expounding the conception of automatism in this sense
as a mechanism, itself indeed unconscious, but in a conscious subject.
Formerly, like Liebault, Bernheim believed that the phenomena of
hypnotism were the more pronounced the more complete the hypnotic
sleep ; the suggestibility seemed to be in proportion to the depth of the
sleep. Now, observation and reflection have led him to modify, and
even reverse, that view. The suggestibility created in this sleep is not
proportional to its depth, but, on the contrary, all its phenomena are
due to conscious psychic conditions (falsifiable by suggestion but not
abolished) which have no existence in deep sleep. Through all stages
of this condition the same tendencies hold good. Catalepsy is simply
a phenomenon of suggestion, and suggestion is a phenomenon of con¬
sciousness ; suggestion can produce in the ordinary waking stale the
same manifestations (anaesthesia, hallucinations, obedience to com¬
manded acts, etc.) as in the induced sleep. Thus it is that Bernheim
concludes with Delboeuf: “There is no hypnotism, there is only sug¬
gestibility.”

It is in accordance with this standpoint that Bernheim insists through¬
out that the phenomena we are here concerned with are never absolute.
Suggestion does not imply complete automatic obedience. Amnesia is
neither constant nor absolute. The subject’s memories of his somnam¬
bulistic state are latent, not effaced. Bernheim is quite unable to
accept Grasset’s well-known conception of the polygon of lower centres,
emancipated from the higher centres, and obedient to the hypnotiser.
On the other hand, there is a certain amount of suggestion and ideo-
dynamism in all our everyday acts. That is our determinism. To a
large extent we are all influenced, even without knowing it, by the
passions and prejudices of the mob. Voxpopuli , vox Diaboli. Hence

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the importance of education in the prophylaxis of morbid suggestions,
and the need to combat the credulity of childhood by developing the
reasoning powers.

A chapter is devoted to the question of moral responsibility. Bern-
heim holds that psychologically there is no absolute free-will, and, con¬
sequently, no absolute moral responsibility. But there is always a legal
responsibility, and all injurious acts must be repressed without regard
to the question of moral responsibility. It is not a question of
punishment but of social defence, and often also of salutary suggestion.
But, it is added, we must remember that the convictions thus rendered
necessary are not for the purpose of casting infamy on the culprit and
his family, but simply to safeguard society.

In a subsequent chapter an attempt is made to define the terms
“ neurosis ” and “ psycho-neurosis.” Bernheim refuses to regard neuras¬
thenia as a neurosis. It is not a neurosis but a morbid constitutional
evolution, doubtless due to some toxic principle in the organjsm. At
the outset of his career, believing, as was generally believed, that neuras¬
thenia is purely functional, he applied psycho-therapeutic treatment,
but without effect.

A functional trouble must not be regarded as a neurosis unless its
evolution shows absence of organic processes. A psychic neurosis
(neurosis constituted by psychic trouble) becomes a “psycho-neurosis ”
or, the emotional cause having disappeared, it is maintained through the
psychic activities alone by mental representation. A psycho-neurosis
alone furnishes the basis on which psycho-therapeutics can act. This
leads on to certain differentiating considerations on hysteria. Medically
speaking, the term “ hysteria,” Bernheim considers, should only be
applied to the well-known nervous crises. It should not be applied to
the large number of women of so-called “hysterical character” who
really have no such crises at all, while the women with true hysteria
usually do not possess the “ hysterical character,” but may be entirely
sound in their ideas and feelings and of high character. Other psycho¬
neuroses than the nervous crises should also not be regarded as
hysteria; thus hemianaesthesia is not to be reckoned among hysterical
symptoms, though it may easily be produced by suggestion whether or
not hysteria is present.

A final chapter is devoted to treatment. It was Liebault who
initiated verbal suggestion in treatment; but he first put the patient to
sleep. It was Bernheim who, in 1884, showed that the preliminary
sleep is unnecessary, and that suggestibility is a physiological function
of the waking human brain. Proceeding from simple verbal affirmation,
Bernheim passes in review the various procedures which are possible
on this basis. The induced sleep may be employed, but though
Bernheim still occasionally adopts this method, he attaches little
or no value to it. Then there is persuasive suggestion by rational
arguments, and for this Bernheim claims credit as against Dubois,
of Berne. There is, further, persuasion by appeals to feelings and
emotional influences. Persuasion, however, may fail, and then there
is active suggestive education, the training of the will. Suggestion
may, further, be disguised in practical methods, such as massage, drugs,
etc. Then there is the method of subterfuges, as relieving pain by

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injecting clear water instead of morphia. Or there is the method by
psychic substitution which consists in suggesting to the patient new
and harmless acts as derivatives for his symptoms. Bernheim admits
that psychoneuroses may yet remain rebellious to all suggestive treat¬
ment, for the patient’s own auto-suggestion may be too powerful, and,
moreover, there are many psycho-neurotic troubles which from the
outset are associated with underlying diseases. But in most cases of
simple psycho-neurosis, he maintains, psycho-therapy remains efficacious,
and is a rational medication which the physician must not neglect.

Havelock Ellis.

Mental Conflicts and Misconduct. By William Healy. Boston :

Little, Brown & Co., 1917. Pp. 330, 8vo.

Dr. Healy, Director of the Psychopathic Institute of the Chicago
Juvenile Court, and author of the important work on The Individual
Delinquent, reviewed in the Journal two years ago, deals here with
some aspects of the fundamental problem of the causation of misconduct.
He is mainly concerned with cases in which hidden early experiences
of inner conflict lead to misconduct often having no apparent con¬
nection with the conflict. In this investigation the author is careful to
explain that he is tied to no one psychological school, and though he
has learnt much from various writers on psycho-analysis he does not
practise, or in his own work find necessary, any strict technical methods
of psycho-analysis, and prefers to use the simpler and more general
expression, “mental analysis.” He regards such investigations as very
necessary in view of the decay of the old ideas of punishment, and the
recognised need of inducing in the offender self-directed tendencies
towards more desirable behaviour. From that point of view the results
here recorded are highly promising and suggestive.

In his first thousand cases of youthful recidivists Healy found
seventy-three instances where mental conflict was a main cause of the
delinquency ; in the second series of a thousand there were seventy-
four. He regards this as much below the real number, for he had not
then realised the importance of such conflicts. Even the incomplete
7 per cent, are not, however, a negligible number. Moreover, the
significant fact emerges that they embrace some of the most important
cases of delinquency, though at the same time Healy is inclined to
think that “individuals particularly well-endowed in emotional qualities
and finer feelings are the more prone to suffer from mental repression
and conflicts.” These cases are also usually about the average in
mental ability.

A great variety of misconduct is found to arise on the basis of mental
conflict, ranging from the sustained bad behaviour of childhood to
deeds of actual crime, including obstinacy, destructiveness, truancy,
vagrancy, stealing (with pathological stealing and so-called “ klepto¬
mania”), forgery, sexual offences, injury to others. It is remarkable
that some of these misdoers are not carrying out their own keenest
desires; their misdeeds are, as it were, “forced by something in them¬
selves, not of themselves ” ; they involve no pleasure. It may be noted
that Healy gives no special attention to sexual offences, as these have

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been much studied by other workers, but he remarks that he has been
greatly surprised to find how much delinquency of various types had
its beginning in unfortunate sex knowledge, which came into the mental
field as a psychic shock, producing emotional disturbance; this is well
illustrated by many of the cases here brought forward.

In successive chapters are reviewed, with numerous illustrative cases,
conflicts accompanied by obsessive imagery, conflicts causing impel¬
ling ideas, criminal careers developed by conflicts, conflicts arising from
sex experiences, conflicts arising from secret sex knowledge, conflicts
concerning parentage (as when the child discovers that he is illegiti¬
mate, or that an alleged parent is not the real parent), conflicts in
abnormal mental types, conflicts resulting in stealing (with instructive
cases of “ kleptomania,” showing that the real concealed source of the
delinquency often has no obvious connection with the nature of the
delinquent act), conflicts resulting in running away, conflicts resulting
in other delinquencies.

The author concludes that mental conflicts do not imply a peculiar
constitution ; they commonly produce misbehaviour in individuals
who prove themselves by examination and history to have, apparently,
normally stable nervous systems. Nor is there any good evidence of
hereditary basis, though, like offenders in general, these cases come
from stock on the average poorer than that ot non-offenders. The age of
onset is youthful, and probably never later than early adolescence. But
the conflict may lie dormant, or repressed and unrevealed, for months
or years. It must not, however, be supposed that these cases are
usually of moody, depressed, or “ shut-in ” types ; they are often frank,
open, cheerful, and, outside their conflicts, healthy-minded. Still they are
sensitive, and tend to respond peculiarly to certain experiences, though
not hypersensitive in other directions. No race or nationality is
specially affected, and in mental ability these cases are far above the
delinquent average. Mental tests have failed to be of diagnostic value.
The author believes that some cases of so called moral imbecility and
consitutional immorality are only instances of misconduct reactions to
mental conflicts. The prognosis is often good, and the results have
sometimes been remarkably satisfactory. In the study of mental con¬
flicts we have a scientific method of approaching certain problems of
misconduct, Dr. Healy concludes, with a prospect of rendering real
service to humanity.

This simple, lucid, and systematic study of a new case-group is the
work of one who must be accounted a master in the field of crimino¬
logy, and cannot fail to be helpful to all whose business it is to explore
and redirect abnormal human conduct. Havelock Ellis.

Manuel de Psychiatric. Par le Docteur J. Rogues de Fursac, ancien
chef de clinique h. la Faculty de Medecine, mtkiecin en chef des
Asiles de la Seine, expert pres les Tribunaux. 1 vol. in-16, de
la Collection m6dicale, 509 pp., cinquikme Edition, revue et
augmentde (Librairie Felix Alcan). 7 fr. 70 net

When a text-book has reached its fifth edition the reviewer has an
easy task. The public to whom it appeals has given a verdict so

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decisive in its favour that little remains to be said in the way of praise
and no condemnation is permissible. Moreover, when that book is
translated into another tongue (English) and in this form reaches a
fourth edition, it is evident that the appreciation of its good qualities is
not confined to the country of its birth. This translation, made by A. J.
Rosanoff, and published in New York, was comprehensively reviewed
in the October, 1917, number of this Journal. Readers, however, will
wish to be informed in what respect the new edition differs from its
immediate predecessor.

Under this heading the matter which attracts chief attention is the
chapter on traumatic and emotional psychoses, which, after a useful
account of the traumatic psychoses of civil life devotes itself to the
psychoses caused by the war. Corresponding to our shell-shock the
French have the word obusi/e, which the author considers passablemetit
barbare. It is a long chapter very well written, and most useful to those
engaged in treating such cases.

War psychoses are divided into three classes. The first class includes
those patients in whom there is gross injury to the brain, the second
those with small haemorrhages in the brain, and the third, those in
whom there is no organic lesion. With regard to the first class, it is
to be noted that though the cerebral lesion may be extensive the mental
disturbance may be slight. The author had under care a wounded
man who had lost the greater part of his two frontal lobes from a
shell explosion. It was thought that about 200 grm. of brain sub¬
stance had been destroyed. Four months afterwards the only symp¬
toms present were slight psychic enfeeblement consisting principally
in weakness of attention and memory. The third class is by far
the largest, and includes those shell shock cases who are suffering
from no apparent physical injury. Their symptoms, the author is
convinced, are entirely of an emotional origin. It would occupy too
much space to follow him through his description, but as regards the
treatment of such cases, he is emphatically of the opinion that they
should be detained at the forward ambulance stations and not sent to
the base hospitals. At first sight such a policy would appear to be
contrary to all common sense, but M. de Fursac makes a very strong
case for this opinion.

A second addition is the chapter on the use of psychotherapy in
mental diseases. This term includes a wide range of measures, eg.,
employment, entertainment, and the like. It is interesting to note that
he forbids dancing which he states to be harmful. This view hardly
coincides with English opinion. No mention is made of the cinema,
which is now becoming a very popular form of entertainment in English
asylums. Psycho-analysis meets with but scant courtesy, and an illus¬
tration is given of the harm which may ensue when it is used without care.

The prophylaxis of mental diseases includes a very interesting study
of the various methods used in different countries to combat the drink
evil.

The unsatisfactory nature of the name “ dementia prascox ” is com¬
mented upon at some length, and schizophrenia is now bracketed with
It has three divisions—simple hebephrenia, catatonia, and delu¬
sional hebephrenia.

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A new chapter appears under the heading of chronic systematised
hallucinatory psychosis which was formerly included under dementia
pnecox. This is a return to former paths, as it is a purely French
conception which lias been graphically described, first of all by Magnan
under d£lire chronique, and later under other names by Seglas, Ballet,
and others. The subject is worthy of a more extended treatment than
can be given in a review.

To sum up, this is a most excellent book, written in the clear, concise
manner which seems to be the special gift of the talented nation across
the Channel. R. H. Steen.

Collected Papers on Analytical Psychology. By C. G. Jung, M.D.,
LL.D. Authorised translation edited by Dr. Constance E.
Long. Second Edition, 1917. London : Baillifere, Tindall & Cox.

The fact that in so short a period as one year a second edition has
been called for must be most gratifying to both author and editor, and
testifies to the interest taken in psycho-analytical matters in English-
speaking countries. The former edition was reviewed in the October,
1916, number of this Journal, so that on the present occasion it will be
necessary merely to describe the new matters introduced. And this is
not so small a task as might be expected, as the present edition exceeds
by exactly one hundred pages the size of its predecessor.

Chapter XIV, which was headed “ New Paths in Psychology,” has
become “ Psychology of the Unconscious Processes,” and has been
rewritten and expanded. A new chapter (XV) has been added, entitled
“ The Conception of the Unconscious,” and though apparently written
at an earlier date contains the final and special views of Dr. Jung in a
summarised form.

To epitomise the thoughts of Dr. Jung in these chapters is almost
impossible within the limits set by the Editors. The author himself
feels that his own words are somewhat of an epitome, as he says in
a foreword to Chapter XIV that “The material is extremely compli¬
cated and difficult. I do not for a moment deceive myself into thinking
this contribution is in any way conclusive or adequately convincing.
Only detailing scientific treatises about the various problems touched
upon in these pages could really do justice to the subject.”

It may, however, be stated that the chapter opens with the history of
psycho-analysis and describes Freud’s work. This is criticised, and the
conclusion is reached that his sexual views are too one-sided. Then
follows a short account of Adler’s work. The two psychological types,
i.e. y the introverted and the extroverted, are described, and the want of
harmony existing between Freud and Adler is explained by the fact that
each observer was dealing solely with one of these types. After this is
discussed, the differentiation of the unconscious into two layers, the
personal (that belonging to the life-history of the individual) and the
impersonal (that belonging to the life-history of the race). As an
example, a dream is given with an analytical interpretation, then with a
synthetic or constructive interpretation and a long discussion on the
transference and its relation to the impersonal or superpersonal uncon¬
scious ends the chapter.

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It is not the present intention to criticise the volume. To do such
with any adequacy would require a lengthy article. Furthermore, the
author in the passage quoted above, disowns criticism. It is only right
to state that at the present time a considerable amount of interest in
matters psycho analytical is being shown in England. The attitude
most frequently adopted is one not of belief, nor of unbelief, but of
careful sifting and weighing. The ordinary man (in contradistinction to
the psycho analytic expert) is woefully confused. He has been led to
think that Adler and Jung are pupils of Freud and yet he finds the last-
mentioned in his History of Psycho-analysis excommunicating these two
followers. Jung apparently feels he will have to plough a lonely furrow,
for he says, “ every pioneer must take his own path alone but hopeful,
with the open eyes of one who is conscious of its solitude and the
perils of its dim precipices.” Jung has sketched a large picture.
Various figures are outlined, and the background requires filling in.
When the picture is finished, then will come criticism. Meanwhile,
what has been produced gives ample food for reflection.

R. H. Steen.

Part III.—Epitome of Current Literature.

i. Physiological Psychology.

The Scope of Behaviour Psychology. {Psychol. Rev ., September , 1917.)

Watson , J. B.

The author begins by defining psychology, in accordance with the
modern tendency, as “a division of science which deals with the
(unctions underlying human activity and conduct.” That is to say, it
is an attempt to formulate how an individual or group of individuals
will adjust themselves to the situations of life, and to establish principles
for the control of human action—which is what everyone is always
doing without calling it psychology. Common-sense, however, useful as
it may be, will not go far enough; we need systematic psychological
procedure.

As a science the task of psychology is to unravel the complex factors
in human behaviour from infancy to old age. The goal of psychology
is “ the ascertaining of such data and laws that, given the stimulus,
psychology can predict what the response will be ; or, on the other
hand, given the response, it can predict the nature of the effective
stimulus.” The word stimulus is used as in physiology, only with a
more extended sense, and when there is a complex group of stimuli,
as in the social world,'we speak of situations. Similarly, response is used
as in physiology, only with a more extended sense, and when it is
manifold we speak of act or adjustment. In distinguishing among types
of acts, the old speculative psychologist introduced needless techni¬
calities and metaphysical concepts like “ purposes,” “ end,” etc.

Psychology is not concerned with these distinctions.” The psycho¬
logist is concerned with behaviour, and behaviour on analysis is “the
separate systems of reaction that the individual makes to his environ-

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ment.” Such adjustments depend on the integration existing among
the receptors, or special sense-organ tissues, and the muscles and glands.
The various possibilities of reaction are thus seen to be vast. But they
fall into four main classes: (1) Explicit habit responses, like tennis
playing, etc.; (2) implicit habit responses, i.e. “thinking,” by which
we mean sub-vocal talking, with all its muscular activities; (3) explicit
instinctive responses, like sneezing, walking, etc.; (4) implicit instinc¬
tive responses, including the whole endocrine secretory activity.

Psychology is separable into eight divisions: individual, vocational,
child, folk, educational, legal, pathological, and social psychology. In
its relations to other sciences, it is dependant on physics, as every
science is at bottom. Its relation to neurology is less essential than is
commonly supposed, and psychological laboratories should not under¬
take to teach neurology, although some notion of the elements involved
in reflex arcs is essential. The distinction of psychology from physiology
is that while the latter teaches us concerning the functions of the special
organs and certain combined metabolic and other processes, psychology
deals with the organism as a whole in relation to the environment as a
whole; they are entirely independent, yet not antagonistic, for “ physio¬
logy is psychology’s closest friend among the biological sciences.” In re¬
lation to medicine, psychology should form the background to the whole
field, but has hitherto been of comparatively slight service because it has
dealt so largely in speculation and philosophy. It should instruct the
physician in those methods of approaching and handling patients which
can be expressed in no other than behaviour terms. Such factors
concern everybody, but especially the physician on .account of the
intimacy of his relation to his patient. “The psychiatrist has not
neglected these factors ; indeed, it has been due to him that they have
been emphasised at all. In so far as psychiatry is concerned, I think
we can say that the psychology the psychiatrist uses is not different
from the psychology we are trying to study.” Havelock Ellis.

2. Clinical Neurology and Psychiatry.

Mutism , Aphonia , and Deafness among Soldiers , of Psychical Origin ,
from Organic Causes: Malingering and Objective Differential
Diagnoses [ Mutisimo , Afonia, Sordi/d nei Militari , di Origine
Psichica, da Cause Organiche: Simulazioni e Criteri Differenziali
Obiettivi ]. (Rivista di Patologia Nervosa e Mentale , March ,

1917.) Gradenigo,Prof. G.

In this paper the writer is not concerned with the sensorial-idealistic
side of the phenomenon of speech, but only with the motor side ; he
is concerned only with mutism or the complete failure of speech (motor
aphasia), and with aphonia or the failure of the laryngeal sound with
persistence of the whispering voice.

The organic causes of these conditions and of deafness may be
divided into two categories : those due to various diseases, and those
due to grave traumatisms of the head and neck. “These traumatisms
in the present war are caused for the most part by terrible explosions,
which produce lesions, sometimes very grave, of the ears, such as

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lacerations and destruction of the tympanum, neurolabyrinthic disturb¬
ances and haemorrhages, fractures of the temporal bones, etc., also
cerebral disturbances, fractures of the skull, etc. Sometimes the
patient has been thrown to a distance with great force, either striking
his head against a rock, or being buried under a heap of stones or
earth.” The same explosions may provoke also morbid psychical
manifestations.

In the majority of the psychical forms of these cases there un¬
doubtedly exists a predisposition to disease of the nervous system, a
feebler power of resistance to morbid factors. The principal predis¬
posing elements are endogenous intoxications and states of exhaustion
of the nervous system (fatigue, insomnia, indigestion, and disease, par¬
ticularly typhoid), and exogenous intoxications (alcohol and tobacco).
Further, the emotions, preoccupations, and the ever-present thoughts of
dangers, w'hich have been overcome, or are about to be overcome, act
injuriously on the nervous system. Among other determinative causes
of the psychical forms are mechanical and acoustic injuries from the
explosions of shells and hand grenades in the vicinity, exposure to
prolonged and intense bombardments, and especially strong psychical
impressions, as fear, etc. The simultaneous action of these various
and energetic causes produce in the patient—especially if his nervous
system has little resistance—stupor, a thundering noise in the ears,
sometimes true psychoses, in which, by the side of the most different
forms of psychical and sensorial disturbances, one finds frequently
deafness, mutism, and aphonia due to the exaggerated stimulation of the
acoustic centres and neighbouring cortical centres of speech. One
easily understands this when one thinks of the intimate connection
between the voice and all tiie manifestations of affective life.

Passing cn to a closer study of the psychical forms, the writer points
out that such patients often behave very much like common malin¬
gerers, because in each category one is concerned with phenomena of
the will. In the case of the really diseased person there is a perversion
and an impotence of the will due to auto-suggestion which is often very
difficult to overcome ; in the malingerer there is the will to deceive.

Complete mutism is rare in the organic forms, while in the psychical
forms it is generally the rule. Psychical mutism is not accompanied
by verbal deafness, agraphia, or optic aphasia. In a psychical form
allied to mutism one observes a scanning, dragging, slow speech. At
other times there is disturbance of the respiration in speech ; for
example, the expiration may be broken and interrupted, as when one
forces oneself to speak after a rapid and fatiguing run

Passing on to aphonia, the writer points out that in the respiratory
function the abduction of the vocal cords is chiefly automatic, being
essential to life, and is concerned with the bulbar centres. On the
other hand, phonation is a function of a higher order, because it is
connected with speech, and is concerned chiefly with cortical centres.
It follows that aphonia is met with principally in psychical cases. The
writer proceeds to study with some degree of detail the connection of
disturbances of the function of deglutition with mutism and aphonia.

In considering the subject of deafness, it is pointed out that the
cochlear nerve, which serves a most important function of psychical

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life, namely, hearing, is chiefly connected with cortical or cerebral
centres; whereas the vestibular nerve, which furnishes impressions
which under ordinary circumstances do not arrive in the field of con¬
sciousness, serves a function of automatic life, and is chiefly connected
with bulbar and cerebellar centres. From this follows an important
clinical fact, namely, that a labyrinthic or rctro-labyrinthic lesion (usually
an injury to the base of the skull) involves generally both of the
sensorial mechanisms, while a central lesion, cerebral or cerebellar,
affects usually only one of these mechanisms ; and since an organic
cerebral lesion never, perhaps, causes complete deafness (too little is yet
known of the cortical centres of hearing, even if there be one in each
cerebral hemisphere or not), it is consequently an organic cochlear
lesion which causes grave or total deafness, and is concerned, at least
for a certain period of the disease, with disturbance of the mechanism
of equilibrium. The traumatic lesions, which cause complete unilateral
or bilateral deafness, are especially fractures, direct or by contre-coup ,
of the temporal bone. In cases of deafness from organic causes, in
addition to deafness itself, there are symptoms of cochlear irritation
(subjective noises), and there are more or less grave disturbances of
equilibrium (uncertainty in the erect posture and in walking, with a
tendency to fall towards the injured side), vestibular nystagmus, vertigo
with nausea and vomiting, etc. Psychical deafness differs from organic
in being almost always complete, and in not being accompanied by
symptoms of cochlear and vestibular irritation.

The writer makes a careful study of the differential diagnosis of
organic, psychical, and simulated deafness. Among the many points
that he mentions, the following are perhaps the most important: The
really deaf person looks you straight in the face when you speak to him.
He follows with attention the gestures and the movements of the mouth
of the speaker. He willingly furnishes detailed indications of his ill¬
ness, and gives precise replies during the functional examination, which
renders it possible to accurately estimate the power of hearing, etc.

The psychical deaf person is often apathetic and indifferent; some¬
times he is hilarious or fatuous; and sometimes he presents the
physiognomy and behaviour of a psychopathic.

The malingerer is sad and diffident. He avoids the glance of the
interrogator, prefers to keep his eyes fixed on the ground, replies
evasively to questions, and sometimes adopts a voluntary mutism or
the rigidity of an automaton, which it is difficult to make him give up.
He lends himself very unwillingly to functional examination, and gives
replies which are generally not very precise, and are sometimes
evidently false. Further, and this is most important, he refuses general
narcosis when it is proposed as a method of cure.

When a loud and unexpected noise is made near the ear of a patient
who hears normally, we may observe certain reflex actions. Sometimes
there is a brusque turning of the head, or even of the whole body
towards the point whence comes the sound. Sometimes there is a
quick winking of the eyelids of both eyes, or of the eye only which is
nearest to the sound. This reflex is rapidly exhausted, particularly if
the sonorous stimulus be renewed rhythmically. Sometimes this reflex
is limited to the eye on the side corresponding to the ear which hears

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best, or it may be quicker on that side. This reflex has been studied
by the writer and by Prof. Amedeo Herlitzka by the means of graphic
methods. It is a reflex of cochlear incidence, and the latent time is
about of a second. Some persons with good hearing succeed in
inhibiting all reflex action. On the other hand, a loud sound may
occasionally cause the reflex in very deaf people.

The article concludes with a few paragraphs on the therapy of such
cases as have been under consideration. In the psychical forms of
mutism, aphonia, or deafness, it is often advantageous to resort to
psychotherapy as well as physical methods of cure. Good results have
been obtained by treating patients suffering from mutism and func¬
tional deafness by a kind of sound-bath in a very resonant room, where
by means of organ-pipes intense sonorous vibrations of different pitch
are produced.

But the method of therapy, which has been most successful in the
hospital to which the writer is attached (Prof. Gradenigo is Lieutenant-
Colonel in the Medical Service of the Italian Army), is that of general
narcosis, produced preferably by ethyl chloride, chloroform, or the
liquore sonnifero dello Zambelletti. It must be understood that it is
illegal to put an Italian soldier under the influence of an anaesthetic
without his consent. Patients who are anxious to be cured are always
very willing to undergo this treatment, and even demand it peremp¬
torily. Sometimes the willingness or unwillingness to undergo this
method of treatment serves to discover a malingerer. Usually, if the
treatment be successful, when the patient wakes up from the narcosis,
he falls into a profound hysterical crisis with various nervous disturbances,
feeling of faintness, profuse sweats, etc. In other cases excellent results
have been obtained in psychical mutism by motor re-education of the
movements of respiration and of articulation.

J. Barfield Adams.

The Brain and Genetic Function. ( Urolog. and Cut. Rev., October ,
1917.) Ceni, Carlo.

Prof. Ceni, of Cagliari, after first summarising some of the earlier
of his well-known and highly-important experiments on the relations of
the sexual impulses to the brain, here sets forth his latest results. His
observations in general have shown that in the cerebral cortex there
are centres which exercise a special influence on the functions and
trophic processes of the sexual glands. Spermatogenesis and ovo¬
genesis take place under the continuous action of the higher centres
which impart regulatory and inhibitory stimuli to the various processes
of procreation. Thus mutilation of a lobe or hemisphere in chickens
or pigeons produces more or less involution, usually, though not always,
transitory, on the whole male or female sexual system. The central
inhibitory centres vary considerably from species to species, and on the
whole in direct proportion to the evolution of the species. In guinea-
pigs the relation is almost nil. It is present in the pigeon and the
rooster, but much more evident in the dog and in man. In the turtle,
on the contrary, as Ceni’s pupil, De Lisi, has shown, total decerebration
has not the slightest effect, immediate or remote, on the trophism and

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functions of the male or female sexual glands, which seem to be regu¬
lated exclusively by the lower centres. Cocks and hens, after total
scarification of the cerebral cortex, retain (after recovering from shock)
their sexual instincts unimpaired, though they are almost incapable of
reproduction. In totally decerebrated pigeons the sexual glands, male
and female, continued to function with apparent regularity. We must
conclude, therefore, that in birds and lower mammals the sexual glands
possess an unquestionable autonomy in relation to the cerebral centres.
In the higher animals we can only speak of a relative autonomy.
Without complete and constant stimulus from the superior centres
through the central sympathetic cortico spinal paths, the inferior centres
lose the equilibrium necessary for their normal function, and the sexual
glands become torpid or easily exhausted. Ceni has made many
experiments in testicular grafts by which, for instance, a capon may be
made a true cock, though unable to procreate. It would clearly appear
that the internal, as well as the external, secretions are conserved in
the transplanted sex-gland. But Ceni does not believe that the inde¬
pendence of the organ from the nervous system is thus demonstrated,
for the graft, when attached, undoubtedly comes into nervous as well as
vascular relation with the rest of the organism. The action of the
higher centres must no longer be ignored, for to them are reserved, not
only the inhibition in general of the sexual glands, but in particular the
regulation of all the laws, outside trophism, around which the mystery
of procreation revolves; sexual periodicity, the procreative potentiality
of the individual, etc.

The effects of psychic influences on generative power are finally dis¬
cussed. The fact that shock of the genital organs corresponds to that
of other visceral organs indicates the correlation with psychic centres.
It is, indeed, more intimate and direct than in the case of other organs.
It is not a question of simple shock, but of grave functional and trophic
disturbances of psychic origin, persisting for weeks or months, and
perhaps leaving a deleterious impression on the progeny. In men the
general condition may be quickly restored, but arrest or aberration of
spermatogenesis continues for months. Very prolonged sterility follows
mental overwork or cerebral exhaustion. Even more unfortunate are
the results following earthquakes, wars, and sieges. “ We would call the
attention of eugenists in particular to the value of these observations in
the tragic moment through which we are passing, and they may well ask
themselves whether the human race is more threatened by the storm of
extermination of the present fury, or by the pain and suffering of the
spirit.”

Prolonged psychic strains are equally important on the individual and
the offspring. Variations in psychogenic stimulus may be either of
deficiency or augmentation. In the former case the individual may
become incapable of reproduction. In the latter case the same result
may be reached through the over-activity of the intellectual centres, as
we see in the frequent sterility of‘great men, though excess of psychic
stimulus may act as a sexual excitant as well as a depressant. “ Thus the
brain as a regulatory organ in the great mystery of procreation acquires
a new place in physiology.” Havelock Ellis.

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3. Sociology.

Evolution and Ethics [EEvolution dans ses Rapports avec PEthique\
{Rev. Phi/., September , 1917.) Lynch, A.

The author discusses in a free and vigorously independent manner,
from his own psychological and philosophical standpoint, the relations
of science and morals. He disputes the right of biologists to speak
with authority on ethics without taking all its new conditions into con¬
sideration, and especially objects to those biological epilogists of war
for war’s sake, who distort even biology itself in order to draw false
deductions. The author regards Truth, Energy, and Sympathy as the
fundamental principles of morals, the “tripod of ethics.” He insists
on harmony between the intellectual and moral constitution, and on
the right of the psychologist and philosopher (not, however, the vague
and aimless metaphysician of the past) to control and revise the con¬
clusions of the biologist, who even in his own domain cannot escape
the psychologist. When, moreover, the matters of a discussion are
furnished by several sciences, the specialist must seek the aid of
philosophy, “mother of all the sciences." Then, turning to Herbert
Spencer, of whom lie speaks with great respect and admiration, the
author explains at some length why he regards the Spencerian principle
as sterile for the development of science, as well as not sufficiently
precise in expression, nor even rigorously correct.

“The amoeba, considered from the point of view of the aim of its
activities, is better developed than any being in creation ; and the
savage, according to Spencer’s formula, should much excel the man of
science.” The criterion of development cannot be established in
vacuo. We must consider the environment and the aim.

While insisting that in science are found the great general lines of
what constitute civilisation on the material side, and that “ the char¬
acter of a nation’s scientific organisation constitutes one of the surest
criteria of the degree of its development and culture; the author also
maintains the principle that “intellectual advance is always accom¬
panied by moral advance," and would even go further and claim that
“it is moral development which communicates the impulsive force to
intellectual development.” It is the flame of the ideal which has
inspired all the great men of science, and without it the man of science
is merely a fortunate mechanic.

In view, moreover, of the social disturbance of modern times, the
author holds that “ the principal efforts of the culture of the civilised
world should be directed to morals," and here attaches importance to
sympathy, in which he includes co-operation and fraternity. In insist¬
ing on the part played by the ideal in the lives of individuals and
peoples, the author points out we are not losing contact with reality,
and he reprobates the “spiritualising” of false idealism. The ideal
must always be bound to the real. The reproductive instinct, the
primitive appetites of man, even his vanities lie at the basis of idealism.
Every flight towards the ideal must be in harmony with truth, without
ceasing to remain in contact with reality. Havelock Ellis.

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Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly Meeting of the Association was held at the Maudsley
Hospital (4th London General), Denmark Hill, London, S.E., on Thursday,
February 21st, 1918, Lieut.-Col. D. G. Thomson, M.D., R.A.M.C. (President), in
the chair.

There were present about one hundred members and visitors. The following
signed their names in the book as having been present at the meeting or as having
attended meetings of Committees :

Sir G. H. Savage, Sir Robert Armstrong-Jones, Drs. Fletcher Beach, David
Bower, A. N. Boycott, A. Helen Boyle, W. M. Buchanan, P. E. Campbell, James
Chambers, P. C. Coombes, Sidney Coupland, Maurice Craig, H. Devine, J. Francis
Dixon, E. L. Dove, R. Langdon Down, Thomas Drapes, R. Eager, J. H. Earl,

F. H. Edwards, G. F. Fothergill, A. Hume Griffith, F. R. King, E. S. Littlejohn,
T. S. Logan, Alfred Miller, W. F. Nelis, D. Ogilvy, N. Oliver, J. G. Porter
Phillips, James Scott, J. Noel Sergeant, G. E. Shand, W. Starkey, R. C. Shaw,

G. E. Shuttleworth, T. W. Smith, T. E. K. Stansficld, P. Steele, James Stewart,
R. Stewart, R. J. Stilwell, W. H. B. Stoddart, F. R. P. Taylor, C. M. Tuke, John
Turner, and R. H. Steen (Acting Hon. General Secretary).

Visitors: Col. H. G. Maudsley, Lieuts. H. A. Dicokin, U.S.A. Army Medical
Service, W. I. Lille, U.S.A. Army Medical Service, G. Taykor, U.S.A. Army
Medical Service, and Drs. A. W. Hall, J. H. Mooney, T. A. Taylor, E. L. Forward,
J. S. Havelock.

Present at the Council Meeting-. Lieut.-Col. D. G. Thomson, M.D., R.A.M.C,
(President), in the chair, Sir Robert Armstrong-Jones, and Drs. A. Helen Boyle,
James Chambers, Thos. Drapes, R. Eager, A. Miller, J. N. Sergeant, T. E. Knowles
Stansfield, G. E. Shuttleworth, and R. H. Sieen (Acting Hon. General Secre-
tary).

Apologies for unavoidable absence n-ere received from : Drs. G. N. Bartlett, C. C.
Easterbrook, H. Wolseley-Lewis, R. H. Cole, J. Mills, R. B. Campbell, T. S.
Adair, John Keay, C. Hubert Bond, H. de M. Alexander, J. G. Soutar, G. D.
McRae, J. R. Gilmour, and Lieut.-Col. H. A. Kidd, R.A.M.C.

The President said that as the minutes were duly published in the January
number of the Journal, he hoped members would take them as read.

This was agreed to, and the minutes signed.

Ballot for New Members.

The President nominated Drs. Boycott and Devine as scrutineers for the ballot
for the following gentlemen :

Goodpellow, Thomas Ashton, M.D.Lond., B.Sc., M.R.C.S., L.R.C.P.
(formerly Resident Medical Officer, Manchester Royal Infirmary), 60, Pala¬
tine Road, West Didsbury, Manchester.

Proposed by Drs. Alan McDougall, David Orr, and R. H. Steen.

Prideaux, John Joseph Francis Engledue, M.R.C.S., L.R.C.P.Lond.,
Resident Medical Officer, Graylingwell War Hospital, Chichester.

Proposed by Lieut.-Col. H. A. Kidd, R.A.M.C., Drs. H. Devine and R. H.

Steen.

They were duly elected.

Obituary.

The President said that one of the melancholy, and, he feared, routine duties
in these times was for the President to announce the deaths of members which had
taken place during the quarter since the last meeting. This quarter showed an
unusually heavy and serious loss in the Society's ranks. He only proposed to
mention some well-known names. First was Dr. Seward, who, as members were
aware, occupied the position of Medical Superintendent of Colney Hatch for many
years, and whose death took place this month. There was also Dr. Ellis, of the
Straits Settlements—perhaps a less well-known member of the Association—who

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died at Singapore on October 8th. Another was Dr. William Julius Mickle,
whom members would remember as a Past-President of the Association, and a
very learned and clever man he was. A long and good account of his career
would be found in the present issue of the Journal of Mental Science, therefore it
would not be necessary for him to recapitulate the features of his life’s work.
Perhaps pre-eminent among those whose death they had to lament to-day was
Dr. Henry Maudsley, who occupied such an outstanding place in the profession
that he proposed to call upon Sir George Savage to say a few words about him.

Sir George Savage.- Mr. President and Gentlemen, I feel deeply the responsi¬
bility that you have placed upon me. Generally, I have felt that the best way,
perhaps, was to utter some unwritten expressions of one’s feelings. I shall never
forget the lesson—one of the many I learned from Dr. Henry Maudsley—when I
delivered a lecture before the College of Physicians, and endeavoured to do so
from notes. He said to me, afterwards : *■ It would have been very much better if
you had read it; you can get a great deal more into reading than you can into
extemporaneous expression.” Therefore, perhaps, you will excuse me if I put
before you what I have to say in that way.

Gentlemen, —At the command of our President, I will occupy a short time in
trying to express our united respect—I might say reverence—for our late member,
Dr. H. Maudsley. Though he died full of years, we shall miss a strong man. It
is sixty years since, at the age of twenty-three, he contributed his first article to
the Journal of Mental Science, and I can strongly recommend all those who have
the earlier numbers of the Journal to read the various reviews and essays contributed
by Maudsley while Bucknill was editor. Maudsley was a deeply-read man, and
his memory for details was extraordinary. I have heard him say that he felt
rather a fraud in winning prizes, for he simply wrote out what he visually recalled
from the text-books. Shakespeare and the Bible seem to me to have fixed his
earlier style, but he was a reader of both English, Scotch, and foreign poets, and
he could quote them most appositely.

He was reserved, and not given to wide general society; and I remember telling
him that his love of humanity seemed to exclude the individual man. A most
careful observer, a great reader, and a voluminous writer, he yet had pleasures
and pastimes, such as bowls and cricket. Later, he showed his Yorkshire breeding
in his love of the horse, and he thoroughly enjoyed driving a well-bred pair.

It is nearly fifty years since first I met Maudsley, and we have been friendly,
but hardly intimate, for he was a man not given to social intimacy. His manner
was distant and cynical, but he appreciated honesty of purpose in word or deed.

As I have already said, he began writing early, and you will find the first of his
articles in the Journal of Mental Science for the year 1859, when he was only
twenty-three, and his writing then was as polished and as fresh as ever it was.
It was full of his knowledge of Shakespeare, the Bible, and Burns. He also made
frequent and apt quotations from Latin and German.

His position as an author cannot be considered here, but his influence was
far-reaching, and men at Oxford in the early sixties read his Physiology of Mind,
and, in some instances, as a result turned to medicine as their life's work. He
was fond of writing of the necessity for each man, while recognising that he has
work to do, also remembering that he was but a unit.

From his early association with his father-in-law, Dr. Conolly, sprang his desire
to grant to the insane the maximum of freedom and all loving consideration.
He was, I think, too dogmatic in opposing all forms of mechanical restraint, and
he also strongly opposed forcible feeding as demoralising to patient and doctor.

He had a Gladstonian habit of sending post-cards, and I have by me such cards
which were sent as warnings or correction. I winced at some of them, but, as a
rule, he was right.

I cannot conclude without referring to the many books he wrote. And it is
pleasant, but sad, to think of his article in our Journal of October, 1917, on
“ Materialism ” as his swan song.

There is little more for me to say now and here, but I am certain that you knew
him, by repute if not personally, and you will agree with me that he was a great
power in our branch of medicine, and has left his example as a beacon for us
to follow. I will conclude in his own words, in which he described the true
philosopher:

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“To afford such exalted faculties as man possesses their right exercise is to live
a life moral, intelligent, and useful to his kind, and after such a life he may faith¬
fully and fearlessly await the inevitable event, welcoming the grave-digger as the
kindest of friends who shall open to him the gates of his Everlasting Mansion.”

Lieut-Col. F. W. Mott, F.R.S., said he, with Sir George Savage, rose to make
a few remarks in this building concerning the late Dr. Henry Maudsley, whom he
had the great honour and pleasure of knowing intimately during the last ten
years. His acquaintance with Dr. Maudsley came about in this way. He called
on him (the speaker) one day and said he would be willing to give ^30,000 to the
London County Council if they would build a hospital for the treatment of early
acute cases of mental disease with the view of preventing such cases entering
chronic asylums. He (the speaker) mentioned the matter to one or two members
of the Committee, including Sir John McDougal, and he suggested it would be
an excellent idea, especially if it could be associated with the University of
London. Accordingly he, Lieut.-Col. Mott, drew up a scheme, with Dr. Maudsley’s
approval, to try and get this proposed hospital connected with the University, so
that it might be made a teaching centre for London, as well as carrying out the
purpose for which the money was originally given. This was approved by the
Principal of the University, Sir Arthur Rucker, and Mr. Balfour. Unfortunately,
the party which favoured it did not get into power, and the numerically stronger
party did not want to spend money. The result was that the scheme hung fire for
a long time. Now, however, things had perhaps turned out much better, because
the present hospital was very suitably situated, and since the war had heen in
operation it had served a very useful purpose. He believed it was an institution
which would do very good work in the future. There was no bust to Dr.
Maudsley, but in building this hospital he had erected a monument more lasting
than bronze. The portrait he showed of the deceased gentleman showed a
magnificent head, and Maudsley's mind was the greatest mind he (the speaker)
had ever encountered. He had enjoyed many opportunities of talking to him,
and on Saturdays it was his custom to go and dine with him. On those occasions
they talked over the difficulties of the situation, and he wondered how Dr.
Maudsley kept it up as long as he did. However, he eventually won, the hospital
was built, and all who had inspected it said it was a very nice one.

Dr. Maudsley felt a great interest in this Association. His earlier work was
intimately connected with it, and he had not forgotten it; and, although he was
not allowed to say officially, his nephew was present, Dr. Henry Maudsley, his
own fellow student, and a worthy representative of his uncle, and that gentleman
told him that, although the will had not yet been proved, a large sum of money
had been left to this Association. Therefore members of the Association would
be extremely grateful to him. And he would like to suggest to Sir George Savage
that when he sent his biographical notes to the Journal for publication he should
supplement them with the remarkable photograph which he now held, copies of
which could be supplied by Messrs. Elliott and Fry.

Dr. Maudsley left an autobiography, in his own remarkable style, and he did
not doubt that the relatives of the late Dr. Maudsley would be willing to allow Sir
George Savage to see that if he desired to do so.

He was very pleased the Association was meeting in this building to-day, and
had Dr. Maudsley been alive he would have extended a W'arm welcome to the
members. Last year the Section of Psychiatry of the Royal Society of Medicine
met here, and Dr. Maudsley showed his kindly appreciation by asking that he
might provide the refreshments. He would have been equally willing to do that
on this occasion. He (the speaker) had nothing more to say than express his
welcome to the building which constituted a great monument to Dr. Maudsley’s
work and his philanthropic spirit. Maudsley’s literary work would last for a very
long time. He read his books now with the greatest pleasure and profit; and if
members would read his Mental Physiology they would see that its author was not
only original and prescient, but he seemed to get a grasp of the whole of the
literature on the subject, a grasp which was extraordinary: it was not a patchwork
knowledge, such as many people’s knowledge was, but consisted of a solid fabric,
woven together in one whole.

The President said he was sure all those present very much appreciated the
words which had been used by Sir George Savage and Lieut.-Col. Mott; and

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certainly they would wish to thank Lieut-Col. Mott for his kind welcome. He
asked the meeting to agree to the following resolution, which he would formally
put from the chair :

" That a vote of condolence be sent to the relatives of the recently deceased
members of this Association, namely (the names already read out).”

The resolution was agreed to by members rising in their places.

Dr. Mott said there was present Dr. Henry Maudsley (Col. Maudsley), and he,
Dr. Mott, would like to take the opportunity of proposing that he be made an
Honorary Member of the Association, because he was a family representative of
the great master who bore the same name.

The President said the proposal which Col. Mott had just made would be
received by the Nominations Committee at their first meeting.

Paper.

Lieut.-Col. F. W. Mott, M.B., F.R.S.: “ War Psychoses and Psychoneuroses.”

There are two conditions in connection with shell-shock—commotion and
emotion. In the old days, when th* soldier came into the hospital and one had
to learn from him what had happened, it was all shell-shock. But since we have
got the new Army Form, we know whether he was blown up or not. 1 had often
had my suspicions that many of these cases were “ shell-shy.” Only those really
have shell-shock who are blown up and lose consciousness, and there is evidence
of a condition arising which may produce organic change. If there is commotional
shock, there is always the possibility of emotional shock at the same time, and
those two factors are often combined in a case. And then you have to consider,
as of even greater importance, the make-up of the individual. If he is of psycho¬
pathic temperament, he will not stand the effect of either emotional or commotional
shock in the same way as will a normal individual. Now, very much depends
on whether the person who is the subject of shell-shock was in a closed space, or
in an open space, when the shell burst. If a shell bursts in the open, there is
plenty of room for the vibrations, the compression and decompression, which
take place, to be lost, and in that case it is more likely to be emotional shock
which has caused the man’s condition. For example, if a man is in a dug-out, or
a “ pill-box,” or in a narrow trench, and a heavy shell bursts in it or on it, there are
produced there all the effects of repercussion, and under these circumstances the
explosion is more likely to cause physical changes in the man. I have questioned
officers who were present on such occasions, and they have said that the men
could be seen lying about dead in various attitudes, or in an unconscious condi¬
tion. In one case, that of a pill-box, a 9'2 in. naval gun had turned it up, and all
the men who were inside it were killed, the shock having been tremendous. We
know what happens when a bomb is dropped in the roadway; powdered glass is
found all over the road, showing that there must be a tremendous air current
caused by the explosion. The mischief is caused by decompression; it is that
which is responsible for the changes seen in the brains of fatal cases which 1 am
exhibiting. Those who are not killed by such an explosion in a dug-out have a
pulse which is scarcely perceptible. Perhaps there is also bleeding from the nose
and ears, the muscles are flaccid, perhaps they are in a hypotonic condition ; and
in addition there is, possibly, incontinence of urine and of faces. Altogether,
the resulting condition is one of marked collapse. When patients are in such a
condition—conscious or semi-conscious—their perceptions are materially inter¬
fered with. Everything seems to them to be dark and depressing, and though
they seem to apprehend what one’s questions are, it is difficult to ascertain what
is their mental state. Perhaps their movements lack precision and are without
purpose. Lumbar puncture is sometimes done at clearing stations, and it is then
found that the fluid comes out under pressure. It may contain blood, and will
contain more albumin than normal cerebro-spinal fluid, which is practically free
from albumin. So lumbar puncture is a very useful way of dealing with the case
therapeutically, as well as for diagnostic purposes. Afterwards, the patient always
complains of severe headache ; there is nearly always tremor, also insomnia and
dreams, generally of a terrifying nature. The following is an illustrative instance.
An officer only remembered a flash of light when the shell burst; he had a vision
of arms and legs flying in the air. He had complete retrograde and anterograde
amnesia. He could not remember going to France, nor travelling up to the Front,

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although he had written letters describing his journey and his experiences there.
In these respects his memory was a complete blank, which could not be made
good afterwards. When a man is blown up, he may have contusion as well, but
I am not now speaking of those cases in which there is visible external injury
sufficient to account for concussion, as many of the cases show. The whole wall
of a dug-out may be blown out, or a beam in it may fall on a man, or it might hit
him in the back. That accident will produce sufficient bruising to show that
concussion is the cause of the symptoms, rather than being the condition which
“ windage ” will sometimes produce. Windage as a factor has been a good deal
disputed, but it is now generally recognised that if a shell bursts within a distance
of 10 metres it is liable to produce these conditions. In the next room 1 shall be
showing you sections from the first case of the kind which has been described.
Unfortunately, in the fatal cases the notes are not very complete, and, of course,
with large numbers of cases coming down from the Front, one can understand the
difficulties of getting full notes. But it was stated in the notes that this particular
man had, six months previously, been getting very nervous and apprehensive,
though he was a good soldier. The day before he was evacuated a number of
shells had burst near him, but had not knocked him out. But then there came
the influence of repercussion. He was in a dug-out, and a large shell burst close to
him, and he then became maniacal, as did many of these cases, without losing
consciousness. And he evidently had visions of Germans attacking, because he
constantly exclaimed, " Keep them back! " It became necessary to give chloro¬
form and morphia to quieten him. He was sent down from the Front to a base
hospital, and next morning he awoke, and was, apparently, all right. Then he
suddenly died. The post-mortem examination was made by Capt. Armstrong—
an excellent pathologist—and he stated that the only condition found which was
abnormal was the state of the lungs and the heart. The right side of the heart
was markedly dilated, and both cavities were full of blood, and there was haemor¬
rhage into the lung. It is known that, when animals are exposed to these high
explosives in a closed space, there ensue marked haemorrhages into the lung; in
fact, the lung condition is a very serious one. Possibly such haemorrhage is due to
the compression and decompression which take place. In this case, too, there is
a little sub-pial haemorrhage, but not very much; I have seen as much following
trauma, such as a burn. But when the nervous system is examined, one does not
find the punctiform haemorrhages in the white matter of the brain which are to be
seen in cases of carbon monoxide poisoning. It makes one think of the possi¬
bility, when a man is knocked over by a shell without sustaining visible injury,
and is buried for some time, that he may have been gassed at the same time. If
a shell has burst in a closed space, or if a mine has been exploded near, the
carbon monoxide gas formed from imperfect oxidation would filter through the
earth and poison the enclosed spaces, wherever they may be. Some of these cases
die from the combined effect of shock and gas-poisoning. In this case, in the
medulla, in the internal capsule, in the pons, and in the cortex of the brain—
indeed, throughout the central nervous system—there are haemorrhages into the
sheaths of the vessels. Under a microscope in the other room-will be seen a
specimen showing a vessel in the median raphe of the medulla with a h;emorrhage
into the sheath; it is close to the vagus accessorius nucleus, the one which
controls the heart, and so that may have been the cause of the sudden death.
The mania which he had 1 attribute, largely, to the condition of the blood-vessels
of the brain. There was marked cortical ansemia, but great congestion of veins,
and haemorrhages all through the brain substance. But the changes in the
ganglion cells were very remarkable. There is not much change in the Nissl
granules; those in the middle of the cortex, except in the vagus accessorius, are
well preserved. And when the Nissl granules are seen in a normal state, the cells
have, clearly, functioned normally. This man had not lost consciousness, but was
in a maniacal state, due to exhaustion of the brain, following upon the anaemia,
the venous congestion, and the other conditions found. He died suddenly, owing
to the failure of the respiratory and cardiac nuclei.

I am also showing another case, which I do not know much about, except that
the man was brought down in a state of complete unconsciousness. The case was
said to be one of shell-shock. There was no visible injury, and yet the corpus
callosum, which forms the roof of the ventricles, was found to have been ruptured

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through. Under the microscope in the next room I have placed a section of the
white matter of the brain in this case, close to the point at which the rupture took
place. All through that portion of the brain, haemorrhages are to be seen. In
that patient every cell of the brain is now affected. The man never recovered
consciousness. The Nissl granules and the cells of Purkinji in the cerebellum will
be found to have disappeared. One of the commonest symptoms of neurasthenia,
especially the shell-shock variety, are the tremors and the muscular weakness, as
well as dizziness. The other case shows a much more marked change in the cells
of Purkinji than in any other cells in the central nervous system ; it shows chemical
change and the absence of Nissl granules. One may naturally ask whether the
changes found in the cerebellum may not account for the tremors. The cerebellum
acts as the organ of reinforcement; indeed, it is the organ of reinforcement, and if
it is removed, asthenia occurs. The conditions which we found in these cases seem
to point to loss of this reinforcing power on the part of the cerebellum. I put
that forward as a possible hypothesis, based on some evidence. Crile held much
the same view. Crile examined the central nervous system, as well as the endo¬
crine glands, in the case of a soldier who had experienced extraordinary hardships,
having had a forced march of 1S0 miles, and been killed in the Battle of the Marne.
Crile found in this case the same change in the cells of Purkinji which I have
spoken about, and he associated it with that other theory concerning the adrenal
glands which there is not time to enter into now. The preparations I am showing
are interesting from two points of view. In one of them you will be able to see
there is an increased vascularity of the brain without the changes in the nerve-cells
which I have been describing. That is to say, there is venous congestion ; the
man retains consciousness, but is in a state of mania, as patients so often are after
shock. Sometimes they become dazed and wander away, and they have no
correct idea of what they are doing. The other is the case of a man who was com¬
pletely unconscious and never regained consciousness at all. In such a case as the
last-named you find much more extensive changes in the substance which we
believe is the essential energy substance of the nerve-cells, namely, the kinetoplasm.

That leads me to describe to you another class of case, of which we have had
several examples here. I refer to the kind of case in which there is delirium, what
is called " dream delirium.” These patients have day-dreams as well as night-
dreams, and these terrifying dreams go on for months. They are usually of
battle scenes ; perhaps a recurrent dream about some terrible experience they have
passed through. You know such cases are not fit to be returned to the Front.
But dreams come rather from emotional experiences. A man who is knocked out
with commotion is not so likely to dream as is the man whose disability is due to
emotion. Early in 1915 I had a man in the main hospital over the way, who was
in the Argyll and Sutherland Highlanders. He had not been at the Front very
long when he was sent as one of a company of thirty men to lepair barbed wire.
A 17-in. shell burst among them and he was blown into a shell-pit some distance
off. He was conscious, he scrambled out, and was unhurt. When he saw what had
happened, he went down with emotional shock, and I have never seen a worse
case; his eyes were staring, and his face wore an aspect of extreme horror. He
was continually putting out his hands, and had visions of the sights he had seen. It
took six months to get him well enough to be discharged. It was pure emotional
shock. It was not the effect upon him of physical force, but what he saw that the
force had done.

Another class of case is this : A man is brought in, and he has a sort of mindless
expression : he is, indeed, in a state of complete anergic stupor : he notices nothing,
and apparently sees nothing. You may not be able to get answers to your
questions, or if you do you soon know there is mental confusion. He does not
apprehend what you are saying to him, and his associations, as to both time and
place, are upset. His condition is very much like that which we see in civil life.
But this further stage of complete anergic stupor and mindless expression, the
patient taking no notice of anything, I have never seen before in war cases. And
what is very interesting is the fact that when these men recover consciousness
sufficiently for them to take a little interest in their surroundings, they behave just
as children do ; they look at picture books, and they not only use the words which
young children use, but the voice is modulated on the same juvenile standard. 1
have full notes of two or three cases of that kind. After a lime they seem to

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recover. Visitors here have said the condition was dementia prsecox, but I tell
them the boy will get well, a view they do not accept. But they have got well.
There is one case in particular. At first he sat in a crouched attitude, and took
no notice of anybody. 1 got two soldiers to take an interest in him and take him
about, and they did, and took a pride in trying to get him well. He began to
look up a bit. The King's trumpeter came here, and he said, “ If I blow my
trumpet I shall wake him up ! ” He blew very hard, but it did not come off. It
took six months, but eventually he got well, and before he left here he was able
to play a game of billiards. 1 think these cases, in the first stage, must show a
considerable change of a functional character in the kinetoplasm of the nerve-
cells. Some of the cases do not recover at all, but go on to permanent dementia.
There was one case, that of a New Zealander, who was buried. We could get no
history from him. He sat up and seemed mindless, and yet an expression seemed
to come into his face. He performed scratching movements. He had been buried
for a considerable time, and this movement of trying to scratch his way out had
become stereotyped.

These cases form an interesting study from a psychological point of view, because
they show how strong are the instinctive reactions of defence. Nearly always in
hysterical conditions we see defence against intolerable situations. A man is
blown down by a shell explosion, and when he gets up he has a pain in his arm ;
and instinctively he simulates hemiplegia, or brachial monoplegia, by auto-
suggestion, and by it he gets out of an intolerable situation. He is sent back to a
base hospital, but do you think he is going to get rid of it? He will not unless
you persuade him. One of the best means of persuading these patients is to
assure them that they are not now of much use as soldiers, but may be made use
of in civil life. That serves as a fine tonic to begin with. Capt. Wilson is most
successful in this way, by his own personal persuasive efforts. The personality of
the individual makes an extraordinary difference in these cases: it is really a
process of counter-suggestion. All our cases are not pure shell-shock by anv
means. Among officers a large proportion arc pure shell-shock cases, but among
the men there are cases of hysterical paralysis and other signs of hysteria. It is
very important to rememher that there may be an organic basis, with a large
functional halo, and we get cases of injury of nerves, and the man has been put up
in a splint for some time. He has got an idea he is paralysed, and there is a
little stiffness in the joints. That gets fixed in his mind. I think daily massage,
electrifying, and sympathetic treatment is the worse course you can adopt in these
cases. If you want to make the condition permanent, that is the way to do it.
Vigorous counter-suggestion is best. We had three cases up from Croydon
Military Hospital, dumb people; and after treating one, we made him shout to
the next man to come in. It not only was good for that patient, but it had a
splendid effect on the man coming in. And it is extraordinary how grateful these
men are for what we can do for them.

You will notice the black footprints on the floor; these are for exercises. A
man has a spastic condition of his legs, gives a Babinski on both sides, but the
greater part of his disability was functional. We knew it, and so we have removed
that halo of functional disability, and he can now walk well. That is what we need
to find out; how much is fur.ctional, how much organic. The French lay great
stress upon this. They say, “ we diagnose the difference between organic and
functional disease by the effect of treatment.” They treat the cases right at the
Front, by faradism and persuasion, and they send 80 per cent, of their hysterical
cases back, and are still doing so. We are getting far fewer of these cases than
formerly, and in a letter I had from Sir Wilmot Herringham he said they are
sending 60 per cent, to 80 per cent, back by treating them at the Front, not
letting them get to the base and think about it; otherwise, they will fix it up.
The sooner you get them under treatment the better. This illustrates the fact
that you cannot make a soldier out of a psychopath, or out of a timid man.
There was a man (named Hogg) who had been conscripted. This man was
the son of an undertaker. The undertaker felt that the boy had not enough
• courage, and in order to try to make him courageous he made him get into a
coffin after he had constructed it: and his mother came at night wrapped in a
sheet, to make him used to ghosts. Then the man died, and the brother came,
and he said he must keep up the reputation, and he used to shut him in the room

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with the corpse to encourage him. But it had no g«od effect. This lad was
conscripted, and was sent to France. He managed to get through his shootingby
a non-commissioned officer firing off his rounds. He had not done bomb-throwing.
They gave him dummy-bombs, and he did well. Then he was sent up. The first
time he got a live bomb he threw it into the air and fell down in a faint. He was of
no use. Wc get these cases, which are of no use ; and it seems absurd to conscript
those who are not only of no use, but are a positive danger when they get to
France. I had a man who had been a congenital imbecile, B 3. A Travelling
Board made him B 1, and then he was raised to A. He was back in a fortnight.
It pays to go into the family and personal history of these cases. Capt. Wilson
did that in 100 cases attending the clinic here, and 100 cases in the surgical wards
in the hospital across the road. He found 80 per cent, of the neurasthenic and
“ shell-shy 11 had somethiug in their history which showed they were neuropathic
in some way, whereas only 20 per cent, of the surgical cases had such a history.
Therefore, the most important factor in connection with insanity is the inborn
tendency of the individual. We talk of “exhaustion psychosis,” as if exhaustion
will produce this condition. There were 10,000 Serbian prisoners, exposed to the
most terrible conditions which could be imagined—starvation, typhus fever, ex¬
posure to wet and cold—and only five of them became insane. And the German
papers have taken something away which shows they appreciate the truth of what
1 am telling you.

Prof. Marinesco, of Bucharest, is showing extremely interesting specimens of
painful neuromata. After an amputation the man will go on all right sometimes,
and then the stump will be so painful that he cannot wear an artificial leg. We
shall know how to treat it when we know what the cause is, and Prof. Marinesco
has shown what the cause is. He has shown that new nerve fibres grow into the
tendon and into the muscle, and even into the walls of the arteries ; and where they
grow there is inflammation. If a tendon moves in an inflamed structure with a
nerve in it, it will cause great pain. Therefore, based upon that, what is done now
is to pull down the nerve a good way, and cut it out; and possibly some micro¬
organisms are in the tissues and lie about in foci, because you can see little nodules
of inflammation, like tubercle. And the Professor is showing some causes of irri¬
tation in some vegetable fibres : they are being eaten up by the giant cells around.
They are beautiful preparations, and I will ask you to look at them.

The President said it seemed unfortunate that the Association could not spend
a week at this hospital, instead of an hour or two. He was sure those present
had listened to Col. Mott with the greatest possible interest and pleasure, and one
only regretted the shortness of time available for the discussion of this valuable
matter. He, however, invited any who wished to do so, to bring forward points
on which further elucidation was sought.

Major Sir Robert Armstrong-Jones said he was sorry to have been unable to
reach the meeting in time to hear the whole of Col. Mott’s address. One knew
that in shell-shock one saw a good deal of muscular movement, such as tremors,
involuntary loss of control, and lack of co-ordination, particularly when any unusual
sound was made. He would like to know whether Col. Mott could give any kind
of physiological explanation for this. Especially during an air-raid, these patients
could scarely be controlled, and many people tried to do more than was necessary.
Why, in particular, should sound re-start these tremors ? He had spoken to
several anatomists on the subject, and they suggested that the sound waves were
conveyed on from the membrane across the middle ear to the stapes, then on to
the endolymph of the internal ear; that the auditory nerve divided into two in
the internal ear, the vestibular branch going to the semicircular canals and having
to do with static equilibrium, the other branch being the true acoustic or auditory
nerve, and that the same vibrations which were communicated to the perilymph
of the one were also communicated to the perilymph of the other. He did not
knowjwhether that was the real explanation, but it did suggest a connection between
loss of self-control and sound. And he had noticed that in a certain number of
cases there was nystagmus, and perhaps Col. Mott would suggest an anatomical
basis for that. He had also heard—he did not know whether it was the true
explanation—that the roots of the motor oculi were very closely connected with
the nuclei of the vestibular-nerve, and that vibrations communicated to one would
be likely to affect the other.

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Dr. Sidney Coupland said he would like to show members rough diagrams
which he unearthed from the dust of forty years on the previous day. It concerned
Col. Mott's interesting pathological surmise as to the occurrence of shell-shock
and the possible influence of carbon-monoxide poisoning. In the Proceedings of
the Pathological Section of the Royal Society of Medicine last year there was
an exceedingly interesting paper in which the author said, in almost as many
words, that the occurrence of punctiforin haemorrhages was pathognomic of
carbonic oxide poisoning, though not absolutely. The author of that paper
guarded himself by the statement that he had never met with such a condition
from purely asphyxia! states unless associated with carbonic oxide poisoning.
Forty years ago, when he (the speaker) was making post-mortem examinations at
Middlesex Hospital, he had a most remarkable case of a kind of which he had not
had another example since, namely, of punctiform haemorrhages in the white
matter of the brain, in which the only factor could have been asphyxia, as
carbon monoxide poisoning could not have entered into the case. The case was
that of a young woman, aet. 21, who was admitted with acute bronchitis. She
w'as very ill, and died within a week from her admission. When she had been in
the hospital two days she became semi-comatose, and then deepened into coma,
and during the last twenty-four hours of life her temperature was 106° F., or
nearly. At the post-mortem examination, in addition to anaemia of the brain and
lungs, on making sections he found what was to him then the unique condition of
a number of vascular points, which at the time he considered to be due to con¬
gestion, and which would be washed away in water. These points were in the
centrum ovale; there were no similar points in the grey matter, nor in the
medullary areas. Moreover, they could not be washed away. The brain substance
was firm, and there was an orange-tinted discoloration around the sections.
Low microscopic power showed them to be minute haemorrhages. As he regarded
that as a remarkable condition, he brought specimens to a meeting of the Patho¬
logical Society, but could get no explanation of the condition. His own idea was
that it was merely the effect of passive congestion with venous stasis carried to
an extreme degree, and that such a condition might occur much more frequently
than it was supposed to. He laid stress on the fact that in that case there was no
reason to suspect carbon monoxide poisoning. He thought that case might be
germane to the present discussion, and if it were so, it shows that acute asphyxia
due to burial may not require the intervention of gassing, in the case of these
soldiers, in order to produce in them this pathological effect.

He would also like to ask whether the occurrence of the air-raids on London is
having any deleterious effect in retarding the convalescence of the sufferers from
shell-shock—He understood from Sir Robert Armstrong-Jonesthat such is the case
—for if so, it becomes a serious question whether an effort ought not to be made
to remove these patients to areas where such raids did not occur.

Dr. E. Prideaux said he would like to ask one or two practical questions as to
treatment for shell-shock. The first was as to how the difficulty was to be got
over of allowing these psychopaths to go back to the trenches. He would like to
know whether there were any means to prevent such men being passed for the
front line by travelling medical boards, the members of which were liable to pass
men into a higher category.

In the actual treatment of the cases he did not think sufficient attention had
been paid to the fact that these objective disorders could be cured at once.
Aphonia, mutism, and stammering could be cured in five to ten minutes by some
form of suggestion. In France the medical officers had been using stammering
classes, and he would like to hear Col. Mott’s views on that point.

He believed that the ideas underlying the treatment were wrong. Stammering
was fixed in the patient's sub-conscious mind, and it became an obsession, and, as
such, it was extremely difficult to cure. He had been using hypnotic suggestion,
but he did not think it was of moment what particnlar form of suggestion was
employed so long as it was strong enough for the disorder if objective. But in
regard to subjective disorders, such as dreams and night-terrors, there he con¬
sidered that hypnotic suggestion was useful and valuable. He asked whether
Col. Mott would make any observations on that point. He had had a good deal
of experience with stammerers himself, and he found that stammering following
shell-shock could be cured at once by a strong enough suggestion.

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Dr. Edwards said he would like to ask whether, if one could eliminate the
emotional side from shell-shock, shell-shock as such would exist at all, in the
opinion of Col. Mott. From that gentleman’s writings, and from others, one
gathered that the condition of shell-shock was, largely, an alteration of blood.
There were sudden changes of pressure in the man's surroundings, and mutism
indicated a psychic change. But in caisson disease, in which pressures were
suddenly changed, and even where men were employed in firing big guns, one had
no emotional state to face, but obviously there were marked and sudden changes
in blood pressure, associated with percussion and repercussion, and this seemed to
go to the root of the conditions of shell-shock. Therefore he asked whether, if
there were no emotional side—the sense of expectancy, of dread, of fear—such as
was to he expected in war conditions, shell-shock would exist at all, or whether it
was purely a mechano-physical process.

