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Boston 
Medical Library 



8 THE FENWAY 



PROCEEDINGS 



OP THE 



American Medico-Psychological Association 



r L^ 



AT THE 



SIXTY-FIRST ANNUAL MEETING 



HELD IN 



SAN ANTONIO, TEXAS, APRIL 18-21, 1905 




PUBLISHED BY 

AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 
19OS 



■OV , ' 1906 




^(« l«{«((ttwa(6 Compani* 




Additions and Changes to February i, 1906, 



Blackford, Benjamin, M. D. Deceased. 

Calder, D. H., M. D., Superintendent State Mental Hospital, Prove City, 
Utah. 

Cossitt, H. Austin, M. D., Second Assistant Physician, etc.. New Jersey 
State Hospital, Morris Plains, N. J. 

Courtney, J. Elvin, M. D., Proprietor, Mount Airy Sanitarium, Denver, 
Colo. 

Dent, E. C, M. D., Secretary-Treasurer. Deceased. 

Dold, William £., M. D., Physician-in*Charge, River Crest, Astoria, Long 
Island. 

Edgerly, J. Frank, M. D., No, i Mt. Vernon Terrace, Newtonville, Mass. 

Graves, Marvin L., M. D., University of Texas, Galveston, Texas. 

Hamilton, Susanna P. Boyle, M. D., 6cx) Washington Avenue, Minne* 
apolis, Minn, 

Howard, Emily Pagelson, M. D., Massachusetts General Hospital, Boston, 
Mass. 

Huyck, aifford J., M. D., Gilbertville, Mass. 

Keniston, James M., M. D. Resigned. 

Langdon, Chas. H., M. D. Deceased. 

Maxfield, Geo. H., M, D., Assistant Physician, Boston Insane Hospital, 
Mattapan, Mass. 

Noble, Alfred I., M. D., Superintendent, Michigan Asylum for the Insane, 
Kalamazoo, Mich. 

Packer, Flavius, M. D., Physician-in-Charge, The Knolls, 261st Street and 
Broadway, New York City. 

Pilgrim, Chas. W., M. D., Superintendent Hudson River State Hospital, 
Poughkeepsie, N. Y. {Secretary-Treasurer). 

Stone, William A., M. D., Assistant Superintendent, Michigan Asylum for 

the Insane, Kalamazoo, Mich. 
Wilgus, Sidney D., M. D., Medical Examiner New York State Board of 

Alienists, Foot East ii6th Street, New York. 



OFFICERS OF 

American Medico-Psychological Association 



FOR 1904-1905 



COUNCIL 

PBKsnoNT T. J. W. BURGESS, M. D. 

VicE-PsxsiisKT C B. BURR, M. D. 

Sbcsetasy and Tbeasuskr - - - - R C DENT, M. D. 

A. B. HOWARD, M. D. 



{. 



AuDnoM , ^^jHUj^ p KILBOURNE, M. D. 



COUNCILORS FOR THREE YEARS 
B. D. Evans, M. D. C R. Woodson, M. D. 

Ernist V. ScBiBNES, M. D. John S. Tukner, M. D. 



COUNCILORS FOR TWO YEARS 
ThOICAS J. MiTCHSLL, M. D. A. P. BUSEY, M. D. 

Chas. W. PiLGuic, M. D. Charles G. Hnx, M. D. 



COUNCILORS FOR ONE YEAR 
Geosgb F. Jelly, M. D. W. H. Hattie, M. D. 

Wii. F. Deewey, M. D. M. J. White, M. D. 



OFFICERS OF 

American Medico-Psychological Association 



FOR 1905-1906 



COUNCIL 

Pmesidbnt C B. BURR, M. D. 

Vio^Pmsidewt C G. HILL, M. D. 

Sbcsktaxy and TkEASuns - - - - R C DENT, M. D.* 

SbCBEIABY AlfD TkBASUBB ElXCT BY COUNCIL, CH AS. W. PILGRIM, M. D. 

A. W. KURD, M.D. 



Auimois 

I W. H. HANCKER, M. D. 



{v 



COUNCILORS FOR THREE YEARS 
G. A. Smith, M. D. J. T. Ssaicy, M. D. 

W. F. Bbuiuer, M. D. N. H. Bbmbi, M. D. 



COUNCILORS FOR TWO YEARS 
6. D. Evans, M. D. C R. Woodson, M. D. 

Ernest V. Scusneb, M. D. John S. Tuines, M. D. 



COUNCILORS FOR ONE YEAR 
Thoicas J. Mitchell, M. D. A. P. Busey, M. D. 

C a Wagneb, M. D. M. L. Pebsy, M. D. 



TABLE OF CONTENTS 



List of Ofl&ccrs, i9Q4-'o5 iii 

List of Officers, i905-'o6 v 

Table of Contents vii 

List of Members 9 

Geographical Distribution of Members and Institutions 28 

List of Honorary Members 44 

Constitution 45 

By-Laws 50 

Note SI 

Proceedings of the Sixty-First Annual Meeting S3 

Address of Welcome of Dr. F. E. Daniel S3 

" " " Rev. Homer T. Wilson, D.D S7 

" " " Hon. F. C Davis 59 

" " " Dr. L. L Shropshire 60 

Response by President 62 

Report of Committee of Arrangements 64 

Registration List of Members Present 65 

Visitors Present 67 

Report of the Council 70 

Treasurer's Report 71 

Report of American Journal of Insanity 72 

Committee Reports, etc 73 

Auditor's Report 80 

Address of Dr. D. R. Wallace 81 

Masked Epilepsy (Received too late for Insertion) 84 

Presidential Address. The Insane in Canada. By T. J. W. Bur- 
gess, M. D 87 

Annual Address. Tripartite Mentality. By J. T. Searcy, M. D 123 

Melancholia. The Psychical Expression of Organic Fear. By J. W. 

Wherry, M. D 133 

Mysophohia with Report of Case. By John Punton, M. D 171 

Discussion of Dr. Punton's Paper ; . . . 180 

A Case of Huntingdon's Chorea. By Harry W. Mh.t.fr, M. B. 

(Tor) 183 

vii 



8 TABLE OF CONTENTS. 

Discussion of Dr. Miller's Paper 192 

Korsakoff s Psychosis. Report of Cases. By Arthur W. Huro, 

A. M., M.D 195 

Discussion of Dr. Hurd's Paper 207 

A Case of Visual Hallucinations and Crossed Amblyopia, etc. By 

Chas. K. Mills, M.D. and C. D. Camp, M.D 209 

The Prevention of Insanity in its Incubation. By J. T. W. RowE, 

M.D 217 

Discussion of Dr. Rowe's Paper 223 

Cholxmia. Its Relation to Insanity. By R. J. Preston, A.M., 

M.D 22s 

Surgery for the Relief of Insane Conditions. By Max £. WrrrE, 

M.D. 229 

Discussion of Dr. Witte's Paper 245 

Epilepsy as a Symptom. By Everett Flood, A. M., M. D 251 

The Therapeutic and Medico-Legal Features of Drug Addiction. By 

George P. Sprague, M. D 259 

A Preliminary Report of the Gynecological Surgery in the Manhattan 

State Hospital, West By LeRoy Broun, M.D 263 

Discussion of Dr. Broun's and Dr. Knapp's Papers 304 

Some Observations on the Relations of the Gastrointestinal Tract to 

Nervous and Mental Diseases. By Robert C. Kemp, M. D 307 

Discussion of Dr. Kemp's Paper 331 

Observations on Some Recent Surgical Cases in the Manhattan State 

Hospital, East By John R. Knapp, M.D 353 

Discussion of Dr. Knapp's Paper (See end of Dr. Broun's Paper). . 304 
The Liver and its Relation to Nervous and Mental Diseases. By 

Charles G. Hill, A.M., M.D 345 

Tuberculosis Among the Insane. By C FLoyd Haviland, M. D. . . . 355 

Discussion of Dr. Haviland's P^per 365 

Memorial Notices: — 

Dr. George Frederick Keene. By Henry Jones, M. D 367 

Dr. James Francis Ferguson. By Wiluam E. Dold, M. D 371 

Dr. F. Savary Pearce. By George Stockton, M. D 374 

Dr. Henry R Allison. By Robert B. Lamb, M. D. 378 

Dr. Merrick Bemis. By E. V. Scribner, M.D 380 

Index 383 



LIST OF MEMBERS. 