Major Eager asked whether Col. Mott experienced any difficulty in differen¬
tiating between the so-called shell-shock and the condition of general paralysis of
the insane. He had himself had 4,000 cases, chiefly instances of psychosis, mental
conditions, whereas those which Col. Mott got seemed to be more functional cases.
But he had been struck by the fact that cases had been sent over from France
diagnosed as shell-shock which had been eventually, without any doubt, proved to
be cases of general paralysis of the insane. He had also had cases sent over to
him from France diagnosed as general paralysis which he regarded as cases of
shell-shock. Another interesting series were those in which, to his mind, the
symptoms of shell-shock had been superimposed on those of early general paralysis.
And he had collected records, which he hoped to publish later, that showed it was
very important, nowadays, to consider the differential diagnosis of shell-shock
from general paralysis. He had seen cases of supposed shell-shock which showed
the usual physical signs of general paralysis, in the tremors, in both tongue and
face, the increase of the deep reflexes, and delusional states, even going on to
delusions of grandeur. The pupil signs and the result of the Wassermann test he
regarded as very important. He could support the impression mentioned by
Col. Mott, that some of the cases seemed to strongly simulate instances of dementia
prsecox. One case was sent to him as dementia priecox, but the symptoms cleared
up in a most remarkable way.

Suggestion he had found very useful in the class of case under discussion, also
the hypnotic form of suggestion, particularly with patients having functional
paralysis. The early treatment now being used at the Front was a great help.

In regard to a further point mentioned by Col. Mott as to unfit men being passed,
he had had a few cases of hydrocephalic imbeciles having been sent into the
Army; such cases should certainly not be accepted by recruiting medical officers.
He had had patients sent to him who could not read or write, and whom one could
only discharge as unfit, but there was always the danger that they might be again
swept up by an energetic recruiting sergeant and passed by a medical officer back
into the Army.

Lieut.-Col. Mott (in reply) said, in answer to Sir Robert Armstrong-Jones, that
tremors were dealt with by him before that gentleman came. In the two cases of
which he was showing specimens, there were changes in the Purkinji cells, and he
also made reference to the cerebellum being the organ of reinforcement. It was
well known that the labyrinth was seriously affected in these cases, and the French
relied on voltaic vertigo in ascertaining whether a case was one of shell-shock or
not. With regard to hyperacusis, he could not say whether the theory put forward
by Sir Robert Armstrong-Jones was the correct one, but there was a connection
between the labyrinth and the cerebellum. He believed the muscular weakness,
the fatigue and tremors were very likely connected with this great organ of
reinforcement, the cerebellum.

He felt much indebted to the same speaker for calling his attention to an
omission ; he had not alluded to the fact that one of the most certain signs in these
subjects was the disturbance caused to them by loud noises. He recently had a
case which was extraordinary in that way, because it so well illustrated the defensive
reflexes. This particular man had a peculiar “ dodging reflex ” : he (the speaker)
went near to him and clapped his hands, and immediately he put out his hand in
a protective way and ran -away, all the time seeming to push something off from
himself. There was no doubt, from the tics and the spasms which these men got,
that they were dodging shells stimulated by the unconscious mind.

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With regard to dreams, many of the conditions seen were the experiences the
men had had at night coming to the threshold of day, and one found these men in
the mornings looking anxious. He had had cases in which there was mania,
owing to hallucinations.

He had been interested in the drawings exhibited by Dr. Coupland, because if
he had seen them earlier he would have mentioned the fact in his lectures. In the
last paper he wrote, published in the Proceedings of the Pathological Section of
the Royal Society of Medicine, he mentioned that other conditions would cause
these punctiform haemorrhages besides carbon monoxide poisoning. Carbon mon¬
oxide acted because of its power of de-oxygenation. He had never seen another
case of that, though he had seen a number of cases of status epilepticus. He had
mentioned why he thought the cause should be in the terminal arterioles of the
white matter of the brain. There was a hyaline thrombosis, such as had been
shown to exist in other conditions, such as malaria and measles. That reminded
him of a case he had of gas poisoning, in which there was marked asphyxia.
There the vessels were found to be blocked with blood-pigment, which had been
produced by the destruction of the ha:moglobin. Thus both the asphyxial and the
embolic factor operated in these cases.

Dr. Edwards asked whether, if the emotional element could be eliminated, there
would beany shell-shock at all. There was a difference of opinion in Germany,
in France, and in England on this subject. He did not think anybody had yet
described changes in the brain such as would be seen in his specimens, with
hemorrhages all through the substance of the brain. It must be remembered that
nerve-cells were not hard structures ; they were delicate colloidal structures, and
if there was enough physical shock to burst blood-vessels by the decompression, it
might be that this caused such a vibration of the particles in the nerve-cells that
shock was produced. Probably it was true that it was the condition of the vascular
centre which caused the shock. It might be a case of anaemia, and, of course, the
emotional shock might be brought about simply by the production of anaemia in
the brain, a temporary condition, For every case of true shell-shock one met with
ten cases of emotional shock.

He had been very much interested in hearing Major Eager’s experience, because
it was based on such a large number of cases, and what Major Eager had said
corresponded entirely with the results in the more limited experience which he (the
speaker) had had.

With regard to the difficulty of diagnosing shell-shock in cases of early general
paralysis, many cases he had seen proved how great that difficulty was; indeed, in
some cases he was doubtful whether it was general paralysis at all. A case in
point was that of an officer, a first-rate man, who had done excellent service, and
who developed mania. He was found to have unequal pupils, and sluggish reaction
to light. But Col. Mott had seen that in ordinary shell-shock cases, especially
those in which there was a history of gassing. The blood of this patient, however,
was examined, and a positive Wassermann obtained. Under ordinary circum¬
stances he did not attach undue importance to a positive Wassermann unless he
knew who had carried the test out. But if one obtained a positive Wassermann
in the cerebro-spinal fluid, that meant something, and he had found that this was
the only really reliable method of determination. In many of these cases no one
save an expert, and only he after the most careful examination, would know that
there was anything the matter with the patient, and, in the absence of definite
symptoms, the patient might even be sent back to the Front. He did not wish, on
the present occasion, to speak of mistakes made in recruiting, but he had seen cases
of quite obvious tabes which had been existing for years admitted into the Army.
Those cases had Argyll-Robertson pupils, pains in the legs, and gastric and other
crises. One man in this condition was sent off to Egypt, had a fit while in that
country, and was sent back again. That kind of thing, of course, was not right.
On the other hand, people who were said to have tabes were found not to have
that disease at all. He could narrate a remarkable instance of that A man was
supposed, owing to the absence of knee-jerk, to have tabes, and he was, accord-
ingly, declared to be unfit for the Army. His wife went to work in a munition
factory, and, when asked why her husband was out of the Army, said he had got
locomotor ataxy. She was, thereupon, told that she had better leave, as she was
infected. Therefore, the woman had to go and have her blood tested.

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In another respect Major Eager’s experience coincided with his own, namely,
that cases which appeared to be so demented that they might readily be taken for
dementia praecox, did recover completely. Many of those present who saw such
cases might think they were entirely irrecoverable, but eventually they did get quite
w.ell.

With regard to Major Eager’s reference to exhaustion psychosis, he would like
to know whether that gentleman regarded this psychosis as really due to
exhaustion. These cases were so diagnosed when possibly most of them had some
psychopathic constitutional tendency.

Dr. Prideaux had made reference to hypnotism in the treatment of these cases.
He, Col. Mott, had not preached hypnotism ; he preferred to arrive at the result
he wanted by means of counter-suggestion and other methods than hypnotism.
Whether success or otherwise was attained depended entirely on the personality
of the individual and the interest he took in the work. No doubt hypnotism,
when practised by a strong personality, would give good results, just as others
obtained favourable ones by counter-suggestion.

Prof. Marinesco (of Bucharest) gave a microscopic demonstration.

IRISH DIVISION.

The Spring Meeting of the Irish Division was held at the Stewart Institution
on Thursday, April 4th, by the kind invitation of Dr. Rainsford.

Members present: Dr. Drapes, Dr. Nolan, Dr. J. O’C. Donelan, Dr. Reding-
ton, Dr. Gavan, Dr. Mills, Dr. D'Arcy Benson, Dr. Rutherford, Dr. Costello, Dr.
Leeper (Hon. Secretary).

Dr. Nolan having been moved to the chair,

Letters of apology for unavoidable absence were received from Dr. Hetherington,
of Londonderry, and Dr. T. A. Greene, of Carlow.

Letters of thanks for the expression of sympathy from the members of the Irish
Division were received from Mrs. Graham, widow, and also from Dr. Samuel
Graham, of Antrim Asylum, on the part of the relatives, of the late Dr. W. Graham,
of Purdysburn House, Belfast.

A letter was read from Dr. Cole, Hon. Secretary Parliamentary Committee of the
Association, stating that a Sub-Committee to consider amendments of the English
Lunacy Law was appointed, and, at the meeting of the Parliamentary Committee
on February 21st, Dr. Cole was directed to write to the Divisional Secretaries in
Scotland and Ireland to suggest that, if the Division deemed it expedient, members
of the Parliamentary Committee in their respective divisions might be formed
into committees to consider the promotion of changes in lunacy legislation in
their countries, such committees to have the power of co-opting others interested
in the subject and to be deemed Sub-Committees of the Parliamentary Committee,
to which Committee they would in due course report. The Chairman stated that
this was a most important letter and one in which most of the members in
happier and more settled times would be keenly interested. Dr. Rainsford and
Dr. Drapes also stated that they were much interested in the matter, and upon
some discussion the Hon. Secretary was directed to place the matter on the
Agenda as a primary subject for the consideration of the Irish Division at the next
meeting in July.

The Meeting next proceeded to elect an Hon. Secretary and two Representative
Members of Council for the ensuing year.

On a ballot being taken, the Chairman announced that Dr. Leeper had been
elected Hon. Secretary, and Dr. Mills, of Ballinasloe, and Dr. Nolan, of Down¬
patrick, had been elected as Representative Members of Council for the ensuing
year. Dr. Rainsford and Dr. Gavin were elected Examiners for the Certificate of
the Association in Mental Diseases.

The following dates of meetings were fixed for ensuing year:

Autumn Meeting : Thursday, November 7th, 1918.

Spring Meeting : Thursday, April 3rd, 1918.

Summer Meeting : Thursday, July 3rd, 1918.

It was decided to accept the kind invitation of Dr. Nolan to hold the Summer
Meeting of the “ Irish Division ” at Downpatrick on July 4th.

Dr. Rainsford next read his communication on “ A Review of the Admissions

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of Imbeciles of the Mongolian Type during the last Twenty Years,” and exhibited
several most interesting cases showing the physical and mental symptoms of this
condition.

A Review of the Cases of Mongolian Imbecility Admitted to the
Stewart Institution during the Past Twenty Years.

The subject of Mongolian imbecility is one that has always greatly interested
me. Possibly the fact that I know so little about it has been one of the causes
for this interest; at the same time one recognises that there must be some well
ascertained cause—could we but find it—which results in producing a class of
cases possessing such well-marked features and easily recognisable. Dr. Shuttle-
worth, in a paper on this subject, read before the British Medical Association
in Belfast, 1909, bases his account of the affection on a study of about 350 cases
seen by him in the course of an extensive experience in this speciality.

His description of the type is very clear. He says: “ Without going so far as
to adopt Dr. Langdon Down's theory of retrogression of ethnic type in such
cases, I think we shall admit, looking at the photographs of children now commonly
designated Mongoloid or Mongolian imbeciles, that though by birth members’of
the Caucasian (or Indo-European) family they favour in a remarkable way the
features of the Mongolian race.” He adds that though so designated they shoiv
striking divergences from the real Mongol or Kalmuck. In the Mongoloid, the
face, though broad, has not the same prominence of cheek-bones ; the hair is not
usually black as in the real Mongol, though straight, wiry, and often scanty; the
obliquely placed and often almond-shaped palpebral fissures, with upward and
outward trend and usually far apart, the flat-bridged snub-nose, with expanded
outward turned alae-nasi, and the tendency to epicanthic folds, are the most
noticeable signs of similarity. Marked flattening of the occipital region is an
almost constant feature.

The shape and appearance of the hands is most characteristic; shortened,
club-shaped fingers, generally blue; hand rather square and stumpy; and some
observers have described an incurvation of the little finger, and sometimes relative
shortness of thumb and little finger.

As regards the general appearance, the most striking feature is the strong family
resemblance in the cases. 1 have nearly always been able, in the case of each new
Mongolian admission, to see a well-marked likeness to some case or cases admitted
previously, and in the photographs which I have seen in various monographs on
the subject I could almost imagine that cases under my care had been taken as
illustrations.

Next to the face and hands, the appearance of the tongue is most characteristic.
It may be described as always large, sometimes apparently too big for the mouth,
venous coloured, with marked transverse or irregular fissures, and hypertrophy of
the circumvallate papillae. So general is this, that it may be said to be pathog¬
nomonic of the fully developed Mongolian type. Deformities of palate are
frequently, if not invariably, present. Dr. Fennell says the deformity he found
most marked among his cases was that of a contracted vault, with the sides sloping
more steeply in front, so that an anterior plateau is formed, usually, but not
always ridged, on the median line.

The circulation is always defective, and the clubbing of the fingers and toes
with the general cyanosed appearance points to venous engorgement dependent
upon some central circulatory defect. Hence such cases are always prone to
severe chilblains, and the extremities are always cold. So frequent is this here
that we invariably treat all bad cases of chilblain of feet in these cases by rest in
bed, the foot of the bedstead being raised on blocks, and we find that in this way
the affection is speedily cured.

I have never had an opportunity—much as I have desired it—of performing a
post-mortem on a Mongolian case. All the appearances would lead me to say that
there must be some congenital valvular defect in the heart, most likely on the
right side. Dr. Fennell records 3 cases of congenital heart deformity, and cases
of patent foramen ovale, and defects in the interventricular septum have been
described. The thymus and thyroid glands have not, as a rule, been found
abnormal.

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As regards the frequency with which this type is found, it is stated that in
England 5 per cent, of all imbeciles are of this type. My record comprises about
30 cases out of all admissions (355) since 1898, a percentage of almost 8.5 per
cent. It is said to be more common in England than in the other European
countries, as in France. Among650 children in industrial institutions only 8 were
Mongols; in Germany the proportion is about 1 per cent., and an eminent Italian
authority states that he had seen only 20 cases in Italy in seven years.

I have not been able to ascertain from inquiry much that would help to
elucidate the causation of this peculiar condition. A history of tuberculosis is
most uncommon, and most of my cases have been members of a family, the other
members of which have been strong and healthy, and of healthy parentage. I do
not think premature birth is an important factor, nor has syphilis much bearing
on the condition.

The general opinion from study of the cases by various experts seems to be
that they are essentially “ unfinished ” children, and that their peculiar appearance
is really a phase of “foetal life.” Dr. John Thomson has termed them fittingly
“ ill-finished,” pointing out that something goes wrong in their early intra-uterine
life,' probably as early as the second month. Dr. Shuttletvorth lays down (1)
T-hat the outstanding point is the advanced age of the mother at the birth of the
child. (2) They are frequently the last born often of a long family, and that
exhaustion by a long series of previous pregnancies is an important factor in
causation. (3) That any depressive toxic influences may, in younger women,
produce reproductive exhaustion. In fine, that the Mongolian child is brought
into the world at a stage of faatal growth below normal, and that his remarkable
facial and other peculiarities are the result of this.

It is well to remember that there are undoubtedly degrees of Mongolianism,
and that one must be prepared from an experience of the type to say how much or
how little of such type any given case shows. This is important from the point
of view of prognosis. For though some writers record cases as living to fairly
advanced years, and being so developed by educational training as to be able to
hold their own with the more normal members of the community, our experience
here shows that few—if any—are capable of much development, can seldom do
any work except of the lightest character, and seldom live beyond twenty-one
years. At the same time, viewed from the mental standpoint, they are by no
means the worst class of case we admit. Almost all of them possess speech,
though their voices are commonly characteristically husky ; they can answer simple
questions, tell their names and where they come from, carryout simple directions,
attend to their own wants, and do not, as a rule, demand much attendance. They
have, as a rule, a musical instinct, drill and class-singing appeal to them strongly.
Dr. Fennell describes them finely as children of much promise but small per¬
formance. They are never physically robust, and so are not able for any hard
outdoor work, but in some cases we have found them useful for light housework,
and they can run messages, and even help to look after the feebler members of
the flock.

With reference to my own cases, I find that I have admitted in the last twenty
years 30 cases of Mongolian imbecility out of a total admission of 355. There
fore, 8 5 per cent, of the total admissions were of this type. This is a higher
percentage than is generally noticed by most observers. Of my 30 cases, 19 were
male and 11 female, and there certainly does seem to be a larger proportion of
this type among the male inmates. Of the 30 thus admitted, 4—3 males and

1 female—are still in residence here, and you will see them to-day. Of the other
26, 17 died in the institution, the causes of death being pulmonary tuberculosis,
3: bronchitis or broncho-pneumonia, 10; 2 died of tuberculous meningitis, 1 of
meningitis from middle-ear disease, and 1 of heart disease. Of the remaining 9,

2 were removed home, dying of tuberculous peritonitis; 1 in a very feeble state,
with feet gangrenous, the mother refusing consent to any operation ; 2 taken home
in last stage of pulmonary tuberculosis ; 2 were removed in feeble health without
any very marked lesion ; 2 only went home in tolerably good health, and are, as
far as I know, alive. Of the 17 deaths, the average age at death was 13'jj- years,
and average duration of residence 35 Jf months, almost exactly three years.

The most dangerous time of the year for these cases is undoubtedly the first
three months. The harsh north and east winds seem to try their vitality severely,

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and when they get bronchitis it is nearly always fatal. The form most usual is
either capillary bronchitis or broncho-pneumonia, and no treatment seems to have
the least beneficial effect.

It is remarkable that, as far as I can remember, not one of these 30 cases was
an epileptic, and I think epilepsy is not common among the Mongolians. None
of them suffered from any form of paralysis, and, though some of them walked
feebly, it was rather due to general weakness than to any deformity.

I think you will agree with me in saying that when called to see any such type
of case a guarded prognosis should be given, and it is to my mind most unlikely
that any well marked case will live beyond twenty years of age. They require
moderate exercise, mild but nourishing diet, and plenty of warm clothing. They
should be kept during winter months in warm surroundings, and never be allowed
out in very cold weather. As I have mentioned, they suffer severely from chilblains
on both hands and feet. These extremities should, therefore, be kept well wanned,
and if the feet get particularly bad, the chilblains having broken, they are best
treated in bed, the foot of the bedstead being raised on blocks to help the venous
circulation. I should mention I never found thyroid treatment of the least benefit.

The members freely discussed Dr. Rainsford’s most interesting paper, and it was
stated that the large numbers of Mongolian idiots observed and treated at the
Stewart Institution were interesting and might be explained by the unique position
of the place as receiving the patients from all over the country, there being no
similar institution existing in Ireland.

The Chairman next asked the permission of the meeting to bring forward a
matter of urgency that had arisen in connection with the unrest and recent conduct
of the attendants in certain Irish District asylums.

A Resolution, proposed by Dr. Redington and seconded by Dr. Mills, express¬
ing the cordial thanks of the meeting to Dr. Rainsford tor his interesting paper and
for his kindness and hospitality, terminated the proceedings.

NORTHERN AND MIDLAND DIVISION.

The Spring Meeting of the Northern and Midland Division was held, by the
kind invitation of Dr. Cowen, at the County Asylum, Rainhill, Lancashire, on
Thursday, April 18th, 1918.

In the absence of Dr. Cowen, who was unfortunately ill, Lt.-Col. E. White, was
voted to the chair and presided.

The following thirteen members were present: Drs. R. Eager, Major, R.A.M.C.;

B. Hart, R.A.M.C.; P. D. Hunter, Lt., R.A.M.C.; N. Lavers, Lt., R.A.M.C.;
E. Mapother, Capt., R.A.M.C.; S. Edgar Martin, Capt., R.A.M.C.; E. Mont¬
gomery, Capt., R.A.M.C.; O. P. Napier Pearn, Capt., R.A.MC.; E. F. Reeve;

C. T. Street; G. A. Watson; E. W. White, Lt.-Col., R.A.M.C.; T. S. Adair;
and three visitors—Capt. Benson Evans, R A.M.C., Major Geoffrey Ramsbottom,
R.A.M.C., and Dr. F. W. Thurnam. A number of apologies for non attendance
were received.

(1) The Minutes of the last meeting were read and confirmed.

(2) A ballot was taken for Wilfred Winnall Horton, M.D.Edin., Medical Super¬
intendent, Wye House Asylum, Buxton, recommended by Drs. Legge, F. W. Mott,
and T. S. Adair as an ordinary member of the Association, and he was unanimously
elected.

(3) Dr. T. Stewart Adair was re-elected Secretary to the Division.

(4) Dr. J. W. Geddes and Dr. H. J. Mackenzie were elected Representative
Members of Council.

(5) The arrangement for the Autumn Meeting was left to the Secretary, and the
kind invitation of Dr. Geddes to hold the Spring Meeting, 1919, at Middlesbrough
was cordially accepted. Dr. Street kindly offered to see what he could do for
the Autumn Meeting at Haydock Lodge.

(6) Major Eager, R.A.M.C., then read a paper entitled, “A Record of the First
Twelve Months’ Admissions to the Mental Section of the Lord Derby War
Hospital.” The paper, though somewhat lengthy, was very interesting, and showed
by statistical figures the movement of the cases admitted, as well as the percentages

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of the various forms of insanity involved. The paper was illustrated by the
description of a large number of typical cases.

(7) Dr. G. A. Watson read a paper by Dr. Cowen and himself on " Pellagra.”
He gave an outline of the disease as met with in asylums, with particular reference
to case* that had occurred at Rainhill, and illustrated it with a large number of
lantern slides and photographs. The pathological changes in the cerebral cortex
were particularly well indicated.

Unfortunately the meeting had to come to a close before the whole of the
programme could be got through.

A very interesting demonstration was given by Dr. Watson in the laboratory
and museum in the forenoon.

A hearty vote of thanks was accorded Dr. Cowen for his kind hospitality, and
sympathy expressed with him in his present illness.

EXAMINATION FOR NURSING CERTIFICATE.

Final Examination, November, 1917.

List of Questions.

1. Describe the sympathetic nervous system. What function does it perform ?

2. Explain the following terms as applied to a fracture : (a) Simple, (h) Com¬
pound. ( c ) Comminuted, (it) Impacted, (e) Complicated.

3. What are the chief waste materials of the body, and what organs are con¬
cerned in their removal?

4. What symptoms would lead you to suppose that a patient might be suffering
from pulmonary tuberculosis ? Describe the precautions which should be taken
to prevent the spread of the disease.

5. State the important points to be observed on the admission of a patient to an
asylum.

6. How would you manage a patient suffering from delirium tremens ?

7. State what is meant by the terms—(a) Obsession. ( b ) Hallucination,
(r) Illusion. Give examples of each.

8 . Describe in detail the various stages of an epileptic fit. What mental
changes may occur in an epileptic patient before the onset of a fit ?

Preliminary Examination, November, 1917.

List of Questions.

1. Describe the symptoms and treatment of—(1) A fracture. (2) A disloca¬
tion. (3) A sprain.

2. Name and give the position of the cranial bones.

3. What is meant by voluntary and involuntary muscle ? Give an example of
each.

4. (a) To what class of poisons does belladonna, vitriol, strychnine belong ?
(b) State signs and symptoms of a poisonous dose in each instance.

5. State the differences in the character of the blood of, and manner of bleeding
from, a freshly-cut vein and artery.

6. How do you differentiate between an apoplectic and a fainting fit? What
treatment would you adopt in each case ?

7. Give a list of the functions of the skin ; describe in full how the skin assists
in regulating the temperature.

8. Describe some of the difficulties in ventilating an asylum day-room as
compared with an ordinary sitting-room.

List of Successful Candidates.

Final Examination, November, 1917.

Denbigh. —Robert Smith, John Davies.

Essex, Brentwood. —Laura Louisa Parsons, Ethel Rose Pickett, Elizabeth L.
Rheinlander, Alice Emily Redman.

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Banning Heath. —Ada F. Wratten, Annie M. Franklin (distinction), Ethel
Gould.

West Sussex. — Kate A. Charles, Olive G. Williams, Joseph T. Nicholson,
Edward Betts.

Cheddleton. —Archer William Sunderland, Gwladys Jones, Sophie Louise Grey.

Stafford.— Jessie Woodfin (distinction).

Derby Borough. —Lucy Griffin (distinction), Mildred A. Coulson, Norah May
Murrell.

Leicester Borough. —Catherine.Theresa Lavin, Florence E. Ecob, Martha E.
Loane.

Norwich City. —Jessie A. Holmes, Florence M. Palmer, Caroline E. Smith.

Bethlem. —Edith Earls, Violet A. Birks.

Camberwell House. —Grace E. Luckhurst, Emma M. Harden, Margaret Stephens.

Retreat, York. —Jessie Scott Macgregor, Edith Kelly, Rachel A. Morley, Dorothy
Bumby (distinction), Aileen D. Hume, Isabella M. Huggard, Frances Newton
(from Bootham).

St. Andrew's. —Andrew Short.

Pietermaritzburg. —Eleanor M. Richardson (distinction).

Federated Malay. —Mutta Kannapathippillai, Hilda May Joseph.

Aberdeen Royal. — Isabella A. M. Shand (distinction), Mary D. Taylor, Caroline
M. Lorimer, Williamina Taylor, Jessie Craig, Flora Pirie.

Aberdeen District. —Charlotte B. Sherriffs, John Smith, Jane A. G Connon.

Edinburgh Royal. —Mary A. Duncan.

Fife and Kinross. —Annie J. McIntosh, Jessie Nicoll (distinction), Mary C.
Fraser, Andrew Paterson.

Gartloch. —Christina Neill, Agnes E. Anderson, Annie Milne, Daniel Kelly.

Inverness. —Beatrice E. Montgomery.

Lanark. —Flora McD. Baillie.

Melrose. —Peter Sinclair.

Murray. —Margaret Henderson, Mary J. Meldrum.

Montrose. —Jessie G. Paton.

Hawkhead. —Elizabeth Lyon Alexander, Annie N. Gilmour, Ida R. List.

Stirling District. —Edith B. Roberts, Hugh McBride (distinction), Mary Anna
Clark (distinction).

Larbert Institution. —Catherine Bryden, Isobel Taylor.

St. Patrick's. —Sarah M. McCready, Margarite C. Nugent.

Richmond. —Patrick Hall, Henry Nugent, Margaret McGloin, Jane Keogh,
Margaret Clarke.

Londonderry. —Susanna Collins.

Portrane. —Caroline S. Noble.

Omagh .—Rebecca Morrow, Andrew Stevenson, Thomas Gavin.

Warwick. —Rose Goodall, Edith Annie Smith, Katherine Aitken (distinction).

Smithston. —Jane Mackinnon.

Farnham.— Martha Atwell (distinction).

Valkenberg. —Mabel E. G. Hawksley.

Bloemfontein. —Agnes Jane Christie.

Grahamstown. —Katrina Phillippina Terblanche.

Fort Beaufort. —Charlotte Gilson, Anna Terblanche (distinction).

Preliminary Examination, November, 1917.

Macclesfield, Chester. — Mary Kate Lyne, Bridget McMullin, Winifred Green,
Bertha Leech, Annie James, Ella A. G. Chambers, Minnie Wigglesworth, Amy
Rose.

Cornwall. —Mary C. Collins, Ida L. M. Runnalls, Eva Bray, Mary Kent, Kathleen
Mitton, Eleanor L. Cooksley, Lottie Harris.

Denbigh.— Jannet Mary Roberts.

Barming Heath, Kent. —Edith F. Broad, Hilda E. Wells, Wilhelmina Kavanagh,
Florence Marie Wise, Dorothy Hamblin, Ella Ansell, Alice A. Hickmott, Hannah
E. Hadingue.

Bexley, London. — Amy Francis, Annie E. Mitchell, Maggie M. Strappini, Marion
Lynch, Florence Carline, Emily Punchard, Nellie K. Brazier, Violet A. Spratley,

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244 NOTES AND NEWS. [April,

Margaret Millar, Margaret Lucey, Annie R. Morgan, Elizabeth M. A. Allen, Helena
Keenan, Mabel G. Shove.

Notts County. —Edith M, Patrick, Sylvia Till.

Cheddleton, Staffs. — Eliza Jane McGarry, Patricia P. J. Glynn.

Chichester, West Sussex. —Winifred M. Taylor, Dorothy E. Hempstead, Eva
O. T. Clack.

Leicester Borough. —Mabel Wakefield, Mary J. Shannon, Dora K. Bannister,
Elizabeth Ridgway, Isabella C. Johnston.

Norwich City. —Winifred A. Mayes, Alice F. Martin.

Camberwell House. —Miriam Bosworth, Muriel B. McFarland, Anna L. Stewart,
Margaret Noble.

Coton Hill.— Mary Vincent, Katherine C. Hutchinson.

St. Andrew's. —James P. O'Hickey.

Retreat. —Albert C. Hart, Henry W. Hart, Marie Gracie, Edith M. Sumner.
Fenstanton. —Eva M. Dufferin.

Aberdeen Royal. —Williamina Burr, Isabella Roy Anderson.

Aberdeen District.— Barbara West, Florence Stephen, Mary A. Thomson, Jane
S. K. Sangster, Jessie S. Roy, Leslie D. Duncan.

Edinburgh Royal. —Margaret Livingstone, Henrietta G. Bell, Margaret A. Finnie,
Isabella Fowler, Jeanie C. Stewart, Mary A. Cormack.

Fife and Kinross. —Angusina M. Rhind, Agnes Cromar, Agnes G. Robertson,
Catherine F. Wilson, Jessie Taylor, Esther Stark.

Gartloch. —Christina A. Macrae, Elizabeth Wilkinson, Marion Macaulay,
Elizabeth Glen Dinning, Jessie Morrison, Elizabeth C. Walker, Elizabeth Ewing,
Annie Mackie.

Woodilee. —Peggie Mclnnes, Isabella E. C. McLaren, Margaret M. Martin.
Inverness. —Christina Graham, Helen Morrison, Clara Walton, Isabella Smith.
Hartwood. —Thomas F. Vincent, Frances Scott Graham, Annie M. Thomson,
Elizabeth Donaldson, Mary Rowan, Marjory C. Gordon, Helen Murray, Claire B.
Clarke, Bella Cobban.

Melrose.— Jane Provan, Joan Mathieson Macrae, Lily Grant, Agnes McK.
Donnelly.

Montrose. —Christina Campbell, Mitchell R. Home, Freda Corner, Matilda N.
McGuthrie, Edith Potter, Annie Clark, Annie Auchterlonie, Marion H. Mason.

Hawkhead. —Margaret McVicar, Mary F. Blackstock, Helen Ritchie, Jessie
Geddes, Nan Glendenning, Florence Tomlin, Catherine Burns, Jane Nicolson.

Riccartsbar. —Elizabeth J. Dawson, Mary B. Morrow, William M. Gavigan,
Joseph Hobson.

Stirling District. —Isabella W. Donnan, Annie O’Hara, Euphemia McLaren.
Larbert Institution. —Margaret M. Murray, Mary C. McLean, Robina Thomson.
Murray. —Isabella Cooper, Jessie Ferrier.

Londonderry. —Martha Boyd.

Omagh. —Albert D. Jones, James Mimnagh, James Jameson, Bridget Sweeney,
Levina F. M. McAnulla, Edna Hamilton, Annie McAnnulla, Catherine McCaffery,
Isabella C. Service, Maggie Lynn, Catherine Kelly, Mary C. Morris, Catherine M.
McCreery, Maria Hadden.

Richmond. —Mary Kiernan.

Portrane. — Henry Falkner.

St. Patrick’s. — Margaret T. Gordon, Ellen L. Mills, Kathleen Soughley.
Warwick. —Gladys E. Griffin, Henrietta D. Mabbett, Maud Victoria Price, Maud
Toogood, Jessica Smith, Katie Larkin.

Rainhill. —Nellie Grisby, Alice May Papineau, Jessie May Spooner, Nellie
Woolhouse, Edith Ellen Unsworth, Nettie Annie Kirk, Ellen Woodrvard, Frances
E. Howitt, Charles Poulteney, Isabella Smith.

Valkenberg. —William A. Hornbuckle.

Pietermaritzburg. —Margaret Lee.

Grahamstown. —Margarette Ann Jones, Katrina Francina Ooshuizen.

Fort Beaufort. —Ellen M. Begbie, Hester C. Botha.

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NOTICES BY THE REGISTRAR.

Nursing Examinations.

Preliminary .... Monday, May 6th, 1918.

Final.Monday, May 13th, 1918.

Papers for Bronze Medal to reach Registrar before June 14th, 1918.
Examination for Certificate in Psychological Medicine will be held early in
July, 1918.

OBITUARY.

William Joseph Seward.

The death of Dr. Seward on February nth, 1918, came as an unexpected shock
to his friends and colleagues in the work of caring for the insane, and although
he had been in retirement owing to ill-health since 1911, the announcement of his
death came to the writer of these lines as a special reminder of the strain and stress
involved in the medical and administrative control of a great mental hospital, for
such in the fullest sense was the Colney Hatch Asylum in the North of London.

Seward may be said to have devoted his life to the service of this Institution
for he had worked in no other. He joined its staff in 1878 as a graduate of the
London University, and he was proud to be one of its Bachelors of Medicine.
Educated at University College Hospital, he was appointed to Colney Hatch
immediately after completing house appointments at the Bristol Royal Infirmary,
which gave him a valuable experience and a full practical knowledge of general
medicine and surgery. His hospital appointments always stood him* in good
stead, for he was an able clinician and he never relinquished his medical interests,
although ol necessity these tended to be submerged in his official work by an
almost overwhelming amount of compelling administrative details.

At Colney Hatch Seward was firstly the assistant to Mr. W. G. Marshall, whose
reputation for personal devotion to his patients was a matter of notoriety to the
older generation of asylum physicians; then later he became the assistant to
Dr. Edgar Sheppard—of fame as the father of the Sub-Dean of the Chapels Royal—
and one of the first Lecturers on Psychological Medicine at a London Medical
School, vie., King’s College. In 1882, when barely 30 years of age, he succeeded
Dr. Sheppard as the Medical Superintendent, and with his old chiefs he remained
upon terms of intimate friendship to the end of their lives.

When the London County Council, with a new sense of public responsibility
assumed the Government of the London (then the Middlesex) Asylums under
the Local Government Act of 1890, Seward was appointed by them, upon the
retirement of Mr. Marshall, to be the administrative medical head of the whole
institution, taking over the care of both the male and female sections and thus
abolishing what until then had been a dual control. The Chairman of that
Committee was the present Member of Parliament for Hampstead, Mr. J. S.
Fletcher, who takes much interest in public affairs. The reconstruction of so great
an undertaking under one head was no easy task, and probably Seward was the only
person who could have assumed this supreme direction for the Asylums Com¬
mittee of the Council not only without friction but also with the full help and
confidence of the governed—a task much more delicate and much more difficult
than the responsibility of opening a new asylum, but Seward accomplished his
work with efficiency and credit.

During his period of service in this Institution was inaugurated the After-Care
Association for the rehabilitation into social life of those patients who had been
discharged recovered; and the inspiring leadership of its founder, the Rev.
Henry Hawkins, the Chaplain, was always a source of personal gratification to
Seward. He continued throughout his life to take the deepest interest in the
Society's welfare, as he also did in the Asylum Workers’ Association of the
Executive Committee, of which he was a member.

One great event cast a deep shadow upon Seward’s life, and he never recovered
from the shock. On January 23rd, 1903, a destructive fire occurred in the new
wooden annexe, adjacent to the main buildings of Colney Hatch, which was

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demolished in about an hour. In this fire fifty-one female patients lost their
lives, and the rest were saved with difficulty. Under ordinary circumstances no
calamity can possibly be more tragic nor more disastrous than a fire, even
when every safeguard and every precaution are ready against its occurrence, but
when such a catastrophe occurs in an institution in which there is a sense of
helplessness among its peoples and a feeling of dependence on the part of those
committed into one's charge, then the anguish inseparable from mental disease
is added to the special claims of humanity, and these tend to intensify acutely the
overwhelming sense of responsibility. This disaster weighed upon Seward like
a black cloud and the tragedy was always before his mental vision, and it is not
surprising that it permanently unnerved him, and some years later he was succeeded
in the appointment of Medical Superintendent by his friend and assistant,
Dr. S. J. Gilfillan.

The treatment of the insane under Seward’s regime was always one of
enlightened and disinterested progress, and the writer of this article is under
the greatest obligation to the memory of his old chiefs, Marshall and Seward,
for their high example, devotion, and attachment to their patients, whilst
the welfare of the staff never escaped either of them. Alcohol, in the shape
of beer, was abolished as an article of diet under Seward; the Turkish
bath for restoring mental patients was first used there; organo-therapy was
encouraged by him ; and the aid of clinical pathology with the application of
the microscope were all adjuncts in treatment which were of intense interest

to Seward, and they continued to be aspects in the practice of medicine which

engaged his leisure and retirement, for he was a frequent visitor at the meetings
of the Royal Society of Medicine, of which he was a Fellow. Seward was an
“intermediary” between the old school and the new research one first started
in the London Asylums by Sir William J. Collins, K.C.V.O. Nothing was
irksome to Seward, and his mind may be described as healthy in the best sense.
He was a Mason, and a member of the London County Council Lodge. He
was a keen angler, and was devoted to Norway where he used to fish, and to
Switzerland where he made many walking tours. He liked a game of whist,
and he was a real cricketer—preferring rather to play in a small match than
to watch the great ones—although he was often seen at Lords.

He was fond of pictures and rarely missed an exhibition in Bond Street; he

was devoted to his garden and he delighted in the cultivation of roses, whilst

he derived great pleasure from the meetings of the Royal Horticultural Society.

He was not a great reader of literature, but he was exceedingly well versed in
contemporary history, and he was a great lover of The Field and The Times —the
latter he may be said to have read daily from cover to cover. He was fond of
hearing some of the great preachers, and the writer and his family often met him
at the Sunday afternoon services in Westminster Abbey.

Seward’s mind was not that of the controversialist, indeed, he rather disliked
debated questions, but he always expressed his opinions—which were well
considered—both critically and fearlessly. His great charm was his complete
detachment from bias—he had cultivated the bias of anti-bias more than any
other man of the writer's acquaintance, and he was a most genial, well-informed
and cheerful personality.

He always maintained the complete confidence and friendship of his Committee,
as well as of their officials, and for Mr. H. F. Keene, their Clerk, he entertained
a great regard. Seward, like Marshall, was never married.

It may be repeated that Seward has left an impression of unique charm upon
those who were privileged to know him.

Robert Armstrong-Jones.

William Riddell Watson.

To an Englishman, at any rate, the late Dr. Watson suggested the typical
practitioner of Scottish fiction. Not that he wore his profession on his sleeve; for
a stranger might have been in his company for a considerable time without
discovering that he was a medical man ; but that he showed that combination of
humanity and scholarly tastes—if not scholarship—which is more common in his
profession north than south of the Tweed. He must have been an ideal asylum

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superintendent, because in him professional and official qualities were completely
fused in personality, so that he could exercise his powers unperceived under the
confidence that he inspired and invited as a man. To his capacity as a healer of
bodies he added the contained moral sympathy and understanding that we associate
with the priestly function, and in matters of administration he would act by influence
rather than command.

Dr. Watson was born in Glasgow on November 1st, 1838. He studied medicine
at Anderson's College, Glasgow, and Aberdeen University—at Marischal College,
with its picturesque association with Dugald Dalgetty. While still a student
Dr. Watson went two voyages as surgeon on a whaler, in one voyage passing
beyond the 80th parallel of N. latitude. His experience of the whale-fishing and
actual participation in such sports as polar bear hunting gave him a stock of
interesting memories, and made him always eager to read the accounts of Arctic
exploration. During his adventures he had one very narrow escape. Falling
through thin ice into the water, his clothes at once froze to him, so that he had to
be carried back to the ship.

Dr. Watson qualified L.R.C.S.Edin. in 1862, taking his L.R.C.P. a little later.
His early training must have been of a kind which, to the lay mind, at any rate,
had certain advantages, professional knowledge being gained, if not in actual
practice, at least in the conditions of practice. In his student days regular
phlebotomy was still performed, though it had disappeared by the time he qualified.
He practised in his early years in Aberdeenshire, Northumberland, Wales, and
Kirkcudbright, thus gaining a wide experience of local character. Then in 1869 he
went as medical officer to a projected British agricultural colony in the Argentine.
The project failed, but Dr. Watson never regretted the attempt, which enabled him
to see a good deal of the Argentine and something of Brazil.

On his return he settled in Irvine, Ayrshire, where he had a large practice, till
1876, when he went to Glasgow to take a Poor Law appointment. In 1883 he
became Medical Superintendent of Merryflatts Asylum, Govan, and in 1894 he was
appointed Medical Superintendent of the new Govan District Asylum at Hawk-
head. The design and organisation of this were practically his own, and during
the next nineteen years his energies were entirely devoted to it. He retired in
1913, settling in London in order to be near his only son, who is Medical Officer at
H.M. Prison, Wormwood Scrubbs.

Till within a few weeks of his death, which occurred on February 9th, Dr.
Watson was apparently in excellent health. His mind to the last remained as
active as ever, and he was as keenly interested in everything as a young man. At
various times during a very busy life he had read widely, and he displayed a
remarkable memory for what he had read. He would quote, for instance, the
opinions and often the exact words of Gibbon, whom he had certainly not read
for half a century. In later years he took a keen interest in folk-lore and the
origin and development of religions. He nad instinctively a very sound taste in
letters, and during the last months of his life he read the novels of Jane Austen
with the keenest relish. Though he was himself the kindest of men, he certainly
had a very special liking for the subtler kinds of satire. It has been said that he
had an eighteenth century mind; certainly the eighteenth century writers, from
Swift and the Spectator to Jane Austen—who really was eighteenth century—
were his favourites.

In his acquirements, and the unobtrusive use he made of them, Dr. Watson gave
new point to the expression “the humanities.” To one who was privileged to
know him chiefly after his retirement he gave the impression of great wisdom and
serenity, as if all within him had ripened. One did not need to be told of the
confidence and affection he inspired in his patients and subordinates. All his life
he was the adviser of all sorts of people, who constantly brought their troubles to
him ; yet nobody could have been further from seeking confidence, or offering
advice, or displaying knowledge. In conversation he seemed to listen to, rather
than express, opinion ; his wisdom came out by the way ; and the effect of talking
to him was always a little humbling in the afterthought—that a man so full and
ripe should have borne so patiently the crudities of smaller experience ; but, above
all, one always came away with the calmed and rested feeling of having sat for a
while in mild sunlight. If an acquaintance may be permitted to touch on family
matters, there was something particularly beautiful in the relationship between

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Dr. Watson and his wife. It was almost impossible to think of them apart, and
their keen sense of humour, and quick, unsparing exposure to onlookers of each
other’s alleged foibles, only confirmed the effect of unity. Certainly on the human
side there could be no better example of the “good physician ” than Dr. Watson.

Dr. Percy John Baily.

It is with great regret that we record the death of Dr. Percy John Baily, late
Medical Superintendent of Hanwell Asylum. He came to Hanwell in November,
1888, and finally succeeded Dr. R. R. Alexander as Superintendent in 1905. His
whole career as a Mental Specialist was thus spent at this asylum. He retired
with a pension last November, but only lived to enjoy it a few months, dying on
March 30th, at Bexhill-on-Sea, in his 57th year.

He was educated at Edinburgh University, where he qualified in 1883 M.B.,
C.M.Edin., with honours. He was for a time Assistant Demonstrator in
Anatomy at that University, and then spent some years travelling as a Surgeon
for the P. & O. Steamship Company. He visited India, China, and the Mediter¬
ranean, and was accustomed to tell many amusing anecdotes of his experiences.
He remained a traveller almost to the end, and spent his holidays in Norway,
Algiers, etc. His chief hobbies were photography, in which he was a true artist,
horticulture, and the study of languages. Of a sympathetic nature, he was
always ready to help anyone in trouble. We miss him at Hanwell both as a
friend and a chief. He took a deep interest in the welfare of the patients, and
spent much of his time in the wards helping them with sympathetic conversa¬
tion. The education of the Staff was one of his leading interests. He lectured
to the nurses for many years and was the author of a book on Nursing the Insane.
The history and traditions of Hanwell were a source of unfailing interest to him,
and he published a short account of the place, with a description of the instru¬
ments of restraint used prior to Dr. Conolly's superintendency.

Never in robust health, he had been in failing health for some time, and the
anxieties of the constant changes rendered necessary by the war added to his
indisposition. In May, 1917, he took his summer holiday, but the symptoms
were in no way alleviated, and on his return in July, after several plucky attempts
to resume his usual active life, he felt bound to resign. For all practical purposes
it may be said that he died in harness.

The following appreciation of Dr. Baily is contributed by an old friend:

Dr. Baily was a man of quiet and reclusive habits which led him to avoid
publicity of any sort. He had a strong and determined personality, which, com¬
bined with a kindly disposition and fairness of mind, ensured his success as a
manager of a large asylum.

His views as regards the treatment of insanity and asylum administration were
to a singular degree of the practical and common-sense variety; and without
being rigidly conservative in his ideas, he had no sympathy with the ultra-modern
psychiatrical school, which betrays such astounding ignorance of the .basic fact
that mental hospitals are designed for the treatment of insane patients, and not
for sane patients afflicted with disorders of mind. He was a great believer in
sound mental hospital treatment for the victims of insanity, which calls to its aid
all the resources of every branch of medicine, and, if necessary, of surgery.

His appointment to the superintendency of Hanwell by the Asylums Com¬
mittee of the London County Council was a popular and, under the circum¬
stances, a very wise measure. The asylum has great traditions, and is one of
the most famous in the world. Both structurally, and to some extent adminis¬
tratively, while splendidly effective, it retained its links with an older school.
Any hasty or revolutionary changes would have been a desecration, and much of
the solid good work achieved there would have been upset without any real
advance being made.

Dr. Baily was always cheerful, thoroughly methodical in his work, a great
upholder of orderliness and punctuality in all things, and was justly proud of his
intimate knowledge of all his patients.

As a pastime for spare moments he delighted in photography, with all the
technique of which he was completely familiar. The fine enlargements he made

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191 8]

NOTES AND NEWS.

249

won general admiration, and will be remembered by many. He had a disability
affecting one of his legs, which gave him a characteristic gait. His footsteps,
which could never be mistaken, will long echo in the ears of the inhabitants of
Hanwell, and the memories of a kindly and charming gentleman who so ably
ruled its destinies are not likely soon to fade.

Dr. Baily married in June, 1910, Ada Janet, youngest daughter of Joseph Kearn,
who was devoted to him, and nursed him tenderly through his long and painful
illness. J. R. L.

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.

The Editors regret that owing to the great shortage of paper the size of the
Journal has to be reduced, the limit assigned being 96 pages, which, however, has
been unavoidably exceeded. For the same reason the entire text has to be printed
in small type.

LXIV.

16

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PRINCETON UNIVERSITY

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.']

\ r o. 266 [

N K \V > E K I K S

No. 2JO.

]

JULY, 1918. Voi,. I.XIV.

James Henry Pullen, the Genius of Earlswood .{') By F. Sano, M.I).

“ What could he think himself to be ? ' Wuotan ? ’ All men answered,

' Wuotan !’ ”—Carlyle.

In old times, when kings occasionally wanted to know the rea'
opinion of their people, they asked their fool, and it has become a
proverb that “ fools tell the truth while laughing.” But the court jester
is not always an agreeable man, and it is also said that before he
teaches you the maxim he “will annoy and pester.” Thus we may
suppose that these were of different kinds.

There is often a peculiar interest in the talk of the simple, as they
see things from a realistic point of view, without any sort of that personal
control which the complexity of influencing by reason develops: “Qui
respiciunt ad pauca, de facili pronunciant.” Some dwarfs have been
famous not less by their degenerated conditions than by their uncommon
and astonishing influence in court, due to their readiness to talk freely.
They kept the attention of the most powerful rulers, and their fame
was so great, that we still find in the museums portraits of them painted
by the greatest masters, e.g., Velasquez and Rubens.

A feature of their character, which seems always to have been a key
to success, was their obstinacy. Nothing could disturb them from their
fixed ideas, and when in a bad mood, no favour of their wealthy pro¬
tectors could induce them to change their attitude.

Where kindness, politeness, obligingness and mutual confidence make
social life agreeable, no open criticism nor “ brutal frankness” can have
its place, no perseverance can attain its final desire, unless very excep¬
tional superiority prevails, which is not to be found in a microcephalic
or in a hydrocephalic brain.

• Such are some of the first thoughts which readily occur to the mind,
when the object of this study is announced to be : The Genius of the

LXIV. 1 7

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PRINCETON UNIVERSITY

JAMES HENRY PULLEN,

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252

[July,

Royal Earlsivood Institution for Feeble-minded at Rcdhill. But they
can only in part be applied to the case.

It was not a synthetic wisdom nor shrewd remarks that could have
made James Henry Pullen the subject of such world-wide interest, and
attracted to him the favour of the late King of England’s gracious
attention ; for Pullen was living in his egocentric preoccupations, and
he hardly uttered more than a few words on his own behalf, as “ very
clever! ” and “ wonderful! ” But these few words were said with such
complete a confidence and so suggestive a power, that everybody who
approached him repeated them with the same conviction. Thus “ very
clever ” he was indeed, let me also say it, and “ wonderful ” his psycho¬
logical success.

Having been impressed, as every child of five or six, by the small
ships which his playmates tried to manoeuvre on narrow puddles along
the roads of Dalston, his birthplace, he got the obsession of making by
himself such toys, and he soon became skilled in carving ships and in
reproducing them in pencil drawings. Until the age of fourteen he
attended school, but always irregularly. Owing to his deafness and
dumbness, he was left isolated, and henceforth followed his own mental
way, growing original, egotistic, such as he remained for his whole long
life, with an undoubtedly childish character.

Until he was seven years old he could only say “ muvver,” apparently
for mother. He afterwards learned from his parents, brothers, and
sisters some monosyllabic words concerning the products of his beloved
occupations, and he later on knew just enough to write in a jealously-
kept memorandum book the summary of the work he had accom¬
plished, the number of the pieces used, and the estimated amount of
pounds sterling he hoped to obtain by selling his so-called model ships.
Thus his vocabulary was very poor, and although he was considered by
those who observed him for years as nearly normal in all his sensorial
organs, with the exception of his ears, he never learned to read nor to
write. He was sensitive to vibrations coming from the ground, and
had arranged an alarm system in his workshop, based upon that sensi¬
bility, which made him aware of a coming visitor. His dumbness was
commensurate with his deafness ; he was unable to give any intelligible
answer, unless he could accompany his broken words by gestures, and
the few formulae expressing his admiration for his own personality were
acquired in his youth, and remained unchanged.

In his own diagrammatic history, a large drawing with forty scenes of
his life, Pullen shows how he was resistive to school teaching in 1851.
After the usual school hours the master tries to give him private lessons ;
but the boy weeps, and puts his head in his arms on the table, making
any attempt to cheer him up ineffective. Two years later, with a smiling
self-contented expression, he pays a visit to his old master, and gratifies

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1918.]

BY F. SANO, M.D.

253

him with the presentation of a small model-ship, which the master will
be proud to place pn the mantelpiece! If Pullen had been simply
affected by sense deprivation, would this have been the course of events ?
Did not Pullen show himself the strongest in the conflict of his indi¬
viduality with the stereotyped pedagogy of his surroundings? Think
of Helen Keller, deprived of sight and hearing, and yet able to acquire
every kind of knowledge that ennobles human understanding. But
Pullen 1 with both his eyes wide open to the bright world of London,
and his skilled ten fingers under complete sense control, Pullen, even
after having been busy for months in the printer’s shop at Earlswood,
could not absorb, digest, or exteriorise the most ordinary sentence of
politeness. To say, “ I am very much obliged to you, Sir,” was strange
to him in grammatical arrangement as well as in social meaning.

His admission into the Earlswood Institute at the age of fifteen gave
him the opportunity of using better tools and of learning much in the
carpenter’s shop. It helped him in the performance of his model-
work ; it allowed him to use better material, to carve ivory, and to bring
to childish perfection the mechanical details of his constructions. Earls¬
wood, however, with its most excellent organisation and its experienced
medical and pedagogical staff, could not make of him anything but
an interesting case of psychiatry, a wandering curiosity in Surrey, an
exceptional advertisement for the institution.

“He was obviously too childish,” writes A. F. Tredgold, ( 3 ) in the
extensive and interesting chapter he devotes to him in his valuable
book on Mental Deficiency , “and at the same time too emotional,
unstable, and lacking in mental balance to make any headway, or even
to hold his own, in the outside world. Without someone to stage-
manage him, his remarkable gifts would never suffice to supply him
with the necessities of life, or, even if they did, he would speedily
succumb to his utter want of ordinary prudence and foresight, and his
defect of common sense” (p. 312).

But as to his tenacity in keeping his own directing idea through
seventy-five years of conscious mental activity, it was as remarkable as
successful. His originality was the result of his patience and perse¬
verance. What made him famous was the realisation of a childish
programme, remaining all through in its limited frame as originally
conceived, but progressively renewed and completed with all the skill
and the experience that memory and maturity of age could bring about.

He was allowed the privilege of a private workshop, and a special
room in which his productions were exhibited. Both rooms are pre¬
served and on view at the institution ; they are worthy of the greatest
attention, as they are an exceptional and typical exteriorisation of the
mental and manual activity of such kind of men as Pullen was.

At the age of twenty-six he made his first representation of the

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254 JAMES HENRY PULLEN, [July,

Universe, which he probably had long pondered over. It is a large
barge, half as wide as it is long. There is a well furnished room in the
centre. White ivory angels are outside at the prow, and Satan (or
Neptunus ?) is at the stern. A centre-rod acts on twelve oars and
forked lightning strikes the top of the construction. Thus there is
partly traditional influence and partly genuine conception, the whole
being a fine illustration as to how men are inclined to accumulate in
one general synthesis their knowledge of the world, as they have per¬
ceived and conceived it. For Pullen the world could only be a ship.
Mankind in its first principles believe alike, our hero yielded to ego
centric, homocentric, and geocentric conceptions.

He was thirty-five years when he began his masterpiece, “ The Great
Eastern,” a complicated model-ship, every piece of which was made by
himself with the greatest patience. It took him more than seven years
to complete it, and it was exhibited at tiie Fisheries Exhibition, where
it obtained the medal, not as the most perfect production of its kind,
but because every screw' and every pulley had been made by the exhi¬
bitioner himself. Thus the prize w’as won by the patience he had
shown, but next to this patience was the inability to take advantage of
others’ skill and help. A normal individual would have obtained
better results by co operation and division of ^’ork. Pullen reached
the goal by his best qualities, as well as by his worst defaults, but both
were extreme, and they made him so exceptional that he was unani¬
mously declared “ superior.”

He thought it possible to impress and frighten people by a giant
mannequin, which he had erected in the middle of his workshop.
Sitting inside this monster he could direct the movements of its arms
and legs, and make a great noise through a concealed bugle fitted to
the mouth of the giant. In this contrivance the attempt to cover
personal weakness by frightfulness was already apparent, but his sus¬
picious tendencies became evidently pathological and dangerous when
he established a man-trap to kill every undesirable visitor who might
try to enter his private workshop during his absence.

Besides his ships, he made book-cases, tables, and some small
model-houses. During the time he had to remain in bed with a broken
leg he made a number of good drawings, and he often began the same
copy again with the same patience and accuracy, just as he made many
of the same models of ships, without ever showing any sign of mental
fatigue or. lack of attention. He also executed a number of ivory
carvings, and made brooches, dress-pins, and walking-sticks.

“ His Majesty King Edward, when Prince of Wales, took great
interest in him,” writes Dr. Caldecott, Medical Superintendent of
Earlswood, “and graciously sent him tusks of ivory to encourage him
in producing his beautiful carvings. He was proud to show these

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JOURNAL OF MENTAL SCIENCE, JULY, 1918.

Fig. 1.—J. H. Pullen, in his best time, wearing Admiral’s Uniform.

Fig. 2.—The Mystic Representation of the World as a Ship,

by J. H. Pullen.

To illustrate paper by Dr. F. Sano.

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

1 918]

BY F. SANO, M.D.

255

gifts, and, although imperfect speech limited his expression to ‘ Present,
friend Wales,’ it was evident he was conscious of the condescension
of his august patron.”

I have twice visited and carefully examined the woikshop and the
exhibition-room of Pullen, and I feel very much indebted to Dr. Calde¬
cott and to Dr. Stephens for most of the information which I here
recall in addition to what Dr. Tredgold has already published. The
following note, which Dr. Stephens wrote on September 15th, 1913,
may describe the decline of Pullen’s glorious career :

“ A very interesting case. He took me round his workshop to day,
and I spent three hours there, being shown besides his ‘ Giant,’and
the excellent models of boats, kites, etc., his journal, carvings in wood
and ivory, and the many intricate but thoroughly ineffectual ‘ man-
traps ’ he had made to guard his treasures. He had the artist’s pride
and vanity in his works, coloured by a great childishness and simple
faith in his unfailing capacity and genius. For he does not seem to
realise that he is weekly growing more feeble, that he has lost his curious
powers of inventiveness and design, and that now he needs must spend
his days in the making of rough carvings in bone and ivory, infinitely
inferior to the worst of his earlier work. He has the artist’s sense of
jealousy, for he would not let me toucli or examine anything. I only
may gaze from a respectful distance ! and he told me confidently that
just before he dies he intends to wreck and destroy everything that he
has made.”

It may be of interest to know what the people, living outside the
asylum, thought of Pullen, who was allowed much freedom. I therefore
interviewed some who knew him, and I had the following description
from one, who being born and having resided for a long time at
Redhill saw Pullen quite regularly about twenty-five and even thirty
years ago:

“ Everyone in the neighbourhood knew Pullen very well; he liked to
seH ivory pins and brooches for a shilling or so, although he never
approached anybody with that purpose. He was proud, and often
remarked that he belonged to a royal family. One spoke always to him
in a simple manner as to a child, and more with signs than with words.
His talk was broken and difficult to understand. He had a curious
shape of head and usually wore a Scotch cap. He knew the value of
money, and returned exactly the change for small amounts.” He some¬
times went for holidays on his own, and our informant, Mr. Holhmvood,
remembers having seen him at Brighton as a self-respecting boarder.

From Pullen’s sister we know that the parents were first cousins ;
thirteen children were born in the family, six of whom died in infancy.
A brother was deaf and dumb, and was a fine drawer. He became
maniacal, and died at Earlswood from cancer at the age of 35.

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256

JAMES HENRY PULLEN,

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[July,

Pullen deceased May 31st, 1916. The post-mortem examination
performed by Dr. Stephens on June ist, revealed senile decay and a
little pneumonia. The left testis was small, shrivelled, and fibrous ; the
right healthy. The condition of the left testicle was caused by a fall
while at work, about fifteen years before death.

The brain was put in a 10 per cent, formalin solution, and later on
forwarded by kind permission of Dr. Caldecott to the laboratory of the
Maudsley Hospital. Col. F. W. Mott handed me the brain for exami¬
nation, and I am very grateful for this confidence, which I have tried to
justify by furnishing an accurate description.

Measurements .—On admission, Pullen was 5 ft. 7^ in.; his weight
was 9 st. 11 lb. The circumference of his head, 2i| in.—when dead,
the circumference was 22$ in.

Measurements of the Cranium (according to Tredgold).

Index of capacity 3382/, (Tredgold’s method). Width of forehead 5 \ ;
callipers 3-9. Tragus to glabella 6J ; callipers 5. Tragus to external
occiput 4^ ; callipers 4 4.

The auditory organ .—The temporal bones were removed, and both
showed the same macroscopical external conditions. The right bone
was decalcified, together with the bone of a normal (S. P—) and with
that of a deaf-mute individual (H. A—). For this comparative exami¬
nation I have taken the papers of Brouwer and Quix as a guide ; until
now, however, only the macroscopical examination could be performed
on sections through the decalcified bones. They enabled me to give
the following information. (See Table on p. 257.)

The bones of Pullen’s skull were rather thin. The deaf-mute, H. A—,
had thickened bones, as often occurs in deaf-mutism ; neither of them
had malformations in the middle ear. Pullen’s external meatus and his
middle ear were well developed, and, notwithstanding his old age, the
tympanum was transparent and in fair condition. In both Pullen’s and
the deaf-mute’s cases the internal ear showed a good condition of
osseous development, the cochlea was of average dimensions, but the
internal meatus of H. A— was shallow. The auditory nerve of H. A—
was atrophied and thin.

The origin of deaf-mutism is very variable, and each case needs to be

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1918.]

BY F. SANO, M.D.

257

examined for itself. In the case of H. A— the eighth nerve was
atrophied, and the notes mentioned that the patient had had three fits
(or convulsions ?) at the age of one year. The brain was of normal
weight (1360), but adolescent insanity developed at the age of 17.
The patient remained demented, and died from recently acquired tuber¬
culosis at the age of 38.

Measurement*.

Normal,

S. P-.

Pullen.

Deaf-mute,
H. A—.

(Juain’s

anatomy.

Age.

67

81

38

.

Height .....

Thickness of the temporal bone

5ft. loin.

5 f‘- in.

5 ft. 6 in.

at the junction of the squamous

mm.

mm.

mm.

mm.

and petrous portions

Opening of external auditory
meatus at the osseous portion :

40

4 '°

90

Greatest diameter

90

10*0

80

867

Smallest diameter

80

60

55

607

Opening of meatus internus
Greatest development of meatus
internus:

30

30

2*0

Greatest diameter

70

65

40

—

Smallest diameter
Surelevation of the superior
semicircular canal on the sur¬
face of the petrous bone, above

58

45

25

the s. petrosus superior

80

5 '°

50

—

Base of the cochlea

8-5

80

80

8*0

Height of the cochlea

5'5

50

50

50

In the case of Pullen no peripheral origin could be traced. There
was evidence of a lack of cerebral development, as will be shown later
on. A brother of Pullen was a deaf-mute; the parents were first
cousins. The deaf-mutism of Pullen appears to have had a cortical
origin.

General Examination of the Brain.

Upon opening the skull the membranes were not found adherent,
and there was no excess of cerebro spinal fluid. The brain was put in
10 per cent, formalin solution.

The brain is small, but the general appearance presented is that of a
satisfactory convolutional pattern. There is marked arteriosclerosis
and enlargement of the ventricles, in the cavities of which the central
nuclei project.

The brain weights (November 14th, 1916), after 5^ months’ harden¬
ing in formalin solution, were :

Grammes.

Left hemisphere .5*0

Right hemisphere . . 525

Rhombencephalon .... 145x8=1160

Total

. 1190

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258 JAMES HENRY PULLEN, [July,

The figures are probably a little higher than the original figures, as
is the case during the first months of hardening in formalin solution,
(later on (August 4th, 1917) the weights of the hemispheres were 485,
475.) The negligible difference between right and left hemispheres and
the figure obtained by multiplying the weight of the rhombencephalon
by 8 show that the cerebellum had been arrested in its development in
accordance with the lack of development of the hemispheres.

The brain had not been suspended in the fluid during the first
period of hardening, and had been lying on its inferior surface, both
hemispheres inclining towards the right side; exact measurements,
therefore, could not be taken. The following results are given with this
reservation, which especially applies to the questions marked with the
asteiisk (*).

Table A .—Measurements according to the System of Cunningham

and Spitzka.

In

cm.

In per cent.

L.

R.

L.

R.

-

—

—

—

—

Tape Measurements.

Maximum length of hemicerebrum

179

179

_

_

Maximum width of cerebrum(*)

13

•8

_

. _

Cerebral index ....

O '77

Maximum horizontal circumference

.Si ’9

—

—

Maximum outer width of hemicerebrumf*) .

67

7 'i

, -

—

J Maximum occipito temporal length(*) .

i8'2

182

—

I Maximum iengih of callosum, and per cent. .

8 s

047

Centro-temporal height (vertex to horizontal

82

9-8

—

—

glass)(*)

Centro-olfactory heightf*) .....

7'5

81

--

—

Supero-mesial border (Cunningham’s method):

From the cephalic point to the central sulcus

150

145

59 ' 28

5708

(frontal index)

From the central sulcus to the occipital

5‘9

59

2332

23 32

transverse (parietal index)

From the occipital transverse sulcus to the

4'4

50

i 7'39

j

1

19-68

occipital pole (occipital index)

Projection Measurements.

Lateral surface; from the cephalic point to:

1. Tip of temporal lobe ....

4‘4

4’4

2458

24'58

2. Junction of sylvian and presylvian fissures

5'0

4'9

27-93

27-37

3. Ventral end of central sulcus .

7-6

67

4258

37-85

4. Junction of sylvian and episylvian fissures

11 ’3

9'5

6312

53"°7

5. Caudal point .....

179

17-9

TOO

TOO

Mesial surface; from the cephalic point to:

6. Cephalic edge of callosum

32

T2

17-87

17-87

7. Porta (foramen of Monro)

6'S

6'5

36-31

36-31

8. Dorsal end of central sulcus

I 1*0

10*2

61-50

56-98

9. Dorsal intersection of paracentral sulcus .

i r8

I 10

65-92

61-50

10. Caudal edge of callosum .

i r6

i r6

64-80

64-80

11. Occipito-calcarine junction

138

136

77-09

75-97

12. Dorsal intersection of occipital transverse
sulcus

•5-9

* 5’5

8944

86-59

1

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Original from

PRINCETON UNIVERSITY

Fig. 3.—Superior Aspect of the B

Frontal pole up. Occipital pole down. L. Left I
prs. Sulcus prrecentralis superior. The dotted lin
central sulcus remains independent from the la
mesial border. The central sulcus has no connecti
on the left side in the cortical projection centre <
hemispheres is artificial and occurred during harde

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in, Projection Drawing (Orthogonal).
nisphere. R. Right hemisphere. C. Central sulcus,
ndicates the supero-inesial border. On both sides the
al fissure (Sylvii), and it does not cut the supero-
s on the right side, it has a connection with the prs
the right hand. The slight distortion shown by the
g, the brain not having been suspended.

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PRINCETON UNIVERSITY

(-») indicate deep gyri. Arrows and numbers on the lower part of the figure refer to the numbers of Table A. Corpus

callosum well developed. Parietal (praecuneus) and occipital regions complex.

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PRINCETON UNIVERSITY

19*8.]

BY F. SANO, M.D

259

The Convolutional Pattern.

Fissura lateralis and sulcus centralis. —The posterior branch of
the lateral fissure {fl) measures on the left side 6'2 cm., on the right
side 4 6; fl has only one anterior ramus at the lateral surface on the
left side, namely, the ascendant ( ra ), the horizontal ramus remaining
at the concealed surface of the operculum orbitale. This operculum
has no other indentations. The left posterior branch ends in a short
ascending branch {rpa) and only an indication of the descending
branch ( rpd).

On the right side an independent sulcus, which does not join fl ,
represents the anterior horizontal branch of fl (rh); ra resembles the
same sulcus of the left side. There are no other sulci on the opercula
orbitale and frontale.

The central sulcus (c) reaches the superomesial border on both sides,
but does not join it; c does not join the lateral fissure either, so that
its end remains independent on both sides. At the left side c is joined
by the superior precentral sulcus, but by no other sulcus, and at the
right side c remains completely independent. On the left side c pre¬
sents a well-indicated middle knee, but there is no superior knee. On
the right side the superior knee is slightly indicated, but there is no
middle knee. The right c has a more straight direction than the left c.

The sulci centrales are not deep; there are no concealed gyri; the
usual buttress is of normal appearance.