Abbot, £. Stanley, M. D., Assistant Physician McLean Hospital, Waverley, 

Mass. 
Adams, Geo. S., M. D., Medical Superintendent Westborough Insane Hos- 

pital» Westborough, Mass. 
Adams, Geo. Sheldon, M.D., Assistant Physician South Dakota Hospital 

for the Insane, Yankton, S. D. (Associate.) 
Adams, W. Herbert, M. D., 102 Liberty St, East, Savannah, Ga. (Asso- 
ciate.) 
Allen, Charles Lewis, M.D., Pathologist and Assistant Physician New 

Jersey State Hospital, Trenton, N. J. (Associate,) 
Allen, Henry D., M. D., Milledgeville, Ga. 
Allison, Wilmer L., M. D., Assistant Superintendent Southwestern Insane 

Asylum, San Antonio, Texas. (Associate.) 
Andrews, Gayton G., M. D., First Assistant Physician Vermont State Hos- 
pital, Waterbury, Vt (Associate.) 
Anglin, James V., M. D., Medical Superintendent Provincial Hospital, 

St John, N. B. (Associate.) 
Applegate, Charles R, M.D., Medical Superintendent Mt Pleasant State 

Hospital, Mt Pleasant, la. 
Armstrong, George G., M.D., Second Assistant Physician Buffalo State 

Hospital, Buffalo, N. Y. (Associate.) 
Arthur, Daniel H., MD., Superintendent Gowanda State Homeopathic 

Hospital, Gowanda, N. Y. 
Ashley, Maurice C, M. D., Medical Superintendent Middletown State 

(Homeopathic) Hospital, Middletown, N. Y. 
Atwood, Chas. £., M. D., Assistant Physician Bloomingdale Asylum, White 

Plains, N. Y. (Associate.) 
Ayer, James B., M. D., Member Massachusetts State Board of Insanity, 

518 Beacon St, Boston, Mass. 
Babcock, J. W., M.D., Medical Superintendent State Hospital for the 

Insane, Columbia, S. C. 
Baker, Benjamin W., M. D., Assistant Physician Taunton Insane Hospital, 

Taunton, Mass. (Associate.) 
Baker, Jane Rogers, M. D., Superintendent Chester County Hospital for 

Insane, Embreeville, Pa. 
Baker, Raymond D., M.D., Assistant Physician New Jersey State Hos» 

pital, Morris Plains, N. J. (Associate.) 



lO AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Baldwin, Henry C, M.D., 126 Commonwealth Ave., Boston, Mass. 

Ballintine, Eveline P., M.D., Assistant Physician Rochester State Hos- 
pital, Rochester, N. Y. (Associate.) 

Bamford, Thos. £., M. D., Assistant Physician Hudson River State Hospi- 
tal, Poughkeepsie, N. Y. (Associate,) 

Bancroft, Chas. P., M. D., Medical Superintendent New Hampshire State 
Hospital, Concord, N. H. 

Bannister, Henry M., M. D. (formerly Assistant Physican Illinois Eastern 
Hospital for the Insane), 828 Judson Ave., Evanston, 111. 

Barnes, H. L., M. D., Contagious Hospital, Kingston Ave., Brooklyn, N. Y. 

Barrett, Albert M., M. D., Pathologist Danvers Insane Hospital, Hathome, 
Mass. 

Bartlett, P. Challis, M, D., Assistant Physician Worcester Insane Asylum, 
Worcester, Mass. (Associate.) 

Beauchamp, John A., M. D., Medical Superintendent Central Hospital for 
the Insane, Nashville, Tenn. 

Becker, W. R, M. D., Consulting Neurologist Milwaukee County Hospital, 
604 Goldsmith Building, Milwaukee, Wis. 

Beemer, Nelson H., M. D., Superintendent Mimico Asylum for the Insane, 
Toronto, Ont. 

Beling, Christopher C, M. D., Assistant Physician New Jersey State Hos- 
pital, Morris Plains, N. J. (Associate.) 

Bennett, Alice, M. D. (formerly Resident Physician Female Department 
Norristown State Hospital), Wrentham, Mass. 

Berkley, Henry J., M. D., 1305 Park Ave., Baltimore, Md. 

Betts, Joseph B., M. D., Assistant Physician Buffalo State Hospital, Buffalo, 
N. Y. (Associate.) 

Beutler, W. F., M. D., Medical Superintendent Asylum for the (Chronic 
Insane, Wauwatosa, Wis. 

Blackburn, I. W., M. D., Pathologist Ck>vemment Hospital for the Insane, 
Washington, D. C. 

Blackford, Benj., M. D., Medical Superintendent Western State Hospital, 
Staunton, Va. 

Blumer, G. Alder, M. D., Medical Superintendent Butler Hospital, Provi- 
dence, R. I. (President, 1903.) 

Bolton, James R., M. D., Physician-in-Charge Riverview, Fishkill-on- 
Hudson, N. Y. (Associate.) 

Bondurant, Eugene D., M. D. (formerly Assistant Superintendent Ala- 
bama Bryce Hospital, 166 Conti St, Mobile, Ala. 

Bradley, Isabel A., ^I. D., Pathologist and Assistant Physician Columbus 
State Hospital, Columbus, Ohio. (Associate.) 

Brooks, Ida J., M. D., Assistant Physician Westborough Insane Hospital, 
Westborough, Mass. (Associate.) 

Brower, D. R., M.D. (formerly Medical Superintendent Eastern State 
Hospital, Williamsburg, Va.), 34 and 36 Washington St., Chicago, IlL 

Brown, Edson C, M. D., Assistant Physician Massillon State Hospital, 
Massillon, Ohio. (Associate.) 



LIST OF MEMBERS. II 

Brown, John P., M. D., Medical Superintendent Taunton Insane Hospital, 

Taunton, Mass. 
Brown, Sanger, M. D., Attending Physician Cook County, St Luke's, and 

St Elizabeth's Hospitals, loo State St, Chicago, 111. 
Brown, W. Stuart, M.D., Physician-in-Charge Sanford Hall, Flushing, 

New York, N. Y. 
Brownngg, Albert Edward, M. D., Medical Superintendent Highland 

Spring Sanatorium, Nashua, N. H. 
Brush, Edward N., M. D., Physician-in-Chief and Superintendent Sheppard 

and Enoch Pratt Hospital, Towson, Md. 
Bryant, Lewis L., M. D., City Physician, Cambridge, Mass. 
Bryant, Percy, M D. (formerly Medical Superintendent Male Department 

Manhattan State Hospital), 134 Hawthorne St, Brooklyn, N. Y. 
Buchan, H. E., M. D., Assistant Superintendent Asylum for the Insane, 

London, Ont (Associate.) 
Buchanan, J. M., M. D., Medical Superintendent East Mississippi Insane 

Hospital, Meridian, Miss. 
Buckley, James M., D. D., LL. D., Morristown, N. J. {Honorary.) 
Bnllard, E. L., M.D. (formerly Superintendent Wisconsin State Hospital 

for the Insane, Mendota, Wis.), 402 Camp Building, Milwaukee, 

Wis. 
Burdick, Charles M., M. D., Assistant Physician St Lawrence State Hospi- 
tal, Ogdensburg, N. Y. (Associate.) 
Burrell, Dwight R., M. D., Resident Physician Brigham Hall, Canandaigua, 

N. Y. 
Burgess, T. J. W., M. D., Medical Superintendent Protestant Hospital for 

the Insane, Box 2581, Montreal, Que. (President, 1905.) 
Burnet, Anne, M. D., Assistant Physician Mt Pleasant State Hospital, 

Mt Pleasant, la. 
Burr, C. B., M.D., Medical Director Oak Grove Hospital, Flini Mich. 

(President-Elect. ) 
Busey, A. P., M. D., Superintendent Colorado State Insane Asylum, Pueblo, 

CoL 
Calder, D. H., M. D., Assistant Physician State Mental Hospital, Provo 

City, Utah. (Associate.) 
Campbell, (George B., M. D., Medical Examiner, New York State Board of 

Alienists, 78 Irving Place, New York. (Associate.) 
Campbell, Merritt B., M.D. (formerly Medical Superintendent Southern 

California State Hospital), 1608 Orange St, Los Angeles, Cal. 
(Campbell, Michael, M. D., Medical Superintendent Eastern Hospital for the 

Insane, Knoxville, Tenn.. 
Caples, Byron M., M. D., Medical Superintendent Waukesha Springs Sani- 
tarium, Waukesha, Wis. 
Carey, Harris May, M.D., Assistant Physician Hospital for the Insane, 

Retreat, Luzerne County, Pa. (Associate.) 
Carlisle, Chester Lee, M. D., Assistant Physician Willard State Hospital, 

Willard, N. Y. (Associate.) 



12 AMERICAN MEDICX>-PSYCHOLOGICAL ASSOCIATION. 

Camel, Henry R, M. D. (formerly Medical Superintendent Illinois Central 

Hospital for the Insane), Jacksonville! 111. 
Chaddock, Chas. G., M. D., 3750 Lindell Boulevard, St Louis, Mo. 
Chagnon, £. Philippe, M. D., Physician to Notre Dame Hospital, 1190 

Laval Ave., Montreal, Que. 
Chamberlain, G. L., M. D., Medical Superintendent Upper Peninsula Hos- 
pital for the Insane, Newberry, Mich. 
Channing, Walter, M. D., Channing Sanitarium, Brookline, Mass. 
Chapin, John B., M. D., Physician and Superintendent Pennsylvania Hos- 
pital for the Insane, Philadelphia, Pa. 
Chase, Robert H., M. D., Medical Superintendent Friends' Asylum, Frank- 
ford, Philadelphia, Pa. 
Cheatham, Wm. A., M. D. (formerly Superintendent Ontral Hospital for 

the Insane), Nashville, Tenn. 
Chilgren, G. A, M. D. (formerly Assista.it Superintendent South Dakota 

Hospital for the Insane), Sauk Rapids, Minn. 
Christian, Edmund A., M. D., Medical Superintendent Eastern Michigan 

Asylum, Pontiac, Mich. 
Christiancy, Mary, M. D., First Assistant Physician Department for 

Women Norristown State Hospital, Norristown, Pa. (Associate,) 
Dark, Daniel, M. D., Medical Superintendent Asylum for the Insane^ 

Toronto, Ont. 
Clark, Joseph Cement, M. D., Superintendent Springfield State Hospital, 

Sykesville, Md. 
Clarke, Chas. K., M. D., Medical Superintendent Rockwood Hospital, 

Kingston, Ont. 
Qarke, Homer R, M. D., Assistant Physician Eastern Michigan Asylun, 

Pontiac, Mich. (Associate.) 
Clouston, Thos. S., M. D., F. R. C. P., F. R. S. E., Physician-Superintendent 

Edinburgh Royal Asylum, Momingside, Edinburgh, Scotland 

(Honoraty,) 
Coe, Henry W., M. D., Medical Director Crystal Springs, Portland, Ore 
(hoggins, Jesse C, M. D., Physician-in-Charge Beaumont Sanitarium, 

Laurel, Md. (Associate.) 
Colby, Fred B., M.D., Assistant Physician Women's Department Boston 

Insane Hospital, New Dorchester, Mass. (Associate.) 
Colebum, Arthur B., M. D., Assistant Physician Connecticut Hospital for 

the Insane, Middletown, Conn. (Associate.) 
Colver, Caroline, M. D., Assistant Physician Massillon State Hospital, 

Massillon, Ohio. (Associate.) 
Cook, (^eo. F., M. D., Superintendent Oxford Retreat, Oxford, Ohio. 
Cook, R. Harvey, M.D., Assistant Physician Oxford Retreat, Oxford, 

Ohio. 
Copp, Owen, M. D., Executive Officer State Board of Insanity, State 

House, Boston, Mass. 
Coriat, Isador H., M. D., Assistant Physician Worcester Insane Hospital, 

Worcester, Mass. (Associate.) 



UST OF MEMBERS. 1$ 

Cort, Paul Lange, M.D., Assistant Physician New Jersey State Hospital^ 

Trenton, N. J. (Associate,) 
Cossitt, Harry A., M. D., Second Assistant Physician and Pathologist 

New Jersey State Hospital, Morris Plains, N. J. (Associate,) 
Cotton, Harry A., M.D^ Assistant Physician Danvers Insane Hospital^ 

Hathome, Mass. (Associate,) 
Courtney, J. Elvin, M. D. (formerly Assistant Physician Hudson River 

State Hospital), 310 California Bldg., Denver, Col. 
Cowles, Edward, M.D. (formerly Medical Superintendent McLean Ho^ 

pital, Waverley), Warren Chambers, 419 Boylston St, Boston, Mass. 

(President, 1S95.) 
Crandall, C^eo. C, M. D., 4287 Olive St, St Louis, Mo. 
Crumbadcer, W. P., M. D., Medical Superintendent Independence State 

Hospital, Independence, la. 
Daniels, Frederick H., M. D., Bellevue Place, Batavia, 111. (Associate,) 
Darling, W. H., M. D., Assbtant Superintendent St Peter State Hospital, 

St Peter, Minn. (Associate,) 
Damall, Rolland F., M.D., Assistant Physician Woodcroft Hospital, 

Pueblo, Col. (Associate.) 
Delacroix, Arthur C, M. D., San Juancito, Honduras, C A. (Associate.) 
Dent, £. C, M.D., Superintendent Manhattan State Hospital, Ward's 

Island, New York, N. Y. (Secretary-Treasurer,) 
De Weese, Cornelius, M. D., Qinical Pathologist Ck>vemment Hospital for 

the Insane, Washington, D. C. (Associate,) 
Dewey, Chas. G., M.D., Examining Physician Registration Department 

City of Boston, $39 Talbot Ave., Dorchester, Boston, Mass. 
Dewey, Richard, M. D., Physician-in-CHiarge Milwaukee Sanitarium, Wau- 

watosa. Wis., and 34 Washington St., Chicago, 111. (President, 

1896,) 
Dewing, Oliver M., M. D., Medical Superintendent Long Island State Hos- 
pital, Brooklyn, N. Y. 
Diefendorf, Allen Ross, M.D., Pathologist Connecticut Hospital for the 

Insane, Middletown, Conn. 
Dill, D. M., M. D., Superintendent Essex County Hospital for the Insane, 

South Orange Ave., Newark, N. J. 
Dold, William E., M.D., Physician-in-diarge Falkirk, Central Valley, 

N. Y. 
Doran, Robert E., M. D., Assistant Physician Willard State Hospital, 

Willard, N. Y. 
Douglas, A. E., M. D., Assistant Physician Central Hospital for the Insane^ 

Nashville, Tenn. (Associate,) 
Douglass, John P., M. D., Medical Superintendent Western Hospital for 

the Insane, Bolivar, Tenn. 
Drew, Chas. A., M. D., Medical Director Asylum for Insane Criminals, 

State Farm, Mass. 
Drewry, William F., M. D., Medical Superintendent Central State Hospital, 

Petersburg, Va. 



14 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Dunton, Wm. Rush, Jr., M. D., Assistant Physician Sheppard and Enoch 
Pratt Hospital, Towson, Md 

Durham, Albert, M. D., Assistant Physician Bloomingdale Asylum, White 
Plains, N. Y. (Associate.) 

Eastman, B. D., M. D., Superintendent Christ's Hospital, Topeka, Kans. 

Edenharter, Geo. F., M. D., Medical Superintendent Central Indiana Hos- 
pital for the Insane, Indianapolis, Ind. 

Edgerly, J. Frank, M. D., 164 Highland Ave., Newtonville, Mass. 

Edwards, John B., M. D. (formerly Medical Superintendent Wisconsin 
State Hospital), Mauston, Wis. 

Elliott, Hiram, M. D., Superintendent Marshall Sanitarium, Troy, N. Y. 

Elliott, Robert, M., M. D., Medical Superintendent Willard State Hospital, 
Willard, N. Y. 

Emerson, Justin E., M. D., Attending Physician St. Joseph's Retreat, Dear- 
bom, Mich. ; Attending Neurologist Harper Hospital and Children's 
Free Hospital, Detroit, 128 Henry St, Detroit, Mich. 

Eshner, Augustus A., M. D., Professor of Clinical Medicine in the Phila- 
delphia Polyclinic ; Physician to the Philadelphia Hospital ; Assistant 
Physician to the Philadelphia Orthopedic Hospital and Infirmary 
for Nervous Diseases ; Physician to the Hospital for Diseases of the 
Lungs, at Chestnut Hill, 1019 Spruce St, Philadelphia, Pa. 

Evans, B. D., M. D., Medical Director New Jersey State Hospital, Morris 
Plains, N. J. 

Eyman, H. C, M. D., Medical Superintendent Massillon State Hospital, 
Massillon, Ohio. 

Felty, John C, M. D., Assistant Physician New Jersey State Hospital, 
Trenton, N. J. (Associate.) 

Femald, Walter R, M. D., Superintendent Massachusetts School for the 
Feeble-Minded, Waverley, Mass. 

Fisher, Theodore W., M. D. (formerly Medical Superintendent Boston 
Insane Hospital), Boston, Mass. 

Fitzgerald, John F., M. D., General Medical Superintendent King's County 
Hospital, Brooklyn, N. Y. 

Flint, Austin, M. D., Consulting Physician Manhattan State Hospital, 60 E. 
Thirty-fourth St, New York, N. Y. 

Flood, Everett, M. D., Superintendent Massachusetts Hospital for Epilep- 
tics, Palmer, Mass. 

Folsom, Chas. F., M. D., 15 Marlboro St, Boston, Mass. (Honorary.) 

Foster, L. S., M. D., Superintendent Eastern State Hospital, Williamsburg, 
Va. 

Franklin, Chas. M., M. D., Assistant Physician Sheppard and Enoch Pratt 
Hospital, Towson, Md. 

French, Edward, M. D., Superintendent Medfield Insane Asylum, Harding, 
Mass. 

Frost, Henry P., M. D., Assistant Physician Buffalo State Hospital, 
Buffalo, N. Y. (Associate.) 



LIST OF MEMBERS. I5 

Fry, Frank R., M. D., Professor of Neurology Medical Department Wash- 
ington University; Consulting Neurologist to St Louis Insane 
Asylum, Linmar Building, St Louis, Mo. 

Fuller, Solomon Carter, M.D., Pathologist Westborough Insane Hospital, 
Westborough, Mass. (Associate.) 

Garlick, J. H., M. D., Assistant Physician Central State Hospital, Peters- 
burg, Va. (Associate,) 

Garrett, R. Edward, M. D., Assistant Physician Maryland Hospital for 
the Insane, Catonsville, Md. (Associate.) 

Gaver, Earle £., M. D., Assistant Physician Columbus State Hospital* 
Columbus, Ohio. (Associate,) 

Gillette, Walter R., M. D., Consulting Physician Manhattan State Hospital, 
24 W. Fortieth St., New York, N. Y. 

Givens, A. J., M. D., Stamford Hall, Stamford, Conn. 

Givens, John W., M. D., Medical Superintendent Idaho Insane Asylum, 
Blackfoot, Idaho. 

Goodwin, Harold C, M. D., Assistant Physician New Hampshire State 
Hospital, Concord, N. H. (Associate.) 