Frontal lobes. —There is a good mesial sulcus {/ms) on the right
side ; it is less developed on the left frontal line. The sulcus frontalis
superior is more developed on the left side, but in neither does it join
the superior precentral {firs) sulcus. The sulcus frontalis medius is
better developed on the right side, and the sulcus frontalis inferior is
interrupted on that side by three annectant gyri, which is not the case
on the left side. The sulcus radiatus and the external piece of the
sulcus fronto-marginalis have a common posterior ending on the right
side; on the left side these two sulci are united in one sulcus of a very
simple pattern. The frontal operculum is very simple. The convolu¬
tional pattern is certainly less complex on the left than on the right side.
This is evident from a comparison of the mesial surfaces ; the accessory
sulci are regularly perpendicular to the sulcus cingulatus on the right
side; they tend to be nearly parallel and not so deep on the left side.

The sulci orbitales are not similar on both sides, but it is difficult to
say which side is the most developed.

Parietal lobes. —The sulcus postcentralis superior is separated from
the sulcus postcentralis inferior in the left hemisphere, but these sulci
join in the right ; poi joins fl on the right, but not on the left side.

The sulcus interparietalis proprius {ip) is interrupted on both sides

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PRINCETON UNIVERSITY

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260 JAMES HENRY PULLEN, [July,

nearly in the same manner, but the interruption exists more posteriorly
on the left. The connections with the postcentral sulci present two
rather unusual types, the frequency of which, according to Retzius, is
respectively 11 per cent, (left) and 4 per cent, (right) j 19 per cent, and
?per cent. (Cunningham); 7 per cent, and 17 per cent, (in my series of
lunatic brains). The second part of ip extends far behind, and joins
oa on the left.

In both supramarginal gyri there is a special sulcus, which joins fl ;
on the right side it joins also poi.

There is an independent portion of the superior parietal sulcus on
the right side.

Tabi.e B.— Particulars concerning Fissure and Sulci.

L.

R.

I.

Fissura lateralis, number of anterior rami

+

+

2.

Fissura lateralis, number of posterior rami

+

2

3 -\

fS. praecentralis superior .

+

4 -

s. praecentralis inferior .

—

1

C
c0

5 -

6 .

Sulcus centralis anastomosis
with ( +)

s. postcentralis superior .
s. postcentralis inferior .

_

-

- 1

7 -

s. subcentralis anterior .

—

—

8.

s. subcentralis posterior

—

_

9 -’

fissura lateralis separately

—

—

IO.

S. centralis cuts superomesial border ....

—

-

r II.

I 2.

\ S. prascentralis superior ( + ) <

s. praecentralis inferior .
s. frontalis superior

+

~ i
+

13 -

S. praecentralis sup. divided into two sections

14 -

S. praecentralis intermedius present ....

LS

s. frontalis superior

—

—

16.

17.

S. praecentralis inf. anasto-

s. frontalis inferior,
fissura lateralis

+

—

18.

mosis with ( + )

s. subcentralis anterior .

—

—

19.

\s. diagonalis .

—

—

20.

Ramus horizontalis separate

+

—

21.

Ramus horizontalis + s. frontalis medius

—

—

22.

S. diagonalis well ( + ) or badly (—) developed

+

+

2 3 -

S. frontalis superior, number of segments

3

I

JO

24.

S. frontalis superior + s. frontalis medius

25 -

S. frontalis mesialis well developed ( + )

—

+

n

26.

S. frontalis medius well developed ....

+

+

0

27-

S. frontalis medius, number of sections ....

1

28.

S. frontalis inferior continuous .....

+

—

29.

S. frontalis inferior + s. diagonalis ....

+

—

30.

S. frontalis inferior + s. radiatus .....

—

—

3 «-

S. frontalis inferior + s. fronto-marginalis

—

—

32.

S. frontalis marginalis, number of sections

S. rostralis superior well developed ....

2

2

33 -

+

+

34 -

S. rostralis medius well developed ....

—

—

35 -

S. rostralis inferior well developed . . : .

—

—

36 .

S. rostralis transversus anterior joining sc. and border .

—

—

37 -

S. orbitalis sagittalis + s. orbitalis transversus

+

+

38 .

S. orbitalis transversus, number of pieces

1

I

$

S. olfactorius well developed

+

+

S. olfactorius mesial (+) or lateral ( —) direction .

+

+

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Original from

PRINCETON UNIVERSITY

Limbic lobe. Occipital lobe. Temporal 1 . Parietal lobe.

1918.]

BY F. SANO, M.D.

26 I

Table B ( continued).

41

42

43

44

45

46

47

it

50

5 *

52

53

54

55
v 56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

7 «

72

.73

(74

75

76

77

78

79

80

81

82

\*3

I 5 '

postcentralis superior

( + )

(s. p
< s. ir
(s. p

S. postcentralis inferior

( + )

S. interparie -1
talis ( + )

postcentralis inferior
interparietalis .
parietalis superior .

6 s. interparietalis .

3 s. subcentralis superior
(. fissura lateralis
S. interparietalis proprius continuous

ramus ascendens s. temporalis superior
ramus ascendens s. temporalis medius
s. intermedins primus
s. intermedius secundus
s. occipitalis transversus
s. parietalis superior
S. parietalis superior independent.

S. parietalis superior number of sections
S. parietalis superior + sulcus praecunei

6 anterior interruption present
S. temporalis superior < middle interruption present

(. posterior interruption present
S. temporalis transversus, joining sulc. temp, superior
S. temporalis medius, number of sections
S. temporalis inferior, number of sections
S. lingualis independent
S. occipitalis anterior present
Arcus intercuneatus, superficial
Lobulus paricto-occipitalis present
S. occipitalis transversus inferior present
S. verticals continuous with fissura retrocalcarina
S. lunatus present ......

S. paramesialis at the lateral surface
S. occipitalis medius (lateralis) + a s. temporalis
S. occipitalis medius continuous .

S. occipitalis inferior independent .

S. rhinicus externus joining the fissura lateralis
S. rhinicus internus present ....

C temporal interruption present
S. collaterals < fusiform interruption present
( lingual interruption present
Isthmus lobuli limbici concealed .

S. subparietalis, number of segments
S. cinguli, number of segments
S. cinguli -f s. subparietalis .

S. intralimbicus present

+

+

+

3

+

+

+

- !

-

+

+

+

+

2

+

4

2

+

+

+

2

1

+

+ means yes; — means no; L for the left hemisphere; R for the right.

Table Bi .—Particulars with respect to the

the Cortex.

Concealed Parts of
L. R.

Transverse temporal divided . . —

Sulcus postcentralis insuke divided . . —

„ praecentralis anterior, insulae divided . —

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PRINCETON UNIVERSITY

262

JAMES HENRY PULLEN,

[July

Operculum orbitale number of sulci

L.

1

R.

0

,, frontale ,, ,, .

0

0

,, centrale ,, „

8

8

„ parietale inferior

1

0

Posterior Heschl badly developed

—

+

Deep gyrus in sulcus centralis

—

—

Deep gyrus in sulcus interparietalis

i

1

Deep cuneus prEecuneus superior gyrus

1

1

„ „ „ inferior gyrus .

—

1

,, lingualis anterior gyrus

1

0

„ „ posterior gyrus

1

0

Temporal lobes .—The superior temporal (is) has an anterior interrup¬
tion in the left side only; on the right the annectant gyrus giving this
interruption remains nearly concealed. The transverse temporal sulcus
reaches the lateral surface on the left side, and a secondary branch
ascends to it from the superior temporal, but there is 2 mm. distance
between their ends. On the right side the Hr is not to be seen on the
lateral aspect, and the secondary branch has half the size of the right
one. The sulcus temporalis medius (tm) is several times interrupted
on both sides and without regularity. The sulcus temporalis inferior
(It) is more regular, and only once interrupted.

Occipital lobes .—The left occipital lobe belongs to a very uncommon
type. There is a marked cuneo-lingual gyrus, and a concealed anterior
gyrus near the stem of the fissure. The fissure docs not join the
collateral sulcus.

On the left the calcarine fissure ends in a straight line; on the pole
is a small vertical sulcus resembling a superior lunatus. Two well-
developed, uninterrupted lateral sulci, not connected with the temporal
sulci, run parallel with the end of the inferior temporal, which is at the
lower border. The superior of these two lateral occipital sulci joins a
well-formed anterior occipital, which does not join the transverse
occipital. A deep gyrus exists at the desciibed junction, and another
more where the interparietal ends. Superadded to this there is a
superior occipital and unusual deep incisure joining the inferior sagittal
sulcus cunei; the superior sagittal is divided into two parts. There is
no inferior transverse temporal. There is no evidence of a paramesial
sulcus along the supero-mesial border, unless the deep abnormal incisure
accounts for it.

The stem of the right calcarine fissure remains also separated from
the collateral sulcus. There is a deep gyrus at the beginning of the
retrocalcarine fissure and one at its end, just before the vertical end,
which is well developed and remains at the mesial surface. Neverthe¬
less, there is a prselunatus on the lateral surface. The three lateral

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PRINCETON UNIVERSITY

* 9 * 8 .]

BY F. SANO, M.D.

263

anteroposterior sulci are also seen here, but the lower is not con
tinuous with the inferior temporal. The superior continues with the
interparietal, without a deep gyrus. There is no anterior occipital
sulcus. The transverse occipital is double, and the lower of them
joins the interparietal.

The deep incisure, as described on the left side, exists also on the right
side, and the superior occipital is independent. There is an independent
inferior sagittal sulcus cunei, and a well-maiked superior sagittal ending
in a paramesial, which covers the superior half of the supero-mesial
border of the cuneus. On the right side are two inferior transverse
occipital sulci, the most posterior of them resulting from the polar sulci
pushed downwards by the development of the lower end of the vertical
calcarine sulcus, the most anterior being formed by the collateral and
the lingual sulci.

Limbic lobes .—The limbic lobe is limited in both hemispheres by a
quite simple boundary. The rhinal sulci do not join the lateral fissure.
The sulcus collateralis is not interrupted. The isthmus is not con
coaled on the left side. The sulcus cingulatus is interrupted on the
left side, where it belongs to type V of Retzius. On the right side
this sulcus shows the common type in No. 1. On neither side is there
a sulcus rhinicus internus.

Indices of Bilateral

Comparison for

the Lobes.

12 male
brains.

Pullen.

ft and c .

764

80

Frontal lobes .

797

76

Parietal lobes .

69'2

62

Temporal lobes

61 ’9

83

Occipital lobes .

72 - o

72

Limbic lobes .

685

70

74'35 ■

73

The greatest differentiation between left and right exists in the
parietal lobes; the least in the temporal lobes.

The following table summarises the measurements of the depth of
the sulci taken in eighteen places of the hemispheres on each side.
As a means of comparison, the same measurements have been taken
in a normal brain and in a heavy brain. Then the radius has been
calculated for a sphere, the volume of which would be the same as the
concerned hemispheres, and the percentage of the depth of the sulci
according to that radius has been given.

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PRINCETON UNIVERSITY

264

JAMES HENRY PULLEN,

[Juiy>

Digitized by

Depth of Sulci in Millimetres and Per Cent, of Radius.

Pullen.

Normal.

Heavy brain.

I,. R.

L. R.

L. R.

Depth of primitive sulci

172 170 .

190 180

. 194 189

mm.

„ of newer sulci

>47 15‘4

160 150

. 185 180

a*

,, of summa (mean) .

i6'3 i6 - 8

178 168

. 188 i8‘2

M

Mean for both hemispheres

163

* 7'3

188

»»

Weight of the hemispheres

1045

,0 55

1420

grm.

Radius of sphere (same vol.)

62 99

63-16

69 77

mm.

Per cent, of radius occupied

2587

2739

2695

per cent.

by depth of the sulci

Whence we see that the normal brain has comparatively the deepest
sulci, the heavy brain less deep, and Pullen’s brain the least deep sulci.
Looking for details, it is to be noticed that this is not the case for the
stem of the calcarine fissure on the right side in Pullen, nor in his
sulcus cingulatus, nor in the sulcus collateralis. The rhinencephalon
and the occipital region appear to have been the least affected by the
arrest of development. The left hemisphere has suffered more in its
accessori sulci than the right.

A microscopical examination has been made on different parts 01
the hemispheres, but the senile deterioration is too advanced to allow
of any conclusions being made about the conditions that may have
existed during Pullen’s period of full mental strength.

Next to its documental value, the brain of Pullen may give us an
interesting example for the study of the convolutional pattern in a
small brain. For this study we would have to review which are the
indications of a more simple pattern, as it is usually found in small
brains of arrested development—these we would have to control by
comparison with the characteristics of a more fully evolved type—and
ascertain whether there is a predominance of one of these tendencies
in the case of Pullen.

In order to do such descriptions with accuracy it would be necessary
to have the results obtained in a sufficient number of brains, methodi¬
cally tabulated in series. I am compiling such tables, but I cannot
yet use them, as they are not worked out. The records obtained in the
study of relative brains are of interest, and may show the modification
of the familial pattern under the influence of differences in weight, and
so allow us to trace which conditions are more likely to be inherited—
independently of any other influence—and which are more under the
influence of personal variability^ 3 )

The scheme of this study, however, is again not enough advanced to
be completely demonstrative, and I have, therefore, used the results of
Spitzka and Cunningham in addition to my own.

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Original from

PRINCETON UNIVERSITY

1 9 1 8.] HY F. SANO, M.D. 265

Tokens of arrested development and simple pattern in the brain of
Pullen :

1. (*) There is only one anterior ramus of the fissura lateralis in both
hemispheres.

2. There is only one posterior ramus of the fl in the left hemisphere.

10. The sulcus centralis does not cut the supero-mesial border (on

both sides), and it does not anastomose with fl at its lower end (No. 9).

23. The sulcus frontalis superior is in three sections on the left side
(usually it is in one or two sections); on the right side it is in one
section ; it may therefore, be considered as badly developed on the
left side.

28. The sulcus frontalis inferior is continuous on the left side, and
not on the right side. This sulcus is interrupted in well-developed
brains, but then the terminal portions anastomose with the neighbouring
sulci, at least at the anterior end. Next, peculiarities observed show
that such is not the case in Pullen. The right fl , therefore, is in better
condition than the left, which is the contrary to what obtains in right-
handed individuals.

29. fi does not anastomose with the sulcus diagonalis on the right
side; it reaches d on the left side, without anastomosis.

30. fi does not anastomose with the sulcus radiatus ( r).

31. Nor with the sulcus fronto-marginalis ( fmg).

41. The sulcus interparietalis proprius is interrupted (ip).

50. There is an isolated sulcus intermedius anterior (ima).

56. The sulcus parietalis superior does not anastomose with the
sulcus praecuneus ( s.pr ).

60. The pattern of the temporal lobe is not bad, except for the
lack of anastomoses of the transverse temporal sulcus with the superior
temporal, but the gyri are shallow, and there are but few secondary
branches on the sulci.

61. There are too many divisions and too few connections in the
middle temporal (/>«).

76. The temporal interruption of col is present, as usually happens,
when the speech centres on the lateral surface have not pressed the
lateral cortex to the lower surface.

79. The isthmus lobi limbici is not concealed in the left hemisphere.

80. The sulcus subparietalis is interrupted in both sides.

82. The sulcus cinguli follows a simple pattern on both sides, type V
on the left, type I on the right.

The former indications show that there is a greater lack 01 develop¬
ment in the left than in the right hemisphere.

Are there indications of superiority, or any peculiarities that might
suggest that the brain belongs in some parts to a higher'type of human
evolution ?

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2 66 JAMES HENRY PULLEN, [July,

67. The occipital lobe is well developed on both sides, and differences
between the two sides are marked. On the left side there is a well,
developed lateral anterior occipital, but a less marked inferior transverse
occipital. On the right side there is an interruption of the calcarine
fissure, which may be a familial characteristic. On the right side there
is a good paramesial, which is evident on the lateral surface ; on the left
side the paramesial is interrupted. On both sides a deep sulcus which
joins the sulci cunei gives an unusual type of greater complexity and
deeper development of the occipital cortex, the distance from real to tr
is smaller on the left side. The good development of the occipital
region is more marked on the left side. Moreover, the occipital
index is small, where the frontal and the parietal indices are larger
than usual.

Corpus callosum .—The length of the corpus callosum exceeds the
usual measurements; it nearly attains the same length as it does in
brains of 1545 and 1593 grm., described by Spitzka. As the length
of the callosum is one of the most constant familial characteristics,
and as Pullen’s parents were first cousins, the large development in
Pullen’s brain is likely to have resulted from a reinforced hereditary
tendency.

Some unknown pathological factors had reduced the brain mass, and
especially arrested the development of the central, temporal, and frontal
lubes. As is usually the case under such circumstances, the left side
was more affected than the right side. The large development of the
corpus callosum, in addition to the better preservation of the occipital
lobes, may have been of no little importance as regards the visual
capacity and the artistic skill that gave Pullen, with his perseverant and
tenacious character, the means of attaining a personal originality and
distinction..

Tredgold, after careful examination, came to the conclusion that the
case was not one of primary amentia, but that it should really be
classed as an example of mild secondary mental deficiency, due to sense
deprivation (deafness). “The condition,” he writes, “is similar in kind,
although differing in degree, to that frequently seen in neglected cases
of congenital deafness, and it is not greatly dissimilar to that of some
non-idiotic savants, who, absorbed in their one particular subject, have
gradually lost interest in, and severed their connection with, the outer
world.”

Every discussion about classification of mental cases has always proved
to be fruitless, except for the demonstration of new facts enabling one
to modify accepted opinions. Much can be said in favour of Tredgold’s
conclusions, but clinical classifications are often too artificial. When
a complete examination can be performed, many cases of so-called
primary amentia may be considered as secondary to some localised

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PRINCETON UNIVERSITY

1918.] AN ECTROMELUS : AN ATAVISTIC RELAPSE.

267

pathological influence, which has caused the arrest of development of
the brain, or impeded education by the severance of social connections.

Pure hereditary influence, affecting the whole of the brain in an
harmonious manner, is hypothetical. Through heredity, pathological
influences act by local processes and disharmony.

At first sight I thought it possible to compare the brain of Pullen,
which appears almost well fissurated, with those cases of infantilism as
described under the name of “ Type Lorrain.” But I had soon to
abandon so hazardous an opinion. The brain is small, its frontal and
temporal lobes are badly developed; there is a lack of complexity in
the convolutional pattern of these lobes, and this is especially marked
in the speech centres ; his deaf-mutism was more central than peripheral
in origin. The parietal lobes were not so bad; the occipital lobes
were good, the corpus callosum was remarkable, and he was bound to
have special capacity in the visual sphere of his mental existence.

I have never thought it possible to explain by the description of the
brain, why Pullen was so tenacious and so industrious. Just as the
complexion—may it have been the internal secretions that granted him
a sound long life ?—the foundation of his character was not only to
be found in his convolutions.

“ Science has done much for us,” says Carlyle, in his Hero Worship;
but it is a poor science that would hide from us the great deep sacred
infinitude of Nescience, whither we can never penetrate, on which all
science swims as a mere superficial film. This World, after all our
science and sciences, is still a miracle ; wonderful, inscrutable, magique,
and more, to whosoever will think of it.”

And so was Pullen.

(') The brain of this interesting case was sent to Lt.-Col. Mott by Dr. Caldecott,
who handed it to Dr. Sano for investigation, who acknowledges with gratitude a
grant from the Medical Research Committee of the National Health Insurance.—(*)
A. F. Tredgold, Mental Deficiency, second edition, London, 1915. Contains a com¬
plete record of Pullen's activity, illustrated by numerous figures. The figures
which I give in this paper have not hitherto been published.—( J ) “Convolutional
Pattern of Relative Brains in Man,” Proc. Roy. Soc. Med., 1917 ; Id. in “ Identical
Twins” ( Philosoph. Trans, of the R.S., 1916). F. Sano.—( 4 ) The numbers refer
to those of Table B.

An Ectromelus (}): An Atavistic Relapse. By S. B. Pal, B.A.,
L.M.S. (Cal. Univ.), Assistant Surgeon, Central Asylum, Federated
Malay States.

Darwin, after a most comprehensive and searching investigation of
the phenomena of life and variation, came to the conclusion that “ man
is the co-descendant with the other mammals of a common progenitor,”
and still “ bears in his bodily frame the indelible stamp of his lowly
LX IV. I 8

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268

AN ECTROMELUS : AN ATAVISTIC RELAPSE, [July,

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origin.” With the immense and varied ancestry man has had, and the
infinitude of his connections with the rest of the animal world, “ata¬
vism,” />., inheritance of characteristics from remote, not from the more
immediate ancestors, is a very interesting subject of study. The pres¬
ence of supernumerary nipples in man may be cited as an example of
atavism. This abnormality has been noticed by me in four patients
during five years’ observations in the hospitals in this country. In
some parts of Central and Eastern Europe a very high percentage of
men is said to possess this abnormality. This characteristic is absent
in apes, baboons, and monkeys, who are men’s immediate successors,
but is found in lemurs, an order of mammals lower in order. The rare
occurrence of multiple births in women is a characteristic which is
reversion, or atavistic towards the condition normal in lower verte¬
brates.

Dr. F. E. Bolton, in his paper on “Hydro-Psychoses” (wateratavism),
brings together some of what he terms “ the abundant proofs of man’s
pelagic ancestry.” One of the characters mentioned in the paper is
the formation of the hand of man. He considers the hand of man is
in shape and bones “ more like the primitive amphibian paddle than is
the limb of any other mammal.” Emerson, in the same way, thinks
that “ the brother of man’s hand is now cleaving the Arctic Sea in the
fin of the whale, and, innumerable ages since, was pawing the marsh
in the flipper of the saurus.”

If our hands are regarded by naturalists as developed from the limbs
of our remote ancestors who lived in the sea, I think that the characters
of the limbs of the ectromelus, photographs of whom are reproduced
here, show a further “ atavistic relapse.”

Besides the superficial similarity of appearance of the upper extremity
of the ectromelus to the fore-limb of the whale or seal, the characters of
the different bones have some similarity to those of Cetaceans (whale
family).

The following diagram of skeleton of the upper extremity of a man,
of the ectromelus, and of the fore-limb of a whale, clearly shows how
that of the ectromelus resembles the fore-limb of a whale.

The points of resemblance between the upper extremity of the ectro¬
melus and the fore-limb of the whale are :

(i) The stunted appearance as compared to the upper extremity of
man.

(ii) The arch-like curvature of the bones of fore-arm.

(iii) The immobility of the palm, the phalanges, except the thumb, of
the ectromelus having no pow'er of flexion or extension.

In whales there are no hints of hind-limbs, and in this ectromelus the
lower limbs are in proportion to those of a normal man very small, as
shown in the diagram below.

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PRINCETON UNIVERSITY

JOURNAL OF MENTAL SCIENCE, JULY

PRINC

To illustrate paper by Dr.

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PRINCETON UNIVERSITY

JOURNAL OF MENTAL SCIENCE, JULY, 1918.

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PRINCETON UNIVERSITY

A (Hard 6° Son &* H'est Newman,

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PRINCETON UNIVERSITY

1918 -]

BY S. B. PAL, B.A.

269

The hind-limb of the whale is represented by a rudimentary femur
and tibia only, and it is remarkable that in this ectromelus there are no

Fore-limb.

fibula or metatarsal bones and the phalanges are rudimentary, consist¬
ing of one digit in each, and unattached to any muscle.

The ectromelus, an Indian Mahomedan, ret. about 36, was admitted

0

O

c

o
O

Ectrome/us.

Hind-limb.

into Batu Gajah Hospital for the treatment of malarial fever. He lives
on the charity of others, and roams about from place to place. Nothing
about his family history can be made out, as he thinks his parents died
or deserted him when he was a baby. There are no points of interest

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PRINCETON UNIVERSITY

270 AN ECTROMELUS : AN ATAVISTIC RELAPSE, [July,

in his previous history, except that he contracted venereal disease about
five years ago.

It would have been very interesting to get radiograms of the limbs,
but in their absence I will try to show in the appended table the size
of the different parts of the body of the ectromelus as compared to
the same parts in the individual who is standing by his side in the
photograph.

Ectromelus.

Man.

Weight ......

6 st. io lb

io st. 6 lb*

Height.

3 ft. i in.

5 ft. 8} in.

Body :

One acromion process to the other

l ft. 4 in.

I ft. 5 in.

Girth of chest at level of nipple .

2 ft. u in.

2 ft. io| in.

One anterior superior iliac spine

to the other ....

11 in.

I ft. i in.

Upper extremity :

Acromion process to outer con-

dyle of humerus

9 in.

I ft. in.

Girth of arm ....

io in.

11 in.

Head of radius to its styloid pro-

cess ......

5 *n.

11 in.

Metacarpals: (a)

First ...

4 in.

2 in.

Second .....

i in.

2} in.

Third.

I in.

2} in.

Fourth.

nil

2} in.

Fifth.

nil

2 in.

Phalanges : ( b)

Thumb .....

I in.

2| in.

Other phalanges

i to i in.

—

Lower extremity :

Anterior superior iliac spine to

lower border of patella

7 in.

i ft. 7J in.

Girth of thigh ....

I ft. io in.

i ft. 8 in.

Head of tibia to inner maleolus .

5 in.

i ft. 4i in.

Fibula.

Wanting

—

Metatarsals .....

Wanting

—

Phalanges: (c)

Big toe .

1 in.

2} in.

Other toes ....

about I in. each .

—

Foot.

5 in.

io} in.

(a) Only the first metacarpal is jointed to the carpus, the second and third being-
only thin spicules of bones, having no connection with the carpus. The third
metacarpal bone is absent in the left hand.

( b) There are six phalanges in the hand, the sixth one arising from the fift*h.
All the phalanges consist of one digit each. The thumb only has power of flexion
and extension, other phalanges being immobile.

(c) The phalanges, five in number, consist of one digit each and are immobile.
They project more from the dorsum of the foot, and do not touch the ground
when the ectromelus walks.

In view of the fact that the limbs of this ectromelus are so very
defective, it is really astonishing what he is able to accomplish. He
can easily walk a distance of a mile or so, and is independent of any

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PRINCETON UNIVERSITY

1918.]

BY S. B. PAL, B.A.

27 I

help from others, or of any mechanical contrivance for eating, dressing
himself, etc. He uses a spoon, which he holds between the thumb
and the palm. To eat “chapati,” he holds one edge between the
thumb and palm and tears a small piece. This piece, with a little
curry over it, he pushes on the dorsum of the right hand with his left,
and then carries it to the mouth. The “ langoti ” (a T-shaped apparel
used as underwear by some men of Northern India), in which he appears
in the photograph, is arranged by himself. He holds a pen between
the thumb and palm or between the external edges of two palms, and
writes tolerably well, as shown in the diagram of writing.

/ lc/ua.1 Size of f>a./rrx (/eft).

He can roll tobacco in paper to make a cigarette and then light it,
as shown in the photograph : and can easily raise the bucket full of
water, weighing 36 lb., as also shown.

To climb a height, as on to the stool on which he is standing in the
photograph, he puts his palm on the top, and with the arms he raises
himself up a little. Then he puts one foot on one of the legs of the
stool and rises up in the same way as we would climb a place nearly
equal to one’s height.

My thanks are due to Mr. S. A. Row, Hospital Assistant, for taking
the photographs according to my suggestions.

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PRINCETON UNIVERSITY

272

THE LORD DERBY WAR HOSPITAL,

[July

References.

(1) A. F. Chamberlain .—The Child.

(2) Thomson .—Outlines of Zoology.

(3) Foster and Shore. —Physiology.

Tanjong Rambutan,

March 24 th, 1918.

(') Derived from Gr. ficrf>ui/ra, abortion, and jiAoc, limb.

A Record of Admissions to the Mental Section of the Lord Derby
War Hospital, Warrington, from June 1 Jth, 1916, to June 16 th,
1917.C) By R. Eager, M.D., Major, R.A.M.C.(T.), Officer in
Charge Mental Division L.D.W.H. and Senior Assistant Medical
Officer Devon County Asylum.

During the fust twelve months of the admission of patients to the
mental wards of the Lord Derby War Hospital there were 2,429 admis¬
sions and 1,466 discharges. The average number of admissions per
month was 202, and the average number of discharges per month was
122. To those who have devoted their time to the admission and
discharge of mental cases in large asylums in peacetime these numbers
alone will convince them that the condition of things must be very
different to what they have been accustomed. The enormous amount
of work in investigating these cases will also, I am sure, be appre¬
ciated, and those who, in addition, have any knowledge of Army Forms
and the preparation of these before the final discharge of a patient
from hospital will realise the amount of routine necessary before these
1,466 patients could be discharged.

I propose now to review the work done during these twelve months,
and in doing so to briefly indicate the nature of the cases coming under
the various groups.

Table No. I shows the total admissions to the mental section of the
hospital during the period under review, grouped under the sources
from which they came. It also shows the discharges under the same
headings and their disposal.

Table No. II shows the cases classified according to the official
nomenclature under the various forms of mental and nervous disorders
represented by these cases.

Before further splitting up these figures into their sub-groups I should
mention that on the opening up of the 1,000 beds provided at the Lord
Derby War Hospital for the accommodation of mental cases a large
amount of the room was very quickly used up by “ home troops.” By
the latter term I mean cases who had not served overseas with an
Expeditionary Force and who had shown mental symptoms sooner or
later after enlistment. From the admission rate of these cases alone

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PRINCETON UNIVERSITY

Table I .—Showing Totals Admitted and Discharged, and How Disposed of.

1918.]

BY MAJOR R. EAGER, M.D

273

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PRINCETON UNIVERSITY

Digitized by

274 THE LORD DERBY WAR HOSPITAL, [July,

it soon became evident that the accommodation would be insufficient,
and it became necessary to limit the reception of cases to this hospital
to men who had served with an Expeditionary Force. The home troops
are now dealt with by other methods. The principle of dealing with
them after their admission to this hospital was similar to that

Table II.— S/towiftg Total Admissions and Discharges according to

their Mental Disease.

Form of mental disease.

rt

0

H

Discharged to
civil occupation.

Sent to asylums.

Transferred to
other hospitals.

Sent to home
duty.

Died.

Still in hospital.

Total*.

Cerebral syphilis

3

1

2

_

3

Epilepsy .....

20

14

—

—

4

—

2

20

Hysteria.

5

3

—

—

2

—

—

5

Somnambulism

1

1

—

—

—

—

—

I

Mental deficiency .

33 8

148

12

18

21

—

*39

33 8

Mania .....

200

52

8

20

25

5

90

200

Melancholia ....

448

170

>4

29

45

I

189

448 1

Mental stupor

54

4

2

12

1

—

35

54

Delusional insanity

37*

I l8

'9

3'

26

I

176

37'

Epileptic insanity .

21

13

1

I

I

5

21

Moral insanity

6

4

—

—

2

6

Impulsive insanity .

5

2

—

«

2

—

—

5

Acute delirium

26

IO

—

2

6

—

8

26 1

Confusional insanity

251

74

3

32

40

2

IOO

251

Alcoholic insanity .

30

12

3

4

2

—

9

30

G. P. I.

112

8

66

5

—

4

29

112

Dementia prrecox

200

44

19

22

12

103

200 |

Secondary dementia

48

21

1

8

-

—

18

48

Mental instability .

4«

26

0

3

7

—

10

48

N. A. D.

25

—

—

'7

6

—

2

25

Shell shock

68

26

—

8

21

I

12

68

Neurasthenia ....

145

71

4

1 I

27

—

32

'45

Concussion of the brain .

I

I

—

—

I

Tumour of brain .

I

—

—

_

I

—

1

Locomotor ataxia .

I

—

_

—

—

1

1

N. Y. D.

I

_

_

—

—

I

I

Totals

2429

823

'54

224

247

18

963

2429 j

adopted by the Army authorities in peace time. They were admitted
for the purpose of examination, observation, and diagnosis, and if con¬
sidered mental cases and were not making rapid improvement they
were certified, and sent to the county asylums to which they were
chargeable. If, however, they showed signs of improvement they were
retained in hospital till they were able to be discharged to the care of
their friends. It will be noted below that only eight cases from the
home troop group returned to duty. Of these one showed no

Google

Original from

PRINCETON UNIVERSITY

BY MAJOR R. EAGER, M.D.

1918 .]

2; 5

appreciable mental disease, and the others had been on garrison duty
abroad and had had very mild symptoms.

Home Troop Cases.

Table III deals solely with the home troop cases, and I will now
proceed to discuss these in detail. Taking the classes represented in
the official nomenclature separately, the largest one is that contained in
the group of “ Mental Defectives.”

Table III.— Showing Total Home Troops , Admissions and Discharges
classified according to their Mental Disease.

Form of mental disease.

sa

c

0.2

•ji

So

to asylums. ■

o —

~ <t
*3 --

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t i

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d

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Concussion of brain

I

I

_

I

Epilepsy ....

3

3

—

—

—

—

3 |

Somnambulism

1

I

—

—

—

—

—

I

Neurasthenia ....

26

21

2

_

2

—

I

26

Mental deficiency .

S 3

42

10

I

—

—

—

53

Mania ...

13

7

4

I

I

—

—

'3

Melancholia ....

37

22

IO

—

4

1

—

37 [

Epileptic insanity .

3

3

—

—

—

—

—

3

Mental stupor

2

I

—

—

—

—

I

2

Delusional insanity

43

27

12

2

—

1

I

43

Moral insanity

1

I

—

—

—

—

—

I

Impulsive insanity .

I

I

—

—

—

—

—

I

Acute delirium

I

1

—

—

—

—

—

I

Confusional insanity

11

7

2

I

—

1

—

11 l

Alcoholic insanity .

9

7

2

—

—

—

--

9 1

G. P. I.

l 6

2

I I

—

—

3

--

16

Dementia praecox .

24

12

12

—

—

—

24

Secondary dementia

10

7

I

2

—

—

—

IO

N A. D.

I

—

—

—

I

—

—

I

Mental instability .

2

2

—

—

—

—

2 1

Totals

258

168

1

66

1

7

8

6

3

|

■

258

Mental deficiency. —There were 53 admissions (or 20 percent, of home'
troop admissions). All types of mental deficiency were met with.

Speaking broadly with regard to the cases of this group, it is quite
clear that they would be of no use for military purposes, and they are
quite unable to come up to the standard required for military discip¬
line. It is clear also that in most cases they have realised their
deficiencies, and a great many have felt very acutely their inability to
compete with their feliows. This has only aggravated their condition.
The question as to whether, if they were collected into a special

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PRINCETON UNIVERSITY

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276 THE LORD DERBY WAR HOSPITAL, [July,

battalion, and treated on different lines to the ordinary soldier, they
could be used for work as labourers under special supervision is a point
for consideration. My opinion is that a great deal of useful work might
be obtained from them under these conditions if they were properly
handled. But under present conditions it is difficult to understand
why so many are being enlisted and passed by recruiting medical
officers as fit for duty. It is quite impossible to expect them to do the
duties they are asked to perform in competition with other men of a
much higher mental calibre.

Delusional insanity .—This represents the next largest group under
home troop cases. There were 43 cases in all (or 16 per cent.).

In many of the cases of this class who were discharged from hospital
to their homes the condition had evidently existed prior to enlistment,
and although they might easily have been certified on discharge, one
felt that they had carried on in civil life previously in spite of their
delusions, and that they would probably be still able to do so. Many
cases had only been in the Army one or two months prior to admission.

Next for consideration is the Melatuholic Group. There were 37,
or it, per cent, classified as such. An example of this group will now
be given.

No. 5399 Pte. K. G—, aet 41. Builder’s labourer. Enlisted Sep¬
tember 4th, 1916. Father committed suicide. Patient was brought
under observation on September 10th, for throwing himself in front of
a motor car. He was in a state of extreme melancholia, and said he
was afraid to be left alone. He wrote a letter addressed to his wife
saying, “I am dying,” and on the envelope was written, “when I am
dead send this to my wife.” Examination elicited the fact that he had
been called up a week previously, and could not settle down to his
drills. Became nervous, and imagined that he was going to be shot.
His tongue and hands were tremulous, and his general condition one
of extreme agitation, but there were no other neurological signs. He
looked old for his age, and his arteries were thickened.

On inquiry into his personal history it was ascertained that he had
always been a very nervous man, afraid to leave the house alone at
night, and would be frightened at a piece of paper in the dark. He had .
had a “ nervous breakdown ” six years previously when he was looked
after at home. He made a steady improvement under hospital treat¬
ment, and was able to be discharged to the care of his wife in
November, 1916.

The above condition was no doubt produced by the stress of training
in a mentally unstable individual with a hereditary predisposition to
mental disease.

The ten cases who were certified were similar cases, in which the
stress of military duties reacted adversely on them, and led to suicidal
attempts. Alcoholic intemperance was an associated factor in several
instances. These cases did not show any signs of rapid improvement,

Google

Original from

PRINCETON UNIVERSITY

1918.] BY MAJOR R. EAGER, M.D. 277

and therefore had to be certified in accordance with Army Council
Instructions.

The fieurast/ienics figure as the next largest group of cases among the
home troops.

There were in all twenty-six cases, one of which still remains in
hospital, and is undergoing a course of 606 and mercurial injections.
As regards the two sent back to duty, of whom one was an R.A.M.C.
orderly belonging to the L.D.W.H., both were mild cases, and were only
eleven days in hospital. On the other hand, the two cases certified
were very severe cases.

Of the twenty-one cases which were discharged to civil duties the
following example will suffice :

No. 194982, Driver H. F—, aet. 36, music-hall manager. Enlisted
August, 1916. About October 1st, 1916, whilst training he was kicked
in the abdomen by a mule, and since that time he had been in bed.
He was admitted to the Hospital on October xoth, 1916, with some
bruising of the testicles and pubis and involuntary micturition. Exami¬
nation by X rays failed to show any fracture. He was in a state of
general nervousness and anxiety with regard to his condition, and
fearful when questioned about himself. He slept badly, but showed no
other mental symptoms. He rapidly regained his self-confidence, how¬
ever, and his incontinence ceased. On December 28th he was brought
before a Medical Board and discharged. This man’s family record
showed that his grandfather was in an asylum for ten years and died
there. His brother was also of a highly nervous disposition, and the
patient himself had a nervous breakdown two years previously after
producing three revues in the music-halls for the War Relief Fund.

Dementia prcecox occupies the fifth highest position and accounts for
24 cases (or 9 per cent, of admissions). Of these, 12 were discharged
home and 12 were certified. The following cases represent types of
this group :

No. 28686, Pte. S. T—, set. 24. Enlisted June 13th, 1916. Previous
occupation a labourer. This patient was admitted to the L.D.W.H. on
September 13th, 1916, with the report from his regimental medical
officer that he had done no duty since joining. On examination he
was very resistive and his expression was sullen. He took no interest
in his surroundings and had marked flexibilitas cerea , and a tendency
to retention of urine. He would not answer questions, and was generally
negativistic.* On September 20th he assaulted one of the orderlies by
striking him. During his stay in hospital he rarely answered questions
and only then in monosyllables, and he remained in a state of inertia
till he was finally disposed of by certification, and transferred to asylum
care on November 14th, 1916. The father of this patient stated that
there was no mental trouble on either side of the family, and the first
indication they had of anything being the matter with the boy was
when he tvas arrested for being an absentee. He stated, however,
that he had always been of a reserved disposition and made no friends
in civil life.

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PRINCETON UNIVERSITY

278

THE LORD DERBY WAR HOSPITAL,

[July,

No. 6005, Pte. H. J—, set. 32, fitter by trade. Enlisted March 16th,
1916. Patient was admitted to the Hospital from the detention
barracks at Wakefield, where he had been undergoing a sentence of
eighty-four days for insubordination. The official records showed that
he had two previous periods of detention of twenty-one and fourteen
days respectively for a similar offence. His history, obtained from his
mother, showed that from November 21st, 1907, to September, 1908,
he had been a patient in the Three Counties Asylum, which was
corroborated on application to that institution. On admission to
hospital from Wakefield he was rambling and inconsequential. He
answered questions irrelevantly and took very little notice of his
surroundings. He had an imperfect appreciation of time and placeand
no insight into his condition, and was generally apathetic and unin¬
terested. He had no neurological symptoms and was in a satisfactory
bodily condition. The more marked symptoms fairly rapidly cleared
up and left him rather dull, stupid, and simple, and he was boarded out
of the Army as permanently unfit for service a month after admission
and allowed to return home to his friends.

Next come the cases of general paralysis of the insane. There were
16 cases (or 6 per cent, of the home troop admissions). Of these,
2 were in a very early stage, and their friends undertook full responsi
biiity for their welfare. Eleven were certified for asylum care and 3
died in hospital. The cases were in all respects similar to those
met with in civil asylums, and, therefore, no further mention will be
made on this group of cases here, and the observations on the Wasser-
mann reaction and other tests will be deferred till dealing with the
Expeditionary Force cases.

I will, therefore, proceed to deal with the cases of mania as the next
largest group. There were 13 admissions, 7 of whom were discharged
home, 4 were sent to asylums, x was transferred to another hospital,
and 1 was considered fit to return to home duty.

The transfer was an Australian, who was boarded and recommended
for repatriation. Of the cases who were sent to their homes and civil
occupations the following is an example :

No. 34040. Lce.-Corpl. P. A—, aet. 39, farm labourer. Enlisted
August, 1915. This case was admitted to the L.D.W.H. on October
13th, 1916, with report that he had been noisy, restless, and excitable.
It was ascertained that he had been twice previously in an asylum, the
first time from February to May, 1913, and on the second occasion
from July to December, 1914. He quickly quietened down after
admission and in November, 1916, was discharged home to his wife.

The one patient returned to duty was a case who rapidly regained his
mental balance. His age was 41, occupation architect. He had a good
character from his Commanding Officer, and was allowed to return to
duty on recovery owing to the mildness of the attack and at the patient’s
expressed desire.

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PRINCETON UNIVERSITY

19 I 8.] BY MAJOR R. EAGER, M.D. 279

The cases coming under the heading of confusional insanity total
eleven. The following case was discharged home :

No. R/17280 Rifleman G—, act. 30, engineer in ship yard. Enlisted
October, 1915. In June, 1916, patient was admitted to hospital. He
was sleepless by night and suffering from visual hallucinations, and was
generally in a state of mental confusion with a certain amount of
clouding of consciousness. His bodily condition was weak, and he
had some cough and expectoration. The latter was subsequently
examined, but tubercle bacilli were not demonstrated. Physical signs
of phthisis were not definite. The condition rapidly improved, and in
November, 1916, he was discharged home to the care of his friends.
In this case his mother was an extremely nervous woman, one of his
maternal aunts and uncles died in an asylum, and his father’s brother
died of phthisis. The strain of training for military duties had been
too much for a subject of this type.

We will now proceed to the cases of secondary dementia. There were
ten returned as such.

Two of these, one of whom was an Australian and the other a South
African, were transferred to other hospitals for purposes of repatriation.
I will give one example :

A case taken home by relatives. No. S/956 Pte. S.C—, set. 53, paper-
hanger. Enlisted August 14th, 1915. Was admitted to the L.D.W.H.
on October 20th, 1916, with a history that he had returned from
India. He had been under observation for mental trouble since May,
1916, and had previously been in the Richmond Asylum, Dublin. He
was sent to hospital as a case of mental deficiency, and it was reported
that he was unable to do his drill, and could not look after himself or
his equipment. It was necessary at once to have him scrubbed as
he was in a verminous condition. There was no history of sunstroke,
fever, or syphilis. He admitted indulgence in alcohol. On examina¬
tion, he was disorientated in time and space. His memory was bad for
recent and remote events, and his general intelligence of a low order.
He was only able to do light work under supervision. Physically, his
arteries were markedly tortuous and thickened, but his general con¬
dition and nutrition were fairly good. His hearing was defective.
Pupils active, deep reflexes increased. The case seemingly was an
ordinary case of progressive dementia with no marked characteristics,
and, as the patient’s father was willing and able to take the responsibility
for his welfare, he was allowed to take him home.

Alcoholic insanity will now be considered. There were admitted in
all nine cases. For the sake of illustration one example will be given.

No. 20725, Pte. B. R—, set. 40, labourer. Enlisted April, 1915. He
was employed on munitions in September, 1915, after he had com¬
pleted his preliminary training. In January, 1916, he fell and injured
his back. He was ordered to report for an examination but failed to
do so, and on a visit being made to his home he was found to be under
the influence of drink. He was admitted to the Hospital on January
22nd, in a dull, confused mental state. Did not seem to appreciate his

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2 80 THE LORD DERBY WAR HOSPITAL, [July,

surroundings, and left to himself he would wander about in an aimless
manner. He smelt of drink on admission, and physical examination
revealed tremors of his tongue, hands, and facial muscles. His pupils
were rather sluggish, but his reflexes did not show any deviation from
normal. His Wassermann reaction was negative. The condition
rapidly cleared up, and in March he was able to give a coherent
account of himself, and was correctly orientated for time and place. He
made no complaints, and behaved in every way rationally and sensibly.
He was, therefore, discharged home.

In the epileptic group there were three cases without any marked
mental symptoms, and three cases in which mental symptoms were
present. They were all discharged to their homes. The following is
an example :

No. 32504, Pte. C. T. J—, jet. 28. Enlisted February, 1916. No
regular occupation formerly. At the age of 12 he fell downstairs.
Following this fall fits at frequent intervals are said to have developed,
He had previously enlisted in the Army, and was discharged in July.
1915, on account of his fits. He re-enlisted early in 1916, and in
May of that year went to India. Fie was in November, 1916, again
regarded as unfit for service owing to the increasing frequency of his
fits. He had since his enlistment been in trouble for being drunk,
using bad language, not complying with an order, and even striking his
superior officer. He was sent back to England and admitted to the
Lord Derby War Hospital, December 28th, 1916. On admission here
he could give but a poor account of himself owing to his slow cerebra¬
tion. He said his occupation in civil life had been distributing hand¬
bills, and that he earned about 145-. a week. His memory seemed
very defective, and at times he would not answer questions, seeming to
realise this defect. He was easily confused. He was unable to give
the date or month correctly, said he thought it was November. He
had three convulsive seizures whilst under observation, and was dazed
all the following day. The condition was typically epileptic, and at
times, whilst in hospital, he was inclined to be rather impulsive. His
friends expressed a wish to take him home on their responsibility,
and this they were allowed to do on January 17th, 1917. The case
appeared to be an advanced case of epileptic dementia.

There were two cases recorded as mental stupor . One of these was a
returned Expeditionary Force soldier doing home duty, who has not
recovered sufficiently to justify his discharge, and is therefore still
retained in hospital. The other case is as follows :

No. 32818, Air Mechanic L. M—, set. 21, a turner. Enlisted
June 16th, 1916. Patient was admitted to L.D.W.H. January 1st,
1917, with report that in the preceding August he became depressed
and worried about being away from his mother. In September he
became more depressed and went home on leave. He gradually lapsed
into a semi-stuporose condition. On inquiry from his relatives no
history of any nervous or mental trouble was admitted to exist in the
family, and he was slated to have had no worries or previous nervous

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281

attacks of any kind. On admission he was dull, stupid, and took no
interest in anything. Had to be spoon-fed and have eveiything done
for him, and was defective in habits. He rapidly improved, and
was able to take an interest in things in an ordinary way. The condi¬
tion was no doubt brought on by exposing a nervous young lad to the
strain of ordinary military service. He was discharged to his civil
occupation on January 15th, 1917, appearing to be in his normal state.

Mental instability .—Two cases were diagnosed as mental instability.
These were both highly neurotic individuals who had a bad history of
mental trouble in the family, and one or more mental breakdowns
prior to joining the Army. They were both discharged to their civil
occupations on recovery.

Only one case was admitted under each of the following headings :

(1) Concussion of the brain, (2) Somnambulism, (3) Impulsive
insanity, (4) Acute delirium, (5) Moral insanity.

There was also one case admitted showing no appreciable mental
disease, and he was returned to duty.

In addition to the cases already noted there were admitted three
Australians who had only served in England, and also twenty-eight
similar cases admitted from the Canadian Forces. These cases were all
retained in hospital pending arrangements for repatriation.

The addition of these Colonials, therefore, brings the total number
of cases dealt with under the heading of home troops up to 289.

Taking them as a whole, the above cases representing the home
troops were a very poor type from the recruiting point of view.

Cases Admitted from the Expeditionary Force in France.

On reviewing the records of the cases admitted to the Mental
Section of the Lord Derby War Hospital from the French Expeditionary
Force during the twelve months from June 17th, 1916, to June 16th,
1917, I should mention that all cases were kept in hospital under
treatment until they had recovered, except in the case of general
paralytics, epileptics, and patients who, prior to enlistment, were found
to have been in asylums. The cases shown as transfers to other
hospitals were Scotch or Irish cases who were transferred to the special
hospitals for mental cases at the Murthly War Hospital, near Perth,
or the Belfast War Hospital respectively; also a few who were trans¬
ferred to the County of Middlesex War Hospital, at Napsbury, near
St. Albans, at the request of their relatives, in order that they should
be nearer their homes. By reference to Table IV it will be seen that
there were 1,652 admissions of which 536 were discharged home, 175
returned to duty, 143 were transferred to other hospitals, 75 were
certified for asylum care, n died, and 712 still remained in hospital.

On looking into the various groups classified in accordance with the

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282 ' THE LORD DERBY WAR HOSPITAL, [July,

official nomenclature, we find that melancholia stands out as the largest
group, and accounts for 18 per cent, of cases from the Western Front.
Thirty-one had a comparatively short attack, and it was thought
justifiable to give them a trial on “home service,” with the under¬
standing that they would not be sent overseas again within twelve

Table IV.— Showing Total Admissions and Discharges of Cases from
the French Expeditionary Foret classified according to their
Mental Disease.

Form of mrntal disease.

Totals.

c
c .2

2.

a.

SO

1 s

u —

« T

5-5

Sent to asylums.

1

Transferred to
other hospitals.

Sent to home
duty.

■6

.Si

Q

Still in hospital.

<c

c

H

Hysteria .....

4

1

3

___

_

I

_

_

4

Epilepsy .....

•5

11

—

—

3

—

I

«5

Neurasthenia ....

99

4 t

2

8

21

—

27

99

Mental deficiency .

233

89

2

14

14

—

114

233

Mania.

*35

37

3

12

l 6

5

62

«35

Melancholia ....

309

114

4

18

3 i

—

142

309

Epileptic insanity .

I I

6

—

I

—

4

II

Mental stupor

33

3

2

7

I

—

20

33 1

Delusional insanity

242

73

5

20

l 7

—

127

242

Moral insanity

3

2

—

—

—

1

3

Impulsive insanity .

3

—

I

2

—

—

3

Acute delirium

'4

6

—

I

—

7

«4

Confnsional insanity

179

60

18.

29

I

71

'79

Alcoholic insanity .

19

5

I

4

2

—

7

19

G. F. I .

7 «

4

48

2

— I

1

23

78

Dementia prrecox .

127

26

6

13

9

—

73

127

Secondary dementia

20

9

—

2

—

—

9

20

N. A. D .

20

—

—

14

4

—

2

20

Mental instability . . .

39

21

2

3

4 !

—

9

39

Cerebral syphilis

3

I

—

—

2

—

3

j Tumour of brain

I

—

—

—

—

I

—

I

Shell-shock

63

25

6

20

I

11

63

Locomotor ataxia .

I

—

—

—

—

—

I

I

N. Y. D. 1

I

~~

“

”

I

I

Totals

1

1652

536

75

143

1

*75

11

712

1652

months. Four were found to have been in an asylum prior to their
enlistment in the Army, and were, therefore, certified again for asylum
care, and eighteen were transfeired to other hospitals under the pro¬
visions already stated. The trying conditions under which men of the
French Expeditionary Force live adequately accounts for the large
number of cases of melancholia admitted.

Tlie second largest group of cases amongst the troops in France are
those classified as delusional insanity. There were 242 admissions
under this heading.

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19 1 8.] BY MAJOR R. EAGER, M.D. 283

The following case was invalided from the Army, but able to be
discharged to his civil employment :

No. 23987, Pte. S. G. W—, set. 25, iron-moulder. Enlisted September,
1914, into the R.A.M.C., but was discharged after six months for vari¬
cocele. Started munition work, and in January, 1916, re-enlisted.
Went to France July, 1916, and had some trench experience. Does
not remember leaving the trenches, but woke up and “found himself”
in some hospital. He then stated that an Indian had given him a
yellow bead which had some mysterious properties. That this individual
was following him to try and steal his wife and regain possession of the
bead. He seemed to hear him outside the door, and during examina¬
tion thought the Indian might hear what was being said. This was
his condition when admitted to the L.D.W.H. on October 17th, 1916,
and he was in a state of great agitation about the whole matter,
evidently firmly believing in the story, and living in constant dread of
the imaginary Indian. This man had been actually associating with
Indian troops in or near the trenches in France, and was admitted to a
stationary hospital, where he was diagnosed as a case of “shell-shock
from mine explosion.” The delusional state seems to have followed on
his return to consciousness. At night in the dark he could see this
Indian’s face in front of him, and he was afraid to go to sleep on this
account. Orientation for time and place were correct, and his memory
was intact, but he had no insight into his condition. There were no
neurological signs. This patient made a good readjustment, as his
delusions gradually left him. He went out frequently with his wife who
came to stay near the hospital, and conducted himself in a rational
manner in every way. On June 21st, 1917, he was brought before a
Medical Board and was discharged home.

The next largest group is represented by the cases of me/italdeficiency.
This is only what one expected to find, knowing that the powers of
endurance of these individuals is much below the average, and that
they are to be looked upon in every way as “ weaklings.” I am quite
aware that certain cases of mild degrees of mental deficiency have done
remarkably well, and even gained promotion in rank in the present war,
but they must be looked upon as the exception, and it cannot be too
firmly asserted that this class of case is of no value as a recruit under
ordinary > service conditions. The total number of cases of mental
deficiency was 233, or 14 per cent, of French Expeditionary Force
admissions. Of these only 14 were considered fit to be tried on home
service. I will quote an example of a case admitted.

No. 23092, Pte. C. E—, ret. 19, fish hawker. Enlisted April, 1915.
Patient was the youngest of a family of fourteen, and his parents
recognised that he had always been deficient mentally. He enlisted
because he was the only one left at home, his brothers having already
joined. He was in France about two months, and appears to have got
as far as the trenches, but his regimental medical officer reports him as
being extremely timid and quite useless. When he received any order

I.XIV. 19

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THE LORD DERBY WAR HOSPITAL,

[July.

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he appeared dazed, and a night’s bombardment completely unnerved
him. He was evacuated to England, and admitted to the L.D.W.H.
on August 26th, 1916, where he was found to be a typical case of
extreme hydrocephalic imbecility, being unable to read or write, and
naming “ London ” as the biggest town in Lancashire after long con¬
sideration. Asked for the name of five animals, gave ‘ sparrow,"
“dog,” and “swan.” He could only with difficulty repeat the months
of the year correctly. The marked features of his physical condition were
his stunted growth—5 ft. in height, and his head circumference, which
was 23 in. He was sent home to his parents on September 26th, 1916.

The next largest group is the group of confusional insanities. There
were 179 admitted, or 10 per cent, of admissions from France. An
example will be briefly described :

No. 64585, Pte. L. J—, ret. 40, grocer’s assistant. Enlisted August,

19 1 5.. One sister subject to attacks of depression, but has not been
in an asylum. Maternal aunt was in an asylum. Patient has always
been a healthy and temperate man. Married fourteen years ; one
boy age 13. Has had a good deal of business worry. Enlisted into
the R.A.M.C. and went to France December, 1915. In the early part
of June, 1916, patient was overworked, and was often for three nights
in succession deprived of rest. On June 22nd he was noted as being
depressed. The condition became worse, and he was evacuated to
England, and admitted to the L.D.W.H. June 4th, 1916. On examina¬
tion, the symptoms displayed were frontal headaches, confusion, and
delusions, e.g., that men were accusing him of drunkenness, cowardice,
and espionage, and that he was going to be shot. These were, no
doubt, the result of auditory hallucinations. Inquiry elicited that his
health had been gradually failing, that he had become constipated, and
could not sleep owing to noises in the head. Disorientation for time
and place were present. There was some exaggeration of his tendon
reflexes, but no other neurological signs. The case did well with rest
and liberal diet. While convalescing he was employed in the hospital
stores, and in March, 1917, was brought before a Medical Board and
discharged to his civil occupation, having made a good recovery.

The next largest group is represented by the.cases of mania.

There were 135 admissions, 37 of whom were discharged home,
3 were certified, 5 died, 16 were returned to duty for home service, and
62 still remain in hospital. The remaining 12 were transferred to other
hospitals.

We will now proceed to consider the dementia prcecox group.

There were 127 cases classed as such. The following example will
be quoted :

No. 22358, Gnr. L. I—, ret. 20, an iron-worker. Enlisted April,

1915. Father was in an asylum. Patient went to France January,

1916. Was admitted to the L.D.W.H. August 12th, 1916, diagnosed asa
hypochondriac. Whilst in France he said he had coughed up blood,
and that he had a “choking feeling,” that his bowels were seldom

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BY MAJOR R. EAGER, M.D.

285

open, and that the medicine given him was poisoning him. On
admission, his facial expression was vacant, and at first sight he struck
one as being unintelligent, but his degree of education was found to be
well up to the average. He, however, made ridiculous remarks to
ordinary questions, e.g., asked against whom we were fighting, said
“ the devil.” He had little insight into his condition, and his emotional
reaction was very much blunted. Physically, he had rather a poor
type of cranial development, and his sensibility to pin pricks was
considerably impaired. Flexibilitas cerea was well marked, but there
were no other neurological signs. Until March, 1917, the condition
seemed stationary, and he required to be dressed and undressed,
etc. From this time onward, however, he made considerable improve¬
ment, and on July 30th, 1917, this was sufficient to enable him to be
brought before a Melical Board for discharge to his home.

This case is one of a group which have been returned as dementia
praecox, and yet have made good recoveries, and I feel that in certain
of them it would be more strictly correct to call them dementia
praecox-like types of mental reaction, giving way under the strain of
active service conditions. For the cessation of the strain seems to
have removed the symptoms, and excellent readjustments have been
made in cases in which an unfavourable prognosis would have been
given from peace-time experiences.

The next group I shall consider is that of the neurasthenics. There
were in all 99 cases. By reference to Table IV it will be seen that this
group accounts for 6 per cent, of admissions from the French Expedi¬
tionary Force, and that of these 22 per cent, were returned to duty for
home service. The following case is an example :

No. 2370, Pte. J. A—, aet. 22, clerk. Enlisted August, 1914. No
history of nervous troubles in the family. Had medals for gymnastics,
and was an assistant scout master two and a half years. Went to
France in February, 1915. After five months’ trench experience had
a nervous breakdown, and was put on clerical duties. In the early
part of 1916 was again sent into the trenches, and towards the end of
June, 1916, he was reported strange in his manner and wandering
about aimlessly. He was admitted to hospital in France, evacuated to
England, and sent to the L.D.W.H. on July 21st, 1916. On admission,
he was in an extremely nervous condition, complaining of pain over
the precordia, and a difficulty in concentrating his attention on any¬
thing. Said his mind was continually wandering on the sights he had
seen in the trenches, and he has, on one or two occasions, found him¬
self crying without knowing why. His memory for recent and remote
events was quite good. He had no hallucinatory disturbance, and he
had good insight and judgment. Tremors were marked in his out¬
stretched hands, and his deep reflexes were all increased. Pupil
reactions were normal, and there were no other neurological signs.
He rapidly improved, and in November, 1916, was considered fit to be
discharged to home duty.

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286 THE LORI) DERBY WAR HOSPITAL, [July,

The next largest group is that of the general paralytics. There were
78 admissions from France, of which 2 are shown as transferred to other
hospitals, 4 were allowed to be taken home by their relatives, 48 were
certified for asylum care, 1 died, and 23 still remain in hospital. It
will be seen that general paralysis of the insane accounts for 47 per
cent, of the admissions from France, or somewhat less than the percentage
in the case of the home troops, which was 6 per cent. In Table II it will
be seen that the total admissions of this form of mental disease from
all sources was 112, or 4 - 6 per cent. ( s )

This group occupies the premier position with regard to cases trans¬
ferred to asylums. Out of the total of 154 cases so transferred up to the
end of the first twelve months 66, or 42 per cent., were cases of general
paralysis. Lest there should be any doubt as to the accuracy of the
diagnosis in these cases the clinical findings have been checked by the
Wassermann test in nearly every instance, and I now propose to give
the results. (Table V shows these in tabulated form.)

Table V.— IVassermann Results in Cases of G.P.I.

Blood examinations. —100 cases gave + reaction in 92 and — reaction
in 8. Of these :

3 -f fluid (bloods converted).

1 (?) fluid.

2 — fluid.

1 — fluid, — globulin, and — cell count.

1 fluid not examined.

Cerebro-spinal fluid. —In 92 cases examined there was + reaction in
84 and — reaction in 8. Of these latter

5 gave + blood reactions.

3 gave - blood reactions.

Globulin test. —In 39 cases examined the reaction was + in 38
and — in 1, corroborating all the other tests.

Cell count. —37 cases showed a leucocytosis out of 39 examined.

In only one case were all the results negative.

Both the blood and cerebro-spinal fluid were examined in most cases,
and since February, 1917, the globulin test and cell count have been
added. Out of the total of 112 cases the test was done in 100. The
blood examination gave a positive result in all except 8. Of these 8
negative blood results, 3 were associated with the positive fluid reaction,
and were evidently bloods converted by treatment. In a fourth case the
fluid was a doubtful positive. In 1 case the fluid was not examined,
and in 2 cases both the blood and fluid were definitely negative. In
the remaining case the globulin test was also negative, and there was
no leucocytosis.

The cerebro-spinal fluid was examined in 92 cases, and found positive

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BY MAJOR R. EAGER, M.D.

287

to the Wassermann reaction in all but 8. The 8 cases in which it was not
examined had all positive bloods except 1. Of the 8 negative fluid reac¬
tions 5 were associated with positive, and 3 with negative blood reaction.

The globulin test and cell-count were done in 39 cases. The
globulin reaction was negative on one occasion, corroborating the
findings of the other tests, and positive in the 38 remaining. In one
of these the blood was negative, and there was no pleocytosis, but the
fluid gave a slight fixation. In another the blood was positive,
the fluid gave a slight fixation, but there was no pleocytosis on the
first occasion. On repetition of the tests two months later however,
all were positive.

With regard to the cell-counts, there was a pleocytosis in all the
39 cases except for the 3 cases just mentioned, 1 of which, on repetition
of the test, gave a definitely positive result. Any count over 'io per
c.mm. was looked upon as abnormal, but the average was 60 or over.

I have to thank Capt. W. Parry Morgan, R.A.M.C., the pathologist
to this hospital, for the above results. ( s )

The following case will serve as an illustration :

No. 20956, Pte. N. G—, set. 39, blacksmith’s assistant. Enlisted
into the Army at the age of 19, and served in the South African
Campaign in 1901. His medical history sheet shows that a month after
his enlistment he contracted a syphilitic sore. In 1904 he went on the
Reserve, and was called up again on August 5th, 1914, at the outbreak
of the present war, since then his conduct sheet contains numerous
entries for “absence without leave,” “drunks,” and “riotous conduct.”
There are seven such entries in one period of five months, and six in
another similar period. He was wounded by shell at La Bass6 in May,
1916, and in October, 1916, he was medically examined at Lucknow,
and thought to be suffering from “ shell-shock,” for which he was
evacuated to England. He was eventually admitted to the L.D.W.H.
on February 24th, 1917. Here he was found to have all the signs of
general paralysis. He had well-marked tremors of his tongue and
facial muscles, his speech was unintelligible and inarticulate, and his
mental condition was approaching dementia. His deep reflexes were
much exaggerated, and his pupils Argyll Robertson in type. His
Wassermann test gave a positive reaction in both his blood and cerebro¬
spinal fluid on February 27th. There was a definite pleocytosis, and
the globulin test was also positive. The case took the usual course.
He showed rapid deterioration mentally and physically, and on
March 14th, 1917, died in hospital.

This case shows the date of the primary infection fifteen years before
the onset of the symptoms of general paralysis of the insane, as is
frequently illustrated in cases where the Army medical history sheet
covers this period.

“ Shtll-shock ” will now occupy our attention.—There were 63 cases.
The following is a typical example :

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2 88 THE LORD DERBY WAR HOSPITAL, [July,

No. 5928, Pte. Y. A—, set. 42, sawyer. Enlisted August, 1914. Was
twenty-four months in France, and his N.C.Os. give him the character
of having always been a very smart soldier. Had only one period of
three days’ leave. Was buried by a shell in July, 1916, being the sole
survivor of a blown-up traverse. He was sent down to the base
through a Field Ambulance and Clearing Station on July 27th, 1916.
On August 1st, 19x6, he was reported missing, and on August 3rd
found wandering at Amiens. On examination by Col. Myers, R.A.M.C.,
he was unable to give any account of himself other than his name, and
was found to be in a confused semi-stuporose condition due to “ shell¬
shock.” On admission to the L.D.W.H. on October 14th, 1916, he
was returning to his normal condition. He said he had been blowm up
and buried, and that when he was taken to hospital he was in a dazed
condition. He was suffering from very severe pain in the head, and
did not know what he was saying. He conducted himself well on
parole for many weeks, and was finally discharged home on April nth,
1917.(8).

The next largest group is that of the cases of so-called mental in¬
stability. This is a term that has been used to denote cases which are
liable to recurrent attacks, and there were in all 39 recorded as such.
Only 4 were returned as fit for service again, even for home duty,
and 2 were sent to asylums, having been previously under asylum care.

There were 33 admissions of cases of mental stupor , and of these 20
still remain in hospital. Only 1 has been returned to home duty.

There were 20 cases of secondary dementia.

Of these, 9 were discharged to their home, 2 were transferred to
other hospitals, and 9 still remain in the L.D.VV.H. Time and space
will not permit of any further consideration of these two groups. The
type of cases included in them were in no way different to those so
commonly met with in asylum practice.

The N.A.D. cases will, therefore, be next considered.

These cases were admitted as “ Mental,” but on examination and
detention showed no appreciable mental disease. There were in all
20 admissions of this kind from the French Expeditionary Force or
1 '2 per cent, of admissions. Of this number, 14 are recorded as having
been transferred to other hospitals. They were really transferred to the
surgical or medical wards in the L.D.W.H. according to their condition,
which had been wrongly interpreted as mental. Four were returned to
home duty, having nothing the matter with them.

Alcoholic insanity accounts for 19 of the cases from the French
Expeditionary Force, or i'i per cent, of the total admissions. The
small percentage of alcoholic case3 reflects very great credit on the
abstinence of our Army in the field. No case admitted to the
L.D.W.H. since its opening seems to have had its origin whilst in war
service. Lord Kitchener’s advice has evidently not fallen on deaf ears
as far as my observations have been able to discover.

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BV MAJOR R. EAGER, M.D.

289

The next group is that of the epileptics .—There were 26 cases. Fifteen
did not show any marked mental symptoms, and 3 of these were given
a trial on home duty. One was still in hospital at the end of the year
awaiting transfer to an epileptic colony, and the other n were dis¬
charged to the care of their relatives. Eleven cases were of the nature
of epileptic insanities, 4 of whom are still in hospital. One was trans¬
ferred to another hospital, and 6 recovered sufficiently to justify their
discharge to the care of their friends.

In only 2 cases of this group was there any history of “ head injury,”
and in 1 of these the notes show that the fits developed after a fall of
timber on the head whilst the patient was in a dug-out. On examina¬
tion, however, no evidence could be detected of any damage to the
skull, and, on further inquiry into the history, attacks of “ petit mal ”
were found to have started seven years previously. Only one case,
therefore, appears to be of the nature of a true “ traumatic epilepsy,”
and I will quote this as an illustration.