Goodwill, V. L., M. D., and C. M., Medical Superintendent Hospital for the 
Insane, Charlottetown, P. E. I. 

Gordon, W. A., M. D., Superintendent Northern Hospital for the Insane, 
Winnebago, Wis. 

Gorton, Eliot, M. D., Superintendent Fair Oaks Sanatorium, 26 New Eng- 
land Ave., Summit, N. J. 

Goss, Arthur V., M. D., Assistant Physician Taunton Insane Hospital, 
Taunton, Mass. 

Granger, Wm. D., M. D., Vernon House, Bronxville, N. Y. 

Graves, Marvin L., M. D., Superintendent Southwestern Insane Asylum, 
San Antonio, Tex. 

Green, Edward M., M. D., Assistant Physician Georgia State Sanitarium, 
Milledgeville, Ga. (Associate.) 

Grosvenor, Frank Livingston, M.D., 31 Nassau St, New York. (Asso- 
ciate.) 

Gundry, Alfred T., M.D., Resident Physician The Gundry Sanitarium, 
Athol, Catonsville, Md. 

Gundry, Richard R, M. D., Member Board of Directors Springfield State 
Hospital; Superintendent The Richard Gundry Home, Catonsville, 
Md. 

Guth, Morris S., M.D., Superintendent and Physician-in-Chief State 
Hospital for the Insane, Warren, Pa. 

Guthrie, L. V., M. D., Superintendent West Virginia Asylum, Huntington, 
W. Va. 

Hall, G. Stanley, Ph.D.,LL.D., President Qark University, Worcester, 
Mass. (Honorary.) 

Hall, Henry C, M. D., Assistant Physician Butler Hospital, Providence, 
R. L (Associate.) 



l6 AMERICAN MEDICXVPSYCHOLOGICAL ASSOCIATION. 

Hall, Lemuel T., M. D., Medical Superintendent State Hospital, Fanning:- 

ton. Mo. 
Hamilton, Susanna P. Boyle, M.D., Assistant Physician Independence 

State Hospital, Independence, la. (Associate,) 
Hancker, W. H., M. D., Medical Superintendent Delaware State Hospital. 

Famhurst, Del. 
Harding, Geo. T., Jr., M,D., First Assistant Physician Columbus State 

Hospital, Columbus, Ohio. {Associate.) 
Harmer, Chas. L., M.D., Philo, Ohio. {Associate,) 
Harmon, F. W., M.D., Medical Superintendent Longview Hospital, 

Carthage, Ohio. 
Harrington, Arthur H., M. D., 6x6 Madison Ave., New York. 
Harris, D. £., M. D., Assistant Physician Massillon State Hospital, Massil- 

Ion, Ohio. (Afsociate,) 
Harris, Isham G., M. D., Assistant Physician Hudson River State Hospital, 

Poughkeepsie, N. Y. 
Harrison, Daniel A., M. D., Breezehurst Terrace, Whitestone, L. I., N. Y. 
Hathaway, George Stimpson, M. D., Assistant Physician Butler Hospital, 

Providence, R. I. (Associate,) 
Hattie, W. H., M. D., Medical Superintendent Nova Scotia Hospital, Hali- 
fax, N. S. 
Haviland, Qarence Floyd, M.D., Assistant Physician Manhattan State 

Hospital, Ward's Island, New York, N. Y. (Associate.) 
Hetherington, Geo. A., M.D. (L. M. Dublin), (formerly Superintendent 

Provincial Asylum), St John, N. B. 
Hildreth, J. L., M. D. (formerly Member Board of Lunacy and Charity of 

Massachusetts), 14 (harden St, Cambridge, Mass. 
Hill, Chas. G., M. D., Attending Physician Mt Hope Retreat, Baltimore^ 

Md. ( Vice-President'EUct.) 
Hill, Ckrshom H., M. D. (formerly Medical Superintendent Hospital for 

Insane, Independence), Equitable Bldg., Des Moines, la. 
Hill, Horace B., M. D., Assistant Medical Superintendent Maine Insane 

Hospital, Augusta, Me. (Associate.) 
Hill, S. S., M. D., Superintendent State Asylum for the Chronic Insane, 

Wemersville, Pa. 
Hills, Frederick L., M. D., Assistant Superintendent New Hampshire State 

Hospital, Concord, N. H. (Associate,) 
Hinckley, L. S., M. D. (formerly Medical Superintendent Essex County, 

Hospital), Newark, N. J. 
Hirsch, Wm., M. D., Neurologist to the German Poliklinic ; Qinical Assist- 
ant in Department of Mental Diseases Cornell University Medical 

School, sa E. Sixty-fourth St, New York, N. Y. 
Hitchcock, Clias. W., M. D., Attending Neurologist Harper Hospital, 270 

Woodward Ave., Detroit, Mich. 
Hobbs, Alfred T., M.D., Superintendent Homewood Sanitarium, Guelph, 

Ont 



LISr OF MEMBERS. 1/ 

• 

Hoch, August, M. D., Assistant Physician and Pathologist McLean Hospi- 
tal, Waverley, Mass. (Associate,) 

Hoch, Theodore A., M. D., Assistant Physician Worcester Insane Hospital, 
Worcester, Mass. (Associate.) 

Hollcy, Erving, M. D., Assistant Physician Willard State Hospital, WiUard, 
N. Y. (Associate,) 

Houston, John A., M. D., Medical Superintendent Northampton Insane 
Hospital, Northampton, Mass. 

Howard, A. B., M.D., Medical Superintendent Cleveland State Hospital, 
Qeveland, Ohio. 

Howard, Emily Pagelson, M. D., Member Board of Trustees Boston Insane 
Hospital, Boston, Mass. 

Howard, Eugene H., M. D., Medical Superintendent Rochester State Hos- 
pital, Rochester, N. Y. 

Howard, Herbert B., M. D., Massachusetts General Hospital, Boston, Mass. 

Rowland, Joseph B., M. D., Superintendent State Colony for the Insane, 
Gardner, Mass. 

Hughes, Chas. H., M. D. (formerly Medical Superintendent State Asylum 
No. I, Fulton), Editor Alienist and Neurologist; Dean of Faculty 
Barnes Medical College, St Louis, Mo. 

Hun, Henry, M. D., Albany, N. Y. (Honorary.) 

Hurd, Arthur W., M. D., Medical Superintendent Buffalo State Hospital, 
Buffalo, N. Y. 

Hurd, Henry M., M. D. (formerly Medical Superintendent Eastern Michi- 
gan Asylum) ; Superintendent Johns Hopkins Hospita\ Baltimore, 
Md (President, 1899,) 

Hutchings, Richard H., M. D., Medical Superintendent St. Lawrence State 
Hospital, Ogdensburg, N. Y. 

Hutchinson, Anna E., M. D., Woman Assistant Physician Manhattan State 
Hospital, Ward's Island, New York, N. Y. (Associate,) 

Hutchinson, Henry A., M. D., Medical Superintendent Western Pennsyl- 
vania Hospital for the Insane, Dixmont, Pa. 

Hutchinson, Marcello, M. D., Superintendent Vermont State Hospital for 
the Insane, Waterbury, Vt 

Hayek, Clifford J., M. D., Assistant Physician Westborough Insane Hos- 
pital, Westborough, Mass. (Associate,) 

Inch, Cjco. Franklin, M. D., Assistant Physician Michigan Asylum for the 
Insane, Kalamazoo, Mich. (Associate.) 

Jelly, Arthur C, M. D., 69 Newberry St., Boston, Mass. 

Jelly, Geo. F., M. D., Chairman Massachusetts State Board of Insanity, 6p 
Newberry St, Boston, Mass. 

Kellogg, Theo. H., M.D. (formerly Medical Superintendent Willard State 
Hospital), Riverdale Lane and Albany Postroad, Riverdale, New 
York, N. Y. 

Kelly, James F., M. D., Assistant Physician Cleveland State Hospital^ 
Qeveland, Ohio. (Associate.) 



l8 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Keniston, James M., M. D., Superintendent Hartford Hospital, Hartford, 
Conn. ( Associate. ) 

Kilboume, Arthur R, M, D., Medical Superintendent Rochester State Hos- 
pital, Rochester, Minn. 

Kindred, J. Joseph, M. D., Gmsulting Physician and Business Manager 
River-Crest Sanitarium, Astoria, L. I., N. Y. 

Kinney, C. Spencer, M. D., Proprietor Easton Sanitarium, Easton, Pa. 

Kline, George M., M. D., Assistant Physician Mt Pleasant State Hospi- 
tal, Mt. Pleasant, la. (Associate,) 

Klopp, Henry I., M. D., Assistant Physician Westborough Insane Hospital, 
Westborough, Mass. (Associate.) 

Knapp, John Rudolph, M. D., Assistant Physician Manhattan State Hos- 
pital, Ward's Island, New York, N. Y. (Associate,) 

Knight, Geo. H., M.D., Superintendent Connecticut School for Imbeciles, 
Lakeville, Conn. 

Knowlton, W. M., M. D., Channing Sanitarium, Brookline, Mass. 

Kuhlman, Helene J. C, M. D., Assistant Physician Buffalo State Hospital, 
Buffalo, N. Y. (Associate.) 

Kulp, John H., M. D., Superintendent Insane Department Mercy Hospital, 
Davenport, la. 