No. 1775, Sergt. S. J—, tet. 30. Enlisted in November, 1902, and
served in South Africa till 1904, when he went to India. Was there
till 1909, when he returned to England. Took his discharge with the
rank of Corporal in 1913. In August, 1914, he re-enlisted. At Loos,
in July, 1916, he was severely wounded in the head by shell, and was
'unconscious till he arrived at Dover, and from there he was sent to
hospital in London. On admission there on August 4th, 1916, he is
described as having a healed semi-circular scar nearly the size of the
palm of the hand over the posterior part of vertex of skull. He com¬
plained a good deal of pain in the back of the head, but had no
paralysis. His pupil reactions were normal. Mentally he had a com¬
plete retrograde and partial anterograde amnesia. In December,
1916, he attempted to throw himself under a train, and later he was
discovered with a razor hidden in his bed. He was eventually
admitted to the L.D.W.H. with the report that he had become very
depressed, and had expressed the idea that life was not worth living.
On admission to this hospital he said he felt quite well, and blamed the
nurses in the London Hospital for his transfer, saying that they did not
understand him. He admitted that when he arrived in London he
could not remember any details of his past life, and that everything
seemed blank, but said that since then his memory seems to have come
back all right. He did not complain of headache, or giddiness, said he
slept well and felt well in every way. He denied having had any liquor
since his head injury. On examination of his skull he was found to
have a large depression in the upper and back part of his right parietal
region extending right up to the vertex. The bone was absent over this
area, and pulsation could be plainly felt on palpation. X-ray examina¬
tion showed a trephine opening about 1} in. in diameter. No metal
was present. Three months after admission he complained of biting
his tongue frequently in his sleep, and a few days later he had a “ fit ”
whilst in the hospital grounds, following whi h he was in bed for a few
days with a definite paresis of his left leg. This passed off and he was

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able to be up and about again as usual in a short time, but his mental
condition became much more irritable, and he seemed to be distinctly
developing the epileptic temperament. He still remains in hospital.

Out of the total number of epileptics admitted to this hospital during
the period under review, viz., 41 cases (see Table II), there was only one
other case of true “traumatic epilepsy,” and this was the case of a
Canadian who died in the status epilepticus twelve months after a gun¬
shot wound of the frontal region from which an abscess had been
evacuated by operation. In this connection I should like to mention
that out of a consecutive series of over fifty cases of head injury received
in action which I have investigated, the two cases here mentioned are
the only instances so far of true traumatic epilepsy.

The next group is the one shown as acute delirium.

There were 14 cases recorded during the year. These were all of
the post febrile variety, following on some acute illness or suppurating
wounds, and the following is an example.

No. 15/37904, Pte. C. T—, <et. 42. Enlisted April, 1916. A
labourer. Went to France in July, 1916. Patient was admitted to
hospital about February 10th, 1917, with pneumonia following an attack
of bronchitis ten days previously. On February 17th his temperature
reached 104-8° F., and he became acutely excited, rambling in his con¬
versation, and quite irresponsible. His temperature came down by
crisis on February 20th, and he was evacuated to England and admitted
to the L.D.W.H. on March 2nd. Here he was found to be in a very
weak, highly nervous condition, but his acute excitement had consider¬
ably quieted down. He could not remember anything of his acute
attack except that he seemed “ to lose his head.” He progressed satis¬
factorily, and at the end of the year (June 16th, 1917), although still
remaining in hospital, he was convalescent and awaiting his discharge.

Under the heading of hysteria there were grouped 4 cases. Three of
these were discharged from the Army to their civil occupations, and .
one was returned to duty on home service.

The following illustration will suffice :

No. 9398, Pte. J. A—, aet. 21. A butcher. Enlisted September 13th,
1913. Went to France in August, 1914. Wounded in the shin in
September, 1914. On December 15th, 1916, he stuck in the mud on
the Somme for over twenty-four hours, and was quite exhausted when
he was pulled out. On arrival at hospital he found he had lost the use
of his legs. He improved with rest, and was able to get about a little
after a week or two, but on January 2nd again became paralysed in the
legs. He was evacuated to England on January 12th, 1917, and
admitted to the L.D.W.H. Here he complained of pains in the back
and legs, and great weakness in the grip of both hands. He also had
severe attacks of headache at times. On February 18th he had a fit of
an hystero-epileptic nature, during which he threw himself about and
attempted to bite his arms. In March he was still in bed, and when

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placed on his feet he at first slipped down and made no attempt to
walk, but with the support of two orderlies he could walk quite well.
There was no wasting of muscles and no tenderness in the limbs. He
continued to have hysterical fits, chiefly at night, up to the end of
March, but since then has had none. On May 25th he had completely
recovered, and was discharged to his civil occupation.

There were 3 cases returned as “ Moral Insanity ,” and of these 2
were discharged to the care of their friends, and 1 still remains in
..hospital. In one of these the moral side of his character seems to have
been definitely affected since a gunshot wound of his head, received
whilst sniping in a shell-hole near Guillemont in September, 1916. He
was a boy set. 19, who was unreliable in his statements and told lies in
the most barefaced manner possible, which was stated by his father and
schoolmaster to be a complete change from his former disposition.

For the other two cases there was a definite history of insubordina¬
tion and moral deficiency prior to enlistment. One had been six years
in a reformatory for larceny, and the other sent to a truant school for
absenting himself from school as a boy. Both had run away from home
as boys, had been discharged from the Army and re-enlisted, and had
been arrested for desertion in France. One also effected his escape
from this hospital. In one of these cases the family history was not
known, and in the other the patient’s maternal aunt was in an asylum.
Both had degenerate faces, with coarse features and poor cranial
developments, but both described themselves as feeling perfectly well;
were alert and replied smartly to questions, and showed a fair amount
of school knowledge. They were extremely plausible, and rarely at a
loss to explain anything away which was contrary to custom. They
seemed proud of their past criminal records, and at the same time pro¬
fessed good resolutions for the future. One boasted that a special
Salvation Army pamphlet had been written about him, and was anxious
that the doctor should read this. Neither of the cases seemed able to
discriminate adequately between right and wrong, and could not be
trusted in anything they did or said. It was certainly a wise proceeding
to evacuate these cases from the Front, as it is impossible to estimate
what mischief they might have caused. One had already obtained the
distinction of throwing a bomb at an officer, and gave as an excuse that
the officer swore at him.

There were 3 cases diagnosed as “ Impulsive Insanity," and of these
2 were returned to duty for home service, and the other was trans¬
ferred to another hospital. The following is a brief description of these
cases :

One patient was in hospital suffering from nephritis, and because he
was kept on milk and not allowed to have any ordinary diet he
threatened to commit suicide, became emotional, refused all nourish¬
ment, and generally abused the medical and nursing professions.

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The second case was on his way up to the Front, and entered the
wrong train. On being ordered out of the railway carriage by an officer
he threatened to shoot him. He was disarmed and sent to hospital,
and became very excitable and emotional about being kept from joining
his unit. He quickly quieted down again.

The other case had been gambling and lost his money, and as a result
had attempted to shoot himself with a revolver. The kick averted the
barrel, and the shot only hit his cap. He ascribed his depression to the
loss of his money, and S3id that the thought of suicide came as a sudden
impulse. He showed no further signs of loss of control whilst under
observation and has returned to duty.

There were 3 cases of cerebral syphilis, of which 1 was discharged to
his civil occupation, and 2 died. An example of the latter is as
follows :

No. 503467, Pte. H. J—, aet. 28. Admitted to the L.D.W.H.
August 31st, 1916, in an exhausted debilitated condition, lying motion¬
less in bed, and requiring spoon-feeding and every attention. Had
some left facial and upper arm paresis, and a left external rectus
paralysis, but seemed to be able to move the left leg fairly well. Pupils
equal, and reacted to light. Both discs well defined and of normal
colour. Surrounding fundi normal. Mentally he was disorientated in
time and space, and was in a generally confused state. Said he had
been sent to hospital in France because a pole hit him on the head.
Now asked permission to go to his depot for money to buy some fruit,
which he said would make him feel “ good,” and he was quite sure he
could make the journey, although his bedridden condition was pointed
out to him. His Wassermann reaction in the blood and cerebro spinal
fluid was positive. He was put on mercurial treatment, and on October
13th had a generalised convulsion with stertorous breathing and uncon¬
sciousness, lasting about ten minutes. This was repeated on the 23rd
inst., and the patient was then obviously going down hill very rapidly.
He gradually became weaker, and on December 10th died.

There was only one case of brain tumour , and this patient died in
hospital when the diagnosis was confirmed at post-mortem , and the
tumour found in the left temporo-sphenoidal region.

There was one case of locomotor ataxia, who had been six months in
France, and returned to England with some memory defect and general
mental deterioration.

The only remaining case to mention is that of a man returned from
France as “ shell-shock,” the confirmation of which has not yet been
established, and is therefore returned as not yet diagnosed (N. Y. D.).

The above groups account for the 1,652 cases admitted from the
French Expeditionary Force, but there were in addition the following
admissions from other sources :

The troops from Mediterranean, 14 ; Mesopotamia, 63 ; Egypt, 141 ;
Salonica, 97 ; East Africa, 4 ; Cameroons, 1 ; Pensioners, 6 ; Officers, 1.

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293

The latter was taken as an emergency case owing to lack of accommo¬
dation elsewhere.

The above admissions, added to those from the French Expeditionary
Force, brings the grand total of admissions from overseas forces during
the year to 2,140.

In comparing the various forms of mental diseases in the different
expeditionary forces as just enumerated, it is found that the highest
percentage of confusional insanity occurred in the cases from Salonica
and France. There were 16 per cent, from Salonica, 10 per cent, from
France, 7 per cent, from Mesopotamia, and 6 per cent, from Egypt.
The cases from Salonica were all of the nature of exhaustion psychosis
following attacks of dysentery and malaria, the latter being the more
common.

Several of these were of the polyneurotic variety, exhibiting Kors-
sakow’s syndrome. The comparatively high percentage from the French
Front is accounted for by the inclusion of cases which were probably
true shell-shock. Owing to the absence of any definite history of shell¬
shock accompanying them from overseas in their records, however, it
was not considered justifiable to diagnose them as such, and they were
therefore returned as “confusional insanities.”

Summary and Conclusions.

Admissions. —The total number of admissions from overseas was
2,140. This number, added to the total admissions figuring as “ home
troops,” which has been shown to be 289, brings the full number of
patients admitted to the mental division of this hospital for the first
twelve months up to 2,429. Of this number 1,466, or 60 per cent.,
were discharged, and 963, or 40 per cent., remained in hospital at the
end of the twelve months. This latter figure will be seen to be
reduced to 390 four months later by referring to the last column of
'Fable 1 ( 5 ).

Discharges. —Out of the 1,466 discharges 247, or 16^9 per cent., were
thought fit to return to duty again for home service. A circular letter
was addressed to the friends of 170 of these cases some months after
their discharge, inquiring into their progress. Replies were received
from 123, and the information obtained showed that 68, or 55 per cent.,
were keeping fit and well, and of this number 28 had already returned
to France on active service. In 27 instances the reply showed that the
men were still on duty, but in an unstable condition, and 19 were shown
to be in hospital again. In 10 instances the reply was to the effect
that the men had been discharged the service, and 5 replied that they
could give no information.

The number of cases discharged from the hospital by a Medical
Board to their civil occupations was 823, or 56 per cent, of the

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total. Inquiries made from the other mental sections in England
and Scotland showed that only 4 had been admitted there who had
been discharged from this hospital, and the number of re-admissions to
this hospital only amounts to 5. It was found necessary to certify
154 cases (10 per cent, of discharges, or 6 per cent, of the total admis¬
sions), and nearly half of these have been shown to be cases of
general paralysis of the insane. The remainder had been in asylums
prior to enlistment, or were cases associated with epilepsy.

Treatment .—The usual asylum treatment was adopted as a matter of
routine, but the relatively larger proportion of medical staff to patients,
and the greater facility for massage and any specialised treatment than
is customary in present-day asylum practice, I feel sure contributed
largely to the high percentage of recoveries. Much more individual
care and attention was possible on the part of the medical staff. Each
medical officer had his own room for private examination of cases,
thereby assuring the patient that his statements would be treated in
confidence. During the interview explanations could be given to each
case as to the nature of his illness, and he could be shown how to
regain his normal condition. Confidence inspired like this has proved
a great help in early cases. Beds in the open air were provided for
those to whom it was thought rest in bed would be beneficial. As
soon as convalescence was established, patients were recommended for
parole, and allowed to go about by themselves in the hospital grounds
and into the neighbouring town, provided they returned to hospital at
the specified time. This privilege was much appreciated, and very
rarely abused. The average number daily having this freedom from
lock and key was 150.

Occupation .—Employment on the farm and in the gardens of the
hospital has been encouraged for suitable cases. About 80 to 100 patients
daily have been so employed. Advantage has also been taken of the
workshops belonging to the hospital, and any man having a special
trade was given facilities for working at this during his period of
convalescence, thus preparing himself for the work he was going
to take up again in civil life on his discharge from the Army. This
has helped in a large measure to establish the man’s self-confidence,
but I feel I should also add that the patient’s convalescence must be
first firmly established, otherwise it is sure to prove a failure, and the
end result will be a confirmation to the patient of his disability and a
protraction of the case.

Wassermann tests .—There were 269 cases so examined between
September, 1916 (when this was first started at the Lord Derby War
Hospital), and June 16th, 1917. Out of this number 209 cases had
the examination done both in the blood and cerebro-spinal fluid, but in
60 the blood only was examined.

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295

Conclusions .—The cases received were all in the early stages of
mental disorder, with the exception of the mental defectives, and even
in these cases many of them showed acute symptoms superimposed on
the congenital defect. A fair comparison, therefore, of the percentages
of recoveries with those of civil asylum statistics cannot be made.
Further, many of the cases admitted would not have been certified for
asylums in civil life, and this seems to be supported by the low
percentage of general paralytics in comparison with the figures avail¬
able from the report of the Commissioners in Lunacy. Many of the
neurasthenics and shell-shock cases would not have been included in
the uncertifiable, but it will also be seen that, strictly speaking, the
only cases which did not show any mental symptoms amounted to 25,
or only 1 per cent, of the admissions. Experience gained amongst this
Jarge number of uncertified mental cases in the early stages of the dis¬
order convinces me that the treatment of such conditions in receiving
hospitals other than asylums would, if properly and carefully organised,
save a large number of cases from the stigma of certification. ( 6 ) The
first essential would be an adequate medical staff to allow individual
attention to every case. It has been a striking feature of the wards in
the mental section of this hospital since its opening that where this was
given the most contented patients were to be found. The mere visit
of the medical officer to the wards and the official “ walk round ” is not
the way to help any cases suffering from mental disorder. It is
necessary to obtain a thorough insight into the nature of each case by
confidential talks with the patient, and to find out the particular
circumstances which have given rise to the symptoms presented. An
explanation of the same to the patient will help him to gain an insight
into his condition, and it is idle to pretend that such a procedure is
unnecessary, and to urge, in extenuation of the omission to search for
causes, that some cases recover under “ quiet” and “rest.”

I have to express my thanks to my colleague, Lieut. E. G. Grove,
R.A.M.C., for much time spent in reviewing the manuscript of this
article, and for many valuable suggestions and alterations. My thanks
are also due to Lieut.-Col. Simpson, R.A.M.C., Officer Commanding
the Lord Derby War Hospital, and Col. Aldren Turner, C.B., A.M.S.,
Consulting Neurologist to the War Office, for giving me facilities for
compiling these statistics.

References to Articles ai ready Published on the War
Neuroses and Psychoses.

Mott, Lieut.-Col., R.A.M.C.—“ Lettsomian Lectures.”

Myers, Lieut.-Col. C. S., R.A.M.C.—“ Contributions to the Study of
Shell-shock,” Lancet , February 13th, 1915; January 8th, March 18th,
and September 9th, 1916.

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Mitchell Clarke, Lieut.-Col. J., R.A.M.C. — "Some Neuroses of the
War,” Bristol Med. Chi. Journ., July, 1916.

Elliot Smith, Prof.—"Shock and the Soldier,” Lancet , April 15th
and 22nd, 1916.

Hotchkis, Major, R.A.M.C. — "A War Hospital for Mental Invalids,”
Journal of Mental Science, April, 1917.

Norman, Capt. H. J., R.A.M.C.—“ Stress of Campaign,” Revieso
of Neurology arid Psychiatry , August-September, 1917.

(') Paper read at Spring Meeting of the Medico-Psychological Association
(Northern and Midland Division) at the County Asylum, Rainhill, April 18th,
1918.—( 2 ) The Commissioners in Lunacy’s Report for the year 1913, Table XIX
shows that of the total male admissions into all institutions for lunatics during the
five years 1907-11, general paralysis accounts for 12 per cent. —f 3 ) Flemming’s
method was used as a control to ihe findings obtained by the original Wassermann
method, modified by the use of human blood instead of that of the sheep and
guinea-pig.—( 4 ) Further observations on cases associated with “ shell shock ” have »
been recorded in another article, see B. M. J., April 13th, 1918.—( 5 ) Of this number
only 101 patients had been resident twelve months.—( 6 ) See letter to the Lancet
of November 24th, 1917, by Sir Robert Armstrong Jones, Major, R.A.M.C.

Clinical Notee and Cases.

Clinical Observations on the Various States of Excitement in
Insanity .(') By R. M. Toledo, M.D., Assistant Physician, Govern¬
ment Lunatic Asylum, Malta.

Mk. President and Gentlemen, —Of the many hundreds of insane,
remitted annually to mental hospitals, the majority are admitted in an
“ excited state.” They all exhibit in common several of the charac¬
teristic signs of what is known as " mania,” yet very few of them are
really “ maniacals.”

My object this afternoon is to point out to you certain signs and
symptoms which may help to decide, as early as possible, of the true
nature of insanity from which a patient, brought to us in an excited
condition, is suffering from. It is evident how this is important for
the proper treatment of the patient himself and for the protection of
others.

Very often a patient is received exhibiting restlessness, resistiveness,
and incoherence of speech. He may answer to your questions rationally
or perhaps not. He generally succeeds to give you his name correctly
and those of his parents or children.

Another patient, “ excited ” as the first one, fails altogether to answer
you ; he is unable to tell you his name or from where he comes. He
does not even take any notice of you and of his surroundings, he utters

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incoherent words, and seems to see “ objects.” The first case is
probably one of real mania, the second one of confusional insanity, or
amentia, as it is often called.

The maniac very seldom loses all his power of attention, and,
although he distracts himself easily from rapid fatigue, yet the doctors
succeed in getting from him one or two sensible answers.

On the contrary, nothing can distract the ament from his “ dreamy
state,” he is totally dissociated from the world, an 1 he even fails to feel
the stimuli of his “ vegetative ” life. He does not care to nourish
himself, he wets his bed, and his habits are dirty.

The maniac is rarely of wet habits, asks for food continually, and
everything attracts his attention. He makes remarks about your
clothes, about the features of the attendants, about the books, lamps,
and clocks he may have noticed in your office. He recognises familiar
faces.

One of the most characteristic signs of. “amentia” when the patient
is not altogether lost to his surroundings, which happens when he is not
at the pitch of the disease, are “ mistakes of identity.” I remember a
seaman who after a fortnight of regular “ dream consciousness ” com¬
menced to answer simple questions. He believed he was still on board,
and mistook me for the master of the ship. He thought he was “ sea¬
sick,” and he was surprised of feeling so after “ twenty years of
seafaring.”

The relatives of the maniac may inform you that some time previous
to the attack the patient was dull, avoided his friends, and refused to
go out; those of the ament, that the symptoms came on suddenly
during the convalescence of influenza, measles, or rheumatic fever, 01
that he had just lost a considerable quantity of blood. I know a case
that came on “twice” within three years after a most severe epistaxis.
It may be the case of a woman nursing her baby.

While mania is of a toxic nature, amentia is due to an insufficient
nutrition of the neurone and its exhaustion.

Our next patient is perhaps between the age of 50 and 60. He
reaches the hospital screaming. He very often refuses to leave the
cab. Looks frightened and stares at everybody. Has an anguished
expression in his look. He is perhaps trembling. He will not sit
down, but paces the room continually. If you question this man, he
answers coherently, and if by way of introduction you ask him to put
his tongue out or to feel his pulse, he very often tells you that he feels
a pain in the region of his heart, one of the most distressing subjective
sensations accompanying mental anxiety. This patient may think that
you are the magistrate or the police inspector and the place he was
brought to a prison or a court of justice. You should never, in the
presence of such patients, go through their admission papers. They

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think you are reading an order to send them to the scaffold or to burn
them alive. Some hear distinctly the voices and the shrieks of their
far-away children. The noise of an approaching cab, the ringing of
bells, the working of an engine, increase their anxiety. Such patients
may tell you that they have been falsely accused of the most horrid
crimes, and that the neighbours have been gossiping about them for
■months. They refuse to keep their bed and to take nourishment. If
their breath becomes offensive, feed them forcibly at once, as they
•exhaust themselves very rapidly. Needless to say, all this symptoma¬
tology points to “ acute melancholia,” as, although such sufferers are
nearly always “ very excited,” yet one can see clearly that there is
always a decided depression in their emotional attitude.

Now I must speak to you about a very serious disease which at its
onset is very often mistaken for simple mania. I refer to dementia
praecox, a disease which is unfortuuately very common and almost
incurable. It is in what it is called the “ predemented stage,” that this
disease is often taken for mania, or, if “hypochondriasis” prevails, for
neurasthenia.

Patients are generally brought to the asylum in a restless condition.
They are incoherent in their talks and troubled with auditory hallucina¬
tions. Very often the relatives will tell you that the patients have been
smashing tumblers and plates at home without any motives and
without exhibiting any anger or the least sign of emotion. This is
characteristic of the disease, and differs much from the way the maniacal
exhibits violent tendencies.

The maniacal fights those around him, especially if he is interfered
with in any way, does not give reasons for his acts, at times he ignores
them ; the praecox finds an old man in a corner and slaps him, and if
you ask him why he did it he perhaps tells you that the old man has
been sneezing too much, or that he was an enemy of his grandfather.
I know of praecox patients whose “ silly ” behaviour in prison has been
mistaken for simple insubordination. As at times, there is very little
apparently indicating “ insanity,” they are often considered as lazy and
insubordinates and severely punished.

Both the maniac and the dement may commit rash acts, but while
the former is unable to explain them, the latter is quite ready to find a
“ motive.”

The following two cases illustrate how absurd these “ motives ”
can be:

Case i.—A lad, while corning from England, jumped into the sea as
the steamer was approaching St. Paul’s Bay. It was a January evening
and bitterly cold.

He was rescued by a fishing-boat not very far from the shore and
sent straight to our asylum as “suicidal.” I received him about mid-

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night, and he laughed heartily on being told that he was sent to the
asylum as the doctors thought that he wanted to do away with his life.

He assured me that he jumped into the sea to have a good swim
before landing. In fact, he swam for a good distance, about a mile,
before being picked up.

Case 2.—A lad was sent to us as a suicidal. He was wounded in
the face, having jumped from a high window. He told me that he did
so to pick up a cigar which he had noticed on the pavement.

There was very little at that time to diagnose prsecox; few months
have sufficed to make of these two lads a complete mental wreck.

If one follows a maniacal and a praecox in the wards, he will soon
notice how differently they behave in their excitement. The maniacal
passes his time jumping on tables and dancing. The dement spends
his hours going round the same chair for hundreds of times, or walking
on tip-toe, or kneeling down. It is characteristic how they can keep
for whole hours the same attitude, however uncomfortable this may be.
They are very fond of corners, putting their faces against the wall.

The maniacal likes to kick, the dement to slap or to bite. Others
spit in one’s face.

At table the maniacal swallows his diet in a minute, the prsecox takes
a full hour to do it, some keep the last morsel in their mouth till the
next meal.

While the maniac sleeps very often quite naked, the dement likes to
muffle himself up with many blankets.

You should be very careful in approaching a. prsecox while he is in
bed. He may strike you, simply to show you that he is not asleep.

One of the most characteristic signs of prsecox is resistiveness. Try
to bend the arm or the head of your patient or to open his mouth or
hand you seldom succeed. You feel them hard as iron.

Laboratory investigations have proved that this muscle over-tension is
due to a toxin similar to adrenalin, the effect of a disturbed gland
metabolism, and at post-mortem examinations, degenerative changes in
the supra-renal glands, testicles, and ovaries have been noticed.

Praecox gets generally very, very stout. Loss of weight should
induce one to examine the patient for tubercle of the lung, as they are
much predisposed to this disease.

I fear that my paper would be considered incomplete if I fail to
refer to a mental condition resembling acute mania, which at times
appears at the very onset of several infectious diseases. It is known
as “acute delirium,” and is characterised by extreme restlessness,
incoherence of speech, and hallucinations of sight and hearing. It has
nothing to do with febrile delirium. The temperature is never high,
and is very often below the normal.

The acute delirium does not generally last long, if it lasts the general
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condition of the patient gets worse rapidly, and collapse and death
follow. The Germans call it “ collapse delirium.”

I have seen several cases in connection with Mediterranean fever
and enteric fever. Three cases ended fatally, including a case of
erysipelas of the arm.

The following two cases are of interest :

Case 1.—A man was found by the police in the street almost naked.
He was gesticulating and screaming and in the act of fighting imaginary
objects. He was taken to the police-station, where he was very rest¬
less and clamorous. The doctors remitted him to our asylum as a case
of mania.

On reception the temperature was ioo° F. He was not clamorous,
but he was muttering incoherent words. He was unable to answer
questions. The examination of the chest revealed lobar pneumonia.
His wife stated that the patient had returned from work on that day
complaining of headache. The next day the delirium disappeared and
the temperature rose to 103° F. The patient was quite sensible in his
answers, and he was able to give to his wife important instructions. He
died the day after from collapse.

Case 2.—A private of the Royal Militia was sent to us from a
military hospital for acute mania. He was received at 8 p.m. in a very
restless state. He spoke incoherently, and passed fteces and urine
involuntarily. Temperature on admission 99 0 F. He could not
answer any questions. He passed a sleepless and restless night.
Early next morning the delirium disappeared, and when I saw him
about six o’clock he asked me where he was and how long he had been
in. He remembered that on the previous day he vomited twice and
that he was removed from Gargur Camp to Valetta Hospital. He did
not remember anything else and wished to be left alone. He com¬
plained of pains in the back and headache. The case proved to bc
one of cerebro spinal fever. The patient was removed to the isolation
hospital of Imtarfa, where he made a good recovery, remaining,
however, completely deaf.

Want of time does not allow me to point out in detail how often
senile dements and alcoholics and sufferers of such neuroses as epilepsy
and chorea are admitted to our wards in a state of excitement.

Each of these diseases has its own symptomatology, and there should
be no difficulty in arriving at a correct diagnosis if a careful history is
taken of the case.

(*) Read at the General Meeting of the Malta Branch of the British Medical
Association on January 21st, 1918.

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Part II.—Reviews.

Sixty-six/h Report of the Inspectors of Lunatics ( Ireland) for the year
ending December 31 st, 1918.

This report, like its predecessor, appears in much attenuated form.
In pre-war days it used to extend to over 200 pages; in this report they
number only 83. The reduction in size is, however, mainly due to the
omis'ion of the Inspectors’ Memoranda on individual institutions, which
took up a considerable space. The report itself is also somewhat cur¬
tailed, and a few of the statistical tables are omitted.

Although caution is still advisable in order to avoid hasty conclusions,
there seems but little reason to doubt that insanity in Ireland is definitely
on the decrease and that the turning-point has been at last reached. The
Inspectors have again to report a reduction in the number of insane
under care, and a very substantial decrease as compared with that of the
previous year, the decrease for the two years having been 77 and 337
respectively. It is curious that in 1915 the reduction in numbers was
confined to males, while the females showed an increase, whereas in
1916 the opposite was the case. The total number under care at the
close of the year was 24,766 as compared with 25,103 in the previous
year.

A table on p. viii gives the proportion of insane under care per
100,000 of estimated population in quinquennial periods from 1880 to
1914, during which period the ratio rose from 268 to 566, or practically
double. But if the percentage increase in each successive five-year
period be computed, we get the following series of figures:

1880-1884

Proportion per
100,000 population.

268

Percentage
• increase.

1885-1889

312

1641

1890-1894

366

17-3°

1895-1899

433

18-30

1900-1904

499

15-24

1905-1908

541

8-42

1910-1914

566

4-62

This table shows a large reduction in the rate of increase during the
15 years 1900-1914. In 1915 the ratio was 579, an increase of 2-29 per
cent, over that of the previous quinquennium, while in 1916 there was,
for the first time, an actual decrease in the proportion of 571, a reduc¬
tion of 1 ‘38 per cent. These figures are highly significant, and may,
we think, without much risk, be taken as a positive indication that in
Ireland insanity is on the decline.

This conclusion is supported by the fact that there was a reduction
in the number of admissions of 171, district asylums showing a decrease
of 141 and private institutions of 30, the decrease being wholly confined
to female patients, while the male admissions showed an increase of 6.
The diminution in the ratios of admissions to population has been
going on for a number of years, the percentage decrease of each of the
quinquennia 1905-1909 and 1910-1914 having been 3-49 and 241 for

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total, and 2^94 and 3’03 for first admissions respectively. This relative
reduction in the ratio has been practically maintained during the last
two years, the figures for 1915 and 1916 being 37 and 3‘84 for total,
and 3‘i2 and 3^22 per cent, for first admissions respectively. From
these facts there would seem to be but one conclusion.

The daily average in district and auxiliary asylums shows a reduction
of 63 males and 51 females, a total decrease of 114, this being the first
occasion on which a decrease could be recorded.

As regards the forms of insanity, by far the large majority were of
mania and melancholia—1,247 maniacal and 1,057 melancholic cases—
the former being in a considerable preponderance.

With respect to causation, heredity was assigned as a principal cause
in 876 cases, a ratio of 26'8 per cent., and as principal or contributory
in 1,147 cases, or 35 per cent. Alcohol appeared to be the principal
cause in 280 cases, or 8 5 per cent.; as principal or contributory in 383,
or 117 per cent. These are comparatively low ratios, but only what
might have been expected from the scarcity and greatly increased cost
of all alcoholic beverages, which puts anything but the most moderate
indulgence, if any, out of the reach of the vast majority of people. It
has often been said that you cannot make people sober by Act of Par¬
liament, but lunacy statistics, at any rate, appear to show that intemper¬
ance is minimised when the facilities for indulgence are reduced.

Mental stress was assigned as a principal cause in only 119 per cent.
of the admissions, as compared with i3 - i6 in the previous year. The
cases in which it was said to play any part were 17‘5 per cent, of the
total, as against 1922 percent, in 1915. This factor, therefore, shows,
as regards its influence in the causation of insanity, a decided falling
off. The cases in which the war was assigned as the principal cause
were 17, being o - 48 per cent, of the total, as compared with 12 or o'32
in the previous year. The total number in which it acted as either
principal or contributory cause was 30, while in 1915 it was 44, showing
a percentage of 0 85 and 1*19 respectively. One hundred and two
soldiers and sailors were admitted, in whom the war was considered to
be a cause of their insanity, but the Inspectors are of opinion that no
conclusions can be drawn from the figures, so few cases of men who
have been on active service have been sent to district asylums.

Of a total of 3,268 admissions, 1,942 were committed as “dangerous
lunatics,” or nearly 60 per cent. It is as surprising as it is regrettable
that this objectionable method of dealing with the insane of the humbler
classes should continue to be in force in Ireland, the only country in
the world where such a method is sanctioned or would probably be
tolerated. Seventy or eighty years ago, before the true nature of insanity
had been properly grasped by the public generally, some justification
for action of this kind might have been forthcoming—for instance, in
the case of violent patients. In this twentieth century and in the light
of our present knowledge, imperfect though it may still be, there is
absolutely no excuse for the perpetuation of such a system. An insane
person is suffering from disease or disorder of the brain—a patient, in
fact, just as much as anyone suffering from disease of any other organ
—heart, liver, etc. Because such a patient, say a woman, threatens to
take her own life when in a condition in which she is not responsible

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1918.]

for her actions, is that any reason why she should be arrested as a
criminal, haled before two magistrates and committed on warrant by
them, and sent to an asylum in charge of police ? There is often,
especially in remote districts, considerable difficulty in getting two
magistrates sitting together, which involves delay and bringing the
unfortunate patient about from post to pillar in search of the proper
authority. It is little short of cruelty to the person principally con¬
cerned, not to speak of the ignominy incurred by having to submit to
these measures, which many patients are quite sensitive enough to feel.
The whole proceeding is a totally out-of-date method, an anachronism,
which admits of no defence in the* present day. It is a blot on the
legal procedure of this country and should be abolished, and the pro¬
cedure in such cases assimilated to that in use in other civilised
countries.

The percentage of recoveries on admissions was 40^6, or 2'4 higher
than that for the previous year. The ratios in different asylums differ
to an almost astounding degree, from the lowest, 12 4 in Sligo, to a
maximum of 86'3 in Monaghan, where the male recoveries reached
the amazing proportion of 100 per cent. I We cannot but think that the
term “recovery” must have a different meaning, or that a different
basis for estimating recoveries is adopted, in the several institutions.

The death-rate also differs considerably, although not at all to the
same extent as the recovery rate, the lowest being in Ennis Asylum, 4^9,
and the highest, 131, in Belfast. It is difficult to discover any cause
for these differences. For instance, Letterkenny comes second highest
as regards mortality, the rate there being 11 '37 per cent. Now, in Ennis
there is great overcrowding, the accommodation being stated to be for
380 patients, while the daily average was 533. In Letterkenny, on the
other hand, the accommodation is for 757, and the daily average 689,
there being thus quite a considerable amount of surplus space available.
The problem would have been easier of solution had the figures in these
two asylums been reversed. In the case of Letterkenny, epidemics of
influenza and enteric occurred, the latter disease suggesting that there
may be some defect in the sanitary arrangements. It is worthy of note
that the outbreak ceased after a large number of inoculations with anti¬
typhoid serum had been performed.

The relative mortality from phthisis continues to fall, having been only
20’1 of the total mortality, as compared with 20 6 in the previous year.
In the period 1895-1899 it reached its maximum, the ratio for that five-
year period having been 29 - 2. Since then it has been steadily decreasing.
The deaths from general paralysis (72 or 4'i per cent.) were higher than
in 1916, when they w r ere only 54 (3‘2 per cent.), the average for the pre¬
ceding 5 years (1910-1914) having been 4^4 per cent. Variations in the
mortality from this disease occur from year to year, but there does not
appear to be any material increase in its incidence.

The total expenditure incurred during the year ending March 31st,
1916, both for maintenance and other charges, including repayment of
loans, was ,£706,197 8j. 2d., showing an increase of £74,569 i8j. as
compared with that of 1914-1915. This is a large increment, amount¬
ing to nearly 12 per cent. But we live in extraordinary times, and
expenditure, like most other things, is bound to be extraordinary.

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With the exception of this last item, the report of the Inspectors is,
on the whole, encouraging.

Alcohol: Its Action on the Human Organism. London : H.M. Sta¬
tionery Office. 19x8. Pp. 144. Price 2 s. 6 d.

The consumption of alcohol in the United Kingdom, as is well
known, has slowly but steadily fallen during the present century. The
year 1900 represents the crest of an upward movement and the con¬
sumption per head of the population reached in that year—alike as
regards beer and spirits and wine—lias been declining ever since. The
recent regulated limitation of consumption has merely accelerated that
decline, and the decrease during the war years 1914-1917, large as it
may seem to some, only represents exactly the same numbers of gallons
per head as the fall during the years 1901-1913.

The Central Control Board, which has been responsible for the regu
lations and arrangements under which this accelerated decline has
occurred, takes a broad and enlightened view of its functions, and in
1916 appointed an Advisory Committee to consider the physiological
action of alcohol and its effects on health and industrial efficiency.
The members of this admirably constituted Committee were Drs.
Cushny, Dale, Greenwood, McDougall, Mott, Sherrington, and Sullivan,
with Lord D’Abernon as Chairman and Sir George Newman as Vice-
Chairman. The Committee resolved, as a basis for further research, to
prepare a review of the existing state of scientific knowledge, as distinct
from surmise, conjecture, or popular belief, and to set forth this review
in a serene and unimpassioned temper likely to further the progress of
those problems in regard to alcohol which still call for scientific inquiry.
The review is embodied in the present little volume which represents
the unanimous judgment of the Committee.

The scope of the inquiry made it necessary to omit various problems
which are still undecided, as well as to leave aside a number of minor
points, such as the different properties of various kinds of alcoholic
drinks—a matter which in practice is often found important—as not at
present susceptible of scientific examination. In this way various items
of possible evidential value, one way or the other, are necessarily
omitted; but all the fundamental problems remain, and the evidence
in regard to most of these is clear. It is not easy for anyone who has
ever examined these questions impartially—to whichever side his own
personal inclinations may direct him—to dispute the exact validity of
the conclusions here presented in clear and untechnical language which
should be intelligible to every educated reader, however ignorant of
physiology and medicine. The main conclusions may be easily sum¬
marised.

There is no doubt that alcohol is a food in the same sense as sugar,
though it is only available for immediate use, not being stored up, and
thus may economise the use of the body reserves; but its use as a food
is limited by its drug action. This drug action is entirely nervous and
cerebral, but the general recognition of the nature of this action has
been difficult because of the euphoria and blunting of self-criticism
which alcohol produces. In all stages and on all puts of the system,

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from first to last, alcohol depresses and suspends function; it is, there¬
fore, not a stimulant, but a sedative and narcotic, drug It is satis¬
factory to find this affirmation made by the Committee in the most
positive and emphatic manner. It is many years since the sedative
and narcotic properties of alcohol were set forth, and many people,
accustomed to careful self-observation, cannot fail to have discovered
empirically that this is its real effect upon themselves; but the popular
superstition that alcohol is to be regarded as a stimulant still prevails in
many even influential quarters with mischievous results. Needless to
add, the value of alcohol is not thus diminished, but rather increased,
yet it is highly important that we should recognise precisely the condi¬
tions for its use. It is useless in enabling us to start work or to con¬
tinue work of any kind, physical or mental, but it is useful in enabling
us to leave off work. In the stress of the highest civilisation that use
is as much demanded as in the routine of the most primitive culture—
indeed, it may be argued that with the increasing strain and momentum
of civilisation the brake becomes even more important than the spur.
While it is, obviously, highly important to recognise this action of
alcohol, it may be added that in some contingencies alcohol acts bene¬
ficially, or, at all events, harmlessly, even when applied on a totally
wrong theory of its action; moreover, even by paralysing the higher
and inhibitory nervous centres it sometimes has a pseudo-stimulatory
action on lower centres. On muscular action, skilled or unskilled,
alcohol never has any beneficial effect; on the contrary, it tends to
impair all muscular acts. It depresses the simple reflexes; it depresses
and accelerates the heatt by its action on the inhibitory nerves; it
decreases muscular work as measured by the ergograph; it lessens
athletic efforts ; it diminishes control of muscular movements ; it impairs
the precision of eye movements; it slows down the speed of voluntary
movements. These results are illustrated in detail and references given
to specimen investigations carried out in various countries, especially
Germany. This recognition of the value of German work may doubt¬
less, unJer present conditions, be counted to the Committee for
righteousness ; but we miss any reference to F£r£’s neat and ingeniously
varied experiments during many years, illustrating the results accepted
by the Committee, and also showing that incidental sensorial stimulation
which the Committee admits but hardly seems to lay enough stress on.
On digestion, while in moderate doses there is no effect good or bad,
the tendency is to retard, and this tendency is much increased in the
case of special alcoholic drinks, especially such as are acid. Gastric
movement is not increased, and some forms of gastric contraction are
diminished, hence the carminative action of alcohol. On the respira¬
tion alcohol in moderate doses has no effect, either in health or disease;
in large doses it produces respiratory paralysis and death. On the
heart, in low concentrations, alcohol has no special action ; in high con¬
centration it is harmful; its apparent beneficial action on persons
recovering from syncope is due to its irritating action on mucous mem¬
brane, and is comparable to the effect of smelling-salts. On temperature
the effect of alcohol, now generally recognised, is to cause loss of heat
through flushing the surface with blood, the deep temperature falling;
so that while it is worse than useless when taken before exposure to

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cold, it is beneficial after such exposure when the surface is chilled.
The effects of alcohol as a drug and a poison are clearly set forth at
some length ; the part of alcoholic excess in the causation of most forms
of insanity is regarded as of secondary importance, rather a symptom
than its cause. The Committee accept the direct and indirect evidence
indicating that the chronic alcoholism of the parents reacts injuriously
on the vitality and development of the offspring; but continuity of
action as well as excess of dose is necessary to constitute chronic
alcoholism, and the habit-forming tendency of alcohol is relatively
slight. Finally, the relation of alcohol to longevity is considered ; it is
pointed out that the evidence presented by insurance companies and
friendly societies as bearing on this matter is highly complicated and
difficult to interpret, so that while it would appear that the death-rate is
lower and the expectation of life longer in total abstainers, it is so diffi¬
cult to isolate the issue from disturbing personal and racial factors that
this cannot be regarded as a scientifically-established conclusion.

Most of these conclusions are simple and elementary; but they are
fundamental propositions in regard to the action of a substance which
is economically and socially of the greatest importance since the inhabi¬
tants of the British Islands deem it of such value that they spend more
on it than on meat and twice as much as on bread. They are, more¬
over, propositions that are still often ignored or denied in quarters
where better knowledge might well be expected. It is, therefore, satis¬
factory to learn that this authoritative little volume has already attained
an extremely large circulation. Havelock Ellis.

Religion and Realities. By Henry Maudsley, M.D. John Bale, Sons
& Danielsson, Ltd. Price 3.L 6 d. net.

There is a pathetic interest attaching to this book. It is the last
product of the author’s pen. To some extent such a recollection
disarms criticism, or would do so were one inclined to severity or
dispraise. Again, the advanced age at which he wrote, and adverse
conditions in regard to health, might have been justly adduced in
mitigation of sentence for errors, solecisms, lapses of memory, or failing
judgment. It is unnecessary to urge such pleas, for here, as in the
case of “ Organic to Human,” there is the same clearness of thought
and lucidity of expression. Nor is there any sign of weakening in regard
to principle, no temporising, as of one who “ feared hell rather than
annihilation.” For this we may be grateful, though, as no one would
have admitted more readily than Dr. Maudsley himself, death-bed
“repentances,” and the utterances of those in the “dreary decline”
of life, maybe fairly discounted when they are at variance with principles
enunciated by the same persons in their prime, or with the whole tenor
of their lives.

As the title implies, this volume is chiefly concerned with the anti¬
thesis of reality as opposed to religion, or rather to the misty abstrac¬
tions in which theological systems have obscured the plain facts of life
and of experience. This has come about because “the persons who
think—hardly one in many thousands—are rare and exceptional.” It
is more easy to give free play to the emotions in “rapturous exultation ”

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than to give time and close attention to observation and experiment.
The same criticism is applicable in other spheres of thought; people
“ have never taken the least pains to make themselves acquainted with
what is known of physical and chemical forces, their modes of action,
and their effects. They choose rather to cherish the miraculous than
to observe the natural, and to pay with words instead of with valid
coin.” So we find that in the study of mental disorders there is, too,
the same besetting sin—theory outruns experience to an extent that
would be incredible had we not all been trained to believe a thing
because it is impossible! On the other hand, “though it would be
wrong no doubt to deny the possibility of what seems impossible, there
is not the least need to manufacture fictitious possibilities and then
teach them as verities.” For century on century we continue along the
same lines, absurdly self-satisfied with our beliefs and our theories, and
unwilling even to make trial of methods which are based upon some¬
thing which does not square with our pre-conceived notions. It is still
fashionable to decry the materialistic conception of the universe, even
though no honest attempt has been made to disprove the assertions of
those who, like Dr. Maudsley, have pleaded in season and out of season
for a fair trial for investigations conducted upon that basis. When they
shall be proved of no avail it will be time enough for opponents to scoff.

It has been said that Dr. Maudsley was a destructive critic, and that
he suggested no constructive system of philosophy. Even were this true
—and it is not—it would be no slight achievement to have cleared away
the accumulated rubbish which has been gathered together by years of
misdirected energy. But we have, as a rule, little gratitude for him who
points out the error of our ways ; we prefer him who flatters our vanity.
It is unlikely, then, that anyone who disavows belief in human perfecti¬
bility, who even criticises our much-vaunted civilisation, can gain popular
acceptance. Nevertheless, his words may yet prove to be nearer the
truth than are the honeyed phrases with which so frequently the ears
of the groundlings are tickled.

It will have been inferred from what has already been said that
Dr. Maudsley had no panacea for human ills to proclaim, no easy path
to the attainment of knowledge to point out, no perfervid optimism in
regard to our future prospects here or hereafter. Nor can we be
surprised that, looking out upon the chaos into which social conditions
had passed, he inclined to pessimism. And pessimism is “alike the
stern conclusion of thinking reason, and the pious confession of reverent
religion." Nor is it a conclusion which is reached gladly, but one which
is forced upon the thinker by the stern logic of events. “ Man that is
born of woman hath but a short time to live, and is full of misery. He
cometh up and is cut down like a flower.”

The essays collected in this volume cover a wide range of thought:
“Old Age,” “Death,” ‘-Life,” “Truth,” “Virtue,” “Vanity,” “Style,”
“ Optimism and Pessimism ”—the titles serve to show the diversity of
subjects. But whatever the subject under discussion, the same clear
light of practical reason is brought to bear upon it. There is no shirking
of the issues, no faltering, even though he realised that he was soon to
pass through the Valley of the Shadow of Death, when the process of
Nature should “complete its particular cycle, and the individual return

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to the dust from which he was created.” The insistent push of vitality,
derived from the sun and providing in its upward wave the basis of
optimism, was dying down and giving place to old age, with its realisa¬
tion of how much in life is mere vanity and vexation of spirit, illusion,
and figments of faith. This, in its turn, must pass into that phase which
we dread, “as children fear to go in the dark,” and yet which is but a
sleep, a rest longed for by the wearied flesh, a “ welcome port to which,
after a long and rough voyage, the weary traveller arrives at last.”

It is well in these days, when the tendency is to give too free play to
the emotions, and to let reason be hindered in its work, that there
should be some who can look as from a tower upon the contest and
dispassionately survey the scene. From the comments of such spectators
we may derive, if not consolation, at least help in our distresses. Such
a wise onlooker was Dr. Maudsley, and in this last book we are given
the ripe reflections of his maturity. It is for others to carry on the
lamp of true doctrine.

The Unmarried Mother. By Percy Gamble Kammerer. With an
Introduction by William Healy, M.D. (Criminal Science Mono¬
graphs). Boston: Little, Brown & Co. 1918. Pp. 342.
Price $3.

The most valuable part of this important work for the psychologist is
that which concerns the 500 histones (not all of them here reproduced)
on which it is statistically based. The great difficulty in dealing scien¬
tifically with the unmarried mother has been, indeed, precisely this lack
of an adequate basis of carefully detailed data. It is true this study
comes from America, but the conditions dealt with are not substantially
different: the illegitimacy rate in the United States (differing widely
from that of some European countries) is almost the same as that of
England, and, moreover, among the 500 cases here dealt with there are
nearly as many women of British as of American birth—more if we
include the French Canadians.

The form the author’s investigation has taken, and the careful attempt
to distinguish and estimate the numerous factors involved, are largely
due to the inspiration and guidance of Dr. Healy. As we might expect,
environmental conditions (notably, absence from home, bad home con¬
ditions, uncongenial surroundings, recreational disadvantages, con¬
taminating industrial conditions) are the most prominent factors, though
low wages are not amongst them, and it is in flourishing and prosperous
communities that the illegitimate rate is highest, in poor and backward
communities that what we call "virtue” most flourishes. Heredity as
a factor was not easy to estimate, partly because we cannot regard the
tendency to produce an illegitimate child as a directly transmissible
character, and partly because the data under this head were too scanty ;
its importance is recognised, but it was not possible to regard it as a major
factor in a single case. Some importance is attached to abnormal physical
conditions, especially those which cause weakness or irritation ; this was
found to be a factor in nearly 100 cases. Not only are under-develop¬
ment, premature birth, congenital syphilis, epilepsy, etc., thus influential,

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but early and over-development may also be a factor—partly because
such development tends to be associated with a developed sexual
impulse, partly because it tends to outrun mental development, and
partly because it is attractive to men. In one group abnormal sexual
suggestibility is found to be important. Eut the strength of the sexual
impulse is not believed to be above the average in the unmarried
mother, and shows the normal degrees of variation ; there was only one
case of such abnormally strong sexual impulse that it was put down as
nymphomania. As a rule, the girls were not passive ; they were equally
responsible with the fathers for their condition ; the ages of the fathers,
moreover, showed the probability of normal sexual attraction, and
stories of rape or assault (usually remarkably similar in their details)
seldom resisted investigation. A chapter of some length is devoted to
mental abnormality. Reliable mental examinations were only made in
some 26 per cent, of the cases, though Kammerer considers that some
35 per cent, of the 500 cases were sufficiently abnormal to have made a
psychological investigation desirable; 167 girls or women were thus
found to show some special mental defect or peculiarity. The mentally
abnormal girl is not necessarily possessed of over-developed sex
instincts, but rather of under-developed inhibitions, and it must be
recognised that a lack of self-control may lead an ordinarily intelligent
woman into the position of an unmarried mother. The feeble-minded
morons are, however, found to form an important group, and to be
very uniform in their sexual behaviour. Two or three cases were
grouped under dementia praecox, and three as hysterical or psycho¬
neurotic, while another group was formed of cases of psychic constitu¬
tional inferiority.

Much useful information is given concerning the social and legal
position of the unmarried mother in various countries and the progress
made in recent years. This is most marked, both on the scientific
and the administrative side in Germany, but it is in Norway that the
position of the illegitimate child has now been made most favourable.
Kammerer has a wide and liberal-minded chapter of “Conclusions,”
and lays due weight on the importance of education, not least in sexual
matters (the sexual ignorance of some of these mothers was incredible);
on the need also for the education of parents; on improved conditions
of industrial work, better homes, and greater opportunities for whole¬
some recreation ; on State supervision when necessary; on better indi¬
vidual training; and on higher moral conceptions in the community,
casting aside outworn conventions, and realising that the mother “must
be judged on her desire to give her child good care, and her success in
doing so, rather than on the fact that she has given birth to a child out¬
side of marriage.” Havelock Ei.lis.

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Part III.—Epitome of Current Literature.

Clinical Neurology and Psychiatry.

Graphomania \_La Graphomanie\ [Revue Philosophique , November,
1914.) Ossip- Lourie.

The majority of men speak with greater facility than they write ; verbal
expression is considered easier than written. Between the faculty of
expression by writing and the spoken word there exist important con¬
nections, but instances of word-deafness indicate that there is no
complete equality or association between the two. Interior mental
life is often confused when the subjective and objective impressions are
too numerous to be anything but vague. During the process of writing
perceptions and ideas, both conscious and unconscious, are gathered
together, but the number of unconscious ideas is often superior to the
conscious. We think beyond what we express. If it were possible to
read the mind in writing, many things would be found there which
cannot be expressed on paper. Interior thought is often only intuitive.
In intuition interior thought appears infinite, immense, boundless, not
circumscribed by limits. For it to become distinct it must be exterior¬
ised by spoken and written speech.

Written language, more than spoken, limits the infinite idea, it fixes it
more solidly upon the attention. It regularises the interior life, solidifies
it, but more, it personifies an impression, a vision, a thought. It exte¬
riorises the ego, it expresses or reflects it.

Written speech is normal when it penetrates the ego, when it
expresses our affective vibration. To write normally implies a creative
effort. The more profound the thought the greater the difficulty of
expression. Writers whose originality is incontestable do not possess
a great facility for writing. To condense, express, crystallise a thought
into a definite form is often to arrest it. Particular faculties are neces¬
sary to render it with more or less justice.

Patients in asylums are often afflicted with a mania for writing, and
writing in this way often has a diagnostic value, but the writer considers
that outside mental hospitals a large number of individuals are afflicted
with what may be described as graphomania—a psychopathic tendency
to write. It is this disorder with which the paper deals.

Graphomania is a malady characterised by an excessive desire for
writing. All writing which does not interpret some positive fact, which
is not the result of some experience, which does not materialise an
image, produce some idea, which does not reflect the interior life, the
personality of the author, belongs to the category of graphomania. It
is an impulse to write without any normal necessity or pretext Such
a mania may exist without desire of publication, but the term must he
applied to numerous publications, executed without appreciable cause,
and which astonish by their futility, strangeness, lack of purpose—
• literary mania. Other forms exist—letter-writing, anonymous letters,
writing on walls, etc., but the writer regards this as the most serious
form because it is so contagious.

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A number of these individuals may be described as “ Graphomania-
simulators,” who desire to profit from the profession of letters, and
“ Graphomania-parasites,” who make themselves known to a celebrated
writer, imitate him, deify him, exist on him as it were. Such types are
more numerous than those with a definitely irresistible impulse to write.

The true literary graphomaniac, exhibits certain intellectual defects.
He has false conceptions as to the value of his contributions, and as to
the social influences of his writings. He abandons himself to his
tendency to imitate and copy others. He imagines his writings exhibit
creative activity, he thinks he himself is the source of inspiration of his
productions. Two forms are observed, the excited and depressed, both
often existing in the same individual. The former exhibit immense
activity, their output is enormous, they belong to every literary society,
they serve on every committee, they are present at every banquet. The
combination of their ideas is purely superficial, the imagination is asleep,
there is a kind of automatism. In the depressed form, the grapho¬
maniac is sensitive, he attaches importance to detail, neglects his serious
interests, mistakes the value of men and things, falls under the influence
of the first comer. He is anxious, gloomy, discouraged, fearful, sus¬
picious, lacking in confidence—yet always writing.

The memory for words and phrases is immense, but there is no selec¬
tion or choice, no attempt to analyse, define or verify. In spite of their
memory, they only possess a poor vocabulary, and they cannot find the
words necessary to render their thoughts, and usually they employ others
in their place. The attention is disturbed, and this explains the mobility,
instability, and obscurity of their thoughts. The clearness of an idea
depends on the attention paid to it.

The inner ambition of the graphomaniac is one which aims at attract¬
ing public attention. All his activities are devoted to this end. The
malady may justly be included in the group of neuropathic disorders.
It is a form of instability; there is a want of harmony between the
thought and the act of translating it into writing. The act of writing
is normal when it expresses the personality; abnormal when the ideo-
psychic forces do not concur in its expression.

As regards the aetiology of graphomania, the whole course of educa¬
tion tends to foster its growth. Copying, dictation, essays on subjects
chosen by the teacher, and the writing of theses suggested by others,,
are all methods which inhibit personal expression in writing. Spelling
and writing are automatic acts, in which the ego does not participate,
and the content itself may readily become automatic. Publicists and
journalists often hardly know what they are writing. The subject is
one of indifference so long as something is produced. Many grapho¬
maniacs at the moment the pen is in their hand are quite ignorant of
what they wish to write. With facility in writing gained by practice, the
act tends to become increasingly automatic.

Imitation and contagion are amongst the chief psychic causes of
graphomania. The aetiology arises in the basis of society, it resides in
its customs. All social life co-operates in producing the psychopathic
conditions which produce in the subject the mania for writing : the
commercialisation of literature, literary prizes, diminution of criticism.
It increases with the advance of civilisation. The feverish activity of

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some, the morbid laziness of others, unbounded desires, the discredit
of manual work, the continual effervescence, increase amazingly the
ranks of the graphomaniacs. H. Devine.

Psychoses Associated with Diabetes Mellitus. (The Journal of Nervous
and Mental Disease , December , 1917.) Singer, H. D., and Clarke ,
S. N.

The writers report two cases in which there is evidence of toxic brain
disturbance—restless apprehension, with sense falsification—associated
with disturbances of metabolism in diabetic subjects.

In the first case the appearance of acute toxic mental symptoms was
associated with a diminution of sugar in the urine. The acute mental
symptoms subsided rapidly with the reappearance of sugar, so that
these two manifestations appeared more or less in an inverse relation to
•one another.

In the second case the acute mental symptoms were noted more in
association with therapeutic measures than with actual diminution of the
amount of sugar excreted. With the resumption of a full diet the patient
returned to his average mental state within a few days. H. Devine.

Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Quarterly Meeting of the Association was held at 11, Chandos Street,
W. 1, on Tuesday, May 28th, 1918, Lieut.-Col. David G. Thomson, M.D,
R.A.M.C., President, occupying the chair.

The following signed their names in the book as having been present at the
meeting or as having attended meetings of committees : Sir G. H. Savage, Lieut.-
Col. Sir Robert Armstrong-Jones, Drs. H. T. S. Areline, Fletcher Beach, David
Bower, J. Carswell, James Chambers, R. H. Cole, Maurice Craig, A. W. Daniel,
J. Francis Dixon, E. L. Dove, T. Drapes, R. Eager, F. H. Edwards, E. L.
Forward, C. F. Fothergill, A. H. Griffith, H. E. Haynes, John Keay, D. G.
Lindsay, A. Miller, Richard Miller, J. M. Murray, H. J. Norman, E. S. Pasmore,
J. G. Porter Phillips, Bedford Pierce, E. Prideaux, J. N. Sergeant, G. E.
Shuttleworth, R. Percy Smith, J. G. Soutar, T. E. K. Stansfield, F. R. P. Taylor,
C. M. Tuke, John Turner, H. Wolseley-Lewis, and R. H. Steen (Acting Hon.
General Secretary).

Visitors: Drs. K. Haslam, E. M. Herford, J. D. Symon, and F. W. Thurnam.
Present at Council Meeting: Lieut-Col. D. G. Thomson, M.D , R.A.M.C.
(President), in the chair, and Drs. H. T. S. Aveline, A. Helen Boyle, James
Chambers, R. H. Cole, Thos. Drapes, R. Eager, John Keay, J. N. Sergeant, T. E.
Knowles Stansfield, G. E. Shuttleworth, H. Wolseley-Lewis, and R. H. Steen.

Dr. J. G. Soutar attended on the invitation of the President.

Apologies for unavoidable absence were received from : Drs. C. C. Easterbrook,
R. R. Leeper, John Mills, H. de M. Alexander, Graeme Dickson, L. R. Oswald,
T. S. Adair, G. N. Bartlett, Donald Ross, J. R. Gilmour, and James M. Rutherford.

The minutes of the last meeting, being printed in the April number of the
Journal, were approved and signed by the President as correct.

Business Arising from the Council Meeting.

The President said his first duty, under this head, was to report to the meeting
that the late Dr. Maudsley had bequeathed to the Association a sum of .£3000.
He thought there was no need for him, on this occasion, to enlarge on the

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importance and munificence of such a bequest, nor on the gratification it would
afford to the members. The terms of Dr. Maudsley's Will did not specify in what
wav this money should be used by the Association, and the Council proposed to
consider that matter at its next meeting, two months hence. He did not doubt
that in the meantime the Council would be very glad to receive suggestions on the
subject from any who were not members of the Council, and all such suggestions
would be welcomed and receive due consideration at the meeting he had referred to.

The other business he had to report on was that Col. Keay, of Bangour
Hospital, Edinburgh, had, he was pleased to know, found himself able, now that
he had got his great hospital into full working order, to devote part of his time to
the duties appertaining to the post of President of this Association. In conse¬
quence of that acceptance it had been arranged at to-day’s Council meeting that
the Annual Meeting this year be held at Edinburgh, under Col. Keay's presi¬
dency, on July 23rd and 24th, just previous to the Annual Meeting of the British
Medical Association.

The following resolution would now be proposed by the General Secretary,
Dr. Steen : "That, owing to the shortage of paper and the difficulty in printing,
the following bye-laws, or portions of bye-laws, be suspended for the duration of
the war, namely: Bye-law 26, Bye-law 67 (n), Bye-law 67(6), Bye-law 67(c),
Bye-law 90 in so far as it requires the General Secretary to issue to each member
of the Association a circular announcing the date of the Annual Meeting, etc.”
Members would have noted that in the paper of business of past annual meetings
it had been the custom to print the names of the officers, examiners, and members
of the standing committees. This had been done as a matter of convenience, not
because ordered by the bye-laws. This practice it was proposed to discontinue
during the war.

Dr. R. H. Steen (Acting Hon. Secretary) moved the resolution, as printed and as
read out by the President, and in doing so said he would like to draw the attention
of members to Article 16 of the Association. This ran as follows: “ At any
general meeting of the Association, bye-laws may be made, varied, or repealed
subject to the following regulation— vie.: Not less than fourteen days before such
meeting, the Secretary shall send, through the post to each ordinary member of
the Association, by prepaid letter addressed to such member at his registered
address, or otherwise as provided by the bye-laws, notice of the hour and place of
meeting, and notice of the resolution to be proposed at the meeting for such making,
varying, or repeal of the aforesaid, provided that the omission to send any such
notice shall not invalidate anything done at such meeting.” Bye-law 36 provided
that the Divisional Secretaries shall send a printed list of the officers and repre¬
sentative members of Council for election from the division. In some divisions
there were 250 members, and these lists had to be printed and posted to each one,
though, he feared, they were not always looked at by the members receiving them;
therefore that was an item on which the Association could save printing and paper.
Bye-law 67 (a) provided that each year the General Secretary should send to each
member a paper showing the attendances of the members of Council at the meet¬
ings. That, he thought, might la^sse during the period of the war. It was required
by Bye-law 67 (A) that a voting-paper be sent containing the names of the officers to
be elected at the Annual Meeting. That, he suggested, was an unnecessary expense.
Bye-law 67(c) provided for the receipt of the voting-papers, and this became void
if Bye-law 67 (A) became inactive. Bye-law 90 said the Secretary should send out
a notice to each member giving the date of the Annual Meeting, and at the same
time make a request for the contribution of papers and other scientific matter
therefor. As a number of members were now absent from England, the printing
of this, and especially the postage, would be a very heavy item, and he did not
think it was, during war time, worth the expenditure. Those were the reasons for
which he moved the resolution.

Dr. Bower seconded.

The President, in asking members to vote upon it, said it would be clear it
was a war measure, and would economise in paper, time, and postages.

Dr. Percy Smith asked how it was proposed to give adequate notice to members
concerning the Annual Meeting. Would it not be the simplest and least expensive
method to send a post-card with this information on it ? That was especially neces¬
sary as, this year, instead of holding the Annual Meeting in London, it was pro-

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[July.

posed to hold it in Edinburgh. Publishing it in the Journal would not suffice,
especially as it would not appear until July.

The Secretary (Dr. Steen) replied that he hoped that members would receive
good notice by having the agenda paper of the Annual Meeting posted to them
three weeks before the date of the Annual Meeting, giving place and all particulars.
If it was thought wise to send post-cards on this occasion, he would remind the
meeting that from June 1st the rate for post-cards would be id.

Dr. Percy Smith expressed himself as quite satisfied.

The resolution was agreed to.

Election of Candidates for Membership.

The President nominated as scrutineers for the ballot Major Eager and Capt.
Norman. The following gentlemen were duly elected :

Anderson, William Kirkpatrick, M.B., Ch.B.Glas., Visiting Physician
Eastern District Hospital, Glasgow, 3, Ashton Terrace, Glasgow.

Proposed by Drs. Neil T. Kerr, R. B. Campbell, and G. Dunlop Robertson.

Archibald, Alexander John, M.B., Ch.B.Glas., Acting Medical Superin¬
tendent, Argyll and Bute District Asylum, Lochgilphead, Argyllshire.

Proposed by Drs. Neil T. Kerr, R. B. Campbell, and G. Dunlop Robertson.

Evans, Tudor Benson, M.B., Ch.B.Liverp., Capt. R.A.M.C. (Temp.), Lord
Derby War Hospital, Warrington. (Home) The Pharmacy, Denbigh.

Proposed by Major R. Eager, Capt. O. P. Napier Pearn, and Dr. T. Stewart
Adair.

Ogilvie, William Mitchell, M.B., C.M.Aberd., Medical Superintendent,
Ipswich Mental Hospital, Ipswich.

Proposed by Drs. J. R. Whitwell, E. S Pasmore, and H. M. Berncastle.

Thienpont, Rudolph, M.D., Temporary Assistant Medical Officer, Cane
Hill Mental Hospital, Coulsdon, Surrey.

Proposed by Drs. Fletcher Beach, Edward Gane, and R. H. Steen.

Paper.

John Turner, M.B., C.M.: “ Observations on the Rolandic Area in a Series of
Cases of Insanity." (This paper, or an abridgement, with discussion, will, it is
hoped, appear in a future number of the Journal.)

The President said Dr. Fothergill had agreed it was now late in the afternoon
to take his paper on “The Prevention and Treatment of Neurasthenia and other
Functional Nervous Breakdowns,” though it was a subject of great importance in
these times. The author had agreed to defer it to an early meeting; probably it
would form a good subject for discussion at the Annual Meeting in July if that
could be arranged.

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, Glasgow,
on Friday, March 15th, 1918.

Present. —Lieut.-Col. Keay, Major Hotchkis, Capt. Roberts, Capt. Buchanan,
R.A.M.C., Drs. Crocket, Carlyle Johnstone, Kerr, T. C. Mackenzie, Macdonald,
Oswald, G. M. Robertson, Jane Robertson, Watson, Yellowlees, and R. B.
Campbell, Divisional Secretary.

On the motion of Lieut.-Col. Keay, Dr. Oswald was called to the Chair.

Before taking up the ordinary business of the Meeting, the Chairman referred
in appropriate terms to the loss which the Association and the asylum service had
sustained since last meeting through the death of Dr. W. R. Watson, for several
years Medical Superintendent of Govan District Asylum at Hawkhead. It was
unanimously resolved that it be recorded in the minutes that the members of the
Scottish Division of the Medico-Psychological Association desire to express their
deep sense of the loss sustained by the death of Dr. W. R. Watson, and their
sympathy with his relatives in their bereavement, and the Secretary was instructed
to transmit an excerpt of the minute to the relatives.

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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 Lieut.-Col. Thomson, President of
he Association, Drs. Easterbrook, Skeen, Tuach-Mackenzie, Alexander, Ross,
Orr, Crichlow, Porter Phillips, and Mills.

The Secretary submitted letters of acknowledgment received from the relatives
of Dr. Urquhart and Dr. Hayes Newington, thanking the members of the Division
for the kind letters of sympathy.

Drs. L. R. Oswald and J. H. Skeen were unanimously elected Representative
Members of Council for the ensuing year, and Dr. R. B. Campbell was elected
Divisional Secretary.

Dr. L. R. Oswald was recommended to the Educational Committee of the
Council as an Examiner for the Certificate in Psychological Medicine, and Dr.
N. T. Kerr was recommended as Examiner for the Final Nursing Examination.

Dr. Isobel Emslie’s paper, “ Notes on Mental Treatment in Macedonia," was in
her absence read by Dr. G. M. Robertson. Her sketch of the primitive methods
in use was most interesting, and her efforts to improve the condition and treat¬
ment of the insane by means of her appeal to the authorities were most com¬
mendable. The members of the Division asked Dr. G. M. Robertson to convey
to Dr. Emslie their thanks for her paper, which was so much appreciated. A
copy of the paper will appear in the Journal.

The Secretary submitted a letter which he had received from the Secretary of
the Parliamentary Committee stating that a Sub-Committee had been appointed
to consider reforms in the English Lunacy Laws, in view of the many problems
which would result after the War. After some discussion it was unanimously
resolved that the members of the Division at present members of the Parliamentary
Committee might be formed into a Sub-Committee having power to add to their
number to consider the whole question, and make any recommendations they
should consider advisable to the Parliamentary Committee of the Association,
and also report to the Division.

A vote of thanks to the Chairman for presiding concluded the business of the
meeting.

SOUTH-WESTERN DIVISION.

Spring Meeting, 1918.

The Spring Meeting of the above Division was held by the kind permission
of Dr. MacBryan at 17, Belmont, Bath, on Friday, April 26th, 1918, at 2.30 p.m.

The following members were present:—Drs. Maiw Martin, MacBryan, Nelis,
Rutherford, and Dr. Aveline, who acted as Hon. Div. Secretary in the unavoidable
absence of Dr. Bartlett.

Dr. Nelis was voted to the Chair.

Letters of regret for non-attendance from Lieut.-Col. D. G. Thompson (the
President), Maj. Eager, Drs. Bartlett, Macdonald, and Starkey were read.