Kunst, A H., M. D., Superintendent West Virginia Hospital for the Insane, 
Weston, W. Va. 

Lamb, Robert B., M. D., Medical Superintendent Matteawan State Hos- 
pital, Fishkill Landing, N. Y. 

La Moure, Chas. T., M. D., Assistant Physician Rochester State Hospital, 
Rochester, N. Y. (Associate.) 

Lane, Edward B., M. D. (formerly Superintendent Boston Insane Hospital, 
New Dordiester, Mass.), 419 Boylston St, Boston, Mass. 

Langdon, Chas. H., M. D., Assistant Physician Hudson River State Hos- 
pital, Poughkeepsie, N. Y. 

Langdon, F. W., M. D., Professor Nervous and Mental Diseases Miami 
Medical College; Neurologist to Cincinnati Hospital; Medical 
Director Cincinnati Sanitarium, 5 Garfield Place, Cincinnati, Ohio. 

Lawton, Shailer E., M. D., Medical Superintendent Brattleboro Retreat, 
Brattleboro, Vt 

Leak, Roy L., M. D., Assistant Physician St Lawrence State Hospital, Og- 
densburg, N. Y. (Associate,) 

Letchworth, William Pryor, LL.D., Glen Iris, Castile P. O., N. Y. 
(Honorary,) 

Lewis, J. M., M. D. (formerly Superintendent Qeveland State Hospital), 
Qeveland, Ohio. 

Logie, Benjamin Rush, M.D., Assistant Physician Government Hospital 
for the Insane, Washington, D. C. (Associate.) 

Ludlum, Seymour DeWitt, M. D., Assistant Physician Friends' Asylum, 
Frankford, Philadelphia, Pa. (Associate,) 

Lyon, Samuel B., M. D., Medical Superintendent Bloomingdale Asylum, 
White Plains, N. Y. 



LIST OF MEMBERS. I9 

Lyons, A. J., M. D., Superintendent Second Hospital for the Insane, 
Spencer, W. Va. 

Mabon, William, M. D., President State Lunacy Commission, Albany, N. Y. 

Macartney, Chas. B., M. D., Assistant Physician Oak Grove Hospital, 
Flint, Mich. (Associate.) 

MacCallum, G. A., M. D., Superintendent Asylum for the Insane, London, 
Ont 

MacQymont, DeWitt C, M. D., Assistant Physician Kings Park State 
Hospital, Kings Park, L I. (Associate.) 

Macdonald, Alexander E., M. D. (formerly Superintendent Manhattan 
State Hospital East, Ward's Island), Columbia Court, 431 Riverside 
Ave., cor. iisth St, New York City. (President, 1904.) 

MacDonald, Carlos R, M. D., 29 E. Forty-fourth St, New York, N. Y. 

Macphail, Andrew, M. D., M. R. C. S., Eng., L R. C P., London ; Professor 
of Pathology and Bacteriology University of Bishop's College, Mont- 
real; Pathologist to Protestant Hospital for the Insane, Montreal, 
Que. (Associate.) 

McBride, James H., M. D., Pasadena, Cal. 

McDonald, William, M. D., Assistant Physician Butler Hospital, Provi- 
dence, R. I. (Associate.) 

McGeorge, James M., M. D., Assistant Physician Massillon State Hospital, 
Massillon, Ohio. (Associate.) 

McGugan, Arthur, M. D. (formerly Assistant Physician Michigan Asylum 
for the Insane), 412-413 McPhee blk, Denver, C6L 

McKee, James, M. D., Superintendent State Hospital, Raleigh, N. C 

McKelway, John Irvine, M. D., Assistant Physician Kings Park State 
Hospital, Kings Park, L I. (Associate.) 

McLeod, George I., M. D., Secretary of State Committee on Lunacy of 
Pennsylvania, 1225 Sansom St, Philadelphia, Pa. 

McNicholl, Eugene C, M. D., Medical Superintendent Cx>bourg Asylum 
for the Insane, Cobourg, Ont 

Macy, Wm. Austin, M. D., Medical Superintendent Kings Park State Hos- 
pital, Kings Park, L I., N. Y. 

Magness, Frank Hosmer, MD., Assistant Physician Manhattan State 
Hospital, Ward's Island, New York, N. Y, (Associate.) 

Mallon, Peter S., MD., Assistant Physician New Jersey State Hospital, 
Morris Plains, N. J. 

Manchester, G. H., M. D., Medical Superintendent Public Hospital for the 
Insane, New Westminster, B. C. 

Manton, Walter P., M. D., Gynecologist Eastern and Northern Michigan 
Asylums; Consulting Gynecologist St. Joseph's Retreat, 32 Adams 
Ave. West, Detroit, Mich. 

Maxfield, C^eo. H., M. D., Assistant Physician New Hampshire State Hos- 
pital, Concord, N. H. (Associate.) 

Maxwell, T. O., M. D., Assistant Physician State Lunatic Asylum, Austin, 
Tex. (Associate.) 



20 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Mayberry, Chas. B., M. D., Superintendent Hospital for the Insane of the 

Central Poor District of Luzerne G)unty, Retreat, Luzerne G)., Pa. 
Mayer, Edward £., M. D., Alternate Alienist St Francis Hospital ; Asso- 
ciate Professor Mental and Nervous Diseases Medical Department 

Western University of Pennsylvania ; 524 Penn Ave., Pittsburgh, Pa. 
Mead, Leonard C, M. D., Medical Superintendent South Dakota Hospital 

for the Insane, Yankton, S. D. 
Meredith, Hugh B., M. D., Medical Superintendent State Hospital for the 

Insane, Danville, Pa. 
Meyer, Adolf, M. D., Director Pathological Institute, Ward's Island, New 

York, N. Y. 
Miller, Harry William, M. D., Pathologist and Assistant Physician Taunton 

Insane Hospital, Taunton, Mass. 
Miller, John F., M. D., Medical Superintendent State Hospital, Goldsboro, 

N. C. 
Mills, Chas. K., M. D., Professor of Mental Diseases and Medical Jurispru- 
dence University of Pennsylvania, 1909 Chestnut St, Philadelphia, 

Pa. 
Mills, Wesley, A. M., M. D., Professor of Physiology McGill University, 

Montreal, Que. (Honorary.) 
Mitchell, H. Walter, M. D., Senior Assistant Physician Danvers Insane 

Hospital, Hathome, Mass. (Associate,) 
Mitchell, S. Weir, M. D., Philadelphia, Pa. (Honorary.) 
Mitchell, Thomas J., M. D., Superintendent State Insane Hospital, Asylum, 

Miss. 
Moher, Thomas J., M. D., Medical Superintendent Brockville Asylum, 

Brockville, Ont 
Montgomery, Wm. H., M. D., Assistant Physician Willard State Hospital, 

Willard, N. Y. (Associate.) 
Mooers, Emma W., M. D., Assistant Physician McLean Hospital, Waver- 

ley, Mass. 
Moore, Dwight S., M. D., Medical Superintendent North Dakota Hospital 

for the Insane, Jamestown, N. D. 
Morel, Jules, M. D., Medical Superintendent State Asylum ; Commissioner 

in Lunacy, Mons, Belgium. (Honorary.) 
Morse, Jason, M. D., Assiistant Superintendent Eastern Michigan Asylum, 

Pontiac, Mich. 
Moseley, Wm. B., M. D., Assistant Physician King's County Hospital, 

Brooklyn, N. Y. (Associate.) 
Mosher, J. Montgomery, M. D., 170 Washington Ave., Albany, N. Y. 
Motet, A. M., M.D., 161 Rue de Charonne, Paris, France. (Honorary.) 
Moulton, A. R., M.D., Senior Assistant Physician Pennsylvania Hospital 

for the Insane, Philadelphia, Pa. 
Munson, James D., M. D., Medical Superintendent Northern Michigan 

Asylum, Traverse City, Mich. 
Murphy, P. L., M. D., Medical Superintendent State Hospital, Morganton, 

N. C 



LIST OF MEMBERS. 21 

Nairn, B. Ross, M. D., Assistant Physician Buffalo State Hospital, Buffalo, 

N. Y. (Associate.) 
Neff, Irwin H., M.D., Assistant Physician Eastern Michigan Asylum, 

Pontiac, Mich. 
Nevin, Ethan A., M. D., Assistant Physician St Lawrence State Hospital, 

Ogdensburg, N. Y. (Associate.) 
Nichols, John H., M.D., Resident Physician and Superintendent State 

Hospital, Tewksbury, Mass, 
Niles, Henry Roland, M.D., Assistant Physician Oak Grove Hospital, 

Flint, Mich. 
Nims, Edward B., M. D. (formerly Superintendent Northampton Insane 

Hospital), 40 Harvard St, Springfield, Mass. 
Noble, Alfred I., M. D., Assistant Superintendent Worcester Insane Hos- 
pital, Worcester, Mass. 
Noble, Henry S., M. D., Superintendent Connecticut Hospital for the 

Insane, Middletown, Cotul 
Noibury, Frank P., M. D., Jacksonville, 111. 
Noyes, William, M. D., Superintendent Boston Insane Hospital, Mattapan, 

Mass. 
Nunemaker, Henry B., M. D., Assistant Physician Pennsylvania Hospital 

for the Insane, Philadelphia, Pa. (Associate.) 
O'Brien, John D., M.D., Pathologist and Assistant Physician Massillon 