The minutes of the last meeting were read and confirmed.

Dr. Bartlett was appointed Hon. Div. Secretary.

Drs. MacBryan and Aveline were elected as representative members of Council.

Drs. Mary Martin and Macdonald were elected as members of the Committee
of Management.

The date of the Autumn Meeting was fixed for Friday, October 25th, 1918, and
that of the Spring Meeting for Friday, April 25th, 1919.

The place of the Spring Meeting was left in the hands of the Secretary for
arrangement.

A letter from Miss Hayes Newington, thanking the members for their kind
expression of sympathy on the death of her father, was read.

A communication was received from the General Secretary announcing an
alteration of the date of the next Quarterly Meeting from May 21st to May 28th.

NORTHERN AND MIDLAND DIVISION.

The October Meeting of the Division will be held at the Maghull Red Cross
Hospital, near Liverpool.

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IRISH DIVISION.

The Summer Meeting of the Irish Division of the Medico-Psychological
Association of Great Britain and Ireland was held, by the kind invitation of
Dr. M. J. Nolan, at Downpatrick, on Thursday, July 4th.

Members present: Dr. J. Colies, Dr. Considine, Lieut.-Col. Dawson, Dr. Drapes,
Dr. J. O’C. Donelan, Dr. Nolan, Dr. Hetherington, Dr. Smyth, Dr. Graham,
Dr. Greene, Dr. Gavin, Dr. O'Mara, Dr. Grimbly, Dr. Cotter, and Dr. Leepcr
(Hon. Secretary).

Dr. Nolan having been moved to the Chair, the minutes of the previous meeting
were read and signed.

Letters of apology for unavoidable absence were read from the following:
Dr. Rainsford, Stewart Asylum; Dr. Mills, Ballinasloe; Dr. McKenna, Carlow;
Dr. Lawless, Armagh; Dr. H. Eustace, Dr. Redington, Portrane; Dr. Irwin,
Limerick; Dr. Revington, Dundrum; Dr. Fitzgerald, Waterford; and Dr. Martin,
Letterkenny.

The Chairman asked, before the regular business of the meeting was proceeded
with, to draw the attention of the members to the loss which the Association
and the whole faculty of Psychological Medicine has sustained by the death of
Dr. Maudsley. The following resolution was proposed by Dr. Drapes, seconded
by Dr. J. O'C. Donelan, and passed in silence, the members standing in their
places:

“ We, the members of the Irish Division of the Medico-Psychological
Association of Great Britain and Ireland, desire to place on record our deep
sense of the loss Psychological Medicine has sustained by the death of
Dr. Henry Maudsley, and of our appreciation of his munificent endowment
of the London Mental Hospital.”

A letter was read from the Inspectors of Asylums, Dublin Castle, acknowledging
the receipt of the resolution passed at the Spring Meeting re recent conduct
of attendants in Irish asylums.

The following candidates having been duly balloted for were declared elected:

The Right Hon. Michael Cox, M.D., R.U.I., Hon. Causa., F.R.C.P.I.,

Physician, St. Vincent’s Hospital, Dublin; Lord Chancellor’s Consulting

Visitor in Lunacy for County and City of Dublin.

Dr. Samuel John Graham, Resident Medical Superintendent, Villa Colony

Asylum, Purdysburn, Belfast.

The Chairman proceeded to introduce a discussion on the proposed alteration
of the Lunacy Laws, in accordance with the work now under the consideration
of the Parliamentary Committee of the Association. He stated that this matter
had received much attention from the Irish Division and that so long ago as
March 26th, 1907, at the Spring Meeting of the Division, the whole question
of Lunacy legislation in Ireland engaged the attention of the members, and all
he considered that could be done by those now assembled was to reconsider the
recommendations then made and to obtain the general sense of the meeting as
regards the proposals for new Lunacy legislation now before the Parliamentary
Committee. The Hon. Secretary read a letter from Dr. Cole, Hon. Sec.,
Parliamentary Committee, stating that three recommendations were now being
made by the Lunacy Legislation Committee and that he hoped to report further
progress. The three recommendations were as follows :

(1) The establishment of Clinics (for the treatment of early cases of
mental disorders by local authorities).

(2) The approval of Homes for borderland Mental cases received for
payment.

(3) The extension of Voluntary Boarders to the County and Borough
Asylums.

The Hon. Secretary read a reply to the letter which he had sent to Dr. Cole.

The Chairman and the members discussed these three proposals, and the sense
of the meeting was obtained from each member present, Dr. Colles, Dr. Considine,
and Lieut.-Col. Dawson giving the greeting valuable information as regards the
legal points raised.

The opinions of the members Were generally as follows:

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Firstly, as regards the establishment of Clinics for the treatment of early cases :
That these were undesirable, except as hospitals attached or adjacent to existing
asylums where patients could be received without certification.

Secondly, the meeting was unanimously opposed to the proposal for setting up
approved Homes for borderland cases for paying patients.

Thirdly, as regards the question of the admission of Voluntary Boarders to
County and Borough Asylums, the Irish Division approved of such procedure, and
desired that a similar facility be extended to Ireland as existed in England and
Scotland for the admission of voluntary patients.

It was proposed by Dr. W. Smyth, seconded by Dr. Graham, and passed
unanimously:

“ That the following committee be elected as a sub-committee of the
Parliamentary Committee of the Association to co-operate in securing
alterations in the Lunacy Laws as affecting Ireland : Dr. Gavan, Dr. J. O’C.
Donelan, Dr. Nolan, Dr. Eustace, Dr. Drapes, Dr. Rainsford; Dr. Leeper to
act as Hon. Secretary."

The Chairman proceeded to draw the members’ attention to the recommenda¬
tions approved at the meeting of the Irish Division held on March 26th, 1907,
when the Irish Councils’ Bill was before the House of Commons.

The first matter dealt with in the memorandum then drawn up was as follows :

“ In order to check retrograde or otherwise undesirable movements, there should
be a strong Commission at the head of the Lunacy Administration of the country,
possessed of ample powers, which should not be merged into any other Govern¬
ment department.”

The meeting strongly expressed the opinion that it would be most desirable to
increase and strengthen the powers of the Inspectors of the Irish Asylums, and a
policy of obtaining powers for the Irish Government Lunacy Officials, similar to
those in the hands of the English Lunacy Commissioners, was endorsed by the
meeting. Dr. C01.LES kindly explained the legal aspects of the case, and Lieut.-
Col. Dawson, Dr. Considine, and Dr. J. O’C. Donelan expressed their views on
the matter, which were of valuable help to the members in forming their opinion
on the subjects. Dr. J. O’C. Donelan spoke as regards the danger of the Irish
asylums being merged under the authority of, the Local Government Board, a
procedure which, if it ever occurred, would be disastrous to Irish asylums, and
prejudicial to the interests of the insane poor.

Tha question of the amendment in the modes of admission of patients to
asylums was next reconsidered. The necessity for such amendment was unani¬
mously felt, and Dr. Gavin spoke in favour of the “Dangerous Lunacy Act ”
being repealed, and, after much discussion, in which almost all present joined,
and cases of gravity having been mentioned, where great hardships were inflicted
upon patients and murder had resulted from failure to have patients promptly
sent to asylums owing to the present obsolete and cumbrous procedure, the
meeting almost unanimously recommend :

(1) “That the law as regards the admission of patients to district
asylums be assimilated to that in England and Scotland.

(2) " That, so far as possible, lunacy should be dissociated from crimi¬
nality, and that the insane poor should not be treated as criminals in order to
receive treatment for their mental disease. That the so-called ' House Form ’
—‘Form D' —be universally used, and that it be obligatory upon asylum
governors to admit patients on the so-called ‘ House Form.’ Certification
should he uniform, and either one medical certificate, or two, if thought
necessary, should be accepted, altering the present anomalous procedure
where a patient requires only one certificate on one form and two on another.”

The question of bail, in the case of patients being removed from asylums, was
discussed, and the present law as regards recognizances in the case of patients
was considered unsatisfactory, as they seemed never to be or to have been enforced.

Dr. Colles kindly expressed the opinion that the existing English Lunacy Act
is an admirable procedure, and covers all the disabilities from which the procedure
in this country suffers.

The question of the conveying of patients to district asylums was next con¬
sidered, and the opinion expressed that policemen should not be in charge of

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female patients so sent, although it was understood that this duty was now always
assigned to a married sergeant of the R.I.C. Nurses should be employed in this
service and not the police.

Dr. Colles drew the attention of the meeting to the present mode of granting
and renewing licences to private asylums, which procedure was similar in Ireland
to that of granting ordinary publicans' licences, and suggested that these licences
should be granted by the Lord Chancellor on the recommendations of the inspectors
of Irish asylums.

The Chairman spoke as to the advisability of deleting the word “destitute”
from Form " D,” which was thought desirable, as this was obviously an error in a
form for a paying patient.

Dr. Hetherington, as the oldest member present, proposed a cordial vote of
thanks to Dr. and Mrs. Nolan for their kindness and hospitality in entertaining
the members. Dr. J. O’C. Donelan, in seconding the resolution, wished to express
to Dr. Nolan the congratulations of the visitors upon the wonderful improvements
in the asylum since his last visit in 1907, and to state the great appreciation by all
those who visited the asylum of its high standard of efficiency and the admirable
condition to which it had been brought by Dr. Nolan. This resolution having
been passed by acclamation, and Dr. Nolan having replied, the meeting ended.

SOUTH-EASTERN DIVISION.

The Spring Meeting of the South-Eastern Division of the Medico-Psycho¬
logical Association was held at u,Chandos Street, Cavendish Square, London,
W. 1, at 2.30, p.m., on Wednesday, May ist, iqi8.

The following members were present: Drs. D. Bower, A. W. Daniel, E. L.
Dunn, F. H. Edwards, L. O. Fuller, A. H. Griffith, G. H. Johnston, H. J. Norman,
E. S. Pasmore, R. P. Smith, and J. N. Sergeant (Hon. Divisional Secretary).

Dr. R. P. Smith took the Chair.

The minutes of the last meeting, having been printed in the Journal, were taken
as read and confirmed.

Dr. J. N. Sergeant was elected Hon. Divisional Secretary, and Major Sir R.
Armstrong-Jones and Drs. D. Bower, M. Craig, and A. W. Daniel Representative
Members of the Council for the year 1918-1919.

Drs. Daniel and Fuller were elected to fill vacancies on the Committee of
Management.

Dr. Walter Folliott Blandford was elected an Ordinary Member of the Association.

It was decided to leave the place and date of the Autumn Meeting, 1918, to the
discretion of the Hon. Divisional Secretary.

It was proposed by Dr. Sergeant, seconded by Dr. Edwards, and carried, “ That
the meeting requests the Council of the Association to consider the advisability of
asking the Board of Control to act by giving badges or otherwise to help the
superintendents of institutions to retain their staff.”

Capt. Hubert J. Norman, R.A.M.C., then read his paper, “ Evolutionary Pro¬
gress in Psychiatry: A Plea for Optimism.” (This paper appeared in the April
number of the Journal.)

A short discussion of the paper followed, in which Drs. Percy Smith, E. S.
Pasmore, J. Noel Sergeant, Francis H. Edwards, and A. Hume Griffith took part.
Capt. Norman replied, and so brought to a conclusion an enjoyable and instructive
meeting.

ASYLUM WORKERS’ ASSOCIATION.

Meeting at the Mansion House.

(Abridged Report.)

The Annual Meeting of the Asylum Workers’ Association was held at the
Mansion House, London, on May 29th, the Lord Mayor (Alderman Charles A.
Hanson, M.P.), in the chair. This was the second occasion on which the Associa¬
tion had been fortunate enough to foregather in the famous building, the first

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being last year, when Sir William Dunn sat in the seat of Whittington. The
present occasion, like its predecessor, was distinguished by excellent speeches and
a large attendance.

The Lord Mayor said that many eminent gentlemen who were expected to take
part in the proceedings were present, and therefore he would not occupy more
than a minute of the meeting's time, but he wished to express the very great
pleasure with which he welcomed the Asylum Workers' Association to the Mansion
House. They had been doing most excellent work, and he hoped that in spite of
all the serious disadvantages which must impede their progress in times like these,
they would continue to carry on in the same spirit and with the same energy and
courage as in the past. He learned from a perusal of the report that their
operations had heen most helpful to suffering humanity.

Dr. G. E. Shuttlkworth (Acting Hon. Secretary), presented the annua 1
report, which was taken as read.

President’s Address.

Sir John Jardine, M.P., President of the Association, moved the adoption of
the report, and remarked that the large gathering before him was particularly
gratifying because it included many persons who had come there prompted by a
sense of duty. He referred to both ladies and gentlemen. Though he did not
profess to be witty, he thought it right on the present occasion to recognise that
brevity was the soul of—what should he say—business. In the first place he
wanted to express the pleasure which the Association felt at meeting in this his¬
toric. building. Last year Sir William Dunn opened its hospitable doors to, and
bestowed the patronage of his name and position as Lord Mayor on the Society.
They owed much to the present Lord Mayor for a renewal of the advantages con¬
ferred by meeting in the Mansion House with the Chief Magistrate of the City of
London in the chair. They might hope that many things which would probably
have been very rough would be made smooth to them when the Lord Mayor used
his great office and all the influences for good combined in it to favour a little
society which was trying to do its duty towards the afflicted. On behalf of the
Association he (the President) thanked the Lord Mayor very much for giving up
his time to assist them, and for enabling them to meet in the heart of the City, with
all the traditions of London’s mayoralty and the many activities of a great and
famous centre of human affairs around them. Glancing through the annual
report, the President said that the objects of the Society were very well put by
Cardinal Bourne when he said that they were "(1) to create and maintain a very
high standard of duty among our members, and (2) to safeguard the claims of
those devoting themselves to the care of the mentally afflicted to liberal and
considerate treatment on the part of the authorities.” Everybody was unsettled
by the terrific and long-continued war, and it was interesting to know that more
than 50 per cent, of the male attendants in asylums had been pressed into the con¬
flict, and a great many of the women workers in asylums had gone into other
phases of national service Some, alas ! they had lost. Dr. L. F. Hanbury, of
West Ham Asylum, had died on active service, like many gallant colleagues at
the Front. They had also to mourn the departure from this life of Dr. W. J.
Seward, formerly Medical Superintendent of Colney Hatch Asylum. Mr. Wm.
Hope, Inspector, the Association’s first Hon. Secretary at Colney Hatch and one
of their earliest gold medallists, died last September. From the list of Vice-
Presidents death had removed the honoured names of Dr. Hayes Newington, Dr.
Percy Baily, and Dr. C. T. Ewart. It was right that they should be mentioned
with honour. The inclusion in the Association of workers in institutions for the
mentally defective was one of the most important matters mentioned in the report.
It affected a large number of people and opened a very important new sphere of
influence for the Society. Thinking of the war prompted him to repeat some
words used by Sir James Crichton-Browne, who said that when he was a young
man he went to Germany to perfect his knowledge of medical methods and science,
but his opinion now was that there was no need for people from the British Isles
to visit Germany in order to get knowledge about lunatic asylums and the proper
treatment of their inmates. Our system was better in every respect. Humanity

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particularly was far more noticeable in the British than in the German treatment
of lunacy. That was Sir James Crichton-Browne’s view, and our experience of
German warfare confirmed it. One of the objects of the Association was to pro¬
mote the just claims of asylum workers, and the report showed that the point was
attended to as much as possible, although the pressure of Government business
and war work prevented private members like himself from introducing Bills into
Parliament. Asylum workers had, however, got something from the Government
in the meantime. And though the Act obtained by Sir William Collins raised
the status of those workers, they intended to obtain, if possible, some further con¬
cessions, which were very much needed. The war had made large claims on the
men and women employed in asylums and had made it harder to do the work as
it ought to be done. It had, however, been well done, and he thought the presence
of so many ladies and gentlemen at this meeting was a sign that the Association
was regarded as having deserved well, and as being likely to continue in the same
career. In this connection it was right to make special mention of their Acting
Hon. Secretary. Dr. Shuttleworth, who in this time of stress, as always, had set a
high example of self-sacrifice in order to help the Association, throwing himself
into the breach and working for the Society as well and even better than anybody
else could have done.

The Dean of Windsor (the very Rev. A. B. Baillie) seconded the motion,
remarking that the only justification he could claim for addressing the meeting
was that for thirty years he had been very closely associated with hospital work
and the staffs of many different hospitals. He would not try to present great
ideals as Cardinal Bourne did when addressing the Association in this same
building last year, but he would say a word or two that might be of practical
value to members of the Association. The great weakness of the generation now
passiarg away was that it did not lay sufficient stress on the importance of per¬
sonality. In all kinds of life we were apt to think of the workers more or less as
machines, going on almost automatically. The war, however, was bringing us
back to a sense of two things—first, that individual personality must be treated
separately. If "men or women were to do good work it must be along the
lines of their own personality. In the second place, the war was bringing us
to remember that however good methods might be their value would entirely
depend on the quality of the people who used them. The merit of the Asylum
Worker's Association lay in the recognition of this essential truth. If we
were to promote the welfare of the people for whom asylums were built, our
first care must be for the personalities of those who were to look after them.
That also was the best thing that we could do for the workers themselves. The
happiness of life as well as its efficiency depended on the development of
personality. The great weakness of modern industrialism was that the con¬
ditions made it difficult for the ordinary worker to develop his personality.
So much of the work was mechanical that it did not create interest, but it
did tire, and when people were tired they could not make proper use of their
leisure. How could we help asylum workers to keep alive the glory and dignity
of their occupation and so to sustain and develop their own personality? It was
necessary to elevate their self-respect in relation to their work. When people lived
almost entirely with their f el low-workers, as in hospitals, and criticised each other
freely, as all fellow-workers did when constantly in touch with the little details of
the daily occupation, it was easy to forget its nobleness. Somebody was needed
to give reminders that those details were merely incidental to a great purpose, and
that in their adequate fulfilment there was something noble. The encouragement
that the Association gave to asylum workers in various ways was good for that
purpose. But that was not all. The more they could get indirect recognition of
the dignity of the work done by attendants and nurses, the better it would be for
those persons and the work itself. Recognition that was not formal was far better
for the raising of self-respect than official recognition. The more people could be
got socially to accept such workers as members of a dignified profession, the
more those workers would be helped to self-respect in connection with their work.
There was a second point which was often forgotten; most nurses and attendants
entered their profession when they were young, and there was an absolute
necessity for enjoyment in youth. What members of hospital staffs really suffered
from at times was staleness—not dulness, which was different, but working without

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the relief of the complete change which came from entirely forgetting one’s work
for a time. He had a great struggle on this subject in a hospital at Coventry one
Christmas. He felt that the nurses were getting stale, and he wanted them to
have something that would refresh their minds. He spoke to the managers on
the subject, but they said “ No ; in war-time it would not be right.” They pointed
out that there were entertainments for the patients, but he replied that they did
not sufficiently take the nurses out of themselves. Finally, he asked whether he
would be allowed to give the nurses a dance, and the managers agreed, but would
not do it themselves. He took a great deal of trouble to collect double as many
dancing men as there were dancing nurses. He got the best music he could, and
he saw that every single nurse had every single dance there was. The entertain¬
ment had the most valuable effect in sending the workers of that hospital back to
their occupations with renewed freshness, because they had something new to
remember and talk about. Nurses could not go on without something to keep up
the freshness of their appreciation of what the patients needed. When one was
ill, how awful it was to be nursed by a dull, stale person. It was the most crushing
thing in the world. He remembered an experience after he had been smashed in
a bad accident He had a friend who came regularly to see him and made him
worse every time. He liked this friend when he was well, but not when he was
ill. He would lean over the end of the bed and get on his (the Dean's) nerves to
such an extent that he almost made him scream. There were nurses like that. We
want them different—fresh, full of interest and capacity to appreciate, because then
they really helped the patients. If this was true of ordinary hospitals it must, with
still stronger reason, be true of asylums. So many hours off duty did not com¬
pletely relieve mental strain. Some new train of thought was necessary, because
if nurses were to" do their work well they must be enabled to avoid staleness
besides bearing in mind the noble idea of helping their fellow-creatures.

Dr. Charles Mercier, supporting the motion, said it was peculiarly appropriate
that he should be called upon to do so in the historic Mansion House of the City
of London, for there was only one thing with which he had been associated longer
than with asylum work, and that was the City of London. As a boy he went to
the Merchant Taylors’ School, then in Suffolk Lane, Cannon Street. The chief
means of education there was the cane. The boys were caned all day. They
were caned for anything and for nothing. He had held out his hand and received
six severe strokes which paralysed his fingers. Then he had been sent to write a
copy, and because he wrote badly he was caned again.

After commenting on some of the more disagreeable aspects of asylum life, and
the difficulties of those in attendance on insane patients, Dr. Mercier continued •

It used to be thought, most mistakenly, that force was the remedy for madness!
A hundred years ago George III was so affected by 4 the death of his favourite
daughter Amelia that he lost his wits for a time, and was placed under the care of
two nurses. They were called keepers in those days. Thirty years ago he knew
an old gentleman who had been born in the reign of George III, and was personally
acquainted with one of the men who had been his keepers. In a conversation on
the subject of the unfortunate king the old gentleman said, “ I asked the keeper
what they did when the king became violent, and the reply was, ‘ We knocked him
down as flat as a flounder.’ ” If the meanest subject of our present Sovereign
were treated in that way the nurse guilty of the offence would be brought before a
court and sentenced to a long term of imprisonment; he would lose his employ¬
ment, forfeit his pension, and be a ruined man, and would richly deserve the
punishment. Fancy the difference between the nursing of mad people in the days
of George III and the nursing of them now. It was immense, and nobody would
wish to reverse the change. At the outbreak of the present war there were some
5,300 male nurses in the asylums of this country. More than half of them had since
joined the Army, and yet the efficiency of asylum administration had not been im¬
paired. In the asylums of England and Wales there were about 130,000 lunatics,
nearly all of whom were potential suicides. Many were actively suicidal, and some,’
though not intentionally so, were ready to commit suicide if the chance presented
itself. How many of the whole body committed suicide in the year 1916 ? Only
four of the 130,000. and that was actually a smaller number than had committed
suicide before the war. In these circumstances he could not too strongly commend
the objects of the Asylum Workers’ Association.

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Major the Rev. S. Lipson, S.C.F., as a member of the Jewish faith, thought it a
great honour to be associated in commending the report of the Association. At
the call of the Motherland many sacrifices had been made, but none could be
greater than that made by people who devoted every minute of their lives to the
care of those who were mentally suffering. He ventured to suggest that the
Asylum Workers’ Association should abandon that name, and should in future
call itself the Mental Hospital Workers’ Association. He liked the action of the
London County Council in using the phrase “ mental hospital," seeing that the
word “ asylum ” had suffered depreciation. Paying a tribute to the late Dr. Seward,
Medical Superintendent at Colney Hatch, as one with whom he had been connected
for many years, and one of the noblest men he had known, the speaker rejoiced
that Dr. Seward's fine example was followed by the present Medical Superintendent,
a fact which gave him the greater pleasure as persons of the Jewish faith were to
some extent congregated at Colney Hatch. In conclusion, Major Lipson said
that in the Great Beyond nobody would be more assured of a place at the right
hand of the Heavenly Father than the men and women who had devoted them¬
selves to the needs of those whose spirits were darkened.

The annual report was unanimously approved.

The President Re-Elected.

The Lord Mayor having left the chair in order to keep another engagement, his
place was taken by Sir John Jardine.

Sir Frederick Needham, M.D. (Board of Control), moved the re-election of
Sir John Jardine, M.P., as President of the Association. They were, he said,
extremely fortunate to have a man of such distinction at their head.

Sir George Savage, M.D., seconding the motion, remarked that Sir John
Jardine had not,only been a ruler in India, but was now one of our rulers in
England, and had the British spirit of always wanting to work. He had been a
most excellent President in the past, and was sure to be the same in the future.

Capt. H. Kirkland-Whittaker, R.A.M.C., supported the motion, and at the
same time called attention to the training of asylum nurses. The authorities of
those institutions, he complained, had to look outside in order to get women to
become matrons and assistant matrons. The present system was not fair to the
nurses who worked for years, and then found the door to higher positions slammed
in their faces. No doubt the candidates for the higher positions should have had
hospital training, but the authorities of asylums should make it possible for their
nurses to acquire the training necessary to fit them for such posts. For that
purpose there ought to be co-operation between general and mental hospitals.

The motion was carried with acclamation.

The President, thanking the meeting for his reappointment, said that when a
motion like the one just carried was brought forward there ought to be some
person present such as the one that appeared in the Roman Curia—an Advocatus
Diaboli, who would show cause against the proposal. In spite of the kind things
said of him, he feared that Sir John Jardine, as President of the Association, was
no better than he should be. He had tried to do his best, but as far as legislation
was concerned had been hampered by Parliamentary want of touch with the work
of mental hospitals.

Lieut.-Col. D. Thomson, M.D. (President of the Medico-Psychological Associa¬
tion), moved the re-election of the Vice-Presidents, Central Executive Committee,
and officers of the Association, with the addition of the Lord Mayor and Sir George
Wyatt Truscott, Bart., to the Vice-Presidents, and of Dr. J. Noel Sergeant, Miss
E. A. Macdonald, and Mr. J. E. Stephens to the Committee. There was, he said,
a great and unfortunate divergence between the hospital-trained nurse and the
asylum-trained nurse. This was very much to be deplored, as Capt. Kirkland-
Whittaker pointed out while hinting at co-operation in the training of nurses
between the two classes of hospitals. In the last three years he (Dr. Thomson)
had been associated not only with the asylum-trained nurses but also with a much
more numerous body of hospital-trained nurses who were under his command.
Comparisons were odious, and he would not make them with reference to
individuals, but the more he saw of nurses trained in general hospitals the more
he thought of those trained in asylums. Male attendants he could not speak of,

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323

but he found in the asylum-trained nurse more capacity for mothering attention
than in the nurses who had been generally trained.

Inspector R. Keen (Colney Hatch), seconded the motion, and urged the
Executive Committee to consider the suggestion that the name of their organi¬
sation should be changed to " Mental Hospital Workers’ Association."

The motion was unanimously agreed to.

The President then presented medals to a number of attendants on account of
long and faithful service.

The Rev. John Peck (Holloway Sanatorium), moving a voteof thanks to the
Lord Mayor, the President, and the speakers, protested against the idea of the
insane being unlovable. They were very precious in the sight of God and those
who worked for them. It was true that if one looked at the surface only he found
much that was unpleasant, but below the surface there was something precious.
These afflicted people were engaged in a contest which was our problem as well
as theirs. They were the centre of something sacred. That was why so many
workers were attracted to them. Some of the finest people had at times displayed
bad qualities. St. Peter in the presence of his Lord cursed and swore, but that
did not prove that he was unlovable, and still more allowance must be made for
the afflicted people with whom the members of the Association were concerned.

Dr. Helen Boyle (Brighton), seconded the motion, remarking that two things
had particularly appealed to her in the speeches that afternoon. One was the
dance arranged for nurses by the Dean of Windsor, and the other was Dr. Mercier's
reference to the afflicted people and the nurses. Dr. Mercier’s object was to point
out how difficult the work in asylums often was, but there was help in the sense
of humour, and some of the best laughs she had ever indulged in had been due to
the humour of mental patients. Some of those patients had a jollier and happier
time than sane people because they had lost the habit of self-criticism.

The vote was cordially agreed to, and the meeting came to an end.

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.

LXIV.

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THE

JOURNAL OF MENTAL SCIENCE

[Published by Authority of the Medico-Psychological Association
of Great Britain and Ireland.']

No. 267 [X.Ti'"] OCTOBER, 1918. Vol. LX 1 V.

The Presidential Address on the War and the Burden of Insanity,
delivered at the Seventy-seventh Annual Meeting of the Medico-
Psychological Association, held at Edinburgh on July 23rd and
24th, 1918 By John Keay, M.D., F.R.C.P.E., Lieut.-Col.
R.A.M.C.

Ladies and Gentlemen, —Through your kindness and goodwill,
and not on account of any merit or distinction of mine, you have placed
me in the honourable position I occupy to-day. I gratefully acknow¬
ledge the high honour conferred upon me, and, deeply conscious of my
personal limitations, I shall endeavour to the best of my ability to
justify your confidence.

Four years ago we met in the ancient city of Norwich, and dwelt for
a few days in the shadow of its magnificent cathedral—the quiet peace¬
fulness and the old-world atmosphere of the place made for mental
repose, and pleasant memories of its charming and hospitable people,
its fragrant gardens, and its lazy waters will linger with us for many
a day.

Not one of us, I make bold to say, at that happy meeting had any
idea that the war cloud then just visible on the south-eastern horizon
would presently envelop us, and that within a fortnight we as a nation
should be in deadly grips with a powerful and unscrupulous enemy in
the most stupendous conflict the world has ever seen.

Since our meeting at Norwich five distinguished occupants of this
chair—Clouston, Urquhart, Hayes Newington, Mickle, and Maudsley—
and a President-elect, the genial, great-hearted Turnbull, have solved
the great mystery, and passed from among us. I firmly believe that in
holding our annual meeting here in Edinburgh at the end of the fourth
year of the great world-war we are “ carrying on ” as those doughty
champions and true-hearted patriots would wish us to do, and that they
are with us in spirit to-day.

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The war has exacted a heavy toll of members of the Association and
of their sons, and many of the best and bravest men of the staffs of our
asylums have died glorious deaths in the cause of liberty and justice.
None of us would have had it otherwise. We honour the gallant dead.
We treasure the memory of their valour and self-sacrifice. Let us see
to it that we carry on their unfinished work, so that'they may not have
died in vain.

It is reported of a respected Edinburgh divine that he earned the
gratitude and admiration of his flock by preaching a sermon in which
he never once referred to the great war. Such extraordinary restraint
is altogether beyond me; and this at least may be said in excuse—the
minister well knew that he would return with greater zest to the all-
engrossing subject on the following Sunday, whereas with me it is a
case of now or never. You will 'certainly see to it that my first oppor¬
tunity shall also be my last.

Three and a half years ago Prof. J. Arthur Thomson, in the Second
Galton Lecture on “ Eugenics and War,” pointed out that, biologically
regarded, war meant wastage and a reversal of natural selection, since it
pruned off a disproportionately large number of those the nation could
least afford to lose. With the voluntary system of military service
which we had during the first two years of the present war, the call of
their country attracted the more chivalrous, the more virile, the more
courageous, the more patriotic, and the high death-rate among com¬
batants as compared with non-combatants meant, in some measure at
least, an impoverishment of the race—a reversed selection of the stock
of possible parents. The finest men were those who volunteered for,
or to whom were set the most desperate enterprises, and the con¬
spicuously brave were particularly apt to be killed off.

And so with compulsory military service, the young and strong and
healthy men are deliberately selected to be exposed to imminent danger
of death or disablement, while the old and feeble and unfit are carefully
preserved, with the clergy, and the inmates of our asylums, and the
members of the House of Commons. It is enough to make a eugenist
scream.

Prof. Thomson suggests that recruits with a good record who had
reached maturity should be encouraged to marry. There is patriotism
in dying for one’s country, perhaps also in marrying for her.

But war, however successful it may be, has its sacrifices in treasure as
well as in blood, and in waging war as we have been doing for four
years upon a scale unprecedented in the history of the world there has
been a corresponding expenditure of money. Up-to-date votes of
credit for the carrying on of the war have reached the stupendous sum
of ^7,342,000,000, and the cost per day is now ^6,848,000. It has
been pointed out that, notwithstanding this enormous expenditure, the

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BY LT.-COL. JOHN KEAY, M.D.

327

money market has been in a state of ease that has not been paralleled
for a quarter of a century. The country has been apparently rolling in
money, and our credit has never been higher. The volume of insolvency
throughout the United Kingdom has decreased. Unemployment does
not exist; there is no destitution or distress, and trade and industry
have on the whole been but little interfered with. And while we in
this country have been, although at war, enjoying prosperous times,
trade in other and neutral countries, and even in our own dominions
beyond the seas, has been unduly depressed. This state of matters
seems exactly the opposite to what one would expect.

Prof. Shield Nicholson points out that our apparent prosperity as
compared with countries which are at peace may be likened unto that
of a landowner who finds himself with plenty of money to spend on
having effected a mortgage on his estate. “ The War Loans and the
various extensions of Government Credits are essentially the same as
the borrowings of the landowner, and the immediate effect is the same,
though the moral motive is different. Every new mortgage is accom¬
panied by an abundance of ready money and corresponding extrava¬
gance. The reaction comes when the loan has to be renewed—when
the capital has gone and the interest has to be paid.” “ The immediate
effects of the expenditure of new loans and new taxes must always be
distinguished from the ulterior effects. The immediate effect is an
increase of spending power; the ulterior effect is a diminution of
capital. If the savings of the year are invested in war loans they cannot
at the same time be invested in industrial undertakings. If the taxes
on income are doubled, the annual savings must be less. War taxes
do not cease with the war, and the interest on war loans is practically
perpetual.”

If the matter is gone into carefully it will be found that the trade
activity which we have experienced during the progress of the war has
been confined in great part to industries supplying the Government
and the governments of our Allies with commodities required in war-like
operations. Such activities will at once cease on the conclusion of peace.

It is therefore quite obvious that with the enormous cost of the
war, added to a national expenditure which even in pre-war days had
increased to an alarming extent, this country is going to have an
extremely heavy financial burden to carry for many years to come—in
the case of most of us for the remainder of our lives. A war expendi¬
ture of ^7,342,000,000 means over ^250,000,000 of extra taxation
yearly, simply to pay the interest. With increased taxation all over the
world, less money to spend, and less to devote to industrial enterprise,
it seems more than probable that we have before us more difficult times
than we have ever experienced, more difficult than have been experienced
for a century. History is apt to repeat itself, and the leanest years in our

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national history were those which immediately followed the Napoleonic
wars. During the lean years to come there will be a tightening of the
money-bags, an understanding that the resources of the country must
be husbanded, and the springs of charity and generosity will shrink
and show a tendency to dry up. There will be, if I am not mistaken,
a closer scrutiny by the heavily taxed general public of expenditure by
local authorities than we have been accustomed to.

The moral of these reflections is that we, as individuals and as
trusted public officials, will have to adjust ourselves to more difficult
conditions than w'e have experienced in the past, and will have to
practise thrift as we have never practised it before. It will be more than
ever our duty to initiate plans for thrifty administration, to encourage and
back up our committees in being “ thrifty in expenditure, in postponing
as far as possible all extraordinary expenditure, and in administering our
asylums as economically as can be done with efficiency.”

Dark and lowering, then, is the cloud of war: but the silver lining
is there all the time. A glint of it is seen in the development of
patriotism and kindliness as they have never been seen before—
qualities which have enriched all classes of the people. Good may
come even of war when the spirit of the nation is in it. Lord Rosebery
tells us that the war has given us a new lease of Empire—the threatened
danger has joined the Empire together in a way that could not be
accomplished by a century of federal government. Where, now, are
the croakers who mourned the decadence of the race, and predicted
that our Army would be scattered like thistle-down by that of a conti¬
nental adversary ? The response from the ends of the earth to the
call for men, and the deeds of those men on land and sea, and in the
air, have silenced for many a day the long-faced prophets of evil.
There is, says the Bishop of London, a new spirit in the nation. There
must be something noble, if not in war, at least in what war brings out
in human nature.

And after all, we cannot, if we would, be blind to the fact that in all
ages war has had much to do with the progress of civilisation. Great
wars have been the inspiration of great things. The great wars, for
example, between Persia and Greece, and the defeat of Persia by land
and sea, were the inspiration of the Greek development. The world
owes the literature of Greece, the architecture and sculpture, and the
philosophy of Greece—the whole “glory that is Greece,” to the wars
with Persia. Similarly the extraordinary development of the arts, litera¬
ture, and science of the Roman Empire followed centuries of almost
continuous warfare. So it has been throughout the ages right up to our
own time—the war-like nations have been the virile, progressive nations,
and it is they who have done the great things by which nations are
made immortal.

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The enervating effort of a prolonged period of peaceful prosperity
may be observed in nations as in individuals. Nations, like men, may
become fat, flabby, and lethargic, requiring periodically a course of
energetic eliminatory treatment if incurable degeneration is to be pre¬
vented. Lord Bacon tells us that a foreign war is the remedy : “A Civil
War, indeed, is like the Heat of a Fever ; but a Foreign War is like the
Heat of Exercise, and serveth to keep the Body in Health.” “The
solemn call to arms, the sense of national danger, the striving for
victory, the determination to defy the strength and arrogance of the
enemy, and to secure at all cost the triumph of freedom and justice,
the realisation of the grandeur of the part that is being played in
shaping the destinies of the world, these raise the standard of national
character, brace the national nerves, and kindle the spirit of pride and
exhilaration by which great deeds are accomplished, and an Empire’s
perpetual youth secured.”

The state of affairs in our country during the period immediately
following the coronation of King George suggests the thought that
possibly the war with Germany saved the Empire from events infinitely
more damaging to its future. Stephen McKenna describes it in Sonia:
“ On the other hand, the condition of England was a matter for con¬
siderable searching of heart. A spirit of unrest and lawlessness, a
neurotic state not to be dissociated from the hectic, long-drawn Carnival
that continued from month to month and year to year, may be traced
from the summer of the Coronation. It is too early to probe the cause
or say how far the staggering ostentation of the wealthy fomented the
sullen disaffection of the poor. It is as yet impossible to weigh the merits
in any one of the hysterical controversies of the times. Looking back
on these four years, I recall the House of Lords’ dispute and a light
reference to blood flowing under Westminster Bridge, railway and coal
strikes characterised by equally light breach of agreements, a campaign
in favour of female suffrage marked by violence to person and destruc¬
tion to property, and finally a wrangle over a Home Rule Bill that
spread far beyond the walls of Westminster, and ended in the raising
and training of illegal volunteer armies in Ireland. Such a record in
an ostensibly law-abiding country gives matter for reflection. Sometimes
I think the cause may be found in the sudden industrial recovery after
ten years’ depression following the South African War. The new
money was spent in so much riotous living, and from end to end there
settled on the country a mood of fretful, crapulous irritation. ‘An
unpopular law ? Disregard it! ’ That seemed the rule of life with a
people that had no object but successive pleasure and excitement, and
was fast becoming a law unto itself.

“When, therefore, O’Rane went to Yateley, he went in protest
against certain officers at the Curragh, who, holding the King’s Coin-

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mission and with some few years of discipline behind them, let it be
known that in the event of certain orders being given they did not pro¬
pose to obey them. Then, if ever, the country was near revolution.”^)
Then came the sudden call to arms, and in the twinkling of an eye
parties were no more, controversies were forgotten, and the nation
settled down as one man with calm determination to the grim task of
fighting for its very existence.

The silver lining of the war cloud may also be seen in the remarkable
decrease of serious crime throughout the whole country since the war
began. The darkness of the streets of our cities, and the reduction in
the strength of the regular police-force, would seem to supply the
criminal with unexampled opportunities, and yet the police-court returns
have never been lighter. So also in the case of paupers and vagrants.
The number of paupers per thousand of the population is lower than
it has been for half a century, and Salvation Army shelters have
lost nine-tenths of their habitual occupants. The explanation lies to
some extent no doubt in the increased demand for labour, but surely
the bracing and stimulating effect of a great war also plays a part. A
police-court magistrate has it that “ the criminal has turned patriot.” It
may be, it is said, that slumbering in the breast of the most hardened
of criminals there is a tiny spark, which, fanned by the outbreak of war
and the realisation of the country’s need, bursts into the purifying fire
of true patriotism.

The effect of war upon the mental health of a community is a subject
upon which the gigantic struggle should throw light. Stoddart tells us
that war is a potent cause of insanity, and that insanity was rife among
our soldiers during the South African War, and also among the Russian
soldiers during the Russo-Japanese War.( 2 ) References to the matter in
other modern text-books are vague, and for any definite information we
must go back to the observations of French physicians during the
Franco-Prussian War and the Commune, 1870-71. Certain facts seem
fairly well established, and they are of interest to us at the present time.
For instance, it is recorded that the number of patients received in the
asylums of France during the period of the war was smaller than usual,
and that in the summer of 1871, during the height of the Commune,
there were fewer insane in Paris than there had been for years.
Legrand du Saulle concludes that the late war (that is, the war of 1870)
is another proof that “the gravest political events,although they may
give, at the moment, a colour to the particular form of insanity, do not
produce, as is commonly supposed, an increase in the number of
lunatics.” ( 3 ) Lunier observed that melancholiacs forgot their sufferings
in the fearful suspense of the siege of Paris, and that patients who were
the subject of delusions and hallucinations got rid of them, at least for
the time. He agreed with Baillarger and Legrand du Saulle that “ the

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excitement of the war, the rousing influence it exerted on many minds,
was to some extent a set-off against its baneful effects on the mind,”
and that in those predisposed to mental disorder, “ the war acted as a
powerful diversion to avert the outbreaks of insanity.”

On the other hand, we have Morel insisting upon the great frequency
of insanity arising from the fear of a Prussian invasion, and stating that
the burning of villages caused in many instances “ crises of despair to
which succeeded a state of melancholia with tendency to suicide.” He
agrees wiih Bourdin and Pinel that the effects of war in the production
of insanity are more likely to be seen after the war than during its
course; that it is the children unborn who suffer—“ that they are more
irritable, more disposed to become melancholy, imbecile, or epileptic.”

Ireland tells us that Baron Percy, a French military surgeon, observed
that out of ninety-two children whose mothers had been exposed to the
terrors of a tremendous cannonade at the siege of Landau in 1793,
sixteen died at the instant of birth, thirty-three languished from eight to
ten months and then died, eight became idiotic and died before the
age of five years, and two came into the world with numerous fractures
of the bones of the limbs. ( 4 ) One thinks of what has happened to
Belgium and north-eastern France, and wonders what the aftermath
will be.

The official records of the Boards of Control and the reports of
asylums show that during the present conflict, which has now lasted for
four years, the number of cases of insanity occurring in this country has
diminished. Whether this has also been the case in the countries of
the other belligerents one does not know, but, so far, our experience
seems to be in accord with that of France during the war of 1870.
Whether the decrease will be permanent, or merely temporary and co¬
incident with the period of hostilities, time alone will determine, but one
is fairly safe to assume that the burden of insanity to be borne by the
country when the war is over will not be less than it has been in the
past, and that the burden is no inconsiderable one a very few figures
will be sufficient to show.

In the Annual Report of the London County Council for 1913, it is
stated that the number of insane patients under care in its asylums was
21,000, and that their maintenance involved an annual charge of
^£617,000. Since the London County Council came into existence
twenty-five years before, the number of insane under its care had more
than doubled, and the cost of maintaining them—and this is an important
point—had increased more than threefold. If now we take the corre¬
sponding figures for the whole of the three kingdoms, we find that at
the end of 1913 there were 172,000 insane patients under care who
were supported out of the rates at an annual cost of ^£4,600,000. In
comparison with the cost of carrying on a great war this seems but the

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veriest trifle—it would be swallowed up by even our own expenditure,
not to speak of that of our Allies, in about sixteen hours—yet it would
be sufficient to add to our Navy two super-dreadnoughts, built, armed,
and equipped, every year.

Now, the worst of it is that the expenditure on the insane is, to a
large extent, like the expenditure on war, unproductive, the greater part
of the money being spent —it may be very well spent—in the upkeep of
persons who are for all practical purposes with our present knowledge
permanently disabled, and who will be a burden on the community for
the remainder of their lives. It is, perhaps, within the mark to estimate
that of the 172,000 rate-supported insane in Great Britain and Ireland
at the end of 1913, the proportion of 75 per cent ., or 129,000, costing
for their support for one year ^3,450,000, were chronic, incurable
cases, fated to remain for the period of their lives a charge upon the
resources of their fellow-citizens.

It is, of course, fully recognised that there is no more helpless and
pitiable class than the chronic insane, bereft for their lives of the
priceless possessions of health and personal liberty, and none calling
more urgently for the humane instincts of the community. And let me
at once express the conviction that no saving of expenditure which
would involve a diminution of their comfort or would interfere w ith
the amelioration of their conditions of life would be tolerated for a
moment by the ratepayers of this country, who, after all, by the exercise
of their generous instincts in paying the piper have the right to call
the tune.

It is not, therefore, by niggardliness in the provision made for the
maintenance of the unfortunates who are hopelessly and incurably
insane that expenditure may be lessened, but rather, if it be possible,
by limiting their number, and the problem before us at this great crisis
in our national history, as the advisers of those who are responsible
for them to the community of ratepayers, is to consider whether this
may be by any means accomplished.

This brings us to the question of the prevention of insanity—a subject
all-important, because it is on preventive measures that our hopes for
the future must be largely based. “ The highest function and main
object of medical science is the prevention of disease.” As time goes
on the collective responsibility of the medical profession in regard to
social problems which concern the health of the people is being
recognised and accepted. Its attention, therefore, is being more and
more directed to the study of disease as a social evil, to its causes, and
to the measures which may be taken to effect its cure and prevention.
Following the recognition of this collective responsibility of the pro¬
fession comes sooner cr later a demand by the profession and the
enlightened public for State interference in the interest of the health of

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the people, and it must be admitted that, whenever exercised, this
interference has, upon the whole, brought good to the community.
Bubonic plague, thanks to sanitary precautions, has now no terrors, and
a case of typhus or of smallpox is something of a curiosity. When
scarlet fever appears it is hunted down, traced to its origin, and
stamped out with the confidence begotten of repeated victories. With
the attention now being directed to tuberculosis it will doubtless in the
course of time, and with a generous expenditure of money, share a
similar fate.

Now in the case of insanity the attitude of the public and of the
State has until a very recent date tended rather to encourage the
propagation of the disability than to suppress it. While the citizen
deficient in this world’s goods but of ordinary mental capacity has had
to struggle along, alone and unassisted, in a-life-long endeavour to keep
body and soul together, the lives of the unfit have been carefully
preserved, and in the case of too many of them little or no attempt
has been made to prevent them from reproducing their kind. “ Sterility,
Mott tells us, often accompanies marked mental deficiency, but there
is no limit to the fertility of the higher grade imbecile; in fact, the
poorer the stock in mental and physical power and civic worth, the
more prolific it is.”( 6 ) And, to a great extent, is it not the idiot and
imbecile who are probably sterile that are shut up in asylums and
similar institutions, while the higher grade defective goes at large,
and gives rein to the instinct with which for some inscrutable reason he
has been so richly endowed? And this has been permitted in the full
knowledge of the tendency of like to beget like, and of the hereditary
nature of the infirmity.

In his Presidential Address in 1906, Sir Robert Armstrong-Jones
dealt with this point. “We accept the statement,” he said, “that
society is bound to provide for and to support its own languishing
sick and feeble, but when 1 in every 283 persons of the population
is an inmate of a lunatic asylum, when 1 in every 157 during the year
1905 has undergone a term of imprisonment for offences against the
law, when 1 in every 100 children of elementary school age is so
mentally or physically defective as to require special educational facili¬
ties, and, further, when 1 in every 31 in London is a pauper, it is surely
time that some stir was made !

“ The whole of this so-called ‘ defective class ’ have a right to be
protected against themselves, and the control which they lack should
be supplied to them from without; at the same time, society has a
right to be protected from the transmission of their defective qualities
to future generations.”

Since Sir Robert Armstrong-Jones wrote these words something of a
stir has been made. The public has been to some extent educated to

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a sense of its responsibility in regard to these unfortunates. The public
conscience has been aroused. There are indications that “ that
treacherous phantom which men call Liberty ” shall no longer in
dealing with mental unsoundness be allowed to override every other
consideration, and that in a question between the good of the State
and the liberty of action of an individual the State must come first.
There is a confident expectation that when the war is over, and normal
conditions have returned, a large number of examples of an unfortunate
class of persons too long neglected will be placed under care under the
provision of the Mental Deficiency Acts, and that by their segregation
and control the propagation of the mentally unfit will be to some extent
checked.

But, after all, such measures may lessen the tendency to degeneration,
but cannot improve the race of men. The breeding of a higher type
—the aim of eugenics—will be more difficult to attain.

Dr. Chambers, in his scholarly Presidential Address delivered in 1913,
predicts that “scientific investigation will, in the not remote future,
justify our belief that there are persons leading active and useful lives,
who yet, by reason of some acquired physiological modality, should,
in the interests of the race, abstain from marriage.” Further, “that
research will, we hope, aid in defining for us the circumstances in which
the avoidance of marriage is to be counselled ; and if for the moment
it is not always easy to assert that this strain should be terminated or
that one maintained, we can at least be sure that, if in some cases the
germ-plasm is improvable, there are others of which the contrary may
emphatically be said.”

Galton shows that Athens, by a system of partly unconscious selec¬
tion, built up in one century a magnificent breed of human animals
which were in average ability as much above our own race as our race
is above that of the African negro. “This estimate,” he says, “which
may seem prodigious to some, is confirmed by the quick intelligence
and high culture of the Athenian community, before whom literary
works were recited, and works of art exhibited of a far more severe
character than could possibly be appreciated by the average of our race,
the calibre of whose intellect is easily gauged by a glance at the con¬
tents of a railway bookstall.” “It is essential,” he says, “to the well¬
being of future generations that the average standard of ability of the
present time should be raised.”

But how is the average standard to be raised ? Proposals for breeding
an improved race of men by marriage restrictions and regulations, how¬
ever excellent in theory, have the fault that in practice they are unwork¬
able. It is all very well to say let those who are intellectually gifted,
and who are strong and vigorous physically, marry when they are young
to that they may have large families of children with similar qualities,

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and retard the average age of marriage of those that are weak, so
that they may have few children or none at all. In a few generations
the strong and vigorous will greatly outnumber the weak, who, with
a continuation of the selective process, will in time be eliminated
altogether.

But who is to say these are the strong, and those are the weak ; these
are to marry, and those are to refrain ? And how to compel people to
marry, or not to marry; to have children, or not to have children ?
Who is to say to the priest, the man of natural abilities, strong and
vigorous—“ Celibacy is not for you : your country wants you ; renounce
your vows, marry and beget children like unto yourself?” And to the
erotic neuropath—“You are unfit; marriage is not for you?” The
possibilities of improving the race and coincidentally diminishing the
occurrence of insanity by methods such as these are theoretically
magnificent. In practice such methods would not be tolerated. The
whole subject bristles with difficulties, and, while public opinion is
maturing, and people have attentive ears for instruction and guidance,
it is realised that progress must necessarily be slow, and that precipitate
action in the form of rash proposals for the compulsory limitation of
marriage would probably have the effect of indefinitely postponing the
desired result.

But there is another method. We are losing day by day in the great
world-war the flower of British manhood, and the race depends more
and more for its strength and vigour upon the number and the health
of its children. And if we cannot, in the meantime at least, regulate
the number and the quality of these by arrangements suggestive of the
stud-farm, it is surely our duty in the interest of self-preservation to
make the most of the material available. We must take the child as it
is, with all its defects, hereditary and acquired, and make the best of it.
We can see to it that it does not suffer through ignorance or neglect,
that it receives the best of care from the earliest moment of pre-natal
life up to the full development of manhood or womanhood, and, inci¬
dentally, we can care for and protect the mothers of the race, upon
whom so much now depends, so that their supreme function may be
maintained at the highest point of efficiency.

This is a matter for State supervision and control, and we welcome
the fact that the State is taking it up in an enlightened and progressive
manner. There is also here full scope for voluntary effort, and so the
work of the general practitioner of medicine, the midwife, the health
visitor, and the Public Health Department can all be co-ordinated with
the happiest result. Mott tells us how efficiently this has been done in
France (°), and Prof. Pinard, a well-known authority on the rearing of
children, has given a remarkable report to the Academy of Medicine on
the birth statistics since the war began. “ Contrary to all precedents,”

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he says, “ the health of war children and their mothers has not been
injuriously affected by the war. On the contrary, the Paris death-rate
of mothers in childbirth has fallen, the proportion of stillborn infants
has declined, the infants’ death-rate has fallen, and the proportion of
infants abandoned to the foundling hospitals has also decreased.”
Finally, the Professor affirms : “Never has as fine a set of babies been
seen in Paris as has been born since the war. This is greatly due to
the assistance given to mothers by the association started after the out¬
break of war under the patronage of Madame Poincare.” It should be
stated that Prof. Pinard’s report was rendered at a comparatively early
period of the war.

Of no less importance is the case of the health of the child during its
years at school. It has at long last been recognised that to attempt to
cram with book-learning a pining, diseased, ill-fed, and insufficiently-
clothed child is not only a waste of public money, but downright
cruelty.

We who have the care of the wreckage of humanity are well aware
that in a large proportion of cases the breakdown occurs during the
period of growth and development. We cannot but be interested, there¬
fore, in the important educational measures now under the consideration
of Parliament. We look forward with hopefulness to the results to be
expected from these legislative enactments, and more especially to the
provisions for the medical care, the feeding, the clothing, the physical
training, and all the arrangements which have for their object the
upbringing of a healthier, and therefore a stronger and saner race of
men and women. One is convinced that, if these matters are attended
to as they should be, the intellectual development of the child during
the years at school will naturally follow as a matter of course, and may
to a large extent be trusted to look after itself.

But the necessity for the care and supervision does not cease with his
days at the elementary school. When this point has been reached the
great majority of the youth of the nation are launched into the world
and begin to earn, and it is still necessary to guide and train them to
be healthy and effective members of the community. It is when a boy
has thrown off the restraints of school-life, and has attained the capacity
to earn, that his destiny is fixed. He has come to the dividing of the
ways. Wisely guided, he may choose a trade or occupation in which,
with the assistance of the continuation school, and after years of patient
labour with small remuneration, he becomes a good and useful citizen.
Or, without guidance, and impelled, perhaps, by parental short-sighted¬
ness and greed, he may enter the ranks of unskilled labour, in which,
though at first more money may be earned, there is no advancement to
be looked forward to—nothing but a life of drudgery, with gradual
deterioration mentally and physically.

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When boys and girls have once left school, and have lost the school
habit, it is difficult to get them back to classes of any kind, and there¬
fore the educative process should be continuous—the term “ continua¬
tion classes” suggests this—and they should pass on as a matter of
course from the elementary school to the classes appropriate to their
life work. In this country these continuation classes have not been a
pronounced success for the reason, first, that they have been voluntary
instead of compulsory, and boys and girls easily find more attractive
ways of spending their evenings than in attending classes of any kind,
and, in the second place, because'the classes are held in the evenings
after a full day’s labour, during hours which should be devoted to recrea¬
tion or sleep. The remedy is obvious. First, the classes should be
compulsory; pupils should pass on to them from the elementary
school as a matter of course. Once make them compulsory and the
compulsion will not be felt. Secondly, they should be part of the day’s
work, and therefore should be held in working hours.

It has been the experience in Munich that it pays to run these trade
schools, and to endow them liberally. It pays the employers to give
time off for technical training, because of the increased skill of the workers
thereby attained. It pays the city, because its reputation for good
work in its factories is increased. It is satisfactory to note that in the
Education Bills now before Parliament this important part of the training
of the youth of the nation is dealt with as its importance deserves.

But, it may be asked, what has all this to do with prophylaxis—with
the lightening of the burden of insanity ? Dr. Chambers predicts that
the time is coming when educative processes will be guided by nicer
discrimination than we have hitherto attempted, and that the expert
may then find that he is called upon to play in the adjustment of the
organism to its environment a part of no small importance in the
prophylaxis of mental break-down. He warns us not to try to grow
peaches on the hill top, or to spoil fine peasants that we may have
inefficient clerks, and suggests that we should learn, in choosing human
material for special purposes, to be guided not only by its apparent
texture, but by our knowledge of its derivation.

Much will depend, therefore, upon the wisdom and common sense not
only of those to whom the supreme control of our educational system is
entrusted, but more especially to the teachers in the schools and classes,
who come into direct individual contact with the youth of the nation, and
who have it in their power by suggestion and advice to guide their pupils
into paths of life suitable to their intellectual, no less than their physical
capacities.

There is no likelihood that the raising of the average standard of
intellectual ability of the race would be accompanied by physical
deterioration. Galton tells us that we need as much backbone as we

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can get to stand the racket to which we are henceforth to be exposed,
and as good brains as possible to contrive machinery for modern life
to work more smoothly than at present. And he shows that there is
no incompatibility between the strong arm and high intellectual capacity.
He says—“ I do not deny that many men of extraordinary mental gifts
have had wretched constitutions, but deny them to be an essential or even
the usual accompaniment. University facts are as good as any others
to serve as examples, so I will mention that high wranglers and high
classics have been frequently the first oarsmen of their years.” . . .

“ It is the second and third rate students who are usually weakly. A
collection of living magnates in various branches of intellectual achieve¬
ment is always a feast to my eyes, being, as they are, such massive,
vigorous, capable-looking animals.”

The sound mind goes with the sound body, and there is abundant
reason for the hope that, by increased attention to the care of the youth
of the nation, a race of men will in time be evolved more capable than
the present one to bear the racket and strain of modern life.

Sir Robert Armstrong-Jones told us, in his Presidential Address, that
if only the evils of alcohol and venereal disease were disposed of, then
half the problem of insanity would disappear with them. The evil
effects of alcohol as an exciting cause of insanity, as the determining
agent in bringing into activity brain-weaknesses of all kinds, and as a
cause of race degeneration, have been preached by social reformers,
and in particular by members of our own Association for generations.
Perhaps through the constant repetition of the warnings, and, it may
be, to some extent owing to extreme and intemperate proposals of
temperance faddists, the results as regards the wage-earning classes
of the community have been disappointing. Since the great war began,
however, events have occurred which should surely rouse the nation
to the enormity of the evil, while demonstrating the fact that it is one
which can be mastered by strong and resolute government action. We
were warned by the Prime Minister, and by those at the head of these
great undertakings, that, owing to the drinking habits of those employed
in our ship building yards and armament factories, the output of ships
and munitions of war was in danger of being insufficient for the
ments of the forces engaged in fighting for the preservation of our
country. And we learned that when drastic restrictions were enforced
more and better work was accomplished, and nothing but good resulted
to all concerned.

Another great social evil with which the State has at last been com¬
pelled to deal, by an awakening of the public conscience, is the
prevalence of syphilis, and its effects upon the health of the community.
In our asylums syphilis presents itself to us for the most part in two
forms, viz., general paralysis and congenital mental deficiency, although,

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339

in the cautious language of the official report, “it is not possible to
affirm that syphilis as an aetiological factor in the production of insanity
may not play a considerable part even in those forms of disorder in
which such an association is comparatively infrequent.” ( 7 )

We are agreed, I take it, since Noguchi’s discovery, that syphilis is
an essential cause of general paralysis; and that if we could abolish
syphilis to-day there would not be a case of general paralysis in existence
twenty years hence. What this would mean to the nation will in some
measure be indicated by reference to the statistics relating to the subject
compiled by the General Boards of Control. In England the number
of deaths from general paralysis in asylums during the year 1913 was
1,753 j ' n the Scottish asylums for the same period the number was 221.
These figures represent only the mortality from recognised cases of the
disease in asylums. No account is taken of cases occurring elsewhere,
and that many cases go unrecognised, in asylums, in other institutions,
and in private care there is no doubt.

General paralysis is probably a sequel of untreated syphilis or ineffi¬
ciently treated syphilis. Browning points out that syphilis is a disease
whose manifestations are of the most multifarious description, so that
it frequently escapes detection, while remaining infectious all the time.
Further, that the subjects of syphilitic infection, “ unless treated by the
most energetic methods at our disposal, pass almost invariably through
the carrier stage,” and that “ while, even without treatment, apparently
complete restoration to health may follow the primary and secondary
stages, the presence of the active virus is shown by the fact that the
latent syphilitic is capable of infecting others, and the same holds good
when the latent state-is induced by mercurial treatment.”

The loss of infectivity may not occur for many years. He records
the case of a man who was treated with mercury for .about six months
after the appearance of the primary sore; during the subsequent
twenty-five years he has remained apparently perfectly healthy, but he
infected his wife, whom he married thirteen years after contracting the
disease. The latent syphilitic, then, in the early stage, although
apparently healthy, is a source of great danger to others, and “ cases in
this category are, in the absence of a history, practically unrecognisable
by ordinary clinical methods.”

Browning directs attention to the further complication introduced by
the fact that the primary and secondary stages of syphilis may be
missed altogether, so that the affected individual is actually not aware
of his state. He instances a case of tabes in a highly intelligent and
well-informed man, who had never, to his knowledge, presented any of
the early signs of syphilis, although he volunteered the history o;
exposure to possible infection. The probability is, however, that although
a few may escape, the great majority of syphilitics receive treatment of

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some sort. Whether that treatment is likely to result in the cure of the
disease is quite another matter.

McDonagh states that in the primary stage a cure is possible pro¬
vided sufficient injections of salvarsan, or an efficient substitute, are
given to procure a negative Wassermann reaction in the blood with¬
drawn between the seventeenth and forty-eighth hour after the last
injection, and that the treatment is further augmented by twenty-four
intramuscular injections of mercury—given within twelve months. In
the secondary stage a cure may also possibly be obtained, but the
mercury injections should be continued for another year. Success, be
says, for the same treatment in the latent stage of the disease and in the
stage of early recurrence is improbable, while in the stage of late recur¬
rences—such as gummata and nervous syphilis—a cure is impossible.

McDonagh emphasises the fact that insufficient salvarsan or other
similar treatment in the early stage of syphilis will do more harm than
good, as it gives the patient a false sense of security, and renders him
for a longer period a danger to the community. He instances cases of
patients who had had two injections of salvarsan infecting others when
they themselves thought, and had been told, that they were cured. He
states that the syphilitic organisms reach the nervous system very early
in the disease, and that nervous lesions can only be prevented by
sterilising the whole body by several injections given at short intervals
as early as possible. He takes a gloomy view as to the probable effect
on the incidence of syphilitic nervous diseases of salvarsan or other
similar treatment as usually carried out, He holds the opinion that
these diseases are on the increase, and feels very strongly that, owing
to the spasmodic and inefficient manner in which these remedies are
prescribed, tabes and general paralysis will, in a few years’ time, increase
even more rapidly than is the case to-day, and that they will appear
more quickly after the infection than hitherto. ( 8 )

In no disease can it be more truly said that the sins of the fathers
are visited on the children than in syphilis. With the very union of
the two elements the germ-plasm may be infected, leading to pre-natal
death, or to the birth of an infant degenerate and diseased. Recent
researches by Ivy Mackenzie and Carl Browning, by Kate Fraser and
Ferguson Watson, by Leonard Findlay and Madge Robertson, have
shown that a large majority of idiots and imbeciles are syphilitic, and
the inference is that the syphilis accounts for their non-development.
Prof. Whitridge Williams, of Baltimore, in an investigation into the
cause of 750 foetal deaths occurring in 10,000 consecutive admissions
to the Obstetrical Department of the Johns Hopkins’ Hospital, found
that in 186, or 26^4 per cent., the setiological factor was syphilis. In
addition, of the children born alive 164 were syphilitic, so that no fewer
than 350 syphilitic children had been born of the 10,000 women.

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BY LT.-COI.. JOHN KEAY, M.D.

341

What is wanted is that the public should be awakened to a realisation
of the fact that there is in syphilis rampant in their midst a deadly,
contagious, and hereditary disease, a disease which kills a countless
number of unborn innocents; which is the cause of the mental and
bodily decrepitude of a large proportion of our idiots and imbeciles ;
which in its various manifestations results in life-long incapacity, bodily
suffering, and mental anguish to numbers of people who in happier
circumstances would be capable and vigorous citizens. And yet withal,
a disease which is preventable ; which, in its earlier stages at least, and
with proper treatment, is curable; and which, by energetic, resolute,
concerted action by the great civilised nations could be stamped out
and abolished for ever.

The measure recently passed by our Legislature is all to the good,
inasmuch as by the publication of the Report of the Commission, of
the debates in Parliament, and of various articles and letters in the
Press, the veil has at last been lifted and the attention of the community
directed to the formidable nature of the evil. What the result will
be is in the lap of the future; but to my mind, an attempt to deal
with a world-spread infectious plague like syphilis without compulsory
notification, without compulsory treatment, without joint action on the
part of other nations, is also without the qualities which command
success. In the light of McDonagh’s teaching it is more likely to
result in an increase in the incidence of the nervous manifestations of
syphilis than the reverse.

So far for the possible reduction of the burden of insanity by pre¬
ventive measures. Let us now consider very shortly whether anything
may be done in the same direction by improving our methods of
dealing with the insane.

We are at once confronted with the dismal fact that during the past
thirty years there has been a continuous lowering of the recovery-rate
in our asylums. This has been ascribed by the Commissioners to
the increased use of observation wards in connection with parochial
hospitals, to the accumulation of chronic patients, and to the improved
hospital care and nursing in asylums leading to their being freely used
for the reception of patients whose age and whose mental and physical
condition are such as to preclude hope of recovery (•). We know how
true this is, and how the most trifling mental abnormality is used as the
pretext for sending to the asylum, as the last haven of refuge, the most
helpless and hopeless cases of physical disease and decay.

But surely we are not satisfied that better results cannot be attained ?
Among the chronic patients accumulating in our wards there are many
whose failure to recover was not because of its impossibility, but because
our knowledge of disease is insufficient, and our treatment corre¬
spondingly defective. Who can say because we have not treated
LX1V. 24

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paranoia, or dementia praecox, or general paralysis, or epilepsy, so that
recovery takes place, therefore these diseases cannot be cured ? To
the investigator with the true spirit of scientific research failure to
obtain the desired result is but a stimulus to further and more strenuous
effort. “ Why should insanity be left behind when so much forward
endeavour is made in general medicine ? ”

In our daily routine of ward work perhaps one of the greatest difficulties
with which we have to contend is this—that we see comparatively few
patients who are not the victims of the end-products of disease. Our
patients do not come under care until the most hopeful opportunities
for arresting or curing the malady from which they suffer are past and
gone. If this be true of patients in general hospitals, about whom
Dr. Guthrie Rankin has written in his article on “ The Borderland of
Disease ”( 10 ), how much more does it apply in the case of patients
admitted to asylums ? It has, indeed, been the burden of complaint
in our annual reports to committees so long as one can remember.

It is our duty, I submit, not only to point out that delay in having
patients placed under treatment diminishes the prospects of recovery,
and thereby increases the burden of insanity, but also to show, if we
can, the prevailing causes of such delayed treatment, and the remedies
which may be devised to meet them. Many of them are causes which
operate equally in the case of patients of any general hospital: an
unwillingness to give up work or domestic duties; a careless in¬
difference to symptoms which, though troublesome, do not in the
meantime involve total incapacity; a dread or dislike of remedial
measures and of hospital rule and discipline. Others are specially
applicable in the case of mental patients: failure of the doctor to
recognise the symptoms of disorder until well advanced; dread of the
asylum, or of the stigma of lunacy ; the absence of proper facilities for
the early treatment of mental disorder, so that, broadly speaking, in
the case of the great majority of patients, expert treatment is unattain¬
able until the disease has so far advanced that the patient can be
certified insane; the pauperisation and loss of civil rights involved in
certification.

There must be grave defects in a system under which a man cannot
obtain skilled advice and treatment for his malady until it has become
so confirmed as to be practically incurable. For suggested remedies
for these defects I would refer you to the valuable report of the
Committee of this Association re Status of Psychiatry, and also to
Dr. Bond’s admirable address on “ The Position of Psychiatry and the
R 6 le of General Hospitals in its Improvement ” ( u ).

It must be obvious to everyone who has given the subject serious
consideration that there are serious disadvantages in the absence of a
close relationship between psychiatry and the ot herj departments of

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Dr. Bond in the address already alluded to—the establishment of mental
wards, with associated out-patient departments, in all the large general
hospitals throughout the country. In the case of hospitals connected
with medical schools these would naturally assume the form of full
psychiatric clinics.

To carry this out it would be necessary to reorganise the present
system, and to sever once and for all its connection with the Poor Law—
the system “which compels all persons, except those able to pay
adequately for their maintenance, to apply to the Poor Law authorities
in order to secure treatment,” and under which treatment may be refused
or delayed until the disease has become so pronounced that the patient
can be certified insane—in other words, under which treatment may be
delayed until the curable stage of the malady has passed. “A system
which artificially creates paupers in order to obtain medical treatment
necessarily acts as a deterrent, so that too frequently there is serious
and even disastrous delay.”

We shall look to the Ministry of Health to carry out this reform.

In conclusion, Ladies and Gentlemen, I thank you for your attention,
and apologise for the length and discursiveness of my remarks.

(') Sonia, by Stephen McKenna, p. 258.—(*) Mind and its Disorders, p. 163.—
( 3 ) Annales Medico-psychologiques, vol. vi, p. 222.—( 4 ) Mental Affections of Chil¬
dren, p. 24.—(*) Mental Development, p. 95.—( 6 ) Ibid., pp. 95-98.—(') Sixty-
eighth Report of the Commissioners in Lunacy to the Lord Chancellor, part I, p. 29.—
( 8 ) Brit. Med. Journ., 1914, vol. ii, p. 616.—( 9 ) Fifty-fourth Annual Report of the
General Board of Commissioners in Lunacy for Scotland, p. xii.—( 10 ) Brit. Med.
Journ., 1914, vol. ii, p. 821.—(") Journal of Mental Science, January, 1915.—
( la ) Brit. Med. Journ., January 3rd, 1914.

Observations on the Rolandic Area in a Series of Cases of Insanity.

Abstract of a paper read at the Quarterly Meeting, May 28th, 1918.

By John Turner, M.B.

I have for many years past been impressed with the prevalence of
a peculiar form of Betz cell in the brain of the insane, and in 1914
I had the opportunity of comparing the picture as seen in the cortex
of the insane with that in the corresponding area from a series of
brains from persons dying in London hospitals (Guy’s and London),
and found that among the hospital cases this prevalence of the insane
type (if I may term it so), was much less marked.

Hitherto, however, my observations had been confined to a very
limited* area of the ascending frontal convolution—that which controls
the muscles of the foot and ankle. Here I record a more extended
study of the Rolandic area, dealing with :

(1) Its configuration.

(2) The micrometry of its cortex, in order to ascertain whether, as

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Bolton showed in the case of the visual and prefrontal areas, there was
a deficiency or atrophy in the depth of any of the laminae in different
forms of insanity.

(3) The form of Betz cell here described, to ascertain whether its
prevalence is maintained in the areas controlling the muscles of the
remaining part of the lower extremities, of the upper extremities, and
of the face.

(4) An attempt has been made to correlate differences in the
internal structure of the Betz cells with symptoms.

(5) A theory is advanced as to the significance of the change seen
in the pathology of insanity.

Method .—In every case a drawing was made of the Rolandic area,
and the site of the portions selected for study were marked out in this
drawing. The tissue was fixed in absolute alcohol, passed through
chloroform, embedded in paraffin, all in the course of three or four
days. Sections, including the cortex of both lips of the area, stained
in Unna’s polychrome blue, were drawn on a slightly enlarged scale,
on which were marked the position of the principal Betz cells as seen
under a low power, and also the region in which a definite granule layer
could be detected. Drawings of the different types or of prevailing types
of the Betz cells were made in the majority of cases by the aid of a
“ Zeiss camera lucida," all to the same scale (vie., objective D, ocular 6).
Campbell, in his monograph, calls attention to the valuable aid- in the
study of these cells and their changes this proceeding yields, and I
can confirm his remarks. It is only by comparing a series of such
drawings one with another that one is able at all satisfactorily to
appreciate the enormous difference in the size of the Betz cells in
different cases and to classify the changes seen.

Part I.

1. The Configuration of the Rolandic Area.

Quain states that this fissure is very rarely interrupted in its course,
although on separating its lips it may sometimes be seen that there
is a slight tendency to the appearance of an annectant gyrus about the
level of the superior genu, and it is here that the interruption is liable
to occur. Ebersteller met with this interruption twice in 200 cases, in
both unilateral. Retsius not once in a hundred. A. W. Campbell,
in thirteen instances in 1,400 brains examined, and R. Wagner in the
brain of Prof. Fuchs.

I append some figures as to the mode of beginning and ending of
the fissure of Rolando in cases of insanity, and concerning the frequency
of an annectant gyrus.

The number dealt with is too small to attempt to draw therefrom
any decided conclusions, so I merely give the tables, and refer to one
or two points which they show: First, as regards the upper end of the

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fissure, it fell short of the vertex in 37 per cent, of all cases, least often
in imbeciles. It cuts the vertex in 47 per cent, most frequently in
Class I( 1 ), least frequently in Class II. It extended from half to an
inch on the mesial aspect in 16 per cent, most frequently in Class II,
least frequently in Class I.

In three males, one of each class, and one female of Class III,
instead of passing as usual obliquely backwards on the mesial aspect,
it ran vertically downwards, and in the case of a male of Class II it
passed vertically down for upwards of an inch. A piece of tissue was
cut out, including the cortex of both sides, near its extremity; the
depth of the fissure here was 7 mm. Examination of sections showed
that the cortex on each side was of equal width; on both sides were
equally large and numerous Betz cells, and on both sides the granule
layer was very indistinct; in fact the cortex on both sides was of
precentral type.

Cunningham states that in 60 per cent, the fissure incises the upper
border of the hemisphere, and appears on the inner aspect. In about
ao per cent, it only just reaches the upper margin, and in 20 per cent, it
falls short by an appreciable distance.

Presumably his figures are based on data made from the general
population, and as under the head of cutting the vertex, I have included
those cases in which it did not pass for half an inch on the mesial aspect,
probably there is no great discrepancy in our results. As regards the
lower end, it stopped short of the Sylvian fissure in 86 per cent.
on the right and 73 per cent, on the left, sometimes for upwards
of an inch. The lower end occasionally forms an inverted T-shaped
bifurcation, lying obliquely with its anterior half of the cross-piece on
a higher plane than the posterior. In these circumstances I found that
the posterior half represented the true termination of the fissure of
Rolando, judging by the types of cortex found on each side of the limb.
The lower end terminated, as described by Quain, in half the cases on
the right, in less than half, 43 per cent., on the left. According to
Cunningham, in about 19 per cent, the lower end forms a connection
with the Sylvian fissure by means of the sub-central sulcus. In my
cases this was found in 13*5 per cent, on the right and 27 per cent, on
the left, twice as often on the left as on the right. It may be pointed
out that the normal arrangement, according to Quain, was very con¬
siderably less frequently met with in the imbeciles compared with
Class I, but most frequently, not in this class but in Class II.

Annectani Gyrus at the Buttress.

I have already referred to the occurrence of an annectant convolution
at the site of the buttress, a condition which Cunningham describes as
of extreme rarity, but which Campbell found in 15 out of 1400 brains
examined by him, or roughly in 1 per cent, of all his cases. It was found

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in 8 males and 5 females, in 7 instances on the right side only, in
5 on the left, and once on both sides. Both Cunningham and Campbell
are referring to a complete annectant convolution, that is one which
rises to the surface and is visible without any manipulation of the brain.

Table showing the occurrence of a Partial (p) or Complete (c) Annectant
Convolution at the Buttress in 152 Cases of Insanity.

Total number of
cases examined,
divided into three
classes.

Annectant convolution at buttress.

Percentage
incidence in each
class and sex.

Complete

(r).

Hidden

</)•

Total.

Side on which found.

Right.

Left.

Both.

Class I

Males
Females .

21

52

—

5

5

B

B

2

96

Total .

73

—

5

5

■

2

68

Males

18

I

n

1

9

55

*-4

Females

24

—

4

mm

1

2

1

166

■

■fl

u

Total

42

I

4

5

2

2

I

11’6

Males

17

I

2

3

_

3

—

1 ►-*

Females

20

I

I

2

1

1

—

to

<G

u

Total

37

2

3

5

1

4

13 s

■

Grand total

3

12

IS

4

8

3

9-8

A hidden or partial annectant, which does not rise completely to the
surface, and which is not visible until the lips of the fissure are separated,
is a very common occurrence, I have met with it in 12 cases in 152
brains examined, but, as the accompanying table shows, it was, unlike
Campbell’s cases, more frequently found among women, and most
frequently among women of the dementia praecox type and congenitally

defective males. _ .

It appears to me that the figures in this section relating to the

formation of the fissure of Rolando point to differences between the
sexes, and, also, as might perhaps have been expected, they show that

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departure from the normal type is more common in Classes II and III
than in Class I.

2. Micrometry .

In Table A are given summaries of the average measurements of
the different layers of the cortex of the Rolandic fissure in its frontal
and parietal aspects in the brains of four hospital patients, twenty-nine
insane males, and thirty-one insane females. Three measurements
were made in each case for the ascending frontal and a like number
for the ascending parietal cortex, viz., one obliquely at the lip of the
fissure, one midway down, and one at its deepest part which, like the
first, was slightly oblique. According to Campbell ( 2 ) the precentral type
of cortex does not extend quite to the floor of the fissure in any part; if so,
one of my preoentral measurements must be regarded as post-central.
However, as Campbell himself very positively asserts (p. 80) that it is
the presence of Betz cells which absolutely stamps the precentral type,
and forms a certain guide to its territorial demarcation, and as these
cells almost invariably extend not only down to the level of the floor
of the fissure, but for an appreciable distance on to the post-central
side in both the leg and arm areas, I have had no hesitation in including
this third measurement in my calculations of precentral cortex.

The figures in Table A represent some 6000 measurements. The
sites selected for study were three as follows: Upper segment of the
fissure above the buttress, from that region the cortex of which is
supposed to control movements in the lower extremities; the middle
segment below the buttress, from whence movements of the upper
extremities are controlled; from the lowest segment, quite near the
lower end of the fissure, whence movements of the face and larynx
are confrolled. Of these sites the first is that which is best adapted
for this purpose, as in practically all cases the fissure is straight and
the cortex on both sides of it forms a band of uniform thickness until
it passes beneath the end of the fissure where it becomes much
narrower; whereas in the middle segment the fissure is very deep,
frequently irregularly curved, and the cortex of less regular depth so
that it is generally necessary to make trial cuts at different levels
to obtain a piece suitable for micrometric study, for this reason in
this region the portion selected in each case for measurement comes
from different parts of the segment, whereas at the leg level there is
great uniformity of site in the different cases. At the lowest level the
fissure is often so shallow that it may be difficult to get three distinct
measurements.

My cases, it will be noted, are divided into three classes : In the first
are all cases of acquired insanity; in the second cases of dementia
praecox; in the third imbeciles, with and without epilepsy. Two of

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these classes call for no comment, but as regards Class II it may be
desirable to outline briefly what I mean by dementia praecox, as the
meaning which this name carries is still a matter of considerable
controversy. I look upon simple dementia praecox as in a sense
denoting more a temperament than a disease, including within its scope
the inefficients of all kinds, not alone those within asylum walls, all
persons who may be supposed to be furnished with a nervous system
of deficient durability, liable to break down under comparatively slight
stresses. The inevitable stresses that every person has to undergo are
to them fraught with danger. Most of them cannot stand the stress
of puberty, and of those who can, in the case of women, childbirth
offers fresh risks and later on the menopause. Only a proportion of
such persons find their way into lunatic asylums, many are able to
earn a competent livelihood, or to attend fairly efficiently to their
household duties, provided that their circumstances are favourable,
some are even, under similar conditions, looked upon as persons above
the average ability. But in all, there is what Adolf Meyer terms the
“ hall-mark of this disorder, vis., a constitutional disposition to meet
their difficulties in an inadequate manner.” Esquirol’s term of “acquired
imbecility ” describes very well a large number of cases of dementia
praecox whom, in default of a knowledge of their past history, it may be
impossible to distinguish from imbeciles. The tendency in most cases
is to go from bad to worse, slowly or rapidly; although some improve
to such a degree that they may be discharged from the asylum as
recovered, probably there is in every case a certain degree of permanent
mental infirmity left after an attack.

With regard to my classification of the cortical layers I have adopted
that which is in most general use, viz., Meynert’s :

(1) External or molecular.

(2) Layer of small pyramids.

(3) Layer of large pyramids.

(4) Granule layer.

(5) Line of Baillarger.

(6) Polymorphic, or spindle-cell layer.

Bolton only reckons five, as he regards Meynert’s 2 and 3 as one ;
and as Bolton is our great authority on micrometric studies of the
cortex, it is well to have a classification such as Meynert’s which can be
compared with his.

Dealing first with the cortex as a whole, there are certain points
to which I desire to draw attention. In the first place it should
be noted that the precentral cortex is invariably wider, and very
considerably wider than the post-central, not very seldom twice the
width of the latter. This feature, although it can be traced in each
individual layer, is mainly due to the increased width of the third and

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Google

Original from

PRINCETON UNIVERSITY

1918.]

BY JOHN TURNER, M.B

351

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PRINCETON UNIVERSITY

352

OBSERVATIONS ON THE ROLANDIC AREA, [Oct.,

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sixth layers in the precentral cortex. The greatest difference (I am
now referring to average and not single measurements) I found occurred
in the hospital cases where the average for four gave rig mm. in favour
of the ascending frontal of the leg area. The least difference was in
the face area, as perhaps might be anticipated, inasmuch as here the
distinctive features of pre- and post-central cortex are largely absent.
In this area the difference was fairly constant and ranged between
07 to 0.42 mm.

In the second place the cortex of the Rolandic area is considerably
wider than that in either prefrontal or occipital region. It varies a
great deal, but an average width in the male in the prefrontal is, for
the leg and arm area, 3 mm., in the face area 2*5 or 2*6 mm. In the
female 2*8 mm. for leg and arm, and 2*5 mm. for face respectively.
It tends to be widest in the middle segment in both lips of the fissure.
According to Bolton the width of the prefrontal cortex in a normal
male was r89 mm., in a female i*8i mm., and in his series of imbeciles
and dements it varied from 1*78 to 1*38 mm. In the visuo-sensory
area he gives it as 18 mm., and in the visuo-psychic as 186 mm.

Thirdly, the width of the cortex in males is greater than in females.
Quain gives the difference as only about 1 per cent, in favour of males ;
in my cases it varied from 0*4 to 12 5 per cent. The only exceptions
I met with in my averages were once in the leg area in a female of
Class II, and twice in the face area ; in one of these latter the ascend¬
ing frontal, and in the other the ascending parietal, in a female of
Class I was the wider.

So far as my figures go they show no indication whatever of any
diminution in the width of the cortex either of pre- or post-central, in
cases of prolonged dementia, or where gross atrophy of the hemisphere
is found ; nor does age within the limits of my cases appear to have any
appreciable effect in this direction.

The cortex in the case of E. D—, Class III, is interesting. In her
case her cerebrum was a mere shell with enormously dilated ventricles,
and, when the fluid escaped from them, the brain-wall fell in like a
burst bladder. The white matter was nowhere more than a quarter to
half an inch thick ; the entire thickness of cortex in the three areas was
as follows :

Leg area .
Arm area.
Face area

Ascending frontal.

2*510 mm. (2*835 mm.)
2*630 mm. (2 901 mm.)
2 680 mm. (2*517 mm.)

Ascending parietal.

1820 mm. (2 066 mm.)
2*260 mm. (2*113 mm.)
2*260 mm. (2*060 mm.)

The figures in brackets give the average width for Class III.

Here there was some thinning in the upper two levels of the ascending
frontal, but it was entirely at the expense of the sixth layer. The
supra-granular layer throughout was equal to or greater than the average
for the group.

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Original from

PRINCETON UNIVERSITY

1918 .]

BY JOHN TURNER, M.B.

353

Ascending frontal.

Ascending parietal.

Supra-granular.

Sixth layer.

Supra-granular.

Sixth layer.

Average

Average

Average

Average

E.D.

for

E.D.

for

E.D. for

E.D.

for

Claes III.

Class III.

Class III.

Class III.

| Leg level .

ro40

1-043

0-440

0728

0750 0’702

0380

0*492

Arm level .

1 070

1-058

0600

0-847

i -ooo 0-780

0-450

0-541

1 Face level.

1

0960

0-883

0650

0-726

0830 0-709

0-560

0-597

I am inclined to believe that the width of the cortex is an innate
character, and not markedly affected in after life, apart from normal
development, by prolonged dementia with atrophy of the hemispheres,
nor by age. My observations support the contention of J. Cruickshank
(Journal of Mental Science , January, 1917): “ That the atrophy of the
brain, which is so common a feature at autopsy in chronic cases of
insanity, is due more to the loss of the underlying white than to the
loss of the superficial grey matter.”

I was struck while examining the Rolandic fissure of a female, set. 3,
an epileptic imbecile, to find that as regards the post-central cortex there
was no evidence of any deficiency of width compared with adult cases ;
and as regards the pre central very little. The cortex was of infantile
type, and, although the different layers could readily be distinguished
(except in the case of the second in some parts of the ascending frontal),
this was mainly owing to the arrangement of the nuclei of the unde¬
veloped nerve-cells, only the larger of which showed a distinct body,
and, although the Betz cells were, generally speaking, smaller, some few
were as large as any found in adult cases. The demarcation of cortex
from white was facilitated by the large number of nuclei in the latter
in comparison with those seen in the cortex. Such a condition suggests,
as a corollary to the apparent absence of atrophy of cortex in dementia
and old age, that the full width of the cortex is differentiated from the
white in preparation for the nerve-cells at a relatively very early stage in
life, and by the aid of micrometry we obtain a fairly clear demonstration
that the cortical layers are laid down very early—prior to the formation
of the sulci; for we invariably find that at the dip of the fissure where
the cortex bends round to pass from one side to the other, not only is
it much thinner, but this thinning is chiefly at the expense of the inner
layers—the zonal layer, indeed, is usually wider here than elsewhere.

This is what happens when a plastic material is bent round at an
acute angle, and the inference I draw from these appearances is that the
layers were present before the bending necessitated by the presence of
sulci took place.

Bolton, in the case of the pre-frontal cortex, found that there was a
deficiency in the width of the supra-granular layer in imbeciles and
chronic dements; in the former instance he regarded it as an innate

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354

OBSERVATIONS ON THE ROLANDIC AREA, [Oct.,

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deficiency, and in the latter as due to atrophy, which is in proportion to
the degree of dementia. It is this layer, the supra-granular, correspond¬
ing to Meynert’s second and third, which in Bolton’s opinion is con*
cerned with the intellectual operations of the mind. My figures, as
I have already mentioned, are not to any extent in accordance with
Bolton’s conclusions. They show (see Table A) as regards the entire
cortex, among males, with one exception in the ascending frontal leg
area of dementia preecox, that both in pre- and post-central gyri, it
was as wide (once) or wider than that found in the average of the four
hospital cases. Among females, that it is usually wider in Class I than
in Classes II and III, in this respect agreeing with Bolton’s results.

With reference to the individual layers I found among males, with the
single exception of the leg area of the precentral in dementia praecox,
the supra-granular layer was absolutely and relatively wider in all the
insane than in the hospital cases, and comparing the classes one with
another, although there is found to be in the leg area a slight relative
and absolute deficiency in Classes II and III compared with Class I,
as we might expect on Bolton’s supposition, such a deficiency is not
met with in any other of the regions examined.

In the females comparing the three classes there was no marked
difference between them in either the relative or absolute width of the
supra-granular layer, but, what difference there was, with the exception
of the leg area of the precentral, was in accord with Bolton’s results.

The relative width of the supra-granular layer in pre- and post-central
gyri was within i to 4 per cent, the same in all the regions examined,
except the leg level in Classes II and III, and here there was a differ¬
ence of 9 to 11 per cent, in favour of the pre-central cortex.

Perhaps the only conclusion we can come to from my figures is that
there are considerable differences in the two sexes, not only in the width
of the entire cortex, but also in the relative proportion of one layer to
another.

Part II.

Some Features in the Minute Structure of the Rolandic Cortex.

The ascending frontal cortex is sharply distinguished from the adjacent
ascending parietal cortex by peculiarities of stratification, and also by
peculiarities in its elements; both these mainly showing in its upper
three-fourths.

The first mentioned consists in an almost complete absence of a
definite granule (or stellate) layer.' In a large proportion of cases the
transition from the precentral to the post-central type of cortex, in the
upper two-thirds or three-quarters of the Rolandic area, takes place
fairly abruptly just beneath the deepest part of the fissure of Rolando,

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19 * 8 .]

BY JOHN TURNER, M.B.

355

as seen on transverse sections, but occasionally a definite granule
layer can be seen passing into the precental cortex, and this can be
seen running half, or all the way up the anterior lip of the fissure,
or perhaps even passing around the summit and present on the frontal
aspect of the precentral; sometimes the layer (or band) ceases, and
reappears again a little further on. But in the lowest third or fourth
of the fissure of Rolando, where it as a rule is much shallower, this,
sharp differentiation of the two kinds of cortex ceases, and a granule
layer is found both in the precentral and post-central cortex; but,
although the band in the former site is quite distinct, it is usually
narrower than in the post-central. Unless the granule layer reached a
third of the distance from the deeper to the surface end or summit of-
the precentral cortex in transverse sections, I have not, in the following
account, taken it to be abnormal ; in my 67 cases it exceeded this limit,
in 18 (viz., 7 males, or 24 per cent., and 11 females, or 28 per cent.), and
this occurred usually in the upper level (leg), viz., in 14.

From my figures there appears to be a greater tendency for variation
from the normal condition among congenital cases, for whereas among
22 of them (of both sexes) it was noted to be present in the precentral
cortex in 8, or 36 per cent., it was only so noted in 10 out of 45 cases,
of Classes I and II, or 22 per cent.

On the other hand, it is rare to find it defective, that is to say, in
transverse section it was only once found not to be evident over the
whole stretch of the post-central cortex in a case of dementia prascox
in a male.

Cell peculiarities. —The presence of very large nerve-cells lying in
the inner stripe of Baillarger constitutes its most marked positive
characteristic in this upper region. These, the Betz cells, are far
and away most numerous in the upper third or fourth of the precen¬
tral area, including in this the mesial aspect. But, from the buttress,
usually from its upper portion, they rapidly diminish in number, and
often none can be detected in the lowermost fourth of the cortex.
According to Campbell’s estimation, the number of these cells is 25,000,
and he gives some figures showing the numbers counted in a series
of sections cut at right angles to the fissure of Rolando, taken at
intervals of 5 mm., all the way along its course. The total number
he counted in this series was 249, of which 189, or nearly 76 per cent.,
were above the buttress in the upper third of the area ; over the
remaining two-thirds of the area therefore were only 24 per cent. By
making long sections of the precentral area from above downwards
parallel with its surface, one is able to prepare a diagram showing the
precentral cortex from near its upper to near its lower end. Such
strips shows very clearly not only the dense aggregation of Betz cells in
the uppermost part of the area, but also their position in the cortex at

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PRINCETON UNIVERSITY

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356 OBSERVATIONS ON THE ROLANDIC AREA, [Oct.,

different parts. They show that Betz cells are by no means confined,
or even chiefly confined, to the parietal aspect of the cortex, but extend
thickly all over it on the frontal aspect, and also that they often octur in
fair number in the buttress. Below this region they rapidly diminish
in number, and in the specimens examined none were seen on the
frontal aspect. There is, doubtless, much variation in their distribu¬
tion. Bevan Lewis and Clarke, who were the first, or among the first,
to study them closely, stated that in the uppermost portion of the
ascending frontal convolution they were situated on the parietal aspect
of the convolution, that they rapidly thin out towards the vertex, and
are not found on the frontal aspect. This is a statement which, as I
have just shown, requires modification. These two authorities stated
that in certain places Betz cells were absent, and one of these areas
corresponded to the buttress, where Campbell also noted their absence,
although he himself figures some in this region, and also gives the
number he found in his series of sections taken from one end to the
other of the Rolandic area. In my experience they are quite as often
as not found here—absolutely typical Betz cells of large size.

As a rule, the cells diminish in size as one passes from an examina¬
tion of the upper to that of the lower levels. Campbell, who, of
course, noted this feature, accounts for it in the same way as did Bevan
Lewis, viz., that the farther a nerve-cell has to transmit its energy the
larger it is; but he found the small size of the cells in the buttress, the
area which he believes controls the muscles of the trunk, an awkward
circumstance to fit in with his theory.

This statement as to the size of the cells is one that only roughly
holds good, for quite frequently, in the lowest part of the Rolandic area,
that which is supposed to preside over movements of the face and larynx,
are found Betz cells as large as any in other parts of the area. Such
exceptions militate against the theory of Bevan Lewis, unless we may
suppose that these large and solitary forms are, as it were, aberrant cells
in alien areas

Another point I wish to emphasise is the occurrence of Betz cells in
the ascending parietal convolution. This I take to be an anomaly, but
it is one that occurs frequently.

I have described as Betz cells those of a certain shape, usually not
pyramidal, lying in a definite layer of the cortex—the inner stripe of
Baillarger—and occurring singly or in clusters of two or three, and, com¬
pared to those in their neighbourhood, of very large size. Such cells
I have seen not at all seldom to occur in the ascending parietal con¬
volution, usually in the upper part, near the vertex of the brain. Betz
himself described them in this situation.

They were found in over 40 per cent, of my cases, about equally in
the two sexes, and as one, or at most two or three, sections from the

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Original from

PRINCETON UNIVERSITY

1918 .]

BY JOHN TURNER, M.B.

357

different levels in each case were examined, it is fairly certain that their
occurrence in this convolution is understated. The table gives parti¬
culars as to which class of case they were most often observed in, and
the levels in which they were situated. The circumstance that they
were much more commonly noted in imbeciles than in cases of Class I,
is in favour of the contention that their presence here is an anomaly.
They were most commonly met with, however, not in Class III but in
Class II. It may also be observed that in both Classes II and III
they were much more frequently noted in the levels corresponding to
the arm and face movements than in Class I, where they were usually

Table show:tig Incidence of Betz Cells in Ascending Parietal Convolution

at Different Levels.

I-eg.

Arm.

Face.

Totals.

Sex.

N •>. of
ca*es

c<am-

ined.

N«>. with
Hetz
cells* in
A.P.

No. of
cases

exam¬

ined.

No. with
Bet/
cells in
A.P.

No. of
cases

exam¬

ined.

No with
Betz
cell* in
A.P.

No. of
cases

exam¬

ined.

No. with
Betz cells
in A.P. |

Class I

M.

13

3

12

11

_

>3

3 (23%)

„ II

F.

21

6

17

2

20

—

21

6(29%)

M.

9

4

9

3

9

—

9

5 (55%)

F.

12

6

12

4

12

2

12

7 (58% )

„ HI

M.

10

4

10

2

10

3

10

5 (50% )

F.

11

5

12

1

12

2

12

6 (50% )

only seen in the upper third of the cortex adjacent to the leg level of
the ascending frontal, where Betz himself observed them.

If one may ascribe positive results from electrical stimulation of the
cortex as due to excitation of these cells, their presence in any number
in the ascending parietal cortex may possibly account for the dis¬
crepancies in the results obtained by different experimenters working
in this field.

The tigroid of the Betz cells. —The most conspicuous and distinctive
feature in nerve-cells stained by methylene blue or allied stains, such
as Unna’s polychrome blue, is the tigroid, and the alterations which
this substance undergoes in pathological conditions has been the means
of very greatly furthering our knowledge of the pathology of the nervous
system. Almost from the first since Nissl described this feature in
nerve-cells there has been controversy as to whether it represented a
vital constituent of the cell, or w r as precipitated as such after death.
Nissl himself only claimed for it an equivalent value to a vital structure,
that is to say, he claimed that in a normal condition it presented a
constant pattern, and that the alterations observed in it with abnormal

LXIV. 25

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35 § OBSERVATIONS ON THE ROLANDIC AREA, [Oct.,

or morbid conditions were also constant with regard to each morbid
change.

Many years ago Held maintained that it did not exist during life as
seen in stained nerve-cells, but was precipitated after death by the acid
condition of the tissues then set up ; but his statement, on which he
founded his belief that dilute acids precipitate and dilute alkalies dissolve
it, has been controverted. F. H. Scott ( 3 ) asserts that the reason why
the tigroid does not stain after the treatment of cells with alkalies, is
not because of its disappearance or non-existence as Held thought, but
because by the action of alkalies the masked iron contained in tigroid
and on which the staining depends is dissolved out.

F. W. Mott upholds Held’s view, and adduces as a fact in support
of the artefact nature of tigroid that it is not seen in living nerve-cells,
unstained, when viewed by dark-ground illumination. That is so ;
but unless he can also show that dead nerve-cells under similar
conditions do show tigroid, this fact is no proof of the non-existence
of tigroid during life in the form revealed by Nissl’s method. If this
substance is an artefact, it is very difficult to account for certain
morbid changes seen in nerve-cells ; for example, the acute cell change
of Nissl (coagulation necrosis) and central and peripheral chromatolysis.
In acute cell change it is easy to detect all stages from that in which
the normally bulky blocks of tigroid are beginning to attenuate, through
that when, before it entirely disappears, it is represented as very fine
threads, up to the final stage, when it has disappeared entirely from
view.

In central chromatolysis how comes it that with a post-mortem
precipitation the peripheral blocks of tigroid are apparently unaffected,
whilst in the centre of the cell body they have disappeared or exist
only as fine grains ?

It is almost inconceivable that invariably in certain morbid con¬
ditions a dying cell should assume such distinctive features as seen in
the examples quoted.

There is, on the other hand, great uniformity of opinion as to the
nature, derivation, and function of the tigroid.

It is a nucleo-protein compound containing organic phosphorus and
masked iron, derived from the nucleus of germinating cells, and it is
generally considered to represent stores of latent energy. Experiments
all tend to show that under prolonged stimulation tigroid is used up
and disappears, so that the cell body has a pale aspect. In the cells of
the aged it is reduced in quantity, so that the tendency is for them to
appear pale. On the other hand, apparently, cells in which energy
has accumulated show an increase in the size of the tigroid blocks and
in its amount, so that they stain very deeply, and have been termed
by Nissl “ pyknomorphic.”

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PRINCETON UNIVERSITY

19*8-]

BY JOHN TURNER, M.B.

359

Betz Cells of “ Reaction a Distance" or “ Axonal" Type.

The correlation of diminished energy and rapid fatigue with cells
lacking in tigroid substance is reasonable, and, moreover, absence of
initiative may well be associated also with such cells. We all as we
grow older experience how difficult it becomes to initiate—to form
new habits. We may be able to do quite a respectable amount of
routine work, work we have been accustomed to, but the head of
energy needed to force new nervous paths is lacking, and hence cells
which have a deficiency in the raw material of energy may well be
correlated with this mental defect.

Perhaps three of the most characteristic features in a case of dementia
prsecox are loss of energy, easy fatiguability, and absence of initiative,
and, as I have shown elsewhere, a large proportion of all such cases
show a great preponderance of a form of Betz cell which we have
reason for supposing to be in a condition to satisfy these requirements.

Whether my assumption that the condition is due to an innate
defect, in the form of an arrest of development, or whether in some
cases, as Mott argues, it may be due to defective thyroid secretion,
or whether both these factors come into play, does not alter the fact
that this form of cell characterises such a large proportion of cases of
dementia praecox. I have very little doubt in my mind that, whether
the cells are innately defective or not, a vicious circle is established,
and deficiency or perversion of the internal secretion soon hastens the
stages towards the complete disappearance of the tigroid. But even
more generally speaking, and not confining oneself to one form of
mental disorder, it appears to me very probable that the brains of
the insane are all characterised by an undue proportion of this form
of cell which is most prominently brought to our notice among the
giant cells of Betz, and as these only occur in certain limited regions,
are very conspicuous objects, and only amount altogether to some
thousands (Campbell estimates them at 25,000), the proportion of
the affected ones can be calculated with a fair degree of accuracy;
whereas, although similar changes may be present in the smaller
nerve-cells, they are not so readily seen, and as these number many
millions we cannot estimate their proportion with any approach to
accuracy, except by very laborious investigation in each case.

The type I am referring to resembles very closely that known as
“ reaction k distance ” (Marinesco) or more shortly the “ axonal ” form
as Adolf Meyer termed it, and I believe the failure to recognise the
invariable presence of this type in varying proportions in the brains
of the insane has given rise to much misconception. One frequently
meets with descriptions of pathological changes in cases of insanity
where it is figured and described as the result of injury to axons; but

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360 OBSERVATIONS ON THE ROLANDIC AREA, [Oct.,

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it is rare that we can trace any sign of this, and the fact that the change
is found in such a large number of cells, scattered all over the ascending
frontal region in so great a proportion of all forms of insanity, militates
strongly against the presumption that it is the result of injury to axons.
At all events, unless one is in a position to demonstrate such injury,
I do not think one is justified in invoking it as a cause.

The type is met with in the brains of those who do not happen to
die in an asylum among the general population, but in fewer numbers.
This is what might be anticipated.

It is most common among cases of dementia praecox, and much more
so in females than in males, then follow epileptic imbeciles, imbeciles
without epilepsy and cases of acquired insanity, and general paralytics
in whom it occurs least frequently.

In all these classes it predominates in females, as I found also among
my series of hospital cases examined two years ago.

Dealing now with certain points arising from the cases which form
the subject of this paper, the number of persons in each class in
which 50 per cent, or more of the cells were of axonal type is 2 in
Class I, 11 in Class II, and 8 in Class III. In the table adjoining
the number of such is shown in the leg and arm areas, and occasionally
in the face area, but in the latter region very often no undoubted Betz
cells are seen, and if present there are too few to calculate percentages
with any pretence to accuracy. The results which are given for this
area refer to the cells counted in several sections, whereas in the other
levels, with few exceptions to be mentioned later, the numbers refer to
cells counted in one or at most two sections.

Leg.

Arm.

Face.

Class 1 : Males .

Females
„ 11 : Males .

Females
„ III: Males .
Females

I in 10 (lO% )

1 in 10(10%)

4 in 9 (44% )

7 in 10 (70% )

2 in 10 (20% )

6 in 10 (60% )

1 in 6 ( 17 %)

2 in 7 (28% )

5 >" 9 (55%)

7 in 10 (70% )

2 in 9 (22% )

4 in 9 (44% )

I in 5 (20% )

6 in 7 ( 85 %)

i

None of the four hospital cases showed a percentage of 50.

In a series of insane persons examined in 1916 in which sections
were taken from a similar position in the leg area to those above, and
in which micrometric measurements of the ascending frontal and
ascending parietal were made, but which I discarded for micrometric
purposes, I found as regards the Betz cells showing an axonal type
in Class I, males, 5 in 10, or 50 per cent.; females, 4 in 9, or 44 per
cent. In Class II, males, 2 in 6, or 33 per cent .; females, 9 in 9, or

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*9*8.]

BY JOHN TURNER, M.B.

361

100 per cent. In Class III there were no males examined; females,
5 in 7, or 70 per cent. For a number of years I have been in the
habit of estimating the percentage of these cells in the cortex at the
summit of the ascending frontal including the paracentral convolution,
and the results obtained in this larger series are substantially the
same, so that I can speak with much confidence on this matter of the
prevalence and preponderance of this type of cell in the insane ( 4 ).

In 1914 I was able to examine, through the kindness of Dr. Turnbull,
of the London Hospital, and Dr. French, of Guy’s Hospital, pieces
of cortex from the summit of the ascending frontal and paracentral of
50 hospital cases—30 males and 20 females. In this series only
2 of the males, 7 per cent., and 3 of the females, or 15 per cent.,
showed a preponderance of the axonal type of Betz cell.

In the controls, 30 males and 20 females from among the insane,
the percentages were respectively 36 and 45.

I find that in sections showing a fair number (twenty or thirty) of
Betz cells, as is the case in almost all taken in the leg level, an estima¬
tion of the percentage of this form in one section gives a rough idea of
that which is found, where a number of sections over the same area are
examined. In some of my cases, especially when the number of axonal
forms has been about 50 per cent, or just over, I have examined a
series of sections taken sufficiently far from each other to ensure not
getting the same cell in more than one section, and I get fairly con¬
cordant results.

This widely occurring and even distribution of the affected cells,
which is not confined to any one area or level, is opposed to the idea
that the form in question is due to injury or disease of axons. And the
fact that we are able to give a rough estimate of the proportion of these
cells obtaining throughout the whole Rolandic area, from the examina¬
tion of two or three sections, is one of very great practical importance—
in many cases, I contend, enabling one to give a positive statement
of one of the factors concerned in the production of the insanity;
whereas, however true the claims for the results of micrometry may
prove, they are only applicable to averages and not to any one particular
case.

With regard to the correlation of the amount of tigroid and motor
activity, I believe it is possible (but only very roughly) to correlate the
presence of abundant tigroid, especially in the Betz cells, with excess of
voluntary motor action during life, that is to say, in those cases, however
chronic and demented, who continue to show great motor activity, one
usually finds abundant tigroid in the Betz cells; they are in what Nissl
termed a pyknomorphic condition.

But the converse to this generalisation is less readily established :
cases in which after death no tigroid is found in the Betz cells, are often

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362 OBSERVATIONS ON THE ROLANDIC AREA, [Oct.,

characterised by excess of motor activity up to quite a short time before
death.

I suspect that to a certain extent it is a question of the capacity of
the organism to replace expended tigroid, which determines whether or
not we find it in the cells. To a certain extent it may be due to the
fact that we are dealing with only one of the three levels into which it
is customary to divide the nervous system—so that it is possible that
although the cells of one level are defective in this substance it does not
follow that those of other levels are.

Conclusions.

I. Anomalies in the form of the Rolandic fissure, and in the arrange¬
ment or architecture of its cortex, occur more frequently among the
insane, especially among the dementia pnecox class and imbeciles, than
in normal individuals.

II. There appear to be distinctive characters in the two sexes.

III. As regards a micrometric study of this region, the figures also
indicate sexual differences in the width of the laminae, in which case it
would not be legitimate to mix together male and female cases in
micrometric studies. They fail, so far as I can see, to afford any clue
towards a solution of the problem of the pathology of insanity. It
would appear from them that the width of the cortex and its individual
layers in both pre- and post-central lobes is an innate feature, not
markedly affected by the forms of insanity, nor the degree of dementia
and wasting of the hemispheres, nor by advancing age.

IV. A study of the Betz cells is of very real assistance in this matter.
The undue proportion of the axonal type in the insane enables one to
catch a glimpse of the anatomical basis, so far as the brain is concerned,
in a large number of cases. I submit that this type of cell is one of
defective structure, and probably of deficient durability ; and, moreover,
that the evidence is in favour of its being an innate defect, due to
arrested development.

At all events, whether it is so or not, makes but little difference to its
practical significance, as the morbid influence of perverted metabolism,
to which the change in the cell has been ascribed, is one which probably
comes into action early in the life of the individual. I regard the
presence of this type in more or less numbers as a rough index of the
stability of the brain; other things being equal, a brain with a high
percentage will more readily break down than one with a low per¬
centage.

According to this criterion the brain of the precocious dement is the
most unstable of all, and relatively more unstable in females than in
males, and I hold that this is in accordance with clinical experience.

The brain of a congenitally defective person, though on the average

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BY JOHN TURNER, M.B.

363

less unstable, may be more defective than that of a case of dementia
prsecox.

I have taken as a standard an arbitrary number, merely for conveni¬
ence in contrasting different cases and classes ; according to this
standard those showing 50 per cent, or more of this type are regarded as
positive, and those with a lower percentage as negative.

My observations on this type of cell in a very large number of cases
show that it is much more prevalent among females than males in sane
persons and all classes of the insane.

Discussion.

The President said he was sure all present had listened with great interest to
Dr. Turner’s paper. Dr. Turner had given the Association, once more, evidence
of his extraordinarily industrious labour, and the minute care with which he carried
out his researches. He was not sure that this was a paper which lent itself much
to discussion in the ordinary way at a meeting; it was rather one for leisured study
and assimilation afterwards. Still, if any member felt inclined to discuss any
points with which the paper dealt, he would be glad to hear comments.

Lieut.-Col. Sir Robert Armstrong-Jones said that lest it should be
thought, in the absence of discussion, that there was not sufficient recognition of
the paper just contributed, he would like to make a few comments. The paper
to which members had just listened was an extremely valuable piece of work, and
Dr. Turner had certainly stuck to his text. He, the speaker, did hope that the
author would have shown an inclination to wander over the other portions of the
cortex, although his paper was entitled " Observations on the Rolandic Area in
a Series of Cases of Insanity.” He thought Dr. Turner had divided this series of
cases broadly into two divisions, the qualitative and the quantitative, and he had
limited himself to what might be called quantitative insanity. In the qualitative
type of insanity the Rolandic area was not affected, as the author showed to be the
case in this series. The paper was a difficult one to discuss, because it was the
statement of a fact in anatomy ; but in relation to the purely anatomical side there
was also the psychological, or what might be termed the philosophical aspect, vi*.,
the kind of relationship which the brain bore to the mind, and the effect of the war
had been to make thinkers upon these topics change their views, to some extent,
at any rate, in regard to this relationship. It was well known, before the war, that
materialistic views largely held the field, but now, once more, the prevailing view
was being directed to a psycho-physical parallelism, with the great domination of
the psychic. One saw, in almost every issue of The Lancet , references to what was
termed the "threshold of consciousness”; the great thing in treatment was to be
the raising of the "threshold of consciousness.” Of course, his hearers had all
been doing that from the first moment they qualified; it only meant the importance
of making it more easy to impress the personality of the medical man upon his
patient. He did not think, speaking generally, the appearance of the cortex could
be taken as in any way indicating the presence of insanity, except from the quan¬
titative side, i.e., it could only indicate the amount of dementia. He passed round
for inspection some photographs which were taken by Dr. J. S. Bolton, at Claybury
Asylum, showing the appearance of the hemisphere in different types of insanity.
A large number of these observations by Bolton also referred to quantitative
insanity, and, therefore, to that portion of the cortex which was connected with the
outgoing effect of vo'itions, -via., the Rolandic area. He had preserved photo¬
graphs of the two hemispheres of the brain upon the same plate, in order to show
that there was rarely actual identity between the convolutions of the two hemi¬
spheres, and he submitted these pictures as an addendum to Dr. Turner's paper.
The pictures the author showed were very instructive, but he could not help
thinking that Dr. Turner laid too much stress upon the Betz cells. The appearance
of those Betz cells in the pictures seemed to be more in harmony with the last
picture put upon the screen and showing the toxic effects of hypo-thyroidism, and

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dementia prsecox may be due to a definite toxin in the brain affecting secondarily
the Betz cells and not primarily to a degeneration of these cells themselves. He
was much more inclined to regard dementia prascox as the result of some hitherto
undiscovered toxin acting upon the whole of the cortical cells, but of which the
changes in the Betz cells were only one feature. He remembered at one of the
meetings of the Association, when the pathology of general paralysis was believed
to be primarily an affection of, and entirely limited to, the tangential and molecular
layer of the brain, whereas now it was known to be and described as a cortical
parenchymatous spirochaetosis, and due to the toxin of the Treponema pallidum.
The view that the cortex as a whole was associated with insanity had much to
support it, and it was equivalent to saying that the cortex was the organ of the
mind. Bergson went so far as to say that the cerebral cortex was the organ of
forgetfulness, and that if it were not for the power of inhibition which the cortex
exercised, everything which had been previously experienced would be constantly
coming up into consciousness again in a jumble, with the result that there would
be confusion and conflict, incoherence and purposeless activity. Dr. Turner had
referred to the Rolandic layer as being primarily concerned with conduct, which
would be correct if it referred to all out-going acts. He, the speaker, looked upon
the cortex as a series of arrival platforms for the field of consciousness, an area in
which the material coming in at the platforms was correlated, from the visual area
in the neighbourhood of the calcarine fissure, the auditory area in the transverse
gyrus of Hischl, the uncinate convolution, and the hippocampal tract for smell
and taste, and lastly from that which had been described to-dav as the sensori¬
motor or the Rolandic area. All these had to be taken into consideration in dis¬
cussing insanity. Except in regard to quantitative insanities, he thought little
information about the insanities could be got from a study of the Rolandic area
alone. Dr. Turner had also referred to the tigroid bodies, and stating his belief
that they were artefacts. Even if that were so, they formed the best indication of
pathological change ; they furnished the only clue to deterioration of the cells such
as could be measured or determined by microscopical observation. The paper
dealt in a very able way, with the amentias, with dementia praecox, and also
with that third class, via., imbecility with epilepsy. He would like to hear more
about the association of changes in the Betz cells with dementia praecox, because
Dr. Turner had not mentioned the synapse, nor had he suggested changes in the
synapse that might account for the symptoms. It was known that the nervous
currents passed in only one direction— they could not pass in both—and the
synapses were membranous barriers or valves interposed between two neurons, and
they might be radio-active valves ; at any rate, there seemed to be a polarity about
their action as in the neuron, and this might cause delay. The clinical picture of
dementia prascox was that of a person who understood, whose memory was often
good, who realised what was said to him, but who was the subject of a marked
hesitation or retardation in responding to questions, and lastly to a failure of the
highest mental powers, viz., the reason. There seems to be a delay in the trans¬
mission of a nervous impulse across the synapse which does not occur in the cel!
or the nerve itself. This last-named characteristic could, he thought, be best
explained by some general toxic effect due to inefficient or incomplete metabolism,
and acting on the Betz cells, but certainly acting upon the synapses and the whole
central cortex as well. There appeared to be a non-synaptic network in some of
the diffuse ganglionic plexuses of the sympathetic system in the human body, but
in the highest vertebrates there were grounds for believing in an intermediary
structure between the axons of some neurons and the dendrites of the next. He
made these comments and threw out these hints more as an expression of appre¬
ciation than in a spirit of criticism. The contribution certainly tended to the
speculation as to the actual lelationship between mind and matter, and our views
were doubtless changing in this respect ; there was plainly discernible a reversion
to the view which tended to look upon mind and matter as two separate but real
entities. He thanked Dr. Turner for his scientific and instructive investigations.

Capt. Norman said he would like to intervene in order to very sincerely thank
Dr. Turner for his paper. One could very well judge of the enormous amount of
work entailed in it. To his mind, it bore out very distinctly what one wanted to
see. There had been a tendency to look upon these morbid processes as something
quite apart from the brain, but such investigations as that of which this paper was

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the record showed conclusively that there existed a definite physical substratum of
change. Work along those lines had been hitherto only too limited; there were
very few people like Dr. Turner who were willing to give up the necessary time for
such inquiries or who had the ability to carry them out satisfactorily, therefore the
Association felt greatly indebted to him for the contribution. The record in the
paper and the slides exhibited showed the great interest of the researches which
Crile had been carrying out to show the fatigue of the emotions, which also was
brought about by the physical structural change in the brain. These latter researches
were made on the cerebellar cells, but he believed comparison would show that the
change was very similar in the cerebral cells. Crile's researches also showed
degeneration in the tigroid matter, and it was, to him, exceedingly interesting to
find Dr. Turner’s elaborate work went to bear out the same idea. He felt, per¬
sonally, very much indebted to the author.

Dr. Turner (in reply) said he felt himself to be in accord with much that Sir
Robert Armstrong-Jones said. He looked upon those remarks, however, as coun¬
sels of perfection. The so-called synapses could only be shown by special methods,
very fickle in their action, and not suited for pathological work. The failure to
demonstrate synapses did not mean necessarily they were not there ; it might simply
be that the method had failed to act. But the charm of the other method was its
reliability, and the results, whatever might be their value, were consistent. He was
in agreement with Sir Robert’s remark that the changes noted were only quantitative.
For Capt. Norman’s remarks he was grateful.

(*) For connotation of classes see p. 348.—( J ) Histological Studies on Localisa¬
tion of Cerebral Functions, Camb. Uni. Press, 1905, p. 28.—( 3 ) “ On the Structure,
Micro-chemistry, and Development of Nerve-Cells, with Special Reference to
their Nuclein Compounds,” Trans, of Canadian histitute, vol. vi, 1898-99.—
( 4 ) In 1914 in a paper on the “ Biological Conception of Insanity.” I stated that,
"In dementia pnecox it is extremely rarely, if ever, that it (this prevalence of the
axonal type) does not occur, and we may say that one can count upon finding
it in every case of dementia prtecox katatonia. This statement should refer to
female cases only, and among them a larger experience shows exceptions."

The Psychoneurotic Temperament and its Reactions to Military
Service. By E. Fryer Ballard, Capt., R.A.M.C.(T.), Registrar,
Mental Observation Division, No. 2 Eastern General Hospital.

The term temperament is used in this paper to denote the sum
total of inherent emotional potentialities and kinetic tendencies
peculiar to the individual. A person’s tendencies to action and
reaction, his outlook upon life, and his liability to mental and nervous
disorder, are in a large measure determined by the temperament with
which he is born. Character, in the usual sense of the term, and
personality, at any given time, are the resultant of temperament and
environment in its widest sense, past and present, and previous
reactions thereto, and are varying quantities. Temperament, although
susceptible of modification by external influences, cannot be changed
fundamentally in type.

In what degree temperaments are dependant upon metabolism or
purely psychical characters need not be discussed here. All abnorma
temperaments shade off by imperceptible gradations from individual
to individual, and it may be in the same individual at different times

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into the normal, that is to say, that although specific abnormal tempera¬
ments are fairly clearly defined one from the other, there is no abrupt
line of demarcation between the abnormal and the normal.

From the alienists’ point of view, certain clinical abnormalities of
temperament indicate a liability on the part of their subjects in
excess of that possessed by normal people, to attacks of certain special
psychoses and psychoneuroses. It is well-nigh impossible to draw
a line of demarcation between the temperament and an attenuated
form of the psychosis or psychoneurosis to which the temperament is
specially susceptible. Just as there are gradations between the normal
and abnormal in temperament, so are there gradations between the
abnormal temperament and the psychosis.

In view of the above considerations it will be readily seen that
apparently normal persons may under adverse conditions develop
attacks of psychoses, etc., which implies that, temporarily at any rate,
such persons have acquired the relatively greater liability to the
psychosis which is involved in the abnormal temperament. In a
word, it is probable that, psychologically, abnormal temperaments
differ from normal in the degree of functioning of certain natural mental
and emotional activities.

Combinations of temperaments are common, but for practical pur¬
poses it is desirable to recognise the following varieties :

(1) The hysterical.

(2) The psychasthenic.

(3) The epileptic.

(4) The paranoiacal.

(5) The manic-depressive.

(6) The dementia praecox type.

These six abnormal temperaments fall naturally into two classes.

The first class, in which hyperesthesia and a tendency to excessive
reaction to external stimuli are prominent features, includes the tem¬
peraments associated with the psychoneuroses, hysteria, psychasthenia,
and epilepsy.

The second class includes the temperaments associated with the
psychoses paranoia, manic-depressive insanity, and dementia praecox—
in which such hyperaesthesia is absent. In this paper it is proposed to
discuss only Class I.

The Psychoneurotic Diathesis.

The above term is used here to embrace the hysterical, psychasthenic,
and epileptic temperaments.

In cases of psychoneurosis it is no easy matter to determine exactly
to which individual syndrome particular symptoms belong.

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A special exacerbation of symptoms of fear type occurring in psycho¬
neurotics has been elevated into a fourth syndrome under the name
of the anxiety neurosis.

The present writer is accustomed to classify the symptoms of the
psychoneuroses and the anxiety neurosis roughly on theoretical
psychological grounds; and has found such a scheme valuable in the
treatment and disposal of soldiers so affected.

(1) Symptoms which are disguised fulfilments of suppressed
instinctive complexes, and are not accompanied by the affective
tones of such complexes—are hysterical.

These would include anaesthesias, paralyses, deafness, dumbness,
amnesia, and some cases of stupor, automatism, and inco-ordination
in movement.

(2) Symptoms which are partially disguised expressions of such
complexes, and are accompanied by unpleasant affective tones
not amounting to emotions—are psychasthenic. These would
include coarse tremors, stammering, localised sweating, palpitation,
irrepressible ideas, impulses and phobias, general nervousness and
hyperaesthesia to external and internal impressions (the latter being
associated with visceral neuroses).

(3) Symptoms which are undisguised expressions of the in¬
stinctive state and are accompanied by an acute tone of fear
(i.e., those in which suppression has failed) come under the
heading of the anxiety neurosis.

Such symptoms are fine tremors, generalised sweating, somatic
apprehension, agitation, feelings of impending death, elevated
upper eyelids, dilated pupils, palpitation; and all the manifesta¬
tions of fear, ranging from acute anxiety to terror.

(4) Fits beginning in early life, accompanied by the specialised
traits of the epileptic temperament (vide infra), and associated with
some degree of mental hebetude—constitute epilepsy. Fits that
begin after childhood (apart from organic cerebral lesion), often
called psychogenetic, and, therefore, not associated with the
specialised epileptic temperatment and weak-mindedness, are
hysterical (i.e., explosive results of over suppression), the only
essential difference being one of the chronological incidence of
the fits and the results of this. Equivalents of stupor, malaise
with confusion, delirium, and other dissociations of conciousness,
are not peculiar to epilepsy, but occur in the other neuroses, and
are frequently hysterical, the clinical differences again being due
to the same factors as in the case of fits.

(5) Vertigo, headache, insomnia, vivid dreams, momentary
confusion varying from transitory loss of attention to petit mat,
are found frequently in all the psychoneuroses.

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In the next place it is necessary to describe briefly the temperaments
especially susceptible to the above symptoms.

(a) The Hysterical Temperament.

Perhaps it may be said in passing that the present writer regards
a hyperexcitability of the instincts as one of the main factors in the
production of this temperament. Its subjects are emotional suggestible
dreamers. They tend to react excessively to stimuli arising from
within or without. Affective hyperaesthesia is well marked. They are
easily moved to laughter, anger, or tears by trifling incidents, and
their emotions are essentially evanescent. Although self centred and
sensitive, their auto-criticism is poor, and their power of accurate
introspection defective.

Their tendency to excessive reaction to stimuli (due to affective
hyperaesthesia) results in an habitual impulse to banish from their
minds (/.<?., suppress into the subconscious) the results of stimuli
productive of conflict between instinctive desire and environment, and
hence unpleasant emotions. This process of suppression becomes a
well-marked mental habit.

Hysterical persons, therefore, fail to face and grapple with incidents
likely to result in such conflicts (i.e., unpleasant incidents), but promptly
suppress instead. Consequently, they are occasionally capable in
adverse circumstances of rising transitorily above their environment,
and of acting with decision, promptness, and even heroism, but in an
impulsive, extreme, and ill-considered fashion. Whether they fail to
suppress and therefore act in accordance with their over-excitable
instincts, or suppress and act in opposition thereto, their conduct is
always coloured by this explosiveness. If they suppress their tendency
to instinctive conduct often or long enough they develop episodes.

Hysterics have a craving for sympathy. They like to think they are
misunderstood, and to play the aggrieved martyr, if they do not receive
the meed of mollycoddling they imagine they deserve. Opposition
results in outbursts of emotion, or episodes of somatic type, or fits,
dissociated consciousness, wandering, etc., just as other forms of stress
do in these cases. They are also more liable than normal persons to
psychasthenia, anxiety neurosis, and other neurotic symptoms.

The mechanism of the production of hysterical episodes has been
discussed elsewhere.

(b) The Psychasthenic Temperament.

Under this heading are included the neurasthenic and the anxiety
temperaments. Like hysterics, persons of psychasthenic temperament
are hypersensitive and manifest well-marked affective hyperaesthesia,
but the results are different in the two cases. Although prone when

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taken off their guard to act instinctively and impulsively in response to
stimuli, psychasthenics for the most part consider the stimuli, face their
conflicts—often over estimating their unpleasantness—but realising that
their tendencies to undue reaction must not be allowed play in order
to dissipate the keen affective tones to which.the stimuli have given
rise, they suppress their tendency to instinctive reaction.

Whereas, therefore, the hysteric usually takes the line of least resist¬
ance in conduct, the psychasthenic acts according to his judgment,
paying the penalty of instinctive suppression and voluntary conduct by
getting disturbances of his coenesthesis—unpleasant visceral sensations
and functional disorders, irrepressible ideas, phobias, etc. The hysteric
suppresses the total resultant of unpleasant stimuli and if circumstances
permit acts instinctively; the psychasthenic suppresses this very tendency
to instinctive action.

If circumstances do not permit the former’s instinctive action, he even¬
tually develops some hysterical episode. If the latter (the psychasthenic)
owing to the strength of the stimuli, cannot any longer bring himself to
react according to his judgment, e.g., when he can no longer bear the
affective results of stimuli, and his own previous suppression of tendency
to instinctive reaction, he breaks, and develops the anxiety neurosis.

Psychasthenics when well (i.e., free from anxiety neurosis) are capable
of rapid decision and excellent execution. They are often intellectual,
active, energetic, and hard-working. They are apt to be of a serious
vein, although frequently wearing a mask of light cynicism. Their
judgment is remarkably accurate as regards others, and, as they are
introspective, sound as regards themselves once they have learnt them¬
selves. They are born “ worries,” irritable, impatient, and explosive,
anticipating and exaggerating troubles, usually to surmount them satis¬
factorily when they come to pass; but when of mature years they
become philosophers. Occasionally they are self-deprecatory until they
learn life. Work is their forte, worry their undoing.

Once the anxiety neurosis has become established in these people,
even after their recovery, they are never capable of quite the same
resistance to the jars and buffets of fate. They remain good workers,
but any slight stimulus associated with the exciting cause of their break¬
down invariably tends to bring about a return of the anxiety neurosis.
Thus a psychasthenic after such an attack is permanently broken so
far as some special circumstances are concerned, but quite capable of
grappling with dissimilar stimuli and environments.

(c) The Epileptic Temperament.

The chief features of this temperament as seen in chronic epileptics,
t.e., persons who have suffered from fits, with or without remissions,
from early life, are as follows :

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Sensitiveness to external stimuli with a tendency to excessive reaction,
irritability, explosiveness, a marked tendency to introspection combined
with excellent auto-criticism ; perseverance, energy, and capacity for
taking pains ; modified and accompanied by slow mental action, clum¬
siness in thought and movement, and usually a somewhat limited
vocabulary, i.e., symptoms of slight feeble-mindedness. The episodes
associated with this temperament are, of course, fits and “equivalents,”
both tending to be short, sudden, periodical, similar in those of the
same type, and more or less guiltless of external cause.

In considering the above three temperaments, one cannot fail to
observe the underlying resemblance between them. A likeness probably
pointing to a closely-allied if not common basis.

In ail, the outstanding features are hyperasthesia, with an accompany¬
ing tendency to excessive reaction to stimuli; resulting clinically in
affective sensitiveness, emotional instability, intolerance of unpleasant
affective states, explosiveness of conduct, and, relatively as compared
with normal men, lack of adaptability to environment. In all, emotional
stress results in abnormal but allied reactions—sometimes superficially
diverse clinically, often clinically similar.

With regard to hysteria and psychasthenia, it will be readily seen that
the anaesthesias, paralyses, for example, of the former are represented in
the latter by parasthesias and coarse tremors, inco ordination forming
the link between paralysis and tremor.

Put briefly, the difference between the episodes of these two tempera¬
ments are entirely explicable upon the theory of varying functioning of
suppression.

The resemblances between the hysterical psychical episodes and those
of epilepsy are equally clear. The early incidence of fits in chronic
epileptics probably accounts for the weak-mindedness which colours
their temperament and episodes, periodicity resulting from cerebral
habit.

The hypothesis suggested is that a common inherent nervous insta¬
bility lies at the root of all three psychoneuroses j epilepsy representing
the most severe form, hysteria the next, and psychasthenia the nearest
approach to the normal. Probably, environment in early life also plays
a part in determining which type shall develop from a common psycho¬
neurotic diathesis. This conception brings these psychoneuroses into
line with mania, melancholia, melancholic stupor, and mixed con¬
ditions, which are regarded as manifestations of an underlying manic-
depressive diathesis.

Many considerations point to an inherent abnormality of the vaso¬
motor system playing no inconsiderable part in the aetiology of the
psychoneurotic diathesis. Perhaps evidences of this, seen in the
episodes of all three psychoneuroses, are low blood-pressure, sweats,

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vertigo, fits, flushings, palpitation, feelings of impending death or “ all
goneness,” oedema, blueness of extremities, etc. The question is
worthy of further study by neurologists.

The theory of a common basis for the psychoneuroses appears to be
borne out by the study of the psychoneurotic symptoms of battle-
origin. A very large percentage of battle-syndromes manifest symptoms
of hysteria, psychasthenia, epilepsy, and indeterminate intermediate
signs which might belong to any of the three. Almost all cases also
exhibit some degree of anxiety neurosis. Indeed, one may say that not
a few “shell shocks ” exhibit each psychoneurosis in the same order
and succession as that suggested for the relative severity of the inherent
temperaments, viz. :

(1) Loss, or hysterical dissociations of consciousness. (N.B.—
Chronic “ fitting ” epileptics seldom reach the firing line.)

(2) “Hysterical ” fits, paralyses, commonly dumbness.

(3) Anxiety neurosis.

(4) Psychasthenia.

(5) Recovery.

Or in unfavourable cases, we find instead—

(4) “ Hystero-epileptic ” fits and equivalents.

(5) “ Epileptic ” fits.

Severe cases of war neurosis show mingled symptoms, and many,
according to changes of environment, oscillate backwards and forwards
between all the syndromes. For example : Send a psychasthenic case
back to a reserve unit, let him see a T.M.B^ 1 ), and be marked A, and he
will develop a dissociation of consciousness, or fit, or anxiety state.
Nearly all cases manifest vertigo, headache, insomnia, terrifying dreams,
and momentary loss of power of attention. Chronic “shell-shock”
cases who do not have fits almost invariably suffer from “ equivalents ”
practically indistinguishable except in intensity from those of chronic
epileptics; these usually take the form of vertigo, malaise, headache,
morose depression, and wound-up temper.

The temperamental traits of soldiers suffering from battle-psycho¬
neurosis, who had apparently been normal prior to the war, show a
well-marked mingling of those of the three psychoneurotic temperaments.

Reactions of Persons of Psychoneurotic Diathesis to Military

Service.

(a) The Hysterical Temperame?it.

(1) Pure hysterics who do not manifest somatic episodes, fits, or
dissociations of consciousness in civil life, should be trained rapidly for
the firing line. They sometimes do well for a time, and may occa¬
sionally distinguish themselves in fulfilling a previous heroic day-dream.

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(2) When such cases develop an episode they should be cured at
once near the firing line, by hypnosis or some modification thereof that
provides an outlet for the suppressed fear instinct in dream form, and
returned to the front line.

(3) A second similar breakdown should be followed by base hospital
treatment. If successful, the man should be again sent up.

(4) The supervention of the anxiety neurosis renders it necessary to
send the man home to hospital.

(5) Those hysterics who suffer from occasional episodes while
training at home should be marked permanently for non-fighting service.

(6) Men who are discovered to be markedly unstable emotionally,
and who prior to foreign service, suffer from frequent episodes, should
be invalided out.

(7) Any combination of anxiety neurosis with hysteria should indicate
permanent home service.

(8) Hysteroepilepsy, according to its severity, should mark a man
home service or permanently unfit.

(b) The Psychasthenic Temperament.

(1) Mild psychasthenics, who have never had an anxiety neurosis,
and who only manifest mild stigmata when run down, e. g., stammer,
occasional irrepressible ideas, and “ worrying,” are fit for the firing line.

(2) Psychasthenics who have recovered from an anxiety neurosis not
due to battle nor to family troubles, separation from sick or penurious
relatives ( i.e ., “ the home complex ”), are fit for garrison duty abroad.

(3) Those who have had a home complex anxiety neurosis within
recent years are only fit for home service.

(4) Psychasthenics who have to go sick with anxiety or exhaustion
(true neurasthenic) symptoms frequently in civil life, are useless for
the Army.

(5) Soldiers returned from an Expeditionary Force, whether previously
psychasthenic or not, who develop anxiety neurosis followed by psych-
asthenia, as the result of shell-shock, shell-fright, or battle strain, should
be marked permanently for home service at hospital, and travelling
medical boards should not be allowed to raise their category. My
experience leads me to two conclusions in cases of this sort:

(i) That many “shell-shocked” soldiers are lost entirely to the
Army by travelling medical boards raising their categories, and
thus causing relapses, rendering invaliding necessary in the case of
men previously fit to serve at home.

(ii) That the fear or knowledge of such raising of categories by
T.M.Bs. prevents many “ shell-shock ” cases recovering in hospital
sufficiently to serve at home or on garrison duty abroad; and,
therefore, such men have to be invalided out.

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(c) The Epileptic Temperament.

(1) Long-standing epileptics who have only occasional fits, and no,
or only mild, equivalents such as slight periodical moroseness, can be
sent into the firing line. Apart from shell-shock such cases appear to
be little the worse for useful fighting, probably owing to the all-round
dulling due to the chronicity of their malady.

(2) Persons of epileptic temperament who have recovered from fits,
i.e., in whom there is little dulling of sensibility, are likely to develop
severe equivalents and fits at the Front, and should be kept at home.

(3) It will be seen, therefore, that slight mental deterioration in cases
of class (1) is no contra-indication for active service.

(4) Epileptics of type (1) who have been “shell-shocked,” although
they usually recover rapidly from the hysterical part of their resultant
hystero-epilepsy, should not be sent to the line again.

(5) Epileptics with severe equivalents, whether they have fits at the
time or not, are totally unfit for the Army.

(6) The same is true of persons of epileptic temperament, with or
without fits, who show anxiety or psychasthenic symptoms.

(7) The practice, therefore, of discharging all epileptics who “fit” is
probably a mistaken one. Many can do excellent work in quiet posts,
e.g ., in offices, home hospitals, labour companies, at fatigues, or as
servants in units.

Indications for Treatment of Psychoneuroses in Military

Hospitals.

I. Civil Lije Types , i.e., Cases who have never Served Abroad.

With very few exceptions these are men who have always suffered
from psychoneurotic diathesis, and the question arises—should these
cases be kept for prolonged treatment in military hospitals during
attempts to cure what is in essence a life-long disability, in which home
service has produced an exacerbation ?

I think the answer can only be in the negative. They should simply
be given rest in hospital while their discharge from the service is
being effected, combined with the assurance that the latter is being
done. This is quite sufficient in the vast majority of cases to cure
the exacerbation, and leave them none the worse for their military
experience. If at all disabled for civil life when discharged they should
be given a gratuity, not a pension.

A few cases that break down under excessive stress of one sort or
another while serving at home recover sufficiently in hospital in a
short time merely as the result of the removal of that stress. If it
were possible to guarantee permanent home service for these cases

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they could continue to serve at home, if only O.Cs. of units would give
them suitable work, or if it were possible for M.Os. to recommend
transfer from one unit to another with any likelihood of their suggestions
being considered.

The exacerbations referred to above, include anxiety states, hysterical
episodes, and the more severe stigmata of psychasthenics, as well as
mixed states incapacitating a man for work.

II. Psychoneuroses first appearing after Battle.

In this class are included the cases due to the circumstances of
battle, and giving no history of pre-expeditionary psychoneurotic
diathesis.

Some observers seem to think that such cases always lie about their
past mental history, denying all symptoms before being “blown up,” or
what not, for the sake of pensions.

However this may be at Pensions Boards, it is certainly not so when
these cases are sent into hospital. Before any question of boarding
or even pensions arises the men are carefully examined and their history
taken, and the latter is usually true. In fact, if any of the patients’
statements have to be taken cum grano salt's, it is those in which in
reply to leading questions they agree that they suffered from some
special nervous symptom in civil life. A little experience soon enables
one to separate the grain from the chaff, if chaff there be.

With regard to treatment, the question is an entirely different one
from that considered under the last section. The present type of
patient is suffering (unless he has been the round of military hospitals
and been subjected to too much “treatment”) from one recent affection
with a definite cause, namely, he has functional mental disorder—psycho
neurosis, resulting from outrage of his instinct of self-preservation by
the stresses of battle. In parenthesis, perhaps, I may say for what it
is worth that, although we have had well over five hundred of these
cases (i.e., battle types, not necessarily entirely due to such cause)
through our hands during the last three years, I have never found any
clinical distinctions between cases supposed to be due to “ commotion ”
and those supposed to be due to “ emotion.”