State Hospital, Massillon, Ohio. (Associate.) 
O'Hanlon, George, M. D., Assistant Physician Kings Park State Hospital, 

Kings Park, L. I. (Associate.) 
Orth, H. L., M. D., Superintendent and Physician Pennsylvania State 

Hospital, Harrisburg, Pa. 
Ostrander, Herman, M. D., Assistant Physician Michigan Asylum for the 

Insane, Kalamazoo, Mich. (Associate.) 
Packer, Flavins, M. D., Physician-in-Charge River-Crest Sanitarium, 

Astoria, L. I., N. Y. 
Page, Chas. W., M. D., Superintendent and Physician Danvers Insane Hos- 
pital, Hathome, Mass. 
Page, H. W., M. D., Superintendent Hospital Cottages for Children, Bald- 

winville, Mass. 
Paine, N. Emmons, M. D. (formerly Superintendent Westborough Insane 

Hospital), The Newton Sam'tarium, West Newton, Mass. 
Palmer, Harold L., M.D., Superintendent Utica State Hospital, Utica, 

N. Y. 
Parant, Victor, M. D., Toulouse, France. (Honorary.) 
Parsons, Frederick W., M. D., Assistant Physician Hudson River State 

Hospital, Poughkeepsie, N. Y. (Associate.) 
Parsons, Ralph L., M. D., Private Hospital for Mental Diseases, Green- 

mont-on-Hudson, Ossining Postofiice, N. Y. 
Paton, Stewart, M. D., Director of Laboratory Sheppard and Enoch Pratt 

Hospital; Associate in Psychiatry Johns Hopkins University, Balti- 
more, Md. 



22 AMERICAN MEDICXVPSYCHOLOGICAL ASSOCIATION. 

Pease, Caroline S., M. D., Assistant Physician St Lawrence State Hosinta], 

Ogdensburg; N. Y. (Associate.) 
Perry, Middleton L., M.D., Superintendent Kansas State Hospital for 

Epileptics, Parsons, Kans. 
Peterson, Frederick, M. D., Instructor in Nervous and Mental Diseases 

Columbia College, 4 W. Fiftieth St, New York, N. Y. 
Pettit, Louis C, M.D., Assistant Physician Manhattan State Hospital, 

Ward's Island, New York, N. Y. (Associate.) 
Pilgrim, Charles W., M. D., Medical Superintendent Hudson River State 

Hospital, Poughkeepsie, N. Y. 
Pomeroy, £. H., M.D., The Moraine, Highland Park, 111. 
Porteous, Carlyle A., M. D., Assistant Superintendent Protestant Hospital 

for the Insane, Montreal, Caa (Associate,) 
Potter, Ezra B., M.D., Assistant Physician Rochester State Hospital, 

Rochester, N. Y. 
Powell, Theophilus O., M. D., Medical Superintendent Georgia State Sani- 
tarium, Milledgeville, Ga. (President, 1897.) 
Preston, R. J., M. D., Medical Superintendent Southwestern State Hospital, 

Marion, Va. (President, J902.) 
Prout, Thos. P., M.D., Assistant Physician Fair Oaks, Summit, N. J. 

(Associate,) 
Punton, John, M. D., Superintendent Private Sanitarium; Professor Ner- 
vous and Mental Diseases University Medical College, Kansas City, 

Mo. 
Putnam, Emma, M. D., Assistant Physician Hudson River State Hospital, 

Poughkeepsie, N. Y. 
Quinby, Hosea M., M. D., Medical Superintendent Worcester Insane 

Hospital, Worcester, Mass. 
Ratliff, J. M., M. D., Resident Medical Superintendent Dayton Sanitarium, 

Dayton, Ohio. 
Redwine, J. S., M. D., Superintendent Eastern Kentucky Asylum for the 

Insane, Lexington, Ky. 
Regis, Emmanuel, M. D., Bordeaux, France. (Honorary,) 
Richardson, D. D., M. D., Resident Physician Department for Men State 

Hospital for the Insane, Norristown, Pa. 
Richardson, Wm. W., M. D., Assistant Physician Columbus Hospital, 

Columbus, Ohio. (Associate,) 
Riggs, Charles Eugene, M. D., Professor of Nervous and Mental Diseases 

University of Minnesota ; Chairman Lunacy Commission, 595 Dayton 

Ave., St Paul, Minn. 
Ritti, Antoine, M. D., Maison Nationale de Charenton, Charenton, pr^ 

Paris, France. (Honorary.) 
Robertson, Frank W., M. D. (formerly General Superintendent New York 

State Reformatory at Elmira), 411 West End Ave., New York. 
Robinson, J. F., M.D. (formeriy Medical Superintendent State Hospital 

No. 3), Nevada, Mo. 



LIST OF MEMBERS. 23 

Rogers, Arthur C, M. D., Superintendent Minnesota School for the Fee- 
ble-Minded, Faribault, Minn. 

Rogers, Joseph G., M. D., Medical Superintendent Northern Indiana Hos- 
pital for the Insane, Longdiff, Logansport, Ind. (President, igoo.) 

Rowe, G. H. M., M.D., Superintendent and Resident Physician City 
Hospital, Boston, Mass. 

Rowe, John T. W., M.D., First Assistant Physician Manhattan State 
Hospital, Ward's Island, New York, N. Y. (Associate,) 

Russell, James, M. D., Medical Superintendent Asylum for the Insane, 
Hamilton, Ont 

Russell, Wm. L., M. D., Medical Inspector State Lunacy Conmiission, 
Albany, N. Y. (Associate,) 

Rutherford, James, M.D., F.R.CP., Edin., F.F.P.S., Superintendent 
Crichton Royal Asylum, Dumfries, Scotland. (Honorary.) 

Ryon, Walter G., M. D., Assistant Physician St Lawrence State Hospital, 
Ogdensburg, N. Y. (Associate,) 

Sachs, B., M. D., 21 E. Sixty-fifth St., New York, N. Y. 

Sanborn, Bigelow T., M. D., Medical Superintendent Maine Insane Hos- 
pital, Augusta, Me. 

Schmid, H. Ernest, M. D., White Plains, N. Y. 

Scribner, Ernest V., M. D., Medical Superintendent Worcester Insane Asy- 
lum, Worcester, Mass. 

Searcy, James T., M. D., Medical Superintendent The Alabama Hospitals, 
Tuscaloosa, Ala. 

Searl, Wm., M.D., Medical Superintendent Fair Oaks Villa, Cuyahoga 
Falls, Ohio. 

Sefton, Frederick, M.D., The Pines, Auburn, N. Y. 

Semelaigne, R^^, M. D., Medecin en Chef Maison de Sant£, Neuilly sur 
Seine, Paris, France. (Honorary,) 

Shanahan, Wm. T., M. D., Second Assistant Physician Craig Colony for 
Epileptics, Sonyea, N. Y. (Associate,) 

Sharp, Edward A., M. D., Physician-in-Charge Hillboume Farms, Katonah, 
N. Y. (Associate.) 

Shepherd, Arthur F.^ M. D., Superintendent Dayton State Hospital, Dayton, 
Ohio. 

Shirres, David Alexander, M. D., Consulting Neurologist to the Protestant 
Hospital for the Insane, 919 Dorchester St, Montreal, Can. (Asso- 
ciate.) 

Simpson, J, C, M. D., 1728 isth St, N. W., Washington, D. C. 

Sinclair, Geo. L., M. D. (formerly Medical Superintendent Nova Scotia 
Hospital for the Insane), Provincial Inspector of Hospitals and 
Asylums, 25 Tobin St, Halifax, N. S. 

Skoog, A. L., M. D., Assistant Physician Parsons State Hospital for 
Epileptics, Parsons, Kans. (Associate,) 

Slocum, Qarence J., M. D., Resident Physician Dr. MacDonald's House, 
Pleasantville, Westchester Co., N. Y, (Associate,) 



24 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Smiley, Alton L., M. D., Amsterdam Eye and Ear Hospital, 230 W. Thirty- 
eighth St, N. Y. (Associate.) 

Smith, Edwin Everett, M. D. (formerly Medical Director New Jersey 
State Hospital), Kensett, South Wilton, Conn. 

Smith, Geo. A., M. D., Medical Superintendent Central Islip State Hos- 
pital, Central Islip, L. I., N. Y. 

Smith, Gilbert T., M. D., Assistant Physician State Hospital for the Insane, 
Danville, Pa. (Associate.) 

Smith, J. W., M. D., Superintendent State Hospital No. i, Fulton, Mo. 

Smith, S. E., M. D., Medical Superintendent Eastern Indiana Hospital for 
the Insane, Richmond, Ind. 

Smith, Stephen, M. D., 3 W. 92d St, New York, N. Y. (Honorary.) 

Somers, Elbert M., Jr., M. D., Assistant Physician St Lawrence State 
Hospital, Ogdensburg, N. Y. (Associate.) 

Spellman, Dwight Seymour, M. D., Assistant Phsrsician Manhattan State 
Hospital, Ward's Island, New York, N. Y. (Associate.) 

Spence, James Bevendge, M. D., R. U. I., M. Ch., Resident Physician and 
Superintendent Staffordshire County Asylum, Bumtwood near Litch- 
field, England. (Honorary.) 