Now, these cases must be treated in hospital, even though the results
may be poor in the Army. General considerations have been dealt
with above in reference to their disposal.

The first and most important point to be clear about is that it is
perfectly useless waste of time to psycho-analyse in the Freudian sense
any of these men. We know the complex, if any, suppressed, viz., the
fear complex, and to fish for other things merely does harm. Secondly,
only certain types should be treated psycho-therapeutically at all (I am
not referring to “ therapeutic conversation ” here). If the case is goin

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to be discharged from the Army, tell him so. Patients suffering from
hysterical or psychasthenic episodes should be cured, if possible, by
some method of suggestion, with or without anaesthesia or hypnotism,
or, if you will, by psycho-analysis of buried battle-memories only.

Anxiety types, very recent types (*.«., convoy cases before they have
rested and settled down), should have none of these forms of treatment,
let alone electricity !

The importance of choosing the right time and type of case for
psychical treatment cannot be over-estimated.

III. Psychoneuroses occurring after Battle in Persons previously Neurotic.

These cases are often severe. The majority, of course, were formerly
quite able to carry on in civil life. Here, again, I would submit that it
does not come within the duties of the M.Os. in military hospitals to
spend months trying to make these men normal. One should endeavour
to cure the battle-factor symptoms ; that is to say, tackle the suppressed
fear-complex if there be any suppression; anxiety neurosis types should
be rested, cheered, assured of their discharge, and they will get back,
or very near to, their pre-war level.

I have seen some of the results of Freudian psycho-analysis of these
cases (usually transferred here because they have become suicidal).
One came here with the idea (duly implanted by a psycho-analyst) that
he would never be well until he emigrated and left his father; that his
father had always imposed on him ; and he was filled with a mingled
grief and anger against a perfectly good and sane parent. He was
depressed, anxious, and psychasthenic. He had always been of worrying
type. He made a good recovery after a few weeks, his aversion to his
father having been removed, and the cause of his symptoms, viz.,
battle-strain, explained to him.

Another case was similar. He was admitted in a state of weepy
depression, and imbued with the notion that marriage was the only
thing that would cure him, because he was too fond of his mother. This
man had merely been highly strung in civil life. His military history
was two years in France, a shell-shock of some sort, a subsequent air
raid upon the hospital he was in, and “ two stripes up.” And his con¬
dition was due to incestuous longings for his mother ! After this
nonsense was eradicated from his mind he did very well.

Both these men, however, had to be discharged from the service.

A third case was one of mixed anxiety with depression, with functional
paresis of the legs. He had had ten months’ hospital treatment of
every conceivable variety, both psychical and electrical. He was sent
here because of increasing depression, which improved here, as did
also the paresis, but it was hopeless attemptirig to do anything for him
but reassure him regarding his discharge, and encourage him. He did

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not recover here, but had to be transferred with a recommendation for
discharge as permanently unfit. This man gave no history of civil life
neurosis, nor did he care a button about pensions, being well-off in civil
life. He had had well-marked shell-shock, and a long period in the
line. His one idea was to escape from hospital and treatment. I have
not the least doubt but that he did perfectly well when discharged.

One of the most common varieties of psychoneurotic type being
admitted to this hospital at present are boys of psychoneurotic diathesis,
who, after a few weeks in the Army, develop some serious mental
disturbance. These boys are slightly feeble-minded, but their main
disability lies in their inherent inability to cope practically with Army life.

They have usually been shy, solitary boys, who have never played
games, never dissipated or indulged in pranks, but have all their lives
been timid, seclusive, and introspective. In most cases they have never
left home before. They may have had fits in childhood, or some other
stigmata, or general ill-health, which prevented their regular attendance
at school, or they may have been dunces there. They have in almost
all cases been teased and bullied at school and in the Army. Before
their minds break down they may appear sullen through stupidity
or nervous lack of concentration; they are sometimes regarded as
malingerers by incompetent judges, or as cowards because they are
nervously unstable.

When admitted to hospital the condition is usually one of severe
depression, with or without anxiety and tremor, or, not infrequently, a
state of confusion or hysterical dissociation of consciousness. Quite a
fair proportion of them terminate in dementia praecox, i.e., chronic
lunacy. According to their temperaments they carry on for varying
periods in the Army before they break down, and the longer this (to
them) period of misery, the more severe the break when it does come.

If a boy at school cannot play games, learn his lessons, mix happily
with his fellows, but is a shy game-shirker, a slow scholar in spite of
perseverance, and a butt, he cannot be converted into a soldier at the
age of 18 by our present methods.

In summing up this brief prMs, which touches upon so large a
subject, I would venture to hazard the following suggestions :

(1) That the psychoneuroses epilepsy, psychasthenia, and hysteria
have a common basis, which may be called the psychoneurotic tempera¬
ment or diathesis, which, in turn, is dependent upon deviations in the
degree of activity of natural psychological functions.

(2) That these disorders, whatever their physical basis may be, are
for practical purposes mental disorders, and should be treated as such.
We cannot yet make an unadaptable man adaptable by neurological
methods.

(3) That neurologists and others who have had no civilian experience

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of psychological medicine or mental disorders, but have acquired some
knowledge of psycho-therapeutics, are not the best persons to treat
pschoneuroses or other mental disorders, nor to diagnose them, e.g.,
many so-called “ shell-shocks ” turn out to be “ mental cases,” even in
the restricted sense of the latter term ; not a few early dementia praecox
cases are labelled “neurasthenia” and quite a number of “? mental”
types are discovered to be hysterics.

(4) That psycho-analysis, hypnotism, seclusion, and other forms of
psycho-therapeutics are dangerous weapons in the hands of such neuro¬
logists.

(5) That it is desirable that there should be established central special
Recruiting Boards, to which all mentally doubtful examinees, and those
complaining of psychoneurotic, etc., symptoms, should be referred by
the ordinary Recruiting Boards before passing such cases into the Army.

(6) That the powers of T.M.Bs. should be curtailed over cases
categorised by a special hospital on account of psychoneurotic affections.
It is surely bad policy that the opinion of a T.M.B., founded upon a
few moments’ examination of a man it has never seen before, should
over-ride the considered opinion of a specialist who has had the man
under observation in all his moods for weeks.

(7) That T.M.Bs., before re-categorising recently joined soldiers
complaining of psychoneurotic symptoms or manifesting such, should
send them into a special hospital for report.

(') Travelling Medical Board.

Moral Sanity. By (the Rev.) J. G. James, D.Litt., M.A.Lond.,
Southsea.

Many years ago Mr. H. G. Wells entered the “ den of lions ” and
addressed the “ Mind Association,” which embraces the most distin¬
guished experts in metaphysics, on “Philosophy.” He was well received,
however, and doubtless the expert mind was refreshed by the presenta¬
tion of the philosophy of the “ plain man,” as expounded by the talented
writer. Much more daring and bold is the present writer, who makes no
claim to be a specialist in any direction, and does not possess expert
learning except, perhaps, in metaphysics, in thus writing on so difficult
and technical a subject as sanity for those who have made psycho¬
therapeutics their life study. The object of this paper may, at once, be
stated to be to express the profoundest admiration and appreciation of
the methods of mental specialists, whose principles are in the estimation
of the writer so eminently sound as viewed from the standpoint of both
philosophy and religion.

The first point to be noticed by way of recognition of the value of

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the methods of the psychological school is the position given to psycho¬
logy, properly so-called, in their procedure. Remarkable developments
have taken place of late, and these are rapidly proceeding, in the bifur¬
cation of psychology into epistemology or a branch of metaphysics, on
the one hand, and into psychophysics on the other. The now popular
experimental psychology seems to be tending in the direction of the
biological, if not material, aspect of mental phenomena. We may,
perhaps, trace an analogy here to that school of writers on mental
science whose investigations resolve themselves into the observation
and classification of pathological mental conditions, as though such
analysis were the ultimate aim. It is not for the present writer to
attempt to criticise this school, but rather to express his sympathy with
those writers and practitioners who take a strictly psychological view of
the matter and who treat mental disorders as being the phenomena of
“ mind,” as distinguished, though not separate from, the organism
which, as we are told, is not necessarily impaired or deteriorated in the
case of the insane.

The strictly psychological treatment of mental disease is not pre¬
cluded from adopting certain forms of experimental psychology, as in
the highly-important and invaluable word-reaction method of Jung. In
this method, as well as in the application of some of the basic principles
laid down by Freud, the school to which reference is being made, lays
its chief emphasis, as we understand it, upon the supremacy of mental
complexes as distinguished from merely organic processes. This
position will largely account for, and is in complete harmony with, the
general attitude of the school towards hypnotism, which always more
or less reduces the personality to an automatic condition, with all its
attendant drawbacks and perils. This does not necessarily, of course,
involve a complete ban upon hypnotism in all forms, but it brings the
higher processes of consciousness into operation in preference to the
secondarily-automatic and the subconscious.

The re-instatement of “ Mind ” in mental science is to start with a
great gain in the interests of moral as well as mental sanity. On this
basis it is sought to correct those mental complexes which have become
morbid through the failure of normal adjustment or adaptation to the
world of reality, or “ things as they are.” The study of the nature of
reality would, of course, take us far beyond the scope of descriptive
psychology into the realm of metaphysics proper. It involves the
whole question of subjective and objective, immanence and transcend¬
ence, the individual and the universe. It is the main problem of meta¬
physics for all time, but of late years special attention has been given,
as in the schools of neo-realism, and the systems of Bergson and Croce
and others, to the problem of ultimate, objective, and concrete reality.
Failure to reach reality as objective is to reduce all thinking to barren

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abstractions, or “an unearthly ballet of bloodless categories.” The
dreadful curse of “ solipsism ” which all philosophers are anxious to
avert, if they can but fasten it upon others, is akin to that which
mental specialists realise that they have to combat in the morbid
moods, the subjectivism of the false world of the paranoiac, in which the
phantasy of abnormal complexes lead to the perversions and distortions
of the subconscious states of mind. The want of proper adjustment to
the external world and the conditions of one’s lot, together with the
defence psychoses which are the phases of the abnormal conscious¬
ness, are aspects of that pathological mental condition which corre¬
spond to the “ heresies ” of philosophy and the theologian’s “ state of
sin.”

Still the question persists, What is Reality ? It is not the external
as such and certainly not the merely material. For practical purposes
it may be said that the real world is the world as it exists for us all, and
objectivity is attested by the collective consciousness. Consequently,
we may consider ourselves normal if the world generally acknowledges
us to be so. This rough and ready way of viewing the matter is not
satisfactory for philosophy, as we shall frankly admit. It is, however,
important to note that the right attitude of the spiritual self, and, indeed,
the whole personality is that which does not refuse to acknowledge, and
does not rebel against reality, in so far as it is presented and appre¬
hended. The immediacy of intuition and even faith through which a
man is brought face to face with the truth of things, and by means of
which he receives the impact upon his consciousness of that which has
the right of appeal, would determine his whole attitude towards reality.
That a man should accept his “ station and its duties,” that his sense
of moral values should direct his decisions, that he should free himself
from prepossessions, preoccupations, obsessions, and prejudices would
all make for moral sanity as it forms the main constituent in mental
sanity. It involves the freedom of the mind from self-centred interests
and over-subjectivism, which always tend to morbidity in some form
or degree. This freedom may be considered as healthy for mind and
body, and normal from the standpoint of the physician as well as the
theologian.

The nature of reality may require for its due investigation the whole
range of philosophy and theology, and if by the line of advance, a
spiral line it may be, we may continuously approach or approximate to
it, reality in the ultimate is an ideal which is never wholly apprehended.
Nevertheless, sanity requires that continuous advance should be made,
and if by the right orientation of our souls in that direction we come
to feel its impact upon our consciousness, the hurtful and harmful
illusions of life in consequence will fall away. The world of men and
things around us constitute a challenge for our effort and our service,

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and by accepting the challenge with the knowledge that we are doing
our duty, and that we do not flinch from or refuse the demands of the
hour, our vital activities acquire the proper poise, and our characters
become well balanced. Religion asks that life should be lived always
with reference to “ the spirit of the whole,” and it is only in this way
that the personality gains its dignity, its power, and its sanity.

Incidentally the question may arise, how far the condition of the
world to-day, which almost seems to justify Prince Troubetzkoy’s
description of it as the “ Reign of Nonsense,” is due to mental or
moral insanity. Are the Teutonic peoples, the ruling caste, and the
Kaiser, afflicted with collective paranoia? The great Central Empires
are manifestly obsessed by the idea that the whole of the rest of the
world, led by England, is through jealousy and spite bent on their
destruction. This great fear, amounting at length almost to panic, so
far overrides all moral considerations in a race peculiarly subjective,
and given to strong, if perverted, idealism, that it feels itself justified
in employing any measures, right or wrong, or even barbarous and
diabolical, in order to protect itself against a world in arms, and to
promote its mission of Kultur. Whether mentally or morally diseased
or both, we need not attempt to decide, nor to fix the degree of
culpability; but certainly all the phenomena of paranoia seem to be
exhibited here, and it cannot be said that these nations are completely
sane. The only course of action possible is to administer to the
enemies of mankind and the social order the same restraint, once they
can be overpowered, that must be imposed upon dangerous maniacs for
their own preservation no less than for the protection of the race.

Our main contention is, then, that mental and moral sanity are so
closely allied, if not fundamentally the same, that when the totality of
the powers and functions of personality are considered, the true and
proper relation of vital interest with reality is the final determinant.
Reality, as we have seen, may be variously conceived, as the circum¬
stances attending our station and its duties, the challenging objective,
or the Supreme Reality, according to the standpoint that we take,
mental or moral, philosophical or religious. This being granted, we
are in a position to estimate the importance of the methods employed
by the psychological school. If, as Dr. Henry Devine affirms ( l ),
“ insanity is a matter of personality,” with all its delusional phantasy
and instability of character and ideals, then the most important treatment
is obviously such an analysis as will determine the point at which the
rupture with reality took a serious form, with the object of inducing
the patient to retrace his steps, so as to begin a process of re-education.
This analysis involves a demand for expert knowledge and skill, but
the remedy will consist in what we may term “ moral suasion.” It is a
correction, by suggestion or wholesome advice and watchful interest

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and care on the part of the physician, in the interests of reality and of
the patient himself. Thus it becomes the undoing and the disentangling
of the perverted complexes so as to correct the mischief wrought thereby
on the subconscious mind. The significance of this most difficult and
heroically patient method of treatment lies in the fact that it is precisely
what the faithful and intelligent pastor or priest is endeavouring to do
in his own way, and along his own distinctive lines. To get at the
root of the evil, to induce the sufferer to go back to the beginning and
make a fresh start, all this is involved in the theological concept of
repentance, which is essentially a change of direction and a change of
heart. The same objections are urged against both methods, that it is
unwise to “rake up the past;” but the same justification holds good
in both cases, that, in the interests of healthy-mindedness, the disease
must be properly diagnosed and the evil faced and grappled with, not
for the pleasure of the interest in unwholesome experiences, still less
that the patient may unduly dwell upon morbid conditions. Still, the
need of “ confession ” of the faux pas, and the resolution to face the
issues frankly and fully, is a step gained ; and wise counsel, kindly
suggestion, and a firm handling will accomplish a great deal towards
dispelling the fantastic delusions and the perverted views of life which
have wrought such havoc in the subconscious region of mind. For the
restoration of the mental, and no less the moral, balance it is necessary
that every person should gain a just interpretation of the objective
forms of existence, and come to accept the values of truth, goodness,
and beauty, that are superior to himself, and that he should order his
life accordingly. “ Hereby shall we know that we are of the truth, and
shall assure our heart before Him, whereinsoever our heart condemn us ;
because God is greater than our heart, and knoweth all things.” This
is St. John’s corrective of the morbid temper and misgiving.

These considerations will meet the last remaining objection that may
be raised, that the world owes much of its interest and charm to the
creations of the mind, and most of its reforms to visionaries and dreamers
who were accounted “ mad ” in their day, and who certainly did not
accept the world as it was. But surely it must be acknowledged that
there are objective values in the realm of the moral and the spiritual,
and it is these values which are intuited, appreciated, and accepted by
those who become the prophets and seers, the poets and philosophers
of their time. It is not in their case the triumph of the subjective, but
rather the clearer vision and the fuller grasp of the objective standards.
They may rise above the actual, the ordinary, and the commonplace,
but they do not escape from the real, if they are to stand on solid
ground, and accomplish substantial work in the world.

Finally, as the result of these reflections, we may venture to hope
that a completer mutual confidence and co-operation may exist, not

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only between psychologists and the medical faculty, but also between
the medical faculty and the ministry of religion. The distinctive
functions of each must be maintained, but a little better knowledge of,
and insight into, the respective aims and methods of both would promote
far greater mutual regard and respect. The present writer is glad to
acknowledge the immense debt of gratitude he owes to some slight
study of the principles of psychotherapy. Let us hope that as each
understands a little less imperfectly the work of the other faculty, we
shall the better learn how to do our own, and come to realise that we are
working hand in hand, each in his own sphere, to restore a more healthy
outlook and tone to this sad and insane world.

(') “ The Pathogenesis of a Delusion,” Journal of Mental Science, July, 1911.

Occasional Note.

The Annual Meeting.

It is four years since the Association held its Annual Meeting in
what may be called a normal manner and under normal conditions.
The members who attended the meeting at Norwich in 1914, under
the presidency of Dr., now Lieut.-Col., Thomson, cherish very pleasant
memories of their three days’ sojourn in the interesting old city and its
delightful surroundings. None of those who were there, as our new
President intimated at the opening of his address, could have anticipated
that almost within a few days of their parting a greater catastrophe than
has ever been recorded in history was to overwhelm the continent of
Europe with all the suddenness and destructiveness of an avalanche.
Still less that a war which would extend into its fifth year of duration
was awaiting us. Owing to this our annual meetings have been of a
purely business character, and all held in London, without any of the
usual social amenities which used to form such a pleasant feature on
similar previous occasions. Each successive year it was hoped that the
war would come to an end, and in this expectation Col. Thomson was
asked to continue in office until, with the advent of peace, his successor
would have an opportunity of conducting the proceedings on the old
lines. This, unfortunately, has not been possible owing to the con¬
tinuance of the war. But it was felt that it would be unfair to make any
further demand on Col. Thomson when he had so generously responded
to the wishes of the members in continuing to occupy the chair of
office for four years—a position which he filled to the entire satisfaction
of the Association at large, and the duties attached to which, notwith¬
standing the multitude of other matters constantly requiring his atten¬
tion, far from performing in anything like a perfunctory manner, he dis-

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charged with almost unfailing regularity, with ability of a high order,
and with an unflagging zeal for the best interests of the Association,
which, severally and collectively, owes him a debt of gratitude which the
members would find it difficult, if not impossible, to repay.

If we speed the parting we are equally ready to welcome the coming
guest, and in their selection of Lieut.-Col. Keay as their chief officer
the members of the Association feel that it has been a wise choice on
their part, and in his case an honour well deserved. They are confident
that the interests of the Association will be safe in his hands, and the
recent meeting at Edinburgh may be taken as an index of Col. Keay’s
capacity for fulfilling some of the most important of his presidential
duties, and we have no doubt whatever that, under his aegis, the affairs
of the Association will continue to be transacted in the most efficient
manner.

The one subject that is uppermost in the mind of every citizen of
the Empire is, undeniably, the war. And Bangour Village, having been
for the present converted from an asylum for the insane into a war
hospital, it was only to be expected that the change would be more or
less reflected in the character of the Annual Meeting, which, accordingly,
differed from its predecessors in that it was occupied more with military
than with purely psychiatric interests. In his thoughtful and deeply
interesting Presidential Address Col. Keay took for his subject, “ The
War and the Burden of Insanity”—a theme which, having had the double
advantage of prolonged acquaintance with the many problems of mental
science and of more recently acquired experience of the pathological
results of war, he was peculiarly qualified to treat. And all those
who had the privilege of listening to the address we are sure found it
full of absorbing interest, which was none the less for the soupfon of
humour which gave it extra picquancy and flavour. The points touched
upon are of general and wide-spread interest to lay as well as to profes¬
sional readers. Such are the effects of war, both good and bad—bad,
in removing such a vast number of the fittest of the population, while
the old and feeble and unfit are carefully preserved; with these latter
Col. Keay, with conscious or unconscious humour, classes in the same
category “ the clergy, the inmates of our asylums and the members of
the House of Commons ”; bad, again, in the enormous expenditure—
an outlay of many millions per day of the nation’s wealth in the prosecu¬
tion of the war, notwithstanding which we have been, as regards trade,
“ enjoying prosperous times,” and the country has been “ apparently
rolling in money.” But this is, as it were, merely a flash in the pan, and
the restoration to normal conditions will probably take a generation or
more to accomplish. On the other hand, it cannot be denied that in
some aspects the war has been productive of substantial good, as, for
instance, in quelling what is characterised by Stephen McKenna, as

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quoted by Col. Keay, as “a spirit of unrest and lawlessness” which
prevailed more or less generally throughout the kingdom, and which
included such “ hysterical controversies ” as those connected with the
status of the House of Lords, industrial strikes (with these, unfortu¬
nately, we are by no means done), the female suffrage campaign, and
the Home Rule controversy. It has, moreover, apparently brought
about a decrease of serious crime, of pauperism and of insanity. As
regards that important question, the early treatment of insanity, the war
has undoubtedly been productive of some valuable experience. Now,
for the first time, opportunities have been provided for the immediate
treatment of recent mental cases without certification, which in ordinary
circumstances is, as a rule, only done after a considerable period has
elapsed after the first symptoms have manifested themselves. It is too
soon as yet, and there is not a sufficient amount of statistical information
at hand, to enable us to compute with any accuracy in what proportion
of such cases recovery has taken place under early treatment, and with¬
out the necessity of sending the patient to an asylum; but the facts, so
far as they can be ascertained, are encouraging, and go far to justify the
hope that, if the same facilities could be provided in the case of the
civil population as exist with respect to military patients, equally favour¬
able results would not be improbable. This was an object dear to the
heart of the late Dr. Maudsley, and one which prompted him to the
founding of the institution which bears his name. What success will be
achieved in time to come, when the hospital will be utilised for the
purpose for which it was originally intended, lies still in the lap of
the gods. We must only have faith in the future, and trust that Dr.
Maudsley’s hopes, in which he is joined by not a few, will one day reach
their full fruition.

The pressing questions of the day in direct connection with insanity,
such as those of child care from the period of pre-natal existence through
the successive stages of infancy, childhood, youth and adolescence; the
control—if necessary, State control—of alcoholic indulgence and the pre¬
vention of syphilis were ably dealt with in the address. And as regards
this latter subject, we would like to draw special attention to one
paragraph which, to give greater emphasis to the President’s fearlessly
expressed views, we take leave to reproduce here:

“What is wanted is that the public should be awakened to a realisa¬
tion of the fact that there is in syphilis rampant in our midst a deadly,
contagious, and hereditary disease, a disease which kills a countless
number of unborn innocents; which is the cause of mental and bodily
decrepitude of a large proportion of our idiots and imbeciles; which
in its various manifestations results in life-long incapacity, bodily
suffering and mental anguish to numbers of people who, in happier
circumstances, would be capable and vigorous citizens. And yet,
withal, a disease which is preventable ; which, in its earlier stages at

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least, and with proper treatment, is curable; and which, by energetic,
resolute, concerted action by the great civilised nations could be
stamped out and abolished for ever.”

It would be well if this citation could be blazoned in glowing
characters throughout the civilised world, amongst all the busy haunts
of men.

Although, by what was no doubt mutual consent, there was no annual
dinner, members who attended the meeting, and especially those who
came from a distance, were received with a liberal hospitality by their
Scottish colleagues, in keeping with old Edinburgh traditions of long
standing. The President entertained a large number at dinner on the
Monday preceding the meeting at the North British Hotel; and an
equally pleasant reunion was provided on Wednesday evening at the
Caledonian by Dr. Robertson, who also, along with the kind co-opera¬
tion of the Chairman and Managers of the Morningside Mental Hospital,
gave a most enjoyable “At Home ” on Tuesday evening at Craig House
to a large number of guests.

The visit to Bangour Village, now the Edinburgh War Hospital,
under the command of Col. Keay, on the second day of the meeting
was an altogether delightful experience, and partook rather of the nature
of a picnic than of a purely scientific meeting, although, as shown in
the report, most interesting scientific demonstrations kept the audience,
which included not merely members of the profession, quite enthralled.
The generous hospitality of the President and Mrs. Keay gave abundant
opportunity for genial social intercourse, and, but for a passing shower,
the weather was perfect. On the whole the Edinburgh meeting was a
complete success, and afforded a restful interlude and unalloyed pleasure
to all who were able to attend, and especially to those members of
our specialty who had been engaged in work of strenuous, possibly
exhausting, character throughout the year.

It may be that in the eyes of the “ unco’ guid ” (or unco’ dour) any¬
thing in the way of enjoyment may seem to be altogether out of place
at a time when the nations are wrung with sorrow, and when there is
hardly a family in the kingdom which has not suffered, or is not at
present suffering, anxiety, bereavement, and distress, when Death is
daily claiming his victims from the stricken homes of our Motherland
during the slow progress of this cruel and relentless war. Still, it may
not be the best or wisest course for a nation, or for the individuals who
compose it, to abandon themselves to unrestrained mourning, to shut
out all sunshine from their lives. Would their dead wish it ? We take
leave to doubt it. Those gallant souls who loved not their lives unto
the death, who greeted the unseen with a cheer for love of home and
country, they surely would not wish their glorious self-sacrifice and
devotion to leave nothing in its wake but enduring sadness and gloom.

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EPITOME.

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If they could speak to us surely they would say—“ Be of good cheer.
Let not your hearts be troubled; all is well.” Under such afflicting
circumstances we can, perhaps, the better understand the pertinence of
the words which Shakespeare (who knew most of what is in man) put
into the mouth of Theseus :

“ What revels are in hand ? Is there no play
To east the anguish of a torturing hour ? ”

It is no easy rile to endure sore trial with a smiling face, and any¬
thing which conduces to the lifting of the veil of sadness, to the
taking us out of ourselves and our troubles, even for a season, to
detaching our minds from corroding grief, must receive our commenda¬
tion. It serves to mitigate the poignancy of sorrow, and enables us
who are left behind—and herein lies its worth and justification—with
renewed courage and confidence still to carry on.

Part II.—Epitome of Current Literature.

Clinical Neurology and Psychiatry.

Studies on Hysteria. (.Review of Neurology and Psychiatry , January,
1918.) Hurst , A. F. and Symns,/. L. M.

A series of researches into the various hysterical stigmata. The
writers, as a result of their investigations, support the view of Babinski
that these stigmata are produced by unconscious suggestion of the
physician in the course of the examination of the patient.

The following investigations were made :

(1) Pharyngeal anesthesia. —The results of the observations are
tabulated according to a scale, beginning with o (complete anaesthesia),
and passing to 7 (maximal reflex making laryngoscopic examination
quite impossible). The figures show that pharyngeal sensibility is no
more deficient in patients w’ith hysterical symptoms, than in non-
hysterical cases, and it varies in a similar manner. When care is taken
to avoid suggestion complete pharyngeal anaesthesia is never found.
The conclusion is reached that such anaesthesia is not a stigma of
hysteria, and that when habitually found it must be produced by in
voluntary suggestion on the part of the observer.

(2) Experimental observations on the signs and symptoms ef malinger¬
ings hysteria , and organic nervous disease. —Hysterical symptoms being
produced by suggestion have the characteristics which the patient
believes to belong to the symptom, either from his own knowledge or
that suggested by the examination. This view was tested by the
examination of twenty-nine medical students who had not yet acquired
any clinical knowledge. They were each told to pretend that they had
been in a railway accident, and that they were attempting to swindle the
railway company by claiming compensation because of paralysis of the
right arm and leg, which they alleged had resulted. The symptoms

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and signs obtained, as a result of the investigations, correspond to
those occurring in patients suffering from hysterical paralysis. Many
of the symptoms were produced as the result of leading questions, just
as in the suggested symptoms of hysteria. The deep and superficial
reflexes were normal.

(3) Narrow and spiral fields of vision in hysteria, malingering and
neurasthenia. —Hysterical patients do not spontaneously complain of
disabilities resulting from a narrow field of vision. But if a narrow
field is produced by testing with the perimeter the patient may sub¬
sequently complain of considerable inconvenience. The perimeter
invariably results in suggesting a narrow visual field however carefully
it is used. The writers found also that if the examination was con¬
tinued after the first field was marked out a spiral field was always
obtained identical with that which has hitherto been regarded as a
stigma of hysteria. An inward or outward spiral has been produced in
the same eye on different days according to’the direction in which the
white disk of the perimeter is moved. By testing with the finger
instead of the perimeter no narrowing of the visual field was found in
the “ malingerers ” described in the previous communication.

(4) The supposed association of hysterical ancesthesia of the external
ear with hysterical deafness. —In cases of organic deafness anaesthesia
was frequently found in a marked degree when suggestion was an
element in the physical examination. Similiar results were obtained
in hysterical deafness, and the. writers conclude from their observations
that the supposed association of hysterical anaesthesia of the external
ear with hysterical deafness is a complete fallacy, and that anaesthesia
is likely to occur in a deaf ear, whether the deafness is organic or
hysterical, so long as the individual is sufficiently suggestible and not
too well educated.

. (5) A new group of hysterical stigmata. —If hysterical symptoms are

produced by the observer, hysterical stigmata may be multiplied. This
point is proved by the invention of three new stigmata which were
invariably found when looked for in three suggestible patients. These
stigmata were : (1) An outwardly directed spiral field of vision; (2)
anaesthesia of the nose ; and (3) anaesthesia of the skin round the
umbilicus. H. Devine.

The Rapid Cure of Hysterical Symptoms in Soldiers. {Lancet, August 3rd,
1918.) Hurst, A. F., and Sytnns, f. L. M.

Certain hysterical symptoms have seemed to require a prolonged and
careful re-education for several weeks to complete the cure. Such
symptoms are : The stammer following mutism, tremors—regarded by
Babinski as a special neurosis less amenable to psychotherapy than hys¬
terical symptoms—and those contractions which Babinski and Fromont
have diagnosed reflex neuroses. From their more recent experience
the writers find that prolonged re-education is not necessary in any of
these cases, and they now expect recovery within twenty-four hours
of commencing treatment. The rapid cure depends on the persistence
with the treatment, in spite of the fatigue of the patient and the officer
in charge, until the particular symptom is entirely cured, e.g., the mute

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soldier who stammers upon the recovery of the voice should not be
left until the stammer is also cured.

Relapse is rare if a cure has been obtained within a few weeks of the
onset, and the liability to relapse in long-standing cases is much reduced
if the patient is given open-air occupation, and kept under observation
at the hospital for a few weeks before return to duty.

The essential points in the treatment are simple persuasion and re-edu¬
cation continued with manipulation. The atmosphere of encouragement
which should be fostered in the ward before the commencement of active
treatment is essential for the cure of the case. H. Devine.

The Treatment of Cases of Shell-shock in an Advanced Neurological
Centre. {Lancet, August 1 jth, 1918.) Brown, W.

Observations based on the treatment of between two and three
thousand cases of psychoneurosis, the majority of whom were treated
within forty-eight hours of their breakdowm. Of these ca^es 70 per
cent, were able to return to the line after about a fortnight’s rest.

The essential factors in the treatment are: (1) Persuasion, whereby
the patient is rationally convinced of the true nature of his symptoms ;
(2) the sthenic emotions of confidence, conviction, and expectation.
The symptoms are of emotional origin, and result from the partial
failure of repression whereby the emotion is converted into physical
innervations. The period of incubation of the symptoms corresponds
to the time during which the patient ife endeavouring to repress the
painful emotional memories. The therapeutic method employed in
early cases is one of “abreaction” or “working off” of the painful
emotion. The patient is put into a condition of light hypnosis, and the
experiences at the time of the shock are again revived in the mind of
the patient. This produces a strong emotional reaction, and the patient
again “lives through” his terrifying experience. This method brings
back the lost function, but not by direct suggestion as in ordinary
hypnosis. The patient is told that he will remember all that has
happened to him during his sleep and during the gradual waking, the
suppressed memories are synthetised to his personality by talking to him
of events in his daily life. H. Devine.

(1) Neurasthenia: The Disorders and Disabilities of Fear. {Lancet,
January 26th, 1918.) Mott, F. IV. (2) The Psychology of Soldiers'
Dreams. {Lancet, February 2nd, 1918.) Mott, F. W.

The phenomena of neurasthenia are the result of continued emotivity
and preoccupation, causing a persistent condition of neural excitation.
This tendency to emotivity may be inborn or acquired. This emotional
excitement often finds its source in dreams of a terrifying nature, especially,
of course, in the case of soldiers; obsessional preoccupation is also an
important factor. Thus neurasthenia occurs with considerable frequency
in men who have never been out of England from the fear of con¬
scription or having been conscripted. In such cases the inborn tempera¬
mental disposition plays a considerable rdle. A continued emotivity is
also produced by the fear of being boarded out of service, or not being
allowed to go to the Front. A mental conflict is thus produced in the

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389

mind between the self-conservative instinct and the moral obligation of
duty and patriotism.

The second paper deals more fully with the content and mechanism

of the dreams of soldiers. H. Devine.

•

A Case of Pathological Lying Occurring in a Soldier. (Review of
Neurology atid Psychiatry, July , 1917.) Henderson, D. K.

The case recorded is the only one of this type observed in 1,400
admissions of nervous and mental cases. It presents the usual kind of
history and features found in this type of disorder, and it is published
not only for its dramatic interest, but more for the important educa¬
tional and administrative problems it suggests.

Such cases are to be regarded as a form of high-grade mental
deficiency. The diagnosis rests on the following mental characteristics :
(1) Precociousness ; (2) roving disposition with inability to concentrate ;
(3) blunting of emotional tone—lack of affection, sense of guilt, moral
sensibility; (4) lying with inadequate precautions to prevent detection ;
(5) rather attractive personality; (6) total irresponsibility.

What is to be done with these plausible, dangerous, and attractive
types? They cannot usually be certified, and prison methods only
aggravate the morbid tendencies. The only solution appears to be
recognition of these cases in childhood, and treatment in colonies,
where they may be suitably trained. H. Devine.

Part III—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The Seventy-seventh Annual Meeting of the Association was held on
Tuesday and Wednesday, July 23rd and 24th, 1918, at Edinburgh. The meeting
on July 23rd was held in the rooms of the Royal College of Physicians, 9, Queen
Street, Edinburgh, Lieut.-Col. David George Thomson, the retiring President, in
the chair.

There mere present: Drs. T. Stewart Adair, David Blair, C. Hubert Bond, David
Bower, A. Helen Boyle, L. C. Bruce, W. M. Buchanan, Robert B. Campbell, J.
Carswell, James Chambers, W. H. Coupland, Charles A. Crichlow, James Crocket,
L. K. Davies, W. R. Dawson, J. Francis Dixon, Thomas Drapes, C. C. Easter-
brook, W. F. Farquharson, Claud F. Fothergill, John Fraser, J. W. Geddes, J. R.
Gilmour, R. D. Hotchkis, John Keay, Neil T. Kerr, J. Carlyle Johnstone, J. H.
MacDonald, T. C. Mackenzie, S. Rutherford Macphail, John Macpherson, Alfred
Miller, Bertha M. Mules, M. J. Nolan, W. W. Horton, James H. C. Orr, L. R.
Oswald, Bedford Pierce, W. Ford Robertson, James Grieg Soutar, G. E. Shuttle-
worth, C. j. Shaw, J. Batty Tuke, and R. H. Steen (Acting General Secretary).

Present at the Council Meeting : Lieut.-Col. D. G. Thomson (President), in the
Chair, and Drs. T. Stewart Adair, A. Helen Boyle, Robert B. Campbell, James
Chambers, Thomas Drapes, C. C. Easterbrook, J. W. Geddes, Alfred Miller,
L. R. Oswald, G. E. Shuttleworth, and R. H. Steen. Dr. Soutar attended the
Council on the invitation of the President.

Apologies for unavoidable absence mere received from : Sir Robert Armstrong-
Jones, and Drs. Fletcher Beach, R. R. Leeper, J. B. Spence, H. Wolseley-Lewis,
R. H. Cole, R. Eager, M. A. Collins, Norman Lavers, G. N. Bartlett, F. H.
Edwards, Henry Rayner, P. W. MacDonald, J. G. Porter Phillips, Donald Ross,
James M. Rutherford, R. Dods Brown, H. de M. Alexander, William Brown,
W. Tuach-MacKenzie, and T. E. K. Stansfield.

LX IV. 27

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The minutes of the previous Annual Meeting having appeared in the Journal,
were taken as read and signed.

The President : I am reminded by the Secretary that one of our first duties is
to deplore the decease of a corresponding member of this Association, Dr. R^gis,
of Bordeaux, who was known to many of you by his works on insanity, and was
one of the foremost medico-psychologists in France. I propose a vote of con¬
dolence to his family, which the Secretary will communicate if it is your wish.
(This was assented to by the members rising in their places.)

Now, a very pleasant duty that I have to perform is to propose a vote of
congratulation to be conveyed to Sir Marriott Cooke, the Chairman of the English
Board of Control. I am sure we are all delighted, and, in a distant and indirect
kind of way, honoured that one of our colleagues has been honoured by the King
with a Knighthood of the British Empire. I feel sure that you will pass the vote.
(Agreed.)

The following resolutions were put from the chair and carried:

(a) That the officers of the Association for the year 1918-19 be :

President —John Keay.

President-elect —Bedford Pierce.

Ex-President —David George Thomson.

Treasurer —James Chambers.

Editors of Journal —John R. Lord, Thomas Drapes.

General Secretary —Robert Hunter Steen.

Registrar —Alfred A. Miller.

(A) That the nominated Members of Council be: A. Helen Boyle, R. D.
Hotchkis, Richard Eager, F. W. Mott, David Orr, G. E. Shuttleworth

( c) That F. H. Edwards and G. F. Barham be appointed Auditors.

(d) That the Parliamentary Committee be re-appointed, and that A. Helen

Boyle, Maurice Craig. J. Francis Dixon, E. S. Pasmore, M. A.
Collins, R. Eager, L. R. Oswald, R. D. Hotchkis, and J. H. Skeen
be added to the Committee.

(e) That the Educational Committee be re-appointed, and that the following

be added thereto: E. B. Sherlock, H. Brougham Leech {ex officio),
M. A.Collins, R. Eager, C. C. Easterbrook, J. H.Skeen, R. D. Hotchkis.
(/) That the Library Committee be re-appointed, and that M. A. Collins
and D. G. Thomson be added thereto.

{g) That the Research Committee be re-appointed, and that M. A. Collins
and D. G. Thomson be added thereto.

The Acting General Secretary then read the Report of the Council as follows :
Annual Report of the Council.

The number of members—ordinary, honorary, and corresponding—as shown in
the list of names published in the Journal of Mental Science for January, 1918, was
678, as compared with 682 in January, 1917.

The following table shows the membership for the past decade:

Members.

1908.

1909-

1910.

191 1.

1912.

|

1913' ! 19*4.

1915-

1916.

1917.

Ordinary

682

673

680

690

696

695 679

644

632

627

Honorary

29

32

33

34

35

34 1 34

34

32

33

Corresponding

«5

*7

17

•9

19

iS 18

|

is

18

iS

Total

726

722

730

743

750

1

747 73 i

696

682

678

During the year no less than twenty members died, many of whom were pillars
of the Association. Their worth and scientific attainments have received due
recognition from the chair at the quarterly meetings and in the pages of the
Journal. The Council, however, feel that in this, their Annual Report, they must
record the loss they have sustained in the death of their beloved and esteemed

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Treasurer, Dr. Newington, who for twenty-three years managed the finances of the
Association, and assisted in enlarging its sphere of usefulness.

Among others not included in the above twenty who have passed away since the
New Year must be mentioned Dr. Henry Maudsley, Honorary Member, a tribute
to whose life and work appeared in the April number of the Journal. The sum
of £2000 which he bequeathed to the Association is a gratifying proof of the
confidence he had in it, and no doubt this money will be used, not only to perpetuate
his great name, but also to further the main object of the Association —the promotion
and cultivation of science in relation to mental disorder.

High honours have been awarded to two members. Sir Marriott Cooke has
been made a K.B.E., and Sir Robert Armstrong-Jones has been knighted.

.Owing to the war, the annual and quarterly meetings were held in London.
The dinners usually accompanying such meetings did not take place. It has,
however, been found possible to provide members with light refreshment at the
close of the meetings, which has rendered possible some social intercourse.

Special mention must be made of the February meeting at the Maudsley
Hospital. This was one of the most largely attended meetings in recent times, and
thanks are due to Lt.-Col. Mott for so kindly inviting members to the hospital.

The Divisions have managed to hold their usual meetings, and, though the
attendances have not been equal to those of pre-war days, the standard of the papers
read and the value of the discussions thereupon have been well maintained.

The Educational Committee has met regularly. The work of the Registrar,
already sufficiently arduous, will shortly be increased by the examinations for the
Certificate of Proficiency in Nursing and Attending on the Mentally Defective,
the first of which will be held in November of this year.

The Parliamentary Committee, besides meeting as usual, has appointed sub¬
committees to consider how best to carry into effect the resolution passed at the
instance of the Status Committee by the annual meeting of 1914.

The Special Committee respecting the College of Nursing is still in being, and,
should necessity arise, will be ready to defend the interests of the mental nurse.

The Special Committee to promote the formation of over-seas divisions has
been able to make little headway owing to the war.

A Special Committee has been appointed to watch the question of a Ministry
of Health. This Committee has met on several occasions, and has conducted
correspondence with other medical bodies.

The Journal has appeared regularly. The editorial work has fallen chiefly upon
the shoulders of Dr. Drapes, who is to be congratulated on the success of his efforts.
Owing to the great increase in the cost of printing and to the shortage of paper,
the Council feel that the time has come when it will be necessary to reduce
considerably the size of the Journal, but they hope that by the use of smaller type
and other measures its usefulness will not be seriously curtailed.

The General Secretary, Capt. M. A. Collins, has found it necessary to resign
owing to pressure of other work. He was appointed in 1912, and spared neither
time nor trouble in the duties of his office. Having received a commission in the
R.A.M.C in 1915, involving absence from home, he was unable to continue his
work from that date. The Council wish to place on record how deeply they
appreciate the value of the services he rendered to the Association.

The finances of the Association are in a satisfactory condition. The thanks
of the Association are due to the Treasurer (Dr. J. Chambers) for accepting office.

Thanks also are due to the Registrar, Committees, and Divisional Sec retaries
for their work.

The President (Lieut.-Col. D. G. Thomson) has created a record in occup ying the
chair for four years. He has not been content to be heal in name only, and has
presided over all the quarterly meetings and has attended many of the Com mittees.
Though pressed by other duties, he has found time to devote himself to the welfare
of the Association, and assist the officers with his sound and valued advice. The
Association is deeply grateful to its retiring President.

Report of the Treasurer.

Dr. Chambers submitted the Revenue Account and Balance-sheet for the year
1917. He stated that the more important part of this period had been d ealt with
by his predecessor, and he wished to add that when perusing the late Treasurer's

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392 NOTES AND NEWS. [Oct.,

records he was profoundedly impressed by the painstaking care and the ability
with which the finances of the Association had been managed. It was owing to
this that a position had been attained which was enabling the Association to carry
on during the existing exceptional conditions.

The Council has sanctioned the investment of a further sum of £250 in War
Loan. The dividends of the Gaskell Fund have accumulated, and the Trustees
will invest a sum of £100 in the same security.

Dr. Maudsley's munificent bequest of .£2,000 has been placed on deposit account
with the Association’s Bankers. The Council has appointed Drs. R. B. Campbell,
R. R. Leeper and R. H. Steen trustees of this fund, and has recommended its
investment in War Loan. A Committee has been asked to consider the objects
on which the income from this fund should be expended, and to make their report
to the Council in November next.

The increased expenditure involved in the production of the Journal is a source
of anxiety; the Council has carefully considered this matter, and has decided to
reduce the size of the Journal.

The two vacancies in the trusteeship of the Association’s funds have been filled
by the Council electing Dr. J. Greig Soutar and Lieut.-Col. D. G. Thomson.

The Report was received and adopted.

Report of the Editors of the Journal.

Dr. Drapes read the following report of the Editors:

The difficulties which, as is well known, are connected with journalism of every
kind during the deplorable conditions which at present exist in this and other
countries, so far from diminishing tend to become more and more acute. Scientific
journals such as our own form no exception to the general rule. Dearth of
material, and more particularly of research work, which has to be reduced to a
minimum owing to the urgent and unceasing demands occasioned by other kinds
of work on the time of investigators, was, of course, to be expected. This, with
the increasing scarcity of paper, and its prodigious rise in price, as well as the
enhanced cost of publication in other directions, makes the task of editing a not
altogether easy one. The wish and aim of the Editors has been to keep the
Journal, as far as possible, up to its normal standard as regards both quantity and
quality of material. How far they may have succeeded in this must be left to the,
they hope, indulgent judgment of the members; but, owing to the circumstances
above mentioned, it is to be feared that, with respect to quantity at least, this
object is no longer attainable. In the matter of expense, that the Editors have not
been unmindful of the exigencies of the case is shown by the fact that during the
four years 1914 to 1917 the number of pages of the Journal has been reduced by
io^ per cent, as compared with the average of the five years preceding the war.
As regards the three numbers already published during the current year, there is a
reduction in size of 13 per cent, on the average of the previous four years, and
of 22 per cent, on that of pre-war issues. But it is quite evident that a still further
reduction in size has become imperative, otherwise the inroads upon the Treasurer’s
financial resources will become greater than can be reasonably expected.

As shown in the Treasurer’s statement, the cost of the production of the Journal
for 1917 was £5*8, as compared with £578 (in round numbers) for the previous
year ; the average cost for the four years 1914 to 1917 inclusive being £450, and
for the five years preceding the w-ar practically £500. That is to say that the
average annual cost during the war years was £50 under that of pre-war years.

The Editors wish to express their acknowledgments to all those who have kindly
contributed papers to the Journal, and also to the Assistant Editors, Drs. McRae
and Devine, for their valued assistance. They are also indebted to Drs. Steen and
Chambers for helpful suggestions willingly given on different occasions. Apologies
on their part are due to the members on account of the lateness in appearance of
the Journal for some time past, which was owing, however, to circumstances over
which they had no control. The exceptional delay in the issue of the last (April)
number was altogether due to a breakdown which occurred in the factory from
which Messrs. Adlard obtain their supply of paper, which caused a suspension
of printing operations for some weeks. John R. Lord.

Thomas Drapes.

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PRINCETON UNIVERSITY

394

NOTES AND NEWS.

[Oct.,

Report of Auditors.

The Acting General Secretary read the report of the Auditors as follows:

We, the undersigned, have had submitted to us by the Treasurer the accounts,
books, and vouchers relative to the finances of the Medico-Psychological Associa-
ti on, and we find that they present a true statement in every respect as shown in the
balance-sheet now presented.

We regret that existing circumstances render it impossible for either of us to
submit the report in person. Maurice Craig.

Francis H. Edwards.

Annual Report of the Educational Committee.

The Acting General Secretary read the report of the Educational Committee
as follows:

During the past year this Committee has met on four occasions.

A Sub-Committee appointed to deal with the question of recognition of institu¬
tions for the training of those engaged in nursing the mentally deficient has met
and submitted a report to the Educational Committee. This has resulted in a
number of institutions being recognised for the purpose of teaching and training,
and it has been decided that, should the authorities of any other institutions desire
recognition, formal application must be made to the Registrar, Hatton, near
Warwick, giving full particulars of the institution in question. It has been decided
that the first Preliminary Examination for the Mentally Deficient Certificate be
held in November, 1918.

A Sub-Committee also has been appointed to inquire into and report upon the
present position of the course of training and examination for candidates for the
N ursing Certificate.

There have been no entries for the Professional Certificate Examination. One
candidate entered for the Gaskell Prize, but eventually withdrew.

Two essays have been sent in for the Divisional Prizes.

Maurice Craig, Chairman.

J. G. Porter Phillips, Secretary.

Report of the Parliamentary Committee.

The Acting General Secretary read the annual report of the Parliamentary
Committee as follows:

Your Committee has met four times during the year.

Many subjects have received careful consideration and attention. Among these
may be mentioned the proposed Ministry of Health, which has been discussed, and
at the instance of your Committee the Council has nominated a Special Committee
to watch the interests of the Association in this matter.

With regard to the question of lunacy legislation, a Sub-Committee has been
appointed for England and Wales. Many meetings have been held, and have
been well attended, and the stage of considering a draft report has been reached.
It may, however, be said that the Sub-Committee has decided to confine its con¬
sideration to what seems to be the most promising matter, viz., the advisability of
securing such modification in the Lunacy Laws as will render possible efficient
treatment for cases of mental disorder at an early stage. Sub-Committees for
Scotland and Ireland have also been formed to deal with the requirements peculiar
to each country. It is the intention of your Committee that these Sub-Committees
should exchange useful information, and in the event of any question involving the
three countries that they should co-operate.

Correspondence has taken place with the Home Office, urging the view of the
Committee that criminal lunatics convicted on more than two occasions should
not be sent to County and Borough Asylums.

Your Committee has been in communication with the Board of Control with
reference to the jurisdiction of magistrates in connection with the licensing of
private asylums.

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i 9 i8 .]

NOTES AND NEWS.

395

Report of Library Committee.

The Acting General Secretary read the report of the Library Committee as
follows:

The Library has been fairly well used for purposes of' reference, and about the
usual number of books have been issued for home reading. Many members on
military service have taken advantage of borrowing books when they have been
on duty in hospitals and camps in this country.

The periodicals have only come to hand very erratically, and some of the foreign
ones have been lost in transit.

The Association is indebted to the family of the late Dr. Hayes Newington for
a handsome donation of about fifty volumes, and to Dr. Henry Rayner for about
thirty volumes. Dr. T. B. Hyslop has also made numerous presentations.

Henry Rayner, Chairman.

R. H. Steen, Secretary.

There were no reports from Special Committees.

On the motion of the Acting Secretary, it was agreed to allow the expenditure
of a sum of £25 on the Library.

Dates for the Various Meetings for the Year.

The following dates were fixed for the Annual, Quarterly, and Divisional
Meetings of the Association and Quarterly Meetings of the Council:

Tuesday, November 26th, 1918; Thursday, February 20th, 1919; Tuesday,
May 20th, 1919.

South-Eastern Division—Left to the discretion of the Divisional Secretary.
Northern and Midland Division—October, 1918; April, 1919, at the Mental
Hospital, Middlesbrough. South-Western Division—October 25th, 1918; April
25th, 1919. Scottish Division—November 15th, 1918; March 14th, 1919. Irish
Division—November 7th, 1918; April 3rd, 1919; July 3rd, 1919.

The President : We now come to item No. 7, the election of honorary members
of the Association. I have to propose Sir Marriott Cooke, K.B.E., M.B.,
Chairman of the Board of Control.

Dr. Soutar: I have very great pleasure in submitting to this meeting the
proposal that has come up from the Nominations Committee and the Council,
that Sir Marriott Cooke be elected an honorary member of the Association. As
you know, this is an honour which is not lightly given. In fact it is very jealously
guarded. In the case of Sir Marriott Cooke, however, there can be no doubt as
to the rightness of the conferring of this honour upon him. Those of us in
England, probably, have had better opportunities than many who are present this
afternoon of knowing the worth of that gentleman. His career from the beginning
up to the present time has been one of extraordinary success and the result of
very fine work. He was elected to the junior staff of the Powick Asylum soon
after he left King's. Within three years he was appointed superintendent of Wilts
Asylum, and then after four years he was called back to Powick, where he remained
for many years, doing excellent work. He took a very great interest in the work
of this Association, and several of his papers have appeared in our Journal. In
1898 he was appointed a Commissioner in Lunacy. This was continued in 1913
with the Board of Control. In 1916, on the resignation of Sir William Byrne, he
became and is now Chairman of the Board of Control. In that position he has
done very great work, work that will live in the history of our Association and in
the history of the Lunacy Department generally. You will remember that when
there was a great call in the country for accommodation for our sick and wounded
soldiers, Sir Marriott Cooke and others of his colleagues met the superintendents
of the asylums and consulted with them. It was one of those instances where we
felt that nothing was to be thrown upon us, but we were consulted and asked
about it, and that we appreciated very, very highly. From that moment until now
this great work has been carried out by a courteous and thoughtful co-operation
between those who require asylums and those who are in a position to grant them.
Again and again it has been acknowledged by the Board of Control and by Sir
Marriott Cooke that if it had not been for the co-operation on the part of the

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NOTES AND NEWS.

[Oct.,

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asylum authorities and the asylum staffs, the work that has been effected and has
been so valuable could never have been carried out. That is how Sir Marriott
Cooke and others have effected this very great work which has resulted in sixteen
of the asylums of England being converted into military hospitals in which over
300,000 sick and wounded soldiers have been treated. I need not say anything
more, because 1 think I have indicated sufficient to show that we are to-day
desiring to honour a man who from the beginning of his career up to the present
time has done most excellent service, and has brought distinction, not only upon
himself, but upon our specialty too. I have very'much pleasure in submitting Sir
Marriott Cooke’s name as an honorary member of this Association. (Applause.)

The President : The next name on our Agenda is that of Dr. William Bevan-
Lewis, M.Sc., M.R.C.S., L.R.C.P., late Medical Director of the West Riding
Asylum, Wakefield, late Professor of Mental Diseases, University of Leeds.

Dr. Bedford Pierce : Mr. President, Ladies, and Gentlemen, I do not think
there is any living man in this country or in any other country who more deserves
honour at the hands of this Association than Dr. William Bevan-Lewis. Dr.
Bevan-Lewis is a highly distinguished man, and is a pioneer in many departments
of medicine. When we think of the early work that he did in connection with the
anatomy of the brain, the histological work that he did in regard to the varying
features of the cortex, the extraordinary clinical work which is recorded in his
Text-Book of Mental Diseases, which for many years will be dug into, and in which
we will find many jewels which some of us are not altogether aware of, when we
also think of the extraordinary influence he had on young men in his laboratory at
Wakefield, where he touched with his wand of enthusiasm so many, and had such
a wide influence in educating and bringing forward so many persons who have
since become prominent—when we think of all these things we shall be agreed
that Dr. Bevan-Lewis should become an honorary member of this Association.
He received one of the earliest honorary degrees at the University of Leeds. I had
the pleasure of being present when he received it, and it is, therefore, also a pleasure
to me to speak a word for him in this room. 1 think that future historians will
find that Dr. Bevan-Lewis has been first in many discoveries which other people
may have appropriated later on. His singular humility perhaps may have stood in
his way, in a sense, of attaining perhaps the full fruits which he really deserves;
but, nevertheless, I think medicine will count Dr. Bevan-Lewis among the truly
great men. 1 am very pleased to support this proposal that Dr. Bevan-Lewis
become an honorary member of this Association. (Applause.)

The President: In No. 8 on the Agenda you will find the three following
gentlemen are proposed for election as ordinary members: Dr. Cedric William
Bower, Dr. A. Edward Evans, and Dr. Francis Sutherland.

The five gentlemen, after ballot, were duly elected.

Dr. Oswald : The great honour has been done me of asking me to put the next
resolution before you—namely, a vote of thanks to the President and Officers of
the Association. This is a resolution which I can put before you with the utmost
confidence, being satisfied that it will be unanimously carried. Those of us who
were present at the induction of Col., then Dr., Thomson, in Norwich in 1914
predicted that his term of office would be a most brilliant one. None of us, alas,
predicted its duration ! Now, at the end of four years of strenuous work, it comes
to an end, and we wish to express to him our thanks for the work he has done,
for the unceasing labour and the great amount of time which he has given to it.
He has not done his work in merely a routine way; he has given of his time and
of his labour when otherwise he was very fully occupied. He has attended the
meetings of the divisions, as well as the meetings in London. Jealous as the
Association naturally is on whom it bestows his highest honour, it must feel to-day
that in the election of Dr. Thomson at that time it did not only honour to him, but
nonour to itself and to every individual member of the Association. 1 am sure it is,
vour wish that we should convey to Col. Thomson our thanks for the work he has
done, for the great amount of time he has given to the work of the Association, for
the painstaking way in which he has presided at all its meetings, and for the utmost
fairness he has shown to everyone, not only at the meetings of the Association,
but at the meetings of Council and other meetings over which he has presided
(Applause.) The resolution which I have to propose is : “ That a vote of thanks
be given to the President and to the Officers of the Association." I feel that to

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397

1918 .]

those who know Col. Thomson better than I do it is presumptuous for me to say
so much. I recall, of course, that he is a brilliant student of the University of
Edinburgh, and, unlike many Scotsmen who have crossed the border and have not
returned, he has come back now. He took up office in Norwich, and it is now
peculiarly appropriate that he should demit office in his own romantic town of
Edinburgh. The others to whom we wish to give our thanks are the Treasurer,
the Editors of the Journal, the General Secretary, and the Registrar, and perhaps
you will allow me to say a single word about each. I suppose I may consider
myself as belonging to the seniors of the Association. For many years I looked
up to the late Treasurer as a man of the highest honour and probity, and as one
whose guidance was to me of the greatest value. The Association cannot do much
more than deplore the fact that since it met in London in 1917 there has passed
from our ranks one who had the respect and the personal affection of every man
with whom he came in contact. The Council’s report has referred to the loss that
has been sustained. Its expression was a peculiarly happy one, that in the last
year it has lost some of its pillars. Fortunately, other pillars take their place, and
1 think that those of us who heard the report of Dr. Chambers to-day, those of
us who heard at the Council meeting his terse and explicit statement of the affairs
of the Association, believe that in him we have one who will be as careful of the
whole affairs of the Association, as jealous of its honour, and as careful of its
finances as was the late Dr. Newington, whose death we so much deplore. The
Editors of the Journal—and I would ask yon to consider along with them the sub¬
editors—are also to be congratulated and to be thanked for the work they have
done in a very, very difficult time. 1 think Dr. Drapes is to be particularly con¬
gratulated on the fact that during very difficult times he has maintained the Journal
at a pitch of excellency regarding which he need have no regrets, and which will
make the last year compare favourably with any of the years that have gone
before. Dr. Lord also deserves the warm thanks of the Association, as do the
sub-editors, who have been very helpful in the work of production of the Journal
and keeping it up to its high standard. In Dr. Robert Hunter Steen, who has
been elected General Secretary of the Association, we have one who has already
proved his worth, he having, as it were, served an apprenticeship to the job.
Having proved his sterling worth and merit, he is now advanced to the full post of
General Secretary, which, I am sure, he will fill with honour and distinction to
himself and with the approval of all those he comes in contact with. As for Dr.
Miller, the Registrar, ever perennial and ever young, every year one sees him
he is more optimistic that he was the year before. 1 cannot say how warmly we
regard him or how much we feel that our thanks are due to him for the work that
he does; I think that even more, the whole of the mental nurses of Great Britain
ought to be specially grateful to Dr. Miller because they have in him a most
sympathetic friend, as was evidenced in the discussion to-day, one who is desirous
of giving them every chance, at the same time one who is most desirous of keeping
the certificate of the Association at such a pitch that it will be valued and regarded
highly, not only by the nurses themselves, but by all those whom they are called
upon to professionally attend. There is an old saying, ladies and gentleman, and
I would ask you to bear it in mind—I think it is by Shakespeare, but I am not quite
sure, “ Still be kind and eke out my imperfections with your mind.” I would
like those gentlemen whom you see before you not to take the measure of our
thanks by the poor eloquence of my words, but to believe that we are deeply and
sincerely grateful to them. We ask them to accept our very best thanks. If I
may close with a personal note it is this, that in coming in contact with the
President and with the office-bearers of the Association I have a constant sense
of encouragement: I never meet them but I feel stimulated and cheered and
encouraged when I think of the fact that in addition to their own work, which
during the last year must have been of the most trying nature, they have given of
their time so freely to work which we appreciate so highly. I have great pleasure
in moving that we give our thanks, our very sincere and hearty thanks, to the
President and to the other Officers of the Association, and to tell them that jealous
as the Association is of the qualities of mind and heart which those who fill its
offices must have, we acknowledge that we have in them men in every way fitted
for the positions which they have held during their term of office. (Applause.)

Dr. Bower : I have been asked to second this proposal, a duty which I gladly

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398

NOTES AND NEWS.

[Oct.,

perform. After what we have heard from Dr. Oswald with regard to Col. Thomson
and the officers of the Association there is very little left for me to say. I saw
Dr. Thomson, as he was then, put in the chair of this Association in Norwich, the
highest honour that we can confer on any of our members, and we ail know that
he has thoroughly deserved it. With regard to the other officers, I need say
nothing more after what Dr. Oswald has said, and I simply second the motion
and put it to the meeting. (Agreed.)

The President : Custom has it that I should reply to the vote of thanks which
you have kindly accorded to myself and to my fellow-officers of this Association.
1 cannot in the least aspire to the extremely eloquent and kind way in which
Dr. Oswald has proposed it, but I thank you very sincerely on my own behalf and
on behalf of my fellow-officers. Appreciation of work done is the highest and best
reward that follows service for one’s fellows. I should just like to add a personal
note. To-morrow week it is forty years since I left my University here, armed
with the magical key to practice, the M.B. of the University. I little thought
when I left here as a graduate that I should ever attain the honour of presiding in
these august halls of the Royal College of Physicians in Edinburgh as the President
of a learned Society. It is a great honour, and I feel it very much. That I may
have given satisfaction to you is, I hope, possible, but I certainly have not given
satisfaction to myself. I had hoped when 1 became President, when we were all
living in a kind of fool's paradise in July, 1914, that I would have the pleasure of
going round and visiting all the Divisional Meetings—a very good example set by
a former President—but that pleasure, of course, has been denied me. I looked
forward to the great many social delights and intercourse that one would have had
■in the course of a year’s presidency with the Council and other members of the
Association, but all one’s years of office have been shorn of these pleasures; and
so, beyond merely attending every meeting possible in London, which is only a
few hours from my own home, and attending the meetings of Committees, and
doing the best I could to advance things which had to be attended to in spite of
the war, and to hold the balance between various contending interests, I have not
come up to my own standard of what the President of this Association should be.
Still, I have done my best, and it is very good and kind of you to accept that best.
A President, however excellent and well-intentioned he might be, would be helpless
without his officers. Dr. Steen has been my right hand. He keeps me right, as
you have seen to-day. He is perhaps rather more severe in Committee than he is
here. You are well aware of his labours, but I do not think you are so well aware
as his fellow-officers are of the immense amount of work he puts in. Most of us
have been secretaries of one kind and another, and we all know the great amount
of detail that one has to attend to. I am more than delighted that Dr. Steen has
taken on the mantle of Dr. Collins and of another predecessor of his whom we
welcome here to-day, Dr. Bond, of the Board of Control. Dr. Chambers is a most
admirable Treasurer, and we look for wise and sound advice from him in succession
to Dr. Newington, perhaps more than we could expect from any other member of
the Association. The same applies, to a lesser degree perhaps, to the other officers
of the Association. Now, we want to get on to the principal business of the
afternoon. After again thanking Dr. Oswald for proposing, and Dr. Bower for
seconding, and you for recording this vote of thanks, I will proceed to introduce
to you my successor. I do not know that this is the place, or even the time, to
tell you about Col. Keay. It is not necessary—you know him. He is here on his
own native heath—at least, that is a mistake, as I think he was born in Ireland—
but, at all events, he is here among his colleagues, who know him better than I can
tell you. We all know of his professional career—first at the Crichton, one of the
great royal asylums of Scotland, and then at Mavisbank, here at Edinburgh, and
at Inverness, and now in his present great post at Bangour. I have made repeated
visits to Bangour, and I am afraid my staff must be perfectly sick of the name of
Bangour. I am always quoting Bangour to them, and I look on it as a place
converted into a war hospital which is an example to any other institutions of the
kind. I may mention that I gave Dr. Keay a few of his first lessons, but he has
far passed his master now. He has developed and is in charge of a war hospital
such as there are few in any other part of the country. With these few words I
introduce Col. Keay to you as my successor, and I invest him with the insignia of
office. (Applause.)

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At this stage Lieut.-Col. John Keay took the chair as President.

The President: Let my first act be to thank you most sincerely for your
kindnesss, and to assure my old friend, Dr. Thomson, that the pleasure and the
honour of which I am the recipient through your kindness are enhanced very much
by the fact that I have received this badge of office at his hand. (Applause.) The
first duty of a President is to present prizes and medals. I have much pleasure in
announcing that a Divisional Prize has been awarded to Dr. Hubert J. Norman,
who unfortunately is unable to be present to receive it. There are no other prizes
or medals to be presented. That clears the way to another duty which unfortu nately
the President has to perform, and that is to deliver a presidential address.
(Lieut.-Col. Keay then delivered his presidential address.)

Dr. Carlyle Johnston : I have been asked to move a vote of thanks to the
President for his address. I am rather sorry that one of the older members of
the Association has not been chosen for this important duty. 1 rather think I am
one of the most junior of the medical officers present. However, in spite of that
objection, I consider it not only an honour but a pleasure to be asked to move this
vote of thanks, because I think that probably I have known Dr. Keay about as long
as anyone here. It is not for me at this particular time, or in this place, to say
anything nice about Dr. Keay—he has already heard some nice things said about
him, and he will hear more before we are done with him—still I should like to say
how much it pleases me, and how much it pleases all my old friends in Scotland
particularly, to see Col. Keay in the chair to-day. Col. Keay, among his other
qualities, good or bad, has one which is very marked, and that is the quality of
self-suppression and withdrawal from the public eye. It is very likely that to
several persons here Col. Keay maybe an unfamiliar figure and his reputation to a
certain extent may be unknown, but it is certainly not unknown in Scotland. I
should like to say that Col. Keay has gained the affection as well as the respect
of every one of his brothers in the specialty in Scotland, and we rejoice to see him
in the position he occupies to-day. We have no doubt that he will be an ornament
to the chair that he occupies. With regard to the presidential address, it has not
been the custom to criticise it, and I do not propose to break that rule nor to make
a long speech, but one cannot sit down without saying something. We have all
enjoyed the address very much. Those of us who know Col. Keay expected to
hear what we have heard—that is to say, an extremely level-headed moderate
speech, a speech dealing with serious topics in a serious way, but not by any
means in a pessimistic way, because Col. Keay, beginning as he began with the
gaiety of the Irishman, and proceeding with the seriousness of the Scotsman
ended with that same note of cheerfulness with which he began, with that hopeful
outlook which has actuated Dr. Keay in all his work. It is scarcely necessary to
go over the different points in the address, because it is a paper that one wants
to study closely. He has dealt with the very serious problems that the war has
brought before us, and, being a Scotsman, he has not attempted to solve these
problems, but it is necessary that we should all think about them, and we shall all
have to think about them. There is no doubt that our financial future will give
very great concern to the younger members of the Association and to their children.
Dr. Keay has referred to and has touched with a firm and discriminating hand the
many social problems that are bound to arise and to interest, not only us here, but
all our fellow-citizens. I only refer to one or two of them. He spoke of the
results of those horrible experiences which many people have suffered from this
war being handed down to their children. Of course, that raises the question
whether such experiences are ever transmitted. It is a good old-fashioned belief
that they are transmitted. While it may be that these horrible experiences will be
handed down, there is also the tradition of the great deeds that have been done in
this country, the noble example of our brothers, our fathers, and our children, and
that will more than obliterate any evil that may arise from the horrors and dreadful
mental experiences that so many of our people have suffered, not so much in this
country as across the Channel. Then passing over practically all the other points
and coming to the end, Col. Keay, in dealing with the question of prevention of
insanity, touched upon what has always seemed to me to be perhaps the most
important practical problem of all, and one which will have to be taken up in a
practical way by our Statesmen in the future. With regard to the treatment of
insanity he also had very many interesting things to say. I think that though he

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only referred to it in a sort of side note, what he said about the treatment, if it
was not very tragic, would be very comic—that we are not allowed to treat an
insane man until there is no hope of doing any good. That has been said before,
and it cannot be said too often. We may hope to get over that when the war is
over. Now, I am afraid I am doing what I said 1 was not going to do, and that is
making a speech. I would only ask you to accord to Col. Keay a very hearty vote
of thanks for his extremely excellent and able address. (Applause.)

Dr. Nolan : I wish to second this vote of thanks to Col. Keay. I am sure you
have all listened, as certainly I have, with the greatest appreciation to his address
on the " Psychology of the War and the Problems arising out of it.” It needs no
words of mine to accentuate your vote of thanks to our President for his extremely
interesting address. (Applause.)

The President: Dr. Carlyle Johnston, Dr. Nolan, Ladies, and Gentlemen,—
I thank you very much for the patient way in which you have listened to me, and
the kind way in which you have received my address. We have two papers to be
read this afternoon, one by Dr. Ford Robertson and one by Dr. Fothergill.
Dr. Robertson has asked me to call on Dr. Fothergill first, because Dr. Fothergill’s
paper was postponed from the quarterly meeting in May. I therefore have very-
much pleasure in asking Dr. Fothergill to read his paper.

Dr. Fothergill and Dr. Ford Robertson having read their papers, the proceedings
were adjourned till the next day.

Wednesday, July 24TH, 1918.

On Wednesday, July 24th, the meeting reassembled at the Edinburgh War
Hospital, known in pre-war days as Bangour Village Asylum, and now a military-
hospital of 3,000 beds. In the forenoon the members and guests were conducted
by the President over portions of the Hospital, and inspected with much interest
the Orthopaedic Section, with its Manual Curative Workshops, its Massage
Department, and its installation of Baths. The Marquee Camp, an extension of
1,000 beds under canvas, was also visited.

During the interval the members and a number of their lady friends were enter¬
tained at luncheon, to which they had been kindly invited by Col. and Mrs. Keay.

In the afternoon interesting demonstrations were given by members of the
visiting staff of the Hospital, and before beginning these the President reminded
members that on the previous day they had been the guests of the Royal College
of Physicians of Edinburgh. He moved that the thanks of the Association be
expressed to the President and Fellows of the College for their kindness and hospi¬
tality, and the motion was cordially agreed to.

The demonstrations were then proceeded with, and there was in the first place a
microscopic demonstration on malaria and dysentery by Major D. G. Marshall,
I.M.S., Consultant in Malaria, Scottish Command, and Dr. Laura K. Davies,
Medical Officer in Charge of the malaria wards at Bangour.

One series of slides showed the malarial parasite at all stages of growth, and
another the differences between benign, tertian, quartan, and aestivo-autumnal
parasites. A display of mosquitoes attracted much attention.

Of special interest to the members were sections showing the changes in the
brain in “ cerebral” malaria and sleeping-sickness.

Under another set of microscopes the organisms of bacillary, amoebic, and
flagellate dysentery were shown, including sections of intestines and liver, in
which the destructive changes due to the Entamoeba histolytica were clearly-
demonstrated.

Lieut.-Col. Sir Harold Stiles, R.A.M.C., Assistant Inspector of Military Ortho¬
paedics, then demonstrated some cases from his department. He said: I am
going to show you just a few cases which I hope will illustrate to you the kind of
work we are doing in the Orthopaedic Department of this hospital. I do not wish
to take any credit for this work at all; the credit should be given to the C.O. of
the hospital and my able assistants, who have so willingly and so loyally assisted
me in the work. I am in rather a peculiar position. 1 happen to be a general
surgeon, and I am responsible for the orthopaedic work in this hospital. I would
like to pay tribute to my assistants for the very able assistance they have given

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me. I think the ideal Orthopaedic Department is one that combines the efforts
of a general surgeon with those of an orthopaedic specialist who has been
trained to this work, and has been specially trained to the after-treatment
of the cases. There is one very important difference to my mind between
orthopaedic surgery and general surgery—and when I refer to general surgery, I
refer more particularly to that department of it which is known as abdominal
surgery, which is a very fascinating branch of surgery, and has, I think, been rather
responsible for detracting the general surgeon from the problems that we have to
deal with in orthopaedic surgery. The general surgeon does some very dangerous
and important operation: he shuts up the abdomen and Nature does the rest.
Why ? Because he is dealing almost entirely with involuntary muscles, and
when he has done his work there is practically nothing more to do. Now, when
the orthopaedic surgeon has performed his operation, he has done only half of his
work. The other half consists in the after-treatment, which is very often a tedious
and laborious business, requiring a great deal of conscientious intensive work.

The first case 1 am going to show you is not orthopaedic, but is a nervous case,
and that is the reason I am showing it. This man got a piece of shrapnel inside
his skull in the month of April. He was taken to the casualty clearing station and
was X-rayed, and a fragment was discovered inside the skull. An opening was
made in front, but the fragment was not found, and very wisely no further or more
persistent attempt was made at that time. He eventually arrived at this hospital.
He had no paralysis, but had a very serious symptom in the shape of a persistent
headache. I found no eye symptoms and no other symptoms except the headache.

1 got Capt. Bramwell to see him, and we both agreed we would see whether there
was any chance if the headaches would improve. They did not improve, and the
patient begged me to do another operation. The first thing was to localise the piece
of shrapnel—it was a cubical piece, about the size of an ordinary die. It was
localised as being nearly two inches from immediately behind the ear. Before I
attempted the operation 1 said to Major Rankine, who has charge of the X-ray
Department, “ It is all very well to tell me it is two inches from the ear, but I
would like to control that experiment, and 1 would like to know exactly how far it
is from a corresponding point on the opposite side of the head, and you will kindly
X-ray him over again.” 1 got a report showing that it was just four centimetres
from this side and ten centimetres from a corresponding point on the other side.
We then got a skull and bored a hole on the corresponding point of entrance and
on the corresponding point on the other side, and we got a string and stretched it
through. (Explained on skull.) We got the foreign body in almost the same
position as it was X-rayed before. I said, “ The next thing I want to do is to
measure the man’s head with a pair of calipers from these two points. If the
localisation was correct, then the calipers should give a measurement of fourteen
centimetres”—and that is exactly what it did. Then I said, “ I am quite willing
to go on.” The flap was turned down and the base of the brain was lifted up.
After some little difficulty we found the foreign body between the base of the brain
and the skull adhering to the membranes, and I was able to hook it out. That was
done about three weeks ago. If you ask the man how he is now, he says that he
is all right, that he has no headache except a little at night. Following the
operation, the man could not quite lift his foot—foot-drop—but now he can ,
lift the foot. The|hand dropped a little—there was slight paralysis of the hand,
but he can now move his hand and fingers. It is only three weeks since the
operation. The paralysis is rapidly disappearing, and I am sure it will be all right.

The next case. This man was wounded last year—an extensive shrapnel wound
which lacerated the median nerve in the upper half of the forearm. It was so
extensively destroyed that we could not get the ends together. Now, I want to
show you what the result is of paralysis of the muscles in the hand which are
supplied by the median nerve. The man bends his wrist perfectly well, and he
bends his thumb and the fingers; so he has only paralysis below where he was
injured. These muscles include two and a half muscles of the thumb, what we
call the abductor of the thumb, the opponens, and one half of the short flexor.
Now, first let me show you what kind of disability the paralysis of these muscles
produces. What is the function of these two and a half muscles? The main
function is to oppose the thumb to the other fingers, and to help to produce a pincer
action between the fingers and the thumb. That is what these muscles do along

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with the long flexors. We will ask this man to do this. You will see he is not
efficiently opposing the pulp of the forefinger and the thumb. Next, let us ask
how powerful are his attempts. We can test that at once. If I take a card in
my hand and grip it firmly, thus, I am flexing my forefinger and I am flexing my
thumb. Now, you will see this man cannot grip the card in the same way, try
all he can. He can write, but only with a very large pencil. This case demonstrates
that you cannot write properly unless you have the small muscles which are
supplied by the median nerve. Now, why? The median nerve does not only-
supply these two and a half muscles; it supplies two other muscles, the outer
two lumbricals. This case illustrates the importance of these lumbrical muscles.
When you have not that muscle you find that when the flexor tries to bend
the finger there is nothing to resist it. The flexor muscles will never contract
powerfully unless you have extensor muscles to resist them; and, therefore,
when we close our hand like that, and bring our flexor muscles into action—if you
look on the back of my arm you see these muscles. (Shows.) The object of the
lumbrical muscle is in part to give sufficient resistance to the flexor muscle. Now,
he has the interosseous muscle—it is not paralysed, but it shows you that the
lumbrical muscle helps the interosseous muscle, and, if he has not it, he has not
enough resistance to allow him to grip. So it produces a distinct disability, and
that is why, in spite of these muscles alone being involved, it is important in these
cases. There is one other point I want to show you. This man has loss of
sensation in the outer two fingers. You will see what happens when he tries to
button his coat. He can bend his finger and his thumb perfectly well, but he
cannot button his coat. The explanation of that is that he cannot feel the button,
and he does not know when he is grasping it properly.

The next case is a man whose ulnar nerve was shot through, which is rather the
more important muscle nerve as regards the intrinsic muscles of the hand. He is
shown to demonstrate what disability is produced by paralysis of the muscles of the
hand supplied by the ulnar nerve. We shall find that the superficial muscles of
the thumb are present—that is to say, he can oppose the thumb and the fingers—the
pincer action ; he can grip firmly. Now, if you ask him to grip like this, between
the thumb and the palm, he cannot grip firmly; so he has lost the muscles which
allow the thumb to press against the palm in this position which I show you. The
ulnar nerve supplies all the interosseous muscles. When this man was first
wounded he had only the lumbrical, and he had not the interosseous muscle, but
the condition is improved, because, although he has lost his interosseous muscle,
he has developed his lumbrical muscle by exercise. You see a long scar here.
The reason for that is that he had a large part of the ulnar nerve destroyed. The
ulnar nerve runs along here (shows), and so when you bend the elbow you put it
on the stretch, and when you straighten it you tend to relax it, so it is obvious
that when you have taken a bit out of the ulnar nerve you must not flex the elbow.
That creates a difficulty in bringing the ends of the nerve together. You must,
therefore, in order to get the ends together, transpose the nerve, and so we dissect
the nerve here (explains) and transpose it to the front of the elbow. The result
is, if we do that, we can take away two and a half inches of the ulnar nerve and
stili get the ends together. That was done in October last.

Next case. This man had a not uncommon wound. As he was marching along
he got a bullet through his upper arm from front to back—the median and ulnar
nerves were both cut and were subsequently sutured. He has not yet entirely
recovered. Now, I want to show you the disability which he has from both nerves
being involved. His median nerve has partly recovered—it is recovering better
and quicker that the other one. You will observe that he is able to bend his fore¬
finger and thumb, proving that the supply has already reached these long muscles
of the forearm, but it has not yet reached the small muscles of the hand. The result
is that this man has paralysis of all the intrinsic muscles of the hand. I have shown
you paralysis of the median and the ulnar separately, and I will now show you the
two combined. Although he has the long flexor muscles we will ask him to
convert the forefinger and the thumb into a pair of pincers; he cannot do it. He
cannot bring the point of his index finger and the thumb into opposition. He rolls
up the index finger. Why is that so ? Because he has paralysis both of the
lumbrical and interosseous muscles; both these muscles are paralysed. The
function of these two muscles is to keep these two joints partly extended and to

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act in opposition to the flexor. If there is no opposition to the flexor, then it
folds up the finger, and the finger never reaches the point of the thumb.

Next case. This man has the median nerve injured here. (Showing.) He has
not complete paralysis; he can bend the thumb and the forefinger. He has irritation
of the sensory fibres and neuralgia in the palm of the hand. We must operate.

Next man. This man was lying in bed underneath an open window, and he
developed paralysis of one muscle, the muscle which should keep the scapula in
position and fix it to the chest wall. What is the cause of that paralysis ? Why
should the one muscle be paralysed ? The answer is an anatomical one. It is
generally said that it is due to rheumatism, but it is very difficult to see how
rheumatism should attack one nerve only, and, therefore, we want to know its
anatomy. It is peculiar. It has three roots. These three roots are slender, and
all three little roots have to traverse a very thick, strong muscle in the neck
before they join, and this muscle is the scalenus medius. It was an inflammation
of that muscle which pressed on the roots of the nerves to that muscle. I saw the
other day a lady who said she had been doing farm work ; she had been carrying
the water and turnips. How was that paralysis produced? That is one of the
muscles which helps to keep up the chest wall. There was a drag upon that
muscle, and it was the drag on that muscle that overstretched the three little roots.

Next case. Here is a man who was shot through the neck and the spinal acces¬
sory nerve was severed. Get him to lift up his shoulder. You will see he has great
difficulty in doing so. It is difficult for him to do any work which entails any
sustained elevation of the shoulder.

Next case. I am now going to talk about the musculo-spiral nerve. This nerve
extends the wrist and extends the fingers. This man was injured in the upper arm.
We had great difficulty in getting the ends together, but we found that if he could
bend the elbow we could then get the ends together. Seven days ago we took a
large piece out, and we were able to get the ends together.

Next case. Supposing we could not get the ends of the nerve together, what
would happen ? Some of you have seen soldiers going about with their hands
dangling. This man has had a very severe injury to his upper arm, destroying a
long section of the musculo-spiral nerve. What we have done in this case is to
transplant some of the muscles which are supplied by the median and ulnar nerves
from the front of the arm and from the front of the wrist to the back of the wrist.
Briefly, the pronator radii teres is transplanted into the extensors carpi radialis
longior and brevior; the flexor carpi radialis into the extensors ossis metacarpi
poilicis and brevis pollicis; the paimaris longus into the extensor longus pollicis,
and the flexor carpi ulnaris into the extensors of the fingers. So we have restored
every one of the paralysed muscles to this man’s hand. The man can write
perfectly well.

Next case. Here is a man who had a drop-foot. The drop-foot may be
produced by a wound of his great sciatic nerve. If it is the external division
of the great sciatic nerve, it is only the muscles which lift up the foot that are
paralysed ; if it is the internal, then it is the muscles which plantar flex the foot. In
this case there was an extensive wound involving the external nerve—the nerve which
lifts the foot. That nerve could not be sutured. In a case like this you must do one
of two things. As a rule, you supply the man with a boot which prevents the foot
dropping. You can do away with that apparatus, however, if the man will submit
to an operation, and the operation is to sling the foot. We take the paralysed
extensor muscles and fix them into the bone of the leg, as I show you. The result
is that this man will be able to walk about perfectly well without any apparatus.

Next case. Here is a man with such an apparatus. He has to wear an iron or
something of that sort.

Next case. Here is a man who cannot lift his foot up because the muscles have
been destroyed. We shall do the same thing with him—we shall-sling that foot.

Next case. Here is a serious sort of a case. The man has been shot right
through the shoulder, and he came in with a dangling arm. What is done in such
a case is to open up the wound after it is completely healed, free the end of
the bone, take away all the scar tissue, and jam the two bones together. The
secret of that is the after-treatment, and here is where my orthopxdic friends come
in. Immediately you have done the operation you must put the whole chest and
arm in plaster-of-Paris.

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The President : I am sure we are all very much indebted to Sir Harold Stiles
for the exceedingly interesting demonstration which he has given. (Applause.)

I now call on Capt. Edwin Bramwell, who will show certain cases illustrating
functional neuroses.

Capt. Bramwell said he would confine himself to the examination of a case
which had just been admitted to the Orlhopaidic Department, which he had not
yet examined, and in which the diagnosis did not appear to be quite obvious. In
this way he would have the opportunity of referring very briefly to problems of
diagnosis and treatment as they arose. The patient was then demonstrated. The
man was paraplegic, and it was ascertained that the paralysis, which was of some
months’ duration, dated from a shell explosion, in consequence of which he had
been buried. The paralysis was found to be complete, with the exception of some
flickering movements of the toes of one foot. The absence of muscular wasting
and rigidity was referred to. The facts that the knee- and ankle-jerks were
present, equal and somewhat hyperactive, that there was no ankle-clonus, that
the signs of Babinski, Gordon, and Oppenheim were negative, were noted and
commented upon. A symmetrical sensory loss of the stocking type affecting
both lower extremities to about the level of the knees, and a pronounced defect of
the sense of position in the lower limbs were demonstrated. It was ascertained
that there was no trouble with the sphincters, although for some time after the
accident there had been retention, unaccompanied, however, at any period by
incontinence of urine. The conclusion was arrived at that not only were there no
signs of organic disease, but that certain indications present clearly pointed to the
functional origin of the paraplegia. The question arose, Will an X-ray photo¬
graph of the spine afford additional help in connection with diagnosis ? The
spine had been already X-rayed, but the demonstrator remarked that he did not
wish to see the photograph, for he was quite satisfied as to the diagnosis. Even
granting that the X-rays showed evidence of a fracture, this would in no way
affect his opinion either as regards the nature of the case or the prospect of
recovery.

X-rays are sometimes dangerous. Capt. Bramwell referred in this connection
to the case of an officer whom he had recently been asked to see, and who was
suffering from a paraplegia of two years’ duration, which was, beyond question, of
functional origin. In this case an X-ray had been taken, and the photograph,
which was a very beautiful one, showed a perfectly definite fracture of the lamina of
the fifth lumbar vertebra on one side. The patient had been told that he had fractured
his spine, and by his bedside lay the photograph which he produced in proof of
this perfectly correct assertion. The fracture was not, however, the cause of the
paralysis. Previous opinions expressed to the patient and his relatives had made
such an impression that nothing would convince them that the fracture and para¬
plegia were not related as cause and effect. A distinguished neurologist under
whose care the patient had previously been for a short time, and who had not
insisted on an X-ray examination, was the subject of unjustifiable censure, whereas
the physician who had had the spine X-rayed and diagnosed the fracture had
apparently been the recipient of much kudos, since to him was attributed the
credit of ascertaining the true cause of the paralysis. On the other hand, it was
the very fact that an X-ray had been taken, together apparently with the failure
on the part of the consultants who subsequently saw the case to indicate the
absence of relationship between the fracture and the paralysis, which had been
responsible for the perpetuation of the latter.

After this digression, the demonstrator turned to the patient and told him that
he was satisfied there was no actual injury to the spinal cord or nerves, and that
he could promise him that he would completely recover. How, then, was this to
be achieved in the present case ? In the first place there was to be no question of
mystery. Experience of similar cases justified the assertion as to the diagnosis,
and the patient w r as told that, in popular language, he had actually forgotten how
to move his muscles, and that he required to be shown how to do so—in other
words, he must be re-educated. There was a widespread impression among the
laity that these cases were cured by electricity and massage ; this was an entire
misconception. The electrical current was undoubtedly often of great value in
demonstrating to the patient that the muscles had not lost their ability to contract,
but it was the suggestion and persuasion employed by the operator, and not the

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•electricity, that brought about the cure. Certainty in diagnosis on the part of the
physician, and confidence from previous experience of his powers to convince
the patient, were two essential requisites for success.

A few remarks were then made regarding the value of isolation, and of the
mental atmosphere in the treatment of the functional neuroses.

Note .—There are certain matters to which it is inadvisable to refer before a
patient suffering from functional paralysis. An essential point in the prognosis of
these cases is the desire to get well. The soldier's will to recover is no doubt
■often modified by the fact that he may, when recovered, be returned to the fighting
line, by fears or doubts associated with the recollection of the experiences through
which he has passed, by thoughts of his family and home responsibilities, and
sometimes, it is true, by satisfaction with his too sympathetic attendants and too
comfortable surroundings. Appeals to his sense of duty and patriotism may be
quite unavailing. When the active desire to get well is absent, this may be brought
about by incentive. The rapidity with which improvement occurs in some cases,
\Vhen the soldier knows that he will not again be sent on active service, is often
remarkable. When the paralysis has persisted for long and the patient has obviously
no strong wish for recovery, Capt. Bramwell has sometimes obtained excellent results
by the following expedient: He tells the soldier that he knows he is anxious to
get well as soon as possible, as is only natural, and that he feels certain that he
will submit to any form of treatment which will bring about the desired result. He
then tells him that the state of his nervous system is such that he requires absolute
rest. He places him in bed behind curtains in a ward, admits no one to see him,
gives him milk as his only article of diet, allows him no letters and no tobacco.
This therapeutic procedure, in which a vis d tergo is adopted under the guise of
treatment, is often successful when other measures fail in inducing that wish for
recovery which is essential. As improvement occurs, the rigidity of the regime is
slackened. The method is particularly useful when there is reason for believing
that the patient is inclined to exaggerate his disability.

Then followed a demonstration on “ Provisional Peg Legs" by Lieut.-Col.
Cathcart, R.A.M.C., and Major Rankine.

Lieut.-Col. Cathcart explained that the supply of temporary or provisional
peg legs for soldiers who had lost a leg had only been introduced into British
hospitals since the war began, but that the value of these appliances was being
appreciated more and more every day.

The objects to be attained by their use are:

(1) To obviate the need of crutches, which, besides being cumbrous,
frequently cause musculo-spiral paralysis.

(2) To hasten the shrinkage of the stump, which takes place so rapidly
when an artificial limb is worn that the renewal of the bucket frequently
becomes necessary within a few months of the first fitting.

(3) To train the man in the use of an artificial substitute for his lost limb.

The requirements of such an appliance are that, besides being efficient, it should

be cheap, light, easily made, and quickly applied.

Many different forms of provisional peg leg have been advocated, and several
have been tried at Bangour with Major Rankine's assistance, but none have met
the requirements so well as the “ Belgian Pylon," the only pattern now employed
at this hospital. Major Rankine has entire charge of the supply of these peg legs,
and has introduced many minor improvements in detail of construction.

They consist of a light wooden frame-work, which any carpenter can make, with
a felt-lined bucket of plaster-of-Paris bandage incorporated with the frame-work.
Major Rankine finds that, after he has obtained the necessary materials and has
been able to train his assistants, the time required for an ordinary case is as
follows:

To make the frame-work about half an hour, and to adapt it to the stump
about half an hour. When the plaster has set the appliance is removed for drying.
Next day the man is able to use it, and walks off with the aid of a walking stick.

Major Rankine showed a number of soldiers who had just been supplied with
these provisional peg legs. In the case of very short stumps below the hip and
knee respectively, he explained what additional details were required, vie., a pelvic
band in the one case and steel or elastic supports to the knee in the other. He
pointed out how simply the plaster-of-Paris bandage lends itself to the accuracy of
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the fitting of the sockets, and to the adaptation of these extra pieces of mechanism,
without which such cases could not be fitted at all.

The success attained in this department of the working of the Edinburgh War
Hospital was much appreciated by those present.

In proposing a vote of thanks to the demonstrators, Dr. Bond said: “ Before we
go I should like to say there is one thought in our minds, and that is that we
would like to express our thanks to those who have given us these most interesting
demonstrations. They have been a revelation to a large number. We know the
amount of trouble that has been taken, and we want to express our thanks to those
who have organised the demonstrations, and to those who have been able to show
us so much."

This was seconded in appreciative terms by Lieut.-Col. W. R. Dawson,
R.A.M.C., and carried by acclamation.

Mrs. Keay's “At Home " pleasantly concluded the meeting.

CORRESPONDENCE.

To the Editors of the Journal of Mental Science.

Mv dear Sirs, —I happened to run across the article on “The Psychology of
Fear,” recently written by Sir Robert Armstrong-Jones, in the issue of the Journal
of Mental Science, of July, 1917. I am not a psychology professor or a professional
psycho-analyst, but I was so impressed with the article that I am compelled to
make a criticism of it.

I am glad to see Sir Robert take a step in advance of most psychologists in
maintaining the existence of a conflict of bodily reactions in the case of fear.
However, like others of his tribe, he still seems confused in his distinction between
instincts and emotions. He makes these two statements : “ The fear of solitude,
of being without protection, etc., are notable instances of inherited instincts;"
and " To some natures fear becomes a mental tonic, but perhaps other emotions
. . . help to create the motive for action."

He thus classes fear as both an instinct and an emotion. Possibly he, like
James, regards fear as an emotion only in its more complex stages, with no distinct
line of division between the two forms of reactions. He seems to assent to the
following order of events in the arising of consciousness, which I believe he credits
to MacDougall : (1) Perception of some “existing fact," (2) which sets up reflexly
some bodily disturbance, (3) which commotion is apprehended or realised. These
three phenomena are respectively stimulus, instinct, and emotion. Sir Robert
himself says that an instinct “ attended with a mental side is signified by the
term ‘emotion.’ ” It necessarily follows that instinctive and emotional reactions
do not overlap, but are entirely separate and distinct. The instinct is an unconscious,
inherited reaction, but when two or more assert themselves at the same time they
must necessarily clash, which results in the arising of consciousness (for the purpose
of consciousness is to co-ordinate these conflicting reactions) and the emotion.
All these bodily reactions are purposive, in the sense that they are teleological.

In the case of fear, we will find that the conflicting instincts are those of curiosity
and flight. There are an indefinite number of kinds of such reactions, depending
upon their intensity and general characteristics. The instinct of curiosity may be
one of inquisitiveness or wonder, and that of flight one of concealment, while the
emotion may be terror, fright, anger, timidness, or some other emotion akin to fear.

“ Although danger may be a cause of fear,” says Sir Robert, “ there are
many instances of strong and adventurous persons who long to meet danger in
order to conquer it.” Using the principles already outlined as a basis on which
to work, we cannot say that danger necessarily produces fear. There may be fear
without danger and danger without fear. There may be the gravest kind of
danger, but if either the instinct of curiosity or that of flight is not present, fear
will not be experienced.

When the miner lights the fuse for the blast the instinct of flight compels him
to run, but he is not frightened. The instinct of curiosity does not assert itself
because he is experienced, and knows when the explosion will take place and what
its force will be. If one is fully determined to face danger he may eliminate the
assertion of the flight instinct, and thus overcome fear. The experiences of big
game hunters bear out this statement. In the Outlook (New York) several years

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ago was portrayed a vivid description of the emotions experienced by a Montana
minister attacked by two famished mountain lions one cold winter morning.
While he was running his hair stood on end, and he trembled with fear, but when
he could control himself sufficiently to turn round and face the beasts he became
very calm, although all odds seemed against him. Through the sudden and
unexpected appearance of a freight train he lived to tell the story.

The overcoming of the flight instinct is seen clearly in the action of the soldiers
at the Front. Henri Barbusse, in describing a charge, says : “ We are now as men
possessed ; we have forgotten our fears, and all we want now is to meet the enemy
face to face; we are lusting for blood.” Sir Robert himself tells of a young
officer who, being overcome by a sudden fear, began to tremble, but by an effort of
will this passed off, otherwise his feeling was to get away from where he was. I
believe this illustration discloses one of the most important contributions to mental
science—the fact that the cure of fear lies in the will. The generally accepted
theory has been that expressed by Helen Williams Post : “ Fear, which is only
another name for ignorance, is all that ails us. Fear is hot a thing that one can
drop in obedience to the will ; it can only be overcome by an intelligent investi¬
gation that leads to a full understanding of it. That which we understand we no
longer fear. Understanding alone conquers fear."

However, in the case cited of the mountain lion attack, where all reason showed
torture and death to be imminent and certain, all the knowledge and understanding
in the world would have been of no avail. Will power, and not knowledge,
overcame this man's fear. Truth will make you free, but intellect will only hold
the links; it takes something else to strike the blow that breaks them.

Most respectfully yours,

F. LeRoy Spangler

3543, 10th Street, N.W.,

Washington, D.C., U.S.A.

August 1st, 1918.

To the Editors of the Journal of Mental Science.

Sirs, —I am obliged to you’ for the courtesy afforded me to read Mr. Le Roy
Spangler’s criticism of my paper upon the “ Psychology of Fear" in the Journal
of Mental Science last year.

He refers to a misapprehension in the use of the terms “ instinct ” and “ emo¬
tion,” which he himself appears to share, for he states that in fear " we find that
the conflicting instincts are those of curiosity and flight ”; yet one is an emotion,
and the other a so-called instinct. I confess that I experience a difficulty in appre¬
ciating a clear line of demarcation between instincts and emotions, and personally
I would prefer to regard all the instincts as reflex actions, and, as we know,
elaborate reflex acts may need even a more extensive nervous apparatus than an
intelligent act.

The origin of the instincts is probably reflex, but as they become more teleo¬
logical, and their ends become more adapted to the welfare of the organism, they
tend to rise above mere reflexes, and to be expressed either without consciousness
along congenitally prepared nervous pathways, or to rise and be presented to
consciousness.

The modern definition of the instincts is “ inherited perceptual disposition," and
if this is accepted the instincts are clearly mental states. We know that they are
best seen in the lower animals such as the social bees and ants among the inverte¬
brates and in birds and some of the lower mammals among the vertebrates.
Witness the migratory tendencies of birds and the constructive acts of the beaver,
and although we have no means of reading mental states into these acts—for only-
in man can this be effected—yet there must be mental elements present as in man,
and we often use the term "instinct” in animals to express mental states.

Further, I fail to see a distinct demarcation between “feeling" in the psycho¬
logical sense and the emotions, unless it be in the organic visceral sensations
which accompany the latter; yet there are probably some hormones with corre¬
sponding internal sensations accompanying every hedonic tone, as the experiments
of Cannon appear to suggest.

My critic denies that danger necessarily produces fear; but if, as I maintain,

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408 NOTES AND NEWS. [Oct.,

fear is a biological reflex, then this primary emotion must be present in the uncon¬
scious mind, and I cannot conceive an actual present state of danger without the
emotion (or instinct) of fear. But here we are upon the elusive territory of the
subconscious, and is it possible to be unconscious of the conscious?— i.e., is it
possible to have impressions without the mind acting?—or, in other words, is it
possible to have a state of pure physiological activity present without mentality ?
I am unconscious of the various ears of corn and straws in a cornfield, although
my reason tells me they are present; I hear the wave on the pebbled beach,
but 1 am unconscious of the sound caused by each pebble. I think, judging by
my actions, that there are many and different emotions in my own mind, but
because they do not rise to consciousness I may be tempted to deny they are
there.

Lastly, he refers to the control of the emotions bv the exercise of the will, and I
think the will rather than the intellect is the claim of man to rise to a higher
sphere. It is well known that the assumption of a movement associated with an
emotion tends to create the emotion. The work of the actor is of this kind. The
substitution by an effort of the will of a movement contrary to the emotion that
will often best control it. A boy whistles when he passes the cemetery at night;
a girl who is annoyed will play her piece of music to divert her emotion, and a
child is taught to count ten before replying in anger.

An assumption of calm will overcome an emotion. One cannot feel chivalrous
or martial when leaning on a lamp-post with hands in pocket. The reason can do
much to show the unreasonableness of an emotion, but it is the will-power that
finally exercises the control, and I cannot help feeling that the muscular element
of thought has been very inadequately studied in connection with the will. I am
obliged to Mr. Spangler for his criticisms.

I am, Sirs,

Your obedient servant,

Robert Armstrong-Jones, M.D.

105, Harley Street, VV.;

September 10 th, 1918.

EXAMINATION FOR NURSING CERTIFICATE.

List of Successful Candidates.

Final Examination, May, 1918.

Chester County. —Sarah J. Partin, Minnie Lloyd, Margaret J. Griffiths, * Lily E.
Robinson, Nellie Griffiths, Annie Elizabeth Eyton, Alice Crook.

Macclesfield, Chester. —Annie M. Craib, Jeanie Killough, Annie M. Peden, Sarah
]. Leigh, Minnie Leigh.

Cornwall. —Annie Redmond.

Carlisle. —Lena Hardy, Ebenezer J. Barton, Hannah Willis, Flora Gray.
Severalls, Essex. —Kathleen V. Murphy, Henrietta E. Hood, Elizabeth A. Robin¬
son, Ethel A. Kent, Ethel F. Randle, Ellen A. Davies, Eleanor W. Griffiths, Arthur
H. Markland.

Bridgend, Glamorgan. —Edward Byrne, Tom Griffiths, Henry A. Murphy, Clara
A. Prew, Sarah J. Tarr, *Maggie Jones, Elizabeth M. Williams.

Banning Heath, Kent. —Mildred C. Tiver, Mildred A. Oliver, Lilian Owen, Annie
F. Burridge, Ellen Cotter, Lillian M. Leverett.

Rainhill, Lancs. —Alice Pemberton, Elizabeth M. Taylor, Mary Coghlan, Annie
E. Yates.

Cane Hill, L.C.C. —Olive Jibb, Emily A. E. Amos, Olive M. Clavey, Annie M.
Talbott, Kathleen C. Mawn, Laura L. Payne, Lilian M. Corby.

Claybury, L.C.C. —Edith M Simons, Annie E. Reeve, Margery C. Barker, Edith
E. Woodford, Maud E. Wiese, Gretto Hyland, Elsie Blake, Ada E. Parrish.

Colney Hatch, L.C.C. —Louisa Jones, Elsie Fisher, Kathleen M. E. Shaw, Alice
N. Fenn, Lois Root.

Hanwell, L.C.C. —Rosa G. G. Brentnall, Jenny Lapidge, Rose Young, Emily C.
Manley, Rose M. Brown, Alice Wildin, Violet G. Smith, Edith L. Knight.

Bicton, Shropshire. —Catherine A. Hogan.

Long Grove, L.C.C. —Grace Banwell, Horatio J. Johnson, Edmund J. Tomkins.

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Cheddleton. —Ada Roulston, Lily Noble, Florence A. Ledbury, Jessie M.
McDonald.

Netherne. —"Alice E. Sparks, "Florence Vickery.

Hellingly. —Ethel M. Tindall, Marion Costigan, Winifred M. Keep, Mary
McPartland.

Derby Borough. —Annie Hall, Lilian Goodall.

Barnsley Hall, Worcester. —"Elsie May Colley, Ada Alice Seeley.

Hull City. — Mary Imelda Carlin, Floris Evangeline Lloyd, Kate Marr, Ella B.
Watson, David Stynes, John D. Moody.

Leavesden. —Adeline Rockliffe, Annie Baker, Grace Ethel Maurice, Mary G.
Hickman, Margaret Blew, Winifred Cox, Elizabeth Marchant, Mildred E. Neate,
Nellie E. Phair, Florence E. Murray.

Leicester Borough. —"Elizabeth Starkey, "Alice E. Whomsley, Miriam Hills,
Ethel Preece.

Notts City. —Edith A. Pearce.

Portsmouth. —Grace E. Norris, Myrtle Phillips, Nellie L. Hill, Florence M.
Webley, David Wren, Ivy W. Cotton.

Sunderland. —Mary Jopling, Violet Lockey.

Bootham Park. —Isabel K. Young.

Brislington House. — Margaret E. Carr.

Camberwell House. —Gladys F. M. King, Jean Elisabeth Prall, Dorothy L. Phelps,
Adelaide G. F. Hart, Beatrice Richards.

Coton Hill. —George A. Wilshaw.

Holloway Sanatorium. —Jessie K. Gray, Florence Barker, Marion L. Boussier,
Ethel C. Holdaway, Muriel Perkins, Winifred M. E. Healey, "Brenda H. Peters,
Edith M. Telfer.

New Saughton Hall. —Isobelle Black.

The Retreat, York. —"Ada M. Ellis, Winifred A. Willey, Lucy Dorling, "Annie
S. Higgins.

St. Andrews. —Katie M. Potter, Lewis Duckett.

Ticehurst. —Eva C. Browning, "Mary C. Clarke.

Aberdeen District. —Margaret R Sutherland, Eliza A. S. Noble.

Argyle and Bute. —Alexanderina McDonald, "Catherine Macleod.

Ayr. —Margaret O. McGill, Grace Mitchell.

Crichton. —Robert Neill, Robert S. Purvis, William Scott, Laurence Walls,
Viola Potts, Grizel E. Brand, Margaret Cameron, Jessie Sidev, Agnes W. L.
Ednie, Mary S. McCartney, Elizabeth Hendry, "Jessie A. Bowie, Annie Brown,
Jessie K. Cameron, Lizzie A. Reid, Mary Munro, Isabel Campbell, Janet G. D.
McDowall, Margaret D. Eadie, Sarah E. Johnston, "Ethel McLennan, Annie
McCullen, Victoria F. Shelbourne, Mary Macdonald, Ellen McCaw, Joseph Dunn.
Dundee District. —Mary M. Duffy, Mina Lovie.

Edinburgh Royal. —Mabel A. Nicoll, "Mary J. Brown, William J. Fraser,
Sarah M. Richmond, Christina B. Donaldson.

Craig House. —Mary T. Brady, Isabella M. Cromarty, Jessie A. Flett, Mary
Finnigar, Margaret W. Young, Margaret M. McLean, Elise le Gentil, "Annie H.
Lawrence, Elltn Morrison, Grace McHaffie, Margaret Brady, Jean Davidson,
Mary R. Robertson, Mary E. Shearer.

Fife and Kinross. —Mary Duncan, Kate Lobban.

Gartloch. —Elizabeth Black, Allison R. Russell, Katie A. KcKinnon, Mary S.
Laing

Gartnarel. —Catherine McKerchar, Annie Marshall, Annie B. Lorimer, Agnes
Barbour, Annabeila Finlayson, Isabella Eadie, James Cameron.

Woodilee. —Mary Denny, Margaret B. McLean, Marion Lithgow, John Welsh,
Mary Kennedy (or Bownas), Ellen Devins, Annie J. M. Maepherson.

Hawkhead. —Elizabeth D. Gibson, Jeannie McBain, Anna McDonald, May
Travers.

Inverness. —Maria S. Sutherland, Margaret Campbell, Sarah Macnab.

Lanark. —Mary Purvis, Elizabeth Singer.

Melrose. —Charles Cowie, "Lizzie W. C. P. Webster.

Montrose. —Margaret Potter, Margaret Munro.

Murray. —Agnes M. Ross.

Dykebar. —Marion Cameron, Murdoch Mackay.

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NOTES AND NEWS.

[Oct.,

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Riccartsbar, Paisley .—Robert J. Mitchell.

Enniscorthy. —Arthur Doyle.

Portrane. —Patrick Glennon, John Cullen, Bartholomew Dowdall, Mary E.
Carolan, Bina Fahy, Ellen Kelly.

Richmond. —Elizabeth Doyle.

St. Patrick's. —Margaret Hogg.

Smithston, Greenock. —William Cameron, ‘Isabella J. Murray, Thomas S. Goldie.

Banstead. —Jean Curtenelle, Elsie E. Gill, Jeanie A. F. Fisher, Susan E.
Howard, Emily Trevorrow, Naomi R. L. Langley.

Wadsley. — Sydney A. Culverwell.

Warwick County. —Elsie Jones.

(The successful candidates from South Africa not included in the above list.)

* Passed with distinction.

Preliminary Examination, May, 1918.

Berks County.— Olive M. Allum.

Chester County — Elsie Littler, Margaret H. Timmis, Margaret Langton, Evelyn
Bailey, Edith Taylor, May Jeffries, Emily Pritchard, Lily Summerfield, Honora
Doherty, Daisy Roberts, Violet V. Vernon, Betty Williams, Beatrice Lewis.

Macclesfield, Cheshire. —Marjorie A. Barnett, Isabella M. Darragh, Elizabeth E.
O’Connor, Maude L. Bloor, Celia Moore, Frances Dale, Bessie Davies, Kathleen
Le Cras, Alyce L. Potter, Gertrude Shallcross, Ethel Ascroft.

Cornwall County. —Gladys Coleman, Hannah M. Cooksley, Lily Bassett.

Carlisle.— Elizabeth Moffat, Hannah Graydon, Alice Ranie, Anice M. Hodgson,
Annie Bell.

Derby County. —Sarah A. Radford, Gertrude A. Webster, Janet Mycroft, Mary
Burke, Dorothy E. Mordy.

Dorset County .— Louisa Stelling, Bertha Feltham, Annie Elligate, Anna
Hennessey, Dorothy J. Evett, Annie M. M. Atkins, Marion Mclnerney, Alice
Walshe, Bridget A. McDonnell, Kathleen H. Frampton, Norah B. Behan.

Brentwood, Essex .—Annie E. Rand, Rachel Parkin, Bertha H. Carne.

Severalls, Essex .—Mabel B. Button, Julia M. Wiles, Harriet Cole, Eva Gladys
Brown, Jean Thompson Barr, Bessie B. Luscombe, Agnes M. Duncan, Evelyn
Gray, Mabel G. Taylor, Florence Smith, Dorothy E. Finch, Frances J. Thompson,
Lilian M. Hull, Roseanne McNulty.

Bridgend, Glamorgan .— Elizabeth J. Allen, Elizabeth J. Jones, Gwladys
Llewellyn, Elizabeth Ann Roberts, Margaret Evans, Edith Lewis.

Isle of Wight .—Harriette M. Pauli.

Maidstone, Kent .—Bertha Thompson, Frances C. Arnold.

Cane Hill, L.C.C.— Henrietta E. Love, Jane Keating, Stella M. South, Dorothy
Williams, Myra Johns, Gertrude King. Lucy B. Webb, Mildred E. Sims,
Florence R. Cook, Alma L Sims, Edith M. Selwood, Mary A. Keane.

Claybury, L.C.C .—Margaret J. Gittins, Grace P. Baxter, Dorothy E. Harrison,
Dorothy M. Parrish, Annie M. Jones, Katie Healv, Edith S. J. Reid, Katie
Pritchard, Rosina M. Jarratt.

Colney Hatch, I..C.C. — Rose Elizabeth Bradshaw, Wilhelmina Gibson S. Brown,
Myra Compton, Nora Annie Colts, Emily Maguire, Victoria A. Palmer.

Hanwell, L.C.C .—Janet Williams, Florence Marshall, Lillian May Bond,
Madeleine Scholtus, Margaret A. Lovell, Gladys Griffiths, Gladys Helen Bullack,
Minnie McGuinness, Winifred H. Bowler, Marie Plumb, Ivy G. Baker, Florence
Keen, Margaret Morris, Jessie L. Winsor, Isabel E. M. Currey.

Long Grove, L.C.C .—Jessie L. Skuse, Mabel E. Meadmore, Lilian M. Blythe,
Ann Ja«ie Jones, Olive S. Jenkins, Honoria M. Byrne.

Napsbury, Middlesex .—Sarah Ann Christian, Lucy H. Downes, Annie Way,
Elsie G. Rogers, Ethel M. Davies, Gertrude L. M. Thomas, Annie K. Richardson,
Alice M. Bromley.

Abergavenny .—Agnes H. Pugh, Gwladys Waring Chilcott, May Price, Lena M.
Ray, Sarah Lewis, Frances Talbot.

Notts County .—Florrie Leeson, Annie Gamble, Betsey Todd.

Bicton, Shropshire .—Sarah E. Davies, Louisa W. Cooper, Lily Brown, Sarah J.
Rawlings, Nellie Blocksidge, Frances Nellie Dodd.

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Cheddleton, Staffs. —Jennie M. Cassidy, Eva Mary Murphy, Mary McDonnell,
Mabel Adeline Horlock.

Nethern-', Surrey. —Teresa K. Quinn, Louie E. Chivers, Edith Hilda Harris,
Ethel S. Wallcroft, Edith E. Kinch, Hanna McEllistrim, Emily E. Coles, Violet
Waters, Harriet Bastin.

Hellingly, Sussex. —Blodwen Hughes, Lillian Thompson, Doris L. Lucia, Nellie
Cunningham. Elsie F. H. Thorne, Margaret Thomas, Amy Allerton.

Storthes Hall, Yorks. —Winifred Holden, Annie Botham, Olive Usher, Elizabeth
Myers, Williamina Morrison.

Barnsley Hall, Worcestershire. —Louisa Shutt, Emily S. D. Rawlings, Marion
Whitehouse, Elsie M. Johnson, Edith M. Firmstone, Mary W. M. Goddard,
Eleanor A. M. Brown, Ada R. Oakes, Mabel Oliver.

Winson Green, Birmingham. —Lilian M. Adams, Lilian M. Davies, Myfanwy
Davies, Rose A. Shilvock.

Canterbury. —Alice M. Austin, Rosina S. J. Clark, Lucy M. Mortimer, Ruth
Hopkins, Beatrice M. Wood.

Derby Borough. — Daisy A. Coulson, Edith A Chambers, Frances A. C. Hulme.
Hull City. —Florence L. Davey, Agnes Ingram, Annie Kirby, Elsie Robinson,
Ethel M. Robinson, Ethel Souley, John H. Mechen

Leicester Borough. —Ida l.angfield, Gertrude Hickling, Bridget O’Halloran,
Eunice F. Joyce, Lillian Soar, Rachel Burton, Kate Cocks.

City of London. — Helen Inglis.

Notts City. —Annie Clements, Maud Clements.

Portsmouth Borough. —Olive K. Newton, Daisy E. Bennett, Cissie A. M.
Hutchens, Margaret E. Boobyer, Ivy B. Strange, Harriet M. Clifford.

Sunderland Borough. —Mary Hewitt, Hannah Shillaw.

Bailbrook House. —Ethel Ada Newth.

Bcthlem Royal.— Elsie K. Lewis, Alice Maud Martin, Marion F. Mullenger.
Bootham Park. —Dorothy E. M. Robinson, Christina Watt, Sarah Hutchinson,
Mary Ross Fearn, Elizabeth Jane Stewart, Florence M. Mitchell.

Brislington House. —Mabel E. Doling, Ada M. Adams, Jennie Alderson.
Camberwell House. —Elsie Everett, Alary S. Roberts, Vera H. Creighton, Ger¬
trude Izod.

Holloway Sanatorium. — Ethel Chesterfield, Frances Mary Marks.

Middleton Hall. —Ada Bruce, Annie Freda Butters, Mary Jane Hodgson.

Retreat, York. —Charles James Allen, Frank Harwood, Louisa McKeever, Harold
John Owles, Ada Jeanette Pettinger, Evelyn M. Torr.

Peckham House. —Winifred Ward, Dorothy Parker, Winnifred D. White, Annie
Packer, Emily Salmon, George H. Case, William S. Griffin, George H. I. Bates.

St. Andrews. —Elsie B. Anderson, Elizabeth E. Biffen, Ralph L. Haynes, Arthur
Easton, Ralph N. Easton, Hugh Owens, Walter Stafford.

Ticehurst. —Louisa Ford, Emily C. Fry, Ivy V. Holtham.

Warneford, Oxon. — Miriam Andrews, Evelyn E. Swadling, Barbara J. Mason.
Aberdeen Royal. —Jessie Davie, Isabella Moir, Frances Ross.

Aberdeen District. —Barbara M. Walker, Lizzie A. S. Duff, Ida Smith, Margaret
Rust, Annie B Connon, Elizabeth H. Gordon, Maggie Johnston, Mary J. Harvey,
Annie Marr.

Argyle and Bute. —Annie McPhee, Mary F. Martin, Agnes McC. Bell, Marion
McDonald, May McGilfs.

Ayr. —Agnes G. Sim, Annie F. Goldie, Isabella M. Thomson, Frances J.
McLaren, Georgina H. McLaren, Agnes Blackwood, Christina Littlejohn, Rosina
McG. McCulloch, Grace H. Campbell, Agnes Herbert, Mary A. Kennedy, Eliza¬
beth L. Gillespie, Jeannie S. Baillie.

Crichton, Dumfries. —Margaret Blackwood, Rebecca McQuarrie, Peggie Macrae,
Elizabeth J. Moodie, Elizabeth D. Ramage, Delia Rowan, Jeannie Raffin, Jeannie
Muircroft, B. Delia Cawley, Maggie Doherty, Elizabeth J. Beaton, Maggie A.
Buchan, Mary W. Brand, Sarah J. Wilson, Mary E. Finch, Elizabeth M. Hickey,
Jeannie T. Sanderson, Mary H. Sanderson, Catherine R. Hunter, Kathleen Sim¬
mons, Sarah Roseweir.

Dundee Royal. —Nellie Morris, Isabella Miller, William Leith.

Edinburgh Royal. —Jean Shannon, Mary Ward, Matilda Adams.

Elgin. —Florence McRae.

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412 NOTES AND NEWS. [Oct.,

Fife and Kinross. —Marion W. Coffield, Isobel Corsie, Flora M. Fraser, Annie
Mitchell, Isabel Nuthall, Margaret J. Slessor, Isabella Turner.

Gartloch. —Angus Sinclair, Helen M. Deas, Mary Deas, Annie Diack, Mary A.
Raeburn.

Craig House. —Margaret A. Nicholson, Williamina J. Imray, Marion S. McKizen,
Mary Cochrane, Elizabeth Milne.

Gartnavel. —Robina Brown, Mary Collins, Brigid Martin, Mary Molloy, Cathe¬
rine McArthur, William Arrol, Mary McKenzie, Annie McMillan, Betty Orr, Isa¬
bella Russell, Euphemia Churchman, Jean C. Greer.

Woodilee. —Grace Inglis, Agnes Maitland, Elspeth P. Taylor, Barbara G. Martin,
Alexandrina Melville, Jessie H. Dunsmore, Jane Higgins, Jessie Angus, Hellen
Chisholm Mathieson, John H. Gavin, Cornelius J. Brooks.

Hatvkhead. —Mary Barclay, Isabella Berry, Meta Y. McFarlane, Margaret Robin¬
son, William F. Hepburn.

Inverness. —William Campbell, Florence A. Boiteux, Isabella D. Stevenson,
Catherine S. Stevenson, Margaret B. Hendry.

Lanark. —Jeannie C. Gray, Janet M. Cochrane, Isabella Boyd, Agnes R. Hutchon,
Mary J. A. Titterington, Margaret Mullin, Margaret Connor, Gertrude H. Howie.

Melrose. —Margaret Provan.

Montrose.-. —Maggie S. Balnaves, Chr-issie Innes, Ella E. C. Y. Gibson, Mary J.
Duthie, Margaret Kennedy, Jane Bowen, Susan Smith.

Murray. —Mary Allan, Annie McLeod.

Dykebar. — Margaret Hart, Norman MacKinnon.

Ballinasloe. —Mary Marner, Mary O’Connor, Margaret Muldoon, Teresa Fitz¬
patrick, Kathleen Dunleavy, Angelina Kilroe, Mary Kenny.

Enniscorthy. —Annie O’Farrell.

Mullingar. —Mary Farrell, Mary Anne Dinnigan, Bridget .Garry, Mary Mullin,
Margaret Tiernan, Kate Maguire, Patrick Devine, Thomas Fry, Mary Duffy, Ellie
McCormack, Mary Anne Reilly.

Portrane. —Maria Flannery, Margaret Gilmartin, Jane Murphy, Nora Helena
McArdle, Lillie Green, Michael Connolly, Thomas Browne, John Callahan, Andreiv
Byrne, Edward Hughes.

Richmond. —Martha Connell, Elizabeth Dalton, Christopher McEntagart, Cor¬
nelius Horan, Annie Lyons.

St. Patrick's, Dublin. —Rebecca M. Belton, Thomas Byrne, James Callaghan,
Samuel Newman, John Stapleton.

Smithston. —Alexander MacLean, Annie E. McCarroll, Bridget McCormack.

Banstead. — Mary Jane Massara, May Taylor, Florence Ruth Morse, Catherine
Mary Lloyd, Annie Elizabeth Clarke, Marcelle Walters, Margaret Priscilla Day,
Lilian Ruth Byram, Violet Winifred Cownden, Dorothy Rose Powell, Lily Dunn,
Ellen Eliza Duncombe, May Gladys Waylan, Bridget Teresa Ryan, Lucy Eleanor
Pownall, Maria Josephine Fenton, Lucy Jordan.

Haddington. —Rita Mary Sinclair, Jean Lawson Skinner, Helen Deagman
Dobie.

JVarwick County. — Lucy Davies, Rita Storey, Marion O'Connell, Nellie
Williams.

South Africa.

Preliminary.

Pretoria. —H. A. E. C. W. Montjoie, I. M. Cloete, G. du Plessis, G. E. Keenan,
J. W. Nell, A. H. Lotter, P. F. Rautenbach.

Grahamstown. —Margaret Mary Rainnie Andrew.

Pietermaritzburg. —J. W. Delport, E. M. Boik.

Bloemfontein. —J. G. Bender.

Valkenberg. —J. C. S. Lotter.

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1 9 1 8.]

NOTES AND NEWS.

413

OBITUARY.

William Reid, M.D.Aberd.

Physician-Superintendent , Royal Asylum, Alerdecn.

The Scottish Division has again to record the death of one of its oldest
members in Dr. Reid, who died at his residence on September 3rd.

Dr. Reid had been connected with the Aberdeen Royal Asylum for the long
period of forty-two years'; he entered it as Assistant Physician in 1876, and on
the death of his predecessor, Dr. Jamieson, he was appointed to succeed him in
1885.

He lived to see the reconstruction of this large asylum almost completed and
no detail in the scheme escaped his attention. He was particularly proud of the
hospital block, which is not surpassed anywhere in the country.

In mental diseases Dr. Reid was extremely conservative ; he would look at no
other book but " Clouston ” until, no new and revised edition appearing, he adopted
De Fursac’s well-known manual. Of all the varieties of insanity he was most
interested in primary dementia.

Dr. Reid was a big man in every way. His handsome presence and indefinable

f iersonality will be missed in Aberdeen for many years to come. He was abso-
utely adored by his patients ; as, though he did not carry his feelings on the surface,
his winning personality and overflowing kindness of heart made him an ideal
mental physician. His old assistants all over the world, as well as his staff,
possessed an affection for him such as is given to few men. The Chief hated
humbug, meanness, self-advertisement, and priggishness of any kind, and expressed
himself pretty forcibly at times when any examples of such came to his knowledge.
Though of a forgiving nature in most instances, he never forgave anyone whom
he had found out “ not playing the game.” He lectured on psychiatry to many
generations of Aberdeen University men, and was seen at his best when describing
the clinical symptoms presented by the cases he brought before them.

Dr. Reid did not care for the artificiality of social functions or meetings and
was seldom seen at these, but he liked to entertain at his own house. He loved
the open air, and his chief recreations were shooting and golf. He was passionately
devoted to the latter game, and his fine figure, clothed in the favourite brown
suit, was well known on the links of Balgownie, Cruden Bay, and Lossiemouth.
His library contained every known book on the game ; and he showed a prevalent
and forgivable human weakness in buying successively the clubs made by the
greatest players of the day, and it was amusing to see the big man wielding the
initial very light clubs used by Harry Vardon. He had a tendency to “ slice,”
which he attributed to loosening his left hand at the top of the swing ; to circum¬
vent this he had a thin metal cover, surrounded with the ordinary leather grip,
made to encircle the upper half of the handle of his clubs; this cover revolved
sufficiently to allow of the left hand preserving the grip at the top of the swing.
The correspondence which ensued with the editor of a well-known golfing maga¬
zine, who did not approve of the contrivance, caused him great amusement.
Needless to say, the “slice” remained, and he discarded the above invention and
adopted another to cure his “ slice ” in the form of a strap, which, however, made
it impossible for his caddie to withdraw one club from his bag without also with¬
drawing the others. A favourite caddie took the law into his own hands and removed
the club straps while his master was at lunch. The resulting interview later was
something to be remembered. He fared better with a tea-urn he invented for his
patients, and the writer has never seen anything to beat it for institutional use.

Dr. Reid’s home life was delightful, and to see the big fellow lying on the floor
building brick houses with his youngest daughter is a pleasant memory. He was
devoted to all children, and they to him.

The war adversely affected Dr. Reid in many ways. His senior assistant, Dr.
Kellas, to whom he was much attached, was killed at Gallipoli; and, later,
two other assistants—Drs. Dewar and Legge—were killed on other Fronts.

He is survived by his wife and two daughters. Prof. R. W. Reid, of Aberdeen,

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414

NOTES AND NEWS.

[Oct., 1918.

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is his brother ; and another brother, Major-General Sir Alexander Reid, K.C.B.,
who made a great reputation for himself in India and China, died a few years
ago. Prof. R. G. McKerron, of Aberdeen, is a brother-in-law.

H. M. de Alexander.

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.

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INDEX TO VOL. LXIV.

Part I.—GENERAL INDEX.

Aberdeen Royal Asylum, report for 1916, 100
Etiology of crime, 129

Alcohol : its action on the human organism, 304

,, relation of, to mental states, particularly in regard to the war, 146
Annual Meeting, 1918, 382
Aphasia in relation to mental disease, 1

Aphonia, mutism and deafness among soldiers of psychical origin, 221
Asylum reports for 1916, 85

„ Workers' Association, annual meeting, 318
Auditors, report of the, 394

Baily, Dr. Percy, obituary, 248
Balance sheet, 393

Bedford, Herts and Hants Asylum, reports for 1916, 86
Bethlem Royal Hospital, report for 1916, 85
Board of Control, third annual report, 1916, 76
Brain and genetic function, 224
Brentwood Asylum, report for 1916, 87

Central nervous system, experimental toxi-infection of the, 18
Clinical neurology and psychiatry, 79, 221, 310
„ notes and cases, 64, 296

Colchester, Royal Eastern Counties Institution, report for 1916, 89

Cooke, Sir Marriott, K.B.E., elected an Honorary Member, 395

Correspondence, 108, 406

Council, annual report of, 390

Crime, aetiology of, 129

Criminology and social psychology, 84

Deafness, mutism and aphonia among soldiers of psychical origin, 221
Diabetes mellitus, psychoses associated with, 312
Dreams, soldiers’, psychology of, 388
Ductless glands, epilepsy and’the, 30

Ectromelus, an : an atavistic relapse, 267
Edinburgh, Morningside Asylum, report for 1916, 94

Edinburgh War Hospital: demonstration of cases on the occasion of the annual
meeting, 400

Editors, report of the, 392
Education Committee report, 394
Election of honorary members, 395
,, of Officers and Council, 390
Emotional hysteria, 82

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INDEX.

4 I 6

Epilepsy and the ductless glands, 30
,, voltaic test in, 79
Epitome of current literature, 78, 220, 310, 386
Essex County Asylum (Brentwood), report for 1916, 87
„ „ „ (Severalls), annual report for 1916, 88

Ethics, evolution and, 226
Evolution and ethics, 226

Evolutional progress in psychiatry: a plea for optimism, 189
Examination for nursing certificates: list of successful candidates, 242, 408
Excitement in the various states of insanity, clinical observations on, 296

Fear, disorders and disabilities of, 388

,, psychology of (correspondence), 406, 407

Genetic function, brain and, 224

Glasgow Royal Asylum, Gartnavel, report for 1916, 98
Graham, William, obituary, 114
Graphomania, 310

Hysteria, emotional, 82
,, studies in, 386

Hysterical symptoms in soldiers, rapid cure of, 387

Idiot, microcephalic, case and post-mortem examination of a, 65
Insanity, clinical observations in the various states of excitement in, 296
„ Rolandic area in a series of cases of, 344
„ war and the burden of, 325

Ireland, sixty-sixth report of the Inspectors of Lunatics for the year ending
December 31st, 1916, 301

Irish Division of the Medico-Psychological Association, meetings, 105, 238, 316

Library Committee report, 395

London, City of, Asylum, report for 1916, 91

Lunacy law, reform in, 66

Maudsley, Dr. Henry, bequest to the Society, 312
,, „ ,, obituary, 118

Mechanism of paranoia, 83

Medico-Psychological Association, alteration of bye-laws, 313
„ „ „ meetings, 101, 227, 312

,, „ ,, seventy-seventh annual meeting, 389

Meetings, dates of the, 395
Members, election of, 102, 227,314, 396
Mental disease, aphasia in relation to, 1
„ disorders, early treatment of, 210

,, process, nature of, 78

,, states, relation of alcohol to, particularly in regard to the war, 146
Mickle, Dr. Julius, obituary, 111

Microcephalic idiot, case and post-mortem examination of a, 65
Middlesborough, Borough of, asylum report for 1916, 91
Military service, psychoneurotic temperament and its reactions to, 365
Ministry of Health : statement by the Royal College of Physicians of Edinburgh
respecting, and correspondence, 109

Mongolian imbecility, review of cases admitted to the Stewart Institution during
the past twenty years, 239
Moral sanity, 377

Mutism in the soldier and its treatment, 54

,, aphonia and deafness among soldiers of psychical origin, 22 1

Neurasthenia: the disorders and disabilities of fear, 388

Northern and Midland Division of the Medico-Psychological Association, meetings.
102, 241, 315

Notes and news, 101, 227, 312, 389

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INDEX.

417

Obituary.—Baily, Dr. Percy John, 248
Graham, William, 114
Maudsley, Dr. Henry, 117, 228
Mickle, Dr. Julius, ill
Reid, Dr. William, 413
Seward, Dr., 227, 245
Watson, Dr. William Riddell, 246
Occasional notes, 66, 210, 382

Paranoia, mechanism of, 83
Parliamentary Committee report, 394

Pathological lying occurring in a soldier, 389
Physiological psychology, 78, 220
Porencephaly, case of, 64
President, installation of, 399

,, retiring, vote of thanks to, 396
Presidential address on the war and the burden of insanity, 325
Psychiatry, evolutional progress in : a plea for optimism, 189
Psychology, behaviour, scope of, 220

,, of fear (correspondence), 406

,, of soldiers’ dreams, 388

,, social, criminology and, 84

Pyscho-neurotic temperament and its reactions to military service, 365
Psychoses and psycho-neuroses, war, 230

,, associated with diabetes mellitus, 312

„ war, 165

Pullen, James Henry, the genius of Earlswood, 251

Registrar, notices by the, 245
Reid, Dr. William, obituary, 413
Report of the auditors, 394
,, of the Council, 390

„ of the editors of the Journal, 392
,, of the Education Committee, 394
„ of the Library Committee, 395
„ of the Parliamentary Committee, 394

,, of the Treasurer, 391

Reviews, 67, 213, 301

Rolandic area, the, a series of cases of insanity in, 344

Roxburgh District Asylum, report for 1916, 98

Royal Eastern Counties Institution, Colchester, report for 1916, 89

Salop, County of, and Borough of Wenlock Asylum, report for 1916, 92
Sanity, moral, 377

Scottish Division of the Medico-Psychological Association, meeting, 104, 314
Severalls Asylum, report for 1916, 88
Seward, William Joseph, obituary, 245

Shell-shock in advanced neurological centres, treatment of, 388
Social psychology, criminology and, 84
Sociology, 84, 226

Soldier, case of pathological lying in a, 389
,, mutism in the, and its treatment, 54
Soldiers’ dreams, psychology of, 388

Soldiers, mutism, aphonia and deafness among, of psychical origin, 221
,, rapid cure of hysterical symptoms in, 387
South-Eastern Division of the Medico-Psychological Association, meetings, 103, 318
South-Western Division of the Medico-Psychological Association, meetings, 103,
315

Toxi-infection, experimental, of the central nervous system, further observations
on, 18

Treasurer, report of the, 391

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41 8 INDEX.

Voltaic vertigo test in epilepsy, 79
War and the burden of insanity, 325

„ psychoses: an analysis of 202 cases of mental disorder occurring in home
troops, 165

„ „ and psychoneuroses, 230

Warrington War Hospital (Lord Derby’s), record of admissions to the mental
section from June 17th, 1916, to June 16th, 1917, 272
Warwick County Asylum, report for 1916, 93
Watson, Dr. William Riddell, obituary, 246
Wenlock, Borough of, Asylum, report for 1916, 92

Part IL—ORIGINAL ARTICLES.

Armstrong-Jones, Major Sir Robert, relation of alcohol to mental states, particularly
in regard to the war, 146

Ballard, Capt. E. Fryer, psycho-neurotic temperament and its reactions to military
service, 365

Bartlett, G. N., some notes on the case and post-mortem examination of a micro-
cephalic idiot—absence of corpus callosum, 65
Bond, H. E., case of porencephaly, 64

Eager, Major R., record of admissions to the mental section of the Lord Derby
War Hospital, Warrington, from June 17th, 1916, to June 16th, 1917, 272

Goring, Charles, aetiology of crime, 129

Henderson, Capt. D. K., war psychoses: an analysis of 202 cases of mental
disorder occurring in home troops, 165

James, Rev. J. G., moral sanity, 377
Jones, S. Evan, see under Prior, G. P. U.

Keay, Lt.-Col. John, presidential address on the war and the burden of insanity,
325

McDowall, Colin, mutism in the soldier and its treatment, 54
Mott, Lieut.-Col. F. W., war psychoses and psychoneuroses, 230

Norman, Capt. Hubert J., evolutional progress in psychiatry : a plea for optimism,
189

Orr, David, and Rows, Major, further observations on experimental toxi-infection
of the central nervous system, 18

Pal, S. B., an ectromelus : an atavistic relapse, 267

Prior, Guy P. U., and Jones, S. Evan, epilepsy and the ductless glands, 30
Rows, Major, see under Orr, David

Sano, Dr. F., James Henry Pullen, the genius of Earlswood, 251
Smith, R. Percy, aphasia in relation to mental disease, 1

Toledo, Dr. R. M., clinical observations in various states of excitement in insanity,
296

Turner, Dr. John, observations on the Rolandic area in a series of cases of
insanity, 344

Part III.—REVIEWS.

Alcohol: Its Action on the Human Organism, H.M. Stationery Office, 1918, 304
Bernheim, H., Automatisme et Suggestion, Paris, 1917, 213

Boyer, Dr. Georges, Automatic Sleep (Le Sommeil Automatique), Paris, 1914, 73

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INDEX.

419 .

De Fursac, Dr. J. R., Manuel de Psychiatric, fifth edition, 217

Healy, William, Mental Conflicts and Misconduct, Boston, 1917, 216

Jung, C. G., Collected Papers on Analytical Psychology, translated by Dr. Con¬
stance E. Long, second edition, 1917, 219

Kammer, Percy Gamble, The Unmarried Mother, Boston, 1918, 308

Lugaro, Prof. E., La Psichiatria Tedexa nella Storia e nell’ Alteralita (German
Psychiatry in History and at the Present Day), Florence, 1917, 71

Maudsley, Dr. Henry, Religion and Realities, 306

Mercier, C. A., Text-book of Insanity and other Mental Disorders, second edition,
1914,67

„ „ The Ideal Nurse, 75

Niceforo, Alfredo, I Germanii: Stori di un Idea et di una “ Rassa,” Rome, 1917, 70

Sixty-sixth Report of the Inspectors of Lunatics (Ireland) for the year ending
December 31st, 1918, 301

Third Annual Report of the Board of Control for the year 1916, 76

Part IV.—AUTHORS REFERRED TO IN THE EPITOME.

Abbot, E. Stanley, 83

Bonola, Dr. F., 79
Brown, W., 388

Carr, Harvey, 78
Ceni, Carlo, 224
Clarke, S. N., 312

D’Onghia, Dr. Filippo, 82

Gradenigo, Prof. G., 221

Henderson, D. K., 389
Hurst, A. F., 386, 387

Mott, Col. F. W„ 388

Schroeder, T., 85
Singer, H. D., 312
Symns, J. L. M., 386, 387

Watson, J. B., 220

ILLUSTRATIONS.

Diagrams, photographs and tables to illustrate Dr. Prior and Dr. Evan Jones's
paper, 30, 32, 33, 41, 45, 47, 50, 52

Photograph of the late Henry Maudsley, LL.D.Edin., M.D., F.R.C.P., 117

Photographs and diagrams to illustrate Dr. Sano’s paper, 254, 256-264

Photographs to illustrate the paper by Dr. Orr and Major Rows, 20, 22, 24

Photographs to illustrate Dr. Pal's paper, 268-271

Tables to illustrate Major Eager’s paper, 273-275, 282, 286

Tables to illustrate Capt. Henderson’s paper, 166, 167, 179

Tables to illustrate Dr. Turner’s paper, 347, 350, 351,353, 357, 360

ADLARD AND SON AND WEST NEWMAN, LTD., LONDON AND DORKING.

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