Sprague, Geo. P., M. D., Superintendent High Oaks Sanitarium, Lexington, 
Ky. 

Spratling, Wm. P., M. D., Superintendent Craig Colony for Epileptics, 
Sonyea, N. Y. 

Stack, M. J., M. D., Assistant Physician Government Hospital for the 
Insane, Washington, D. C. (Associate.) 

Stanley, Charles E., M. D., Assistant Physician Connecticut Hospital for 
the Insane, Middletown, Conn. (Associate.) 

Steams, Wm. G., M. D., Medical Superintendent Oakwood and Lakeside 
Sanitarium, Lake Geneva, Wis. 

Stedman, Henry R., M. D., Boumewood Private Hospital for Nervous and 
Mental Diseases, South St, Brookline, Mass. 

Stevens, Frank T., M. D., Assistant Physician Mt Pleasant State Hospital, 
Mt Pleasant, la. 

Stewart, Nolan, M. D., Assistant Physician State Insane Hospital, Asylum, 
Miss. 

Stockton, Geo., M. D., Superintendent Columbus State Hospital, Columbus, 
Ohio. 

Stoker, Wm. A., M. D., Superintendent Southern Indiana Hospital for the 
Insane, Evansvillc, Ind. 

Stone, William A., M. D., Acting Medical Superintendent Michigan Asy- 
lum for the Insane, Kalamazoo, Mich. 

Stout, E. G., M. D., Assistant Physician Utica State Hospital, Utica, N. Y. 

(Associate.) 
Sweeney, Arthur, M. D., Professor of Medical Jurisprudence University of 
Minnesota; Neurologist to St Joseph's, St Luke's, and City and 
County Hospital. St Paul, Minn. 



LIST OF MEMBERS. 2$ 

Swift, Henry M., M. D., Assistant Physician Danvers Insane Hospital, 
Hathome, Mass. (Associate.) 

Taddiken, Paul Gerald, M. D., Assistant Physipian Long Island State Hos- 
pital, Brookljrn, N. Y. (Associate.) 

Tamburini, A., M.D., Reggio-Emilia, Italy. (Honorary.) 

Taylor, Isaac M., M. D., Physician-in-Charge Broad Oaks Sanatorium, 
Morganton, N. C 

Thompson, J. L., M. D., Assistant Physician State Hospital for the Insane, 
Columbia, S. C. (Associate.) 

Thompson, Whitefield N., M.D., Medical Superintendent The Hartford 
Retreat, Hartford, Conn. 

Tobey, Henry A., M. D., Medical Superintendent Toledo State Hospital, 
Toledo, Ohio. 

Tomlinson, H. A., M. D., Medical Superintendent St Peter State Hospital, 
St. Peter, Minn. 

Tomcy, Geo. H., Jr., M. D., Assistant Physician Utica State Hospital, Utica 
N. Y. 

Toulouse, Edouard, M. D., Physician-in-Chief to Villejuif Asylum; Direc- 
tor Revue de Psychiatric; Director of Laboratory of Experimental 
Psychology, TEcole des Hautes Etudes, Paris; Villejuif (Seine), 
France. (Honorary,) 

Townsend, Theodore Irving, M. D., Assistant Physician Utica State Hos- 
pital, Utica, N. Y. 

Turner, John S., M. D., Superintendent North Texas Hospital for the 
Insane, Terrell, Tex» 

Turner, O. M., M. D., Pathologist to State Insane Hospital, Jackson, Miss. 

Tuttle, Geo. T., M. D., Medical Superintendent McLean Hospital, Waverley, 
Mass. 

Urquhart, Alexander R., M. D., F. R. C. P. E., Superintendent Rojral Asy- 
lum, Perth, Scotland. (Honorary.) 

Van Deusen, Edwin H., M. D. (formerly Superintendent Michigan Asy- 
lum for the Insane), Kalamazoo, Mich. 

Villcneuve, George, M. D., Medical Superintendent Saint Jean de Dieu 
Hospital for the Insane, Longue Pointe, Que. 

Voight, Amo C, M. D., Hawley, Pa. (Associate.) 

Voldeng, M. Nelson, M. D., Superintendent Cherokee State Hospital, Cher- 
okee, la. 

Wade, J. Percy, M. D., Medical Superintendent Maryland Hospital for the 
Insane, Catonsville, Md. 

Wagner, Charles G., M. D., Medical Superintendent Binghamton State 
Hospital, Binghamton, N. Y. 

Walker, Irving Lee, M. D., Assistant Physician Central Islip State Hos- 
pital, Central Islip, L. I. (Associate.) 

Walker, Lewis M., M. D., Assistant Physician Medfield Insane Asylum, 
Harding, Mass. (Associate.) 

Wallace, D. R., M. D., Waco, Tex. (Honorary.) 



26 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Ward, John W., M. D., Medical Director New Jersey State Hospital, Tren- 
ton, N. J. 

Weeks, Henry M., M. D., Medical Superintendent New Jersey State "Vil- 
lage for Epileptics, Skillman, N. J. 

Welch, G. O., M. D., Medical Superintendent Fergus Falls State Hospital, 
Fergus Falls, Minn. 

Wentworth, Lowell F., M. D., Deputy Executive Officer State Board of In- 
sanity, Boston, Mass. 

West, Calvin B., M. D., Assistant Physician Central Islip State Hospital, 
Central Islip, L. I., N. Y. (Associate.) 

Wherry, J. W., M.D., Medical Superintendent "Glcnwood," Dansville, 
N. Y. (Associate,) 

White, M. J., M. D., Medical Superintendent Milwaukee Hospital for the 
Insane, Wauwatosa, Wis. 

White, Whitman V., MD., Consulting Physician Manhattan State Hos- 
pital, 20x6 Fifth Ave., New York, N. Y. 

White, Wm. A., MD., Superintendent Government Hospital for the In- 
sane, Washington, D. C. 

Whitman, F. S., M. D., Superintendent Illinois Northern Hospital for the 
Insane, Elgin, 111. 

Wilcox, Franklin S., M. D., First Assistant Physician Fergus Falls State 
Hospital, Fergus Falls, Minn. (Associate.) 

Wilgus, Sidney D., M. D., Medical Examiner New York State Board of 
Alienists, 47 R 58th St, New York. 

Williams, G. H., M. D., Assistant Physician Columbus State Hospital, 
Columbus, Ohio. (Associate.) 

Williamson, Alonzo P., M D., Superintendent Southern California Hospital 
for Insane, Patton, Cal. 

Wilsey, O. J., M. D., Physician-in-Charge Long Island Home, Amityville, 
N. Y. 

Wingate, Uranus O., M. D., Professor Nervous and Mental Diseases Wis- 
consin College of Physicians and Surgeons; Neurologist St Mary^s 
and Milwaukee County Hospitals; Consultant in Neurology to St 
Joseph's Hospital; Honorary Member Medical and Surgical Staff 
Milwaukee Hospital for Chronic Insane; Physician-in-Chief Rest- 
haven Sanatorium, 204 Biddle St, Milwaukee, Wis. 

Wise, Peter M., M. D., 502 W. 143d St, Washington Heights, New York. 
(President, 1901.) 

Witte, M E., M. D., Medical Superintendent Clarinda State Hospital, 
Qarinda, la. 

Wolfe, Mary Moore, M. D., Resident Physician Department for Women 
Norristown State Hospital, Norristown, Pa. 

Woodbury, Chas. R, M. D., Medical Superintendent Foxboro State Hos- 
pital, Foxboro, Mass. 

Woodson, C. R, M. D., Medical Superintendent State Hospital No. 2, St 
Joseph, Mo. 



UST OF MEMBERS. 27 

Work, Hubert, M. D., Superintendent and Proprietor Woodcroft Hospital 

for Nenrous Diseases, Pueblo, G)l. 
Worsham, B. lii., lii.D., Superintendent State Hospital for the Insane, 

Austin, Tex. 
Wright, W. £., M. D., Assistant Physician Pennsylvania State Hospital, 

Harrisburg, Pa. (Associate.) 
Yellowlees, David, M.D., RRP.S., LL.D., Physician-Superintendent 

Glasgow Royal Asylum, Gartnaval, Glasgow, Scotland. (Honorary.) 



2S AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 



GEOGRAPHICAL DISTRIBUTION 

OP 

MEMBERS AND INSTITUTIONS. 



ALABAMA — The Alabama Insane Hospitals. 
The Bryce Hospital, Tuscaloosa 
The Mt. Vernon Hospital, Mt. Vernon. 
James T. Searcy, M. D., Superintendent 

Eugene D. Bondurant, M.D., i66 Conti St, Mobile 

ARIZONA— Territorial Insane Asylum, Phcenix. 

ARKANSAS — State Asylum, Little Rock. 

CALIFORNIA— Stockton State Hospital, Stockton. 
Napa State Hospital, Napa 
Agnews State Hospital, Agnews. 
Southern California State Hospital, Patton. 
Alonzo P. Williamson, Superintendent 

Merntt B. Campbell, M. D., 1608 Orange St, Los Angeles. 
James H. McBride, Pasadena. 

MENDoaNO State Hospital, Mendoono. 

COLORADO — Colorado State Insane Asylum, Pueblo. 
A. P. Busey, M. D., Superintendent 

WooDROFT Hospital, Pueblo. 

Hubert Work, M. D., Superintendent 
R. F. Damall, Assistant Physician. 

Arthur McGugan, M. D., Denver. 
J. Elvin Courtney, M. D., Denver. 

CONNECTICUT— The Hartford Retreat, Hartford. 
Whitefield N. Thompson, Superintendent. 

CoNNEcncuT Hospital for the Insane, Middletown. 
Henry S. Noble, M. D., Superintendent 



GEOGRAPHICAL DISTRIBUTION MEMBERS AND INSTITUTIONS. 29 

Charles £. Stanley, M. D.» Assistant Physician. 
Arthur B. G)lebarn, M. D., Assistant Physician. 
Allen R. Diefendorf, M. D., Pathologist. 

Edwin Everett Smith, M. D., Kensett, South Wilton. 
Amos J. Givens, M.D., Stamford Hall, Stamford. 
George H. Knight, M.D., Lakeville. 
James M. Keniston, M.D., Hartford Hospital, Hartford. 

DELAWARE— Delawake Statz Hospital, Farnrukst. 
W. H. Hancker, M. D., Superintendent 

DISTRICT OF COLUMBIA-~GovERNMENT Hospital for the Insane, 

Washington. 

William A. White, M. D., Superintendent 
M. J. Stack, M. D., Assistant Physician. 
Benj. Rush Logic, M. D., Assistant Physician. 
I. W. Blackburn, M.D., Pathologist 
Cornelius De Weese, M. D., Clinical Pathologist 

J. C Simpson, M. D., 1728 isth St, N. W., Washington. 

FLORIDA — Asylum for the Indigbnt Insane, Chattahoochee. 

GEORGIA — State Sanitarium, Milledgeville. 

Theophilus O. Powell, M. D., Superintendent 
Edward M. Green, M. D., Assistant Physician. 

Henry D. Allen, M. D., Invalid's Home, MilledgeviUe. 
W. Herbert Adams, M. D., 102 Liberty St, East, Savannah. 

IDAHO— Idaho Insane Asylum, Blackfoot. 
John W. Givens, M. D'., Superintendent. 

ILLINOIS— Illinois Central Hospital for the Insane, Jacksonvillx. . 
Ilunois Northern Hospital for the Insane, Elgin. 
F. S. Whitman, M. D., Superintendent 

IixiNois Southern Hospital for the Insane, Anna. 
Illinois Eastern Hospital for the Insane, Hospital. 
Ilunois Western Hospital for the Insane, Watertown. 
IixiNois Hospital for Insane Criminals, Menard. 
Ilunois Asylum for the Incurable Insane, Bartonville. 
Cbox County Hospital for the Insane, Dunning. 

Frederick H. Daniels, M. D., Bellevue Place, Batavia. 

D. R. Brow'er, M. D., 34 and 36 Washington St, Chicago. 

Sanger Brown, M. D., 100 State St., Chicago. 



30 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Henry F. Carriel, M. D., Jacksonville. 

Henry M. Bannister, M. D., 828 Judson Ave., Evanston. 

E. H. Pomcroy, M. D., Highland Park. 

Frank P. Norbury, M. D., Jacksonville. 

INDIANA — Central Indiana Hospital for the Insane, Indianapous. 
Geo. F. Edenharter, M. D., Superintendent 
Eastern Indiana Hospital for the Insane, Richmond. 

5. E. Smith, M. D., Superintendent. 

Northern Indiana Hospital for the Insane, Longcuff, Logansfoki: 

Joseph G. Rogers, M. D., Superintendent 
Southern Indiana Hospital for the Insane, Evansville. 

Wm. A. Stoker, M. D., Superintendent 

IOWA— Mt. Pleasant State Hospital, Mt. Pleasant. 
Chas. F. Applegate, M. D., Superintendent 
Frank T. Stevens, M. D., Assistant Physician. 
Anne Burnet, M. D., Assistant Physician. 
Geo. M. Kline, M. D., Assistant Physician. 

Independence State Hospital, Independence. 
W. P. Crumbacker, M. D., Superintendent 
Susanna P. Boyle Hamilton, M. D., Assistant Physician. 

Clarinda State Hospital, Clarinda. 
M. E. Witte, M.D., Superintendent 

Cherokee State Hospital, Cherokee. 

M. Nelson Voldeng, M. D., Superintendent 

Mercy Hospital, Davenport. 

John H. Kulp, M. D., Superintendent 

Gershom H. Hill, M. D., Equitible Bldg., Des Moines. 

KANSAS— OsAWATOMiE State Hospital^ Osawatomie. 
ToPEKA State Hospital^ Topeka. 
State Hospital for Epileptics, Parsons. 

M. L. Perry, M. D., Superintendent 

A. L. Skoog, M. D., Assistant Physician. 

6. D. Eastman, M. D., Topeka. 

KENTUCKY— Eastern Kentucky Asylum for the Insane, Lexington. 

J. S. Redwine, M.D., Superintendent 
Central Kentucky Asylum for the Insane, Lakeland. 
Western Kentucky Asylum for the Insane, Hopkinsville. 

George P. Sprague, M. D., Lexington. 



GEOGRAPHICAL DISTRIBUTION MEMBERS AND INSTITUTIONS. 3I 

LOUISIANA— Louisiana Insane Asylum, Jackson. 

MAINE — ^Maine Insane Hospital, Augusta 

Bigelow T. Sanborn, M. D., Superintendent 
Horace B. Hill, M. D., Assistant Superintendent. 
Eastern Maine Insane Hospital, Bangor. 

MARYLAND — Mount Hope Retreat, Baltimore. 
Charles G. Hill, M. D., Attending Physician. 

Maryland Hospital for the Insane, Catonsville. 
J. Percy Wade, M D., Superintendent 
R. Edward Garrett, Assistant Physician. 

Springfield State Hospital, Sykesville. 

Joseph Clement Clark, M. D., Superintendent 

Sheppard and Enoch Pratt Hospital, Towson. 

Edward N. Brush, M. D., Physician-in-Chief and Superintendent 
W. R. Dunton, Jr., M. D., Assistant Physician. 
Chas. M Franklin, M. D., Assistant Physician. 

R. F. Gundry, M. D., Richard Gundry Home, Catonsville. 

Henry M. Hurd, MD., Superintendent Johns Hopkins Hospital, 
Baltimore. 

Henry J. Berkley, M. D., Baltimore. 

A. T. Gundry, M. D., The Gundry Sanitarium, Catonsville. 

Stewart Paton, M. D., Baltimore. 

Jesse C. Coggins, M. D., Physician-in-Charge Beaumont Sani- 
tarium, Laurel. 

MASSACHUSETTS— McLean Hospital, Waverley. 
Geo. T. Tuttle, M.D., Superintendent 
E. Stanley Abbot, M. D., Assistant Physician. 
Emma W. Mooers, M. D., Assistant Physician. 
August Hoch, M. D., Assistant Physician and Pathologist. 

Boston Insane Hospital. 

William Noyes, M. D., Superintendent, Mattapan. 
Fred B. Colby, M. D., Assistant Physician Women's Department, 
New Dordiester. 

Worcester Insane Asylum, Worcester. 

Ernest V. Scribner, M. D., Superintendent 

P. Challis Bartlett, M. D., Assistant Physician. 

Worcester Insane Hospital, Worcester. 
Hosea M. Quinby, M. D., Superintendent 
Alfred I. Noble, M. D., Assistant Superintendent 
Isador H. Coriat, M. D., Assistant Physician. 
Theodore A. Hoch, M. D., Assistant Physician. 



32 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Danvers Insane Hospital, Hathorne. 

Chas. W. Page, M. D., Superintendent 

H. Walter Mitchell, M. D., Assistant Physician. 

Albert M. Barrett, M. D., Pathologist 

Harry A. Cotton, M. D., Assistant Physician. 

Henry M. Swift, M. D., Assistant Physician. 
Taunton Insane Hospital, Taunton. 

John P. Brown, M. D., Superintendent 

Arthur V. Goss, M. D., Assistant Physician. 

Harry William Miller, M. D., Pathologist 

Benjamin W. Baker, M. D., Assistant Physician. 

Northampton Insane Hospital, Northampton. 
John A. Houston, M. D., Superintendent 

Medfield Insane Asylum, Harding. 

Edward French, M. D., Superintendent. 

Lewis M. Walker, M. D., Assistant Physician. 
Westborough Insane Hospital, Westborough. 

George S. Adams, M. D., Superintendent 

Henry I. Klopp, M. D., Assistant Physician. 

Solomon C. Fuller, M. D., Assistant Physician. 

Ida J. Brooks, M. D., Assistant Physician. 

Qifford J. Huyck, M. D., Assistant Physician. 

FoxBORO State Hospital, Foxboro. 

Charles E. Woodbury, M. D., Superintendent 

State Hospital, Tewksbury. 

John H. Nichols, M. D., Superintendent 

Channing Sanitarium, Brookline. 

Walter Channing, M. D., Superintendent 
W. M. Knowlton, M. D. 

Asylum for Insane Criminals, State Farm. 
C. A. Drew, M.D., Medical Director. 

State Colony for Insane, Gardner. 

Joseph B. Howland, M. D., Superintendent 

Massachusetts Hospital for Epileptics, Palmer. 
Everett Flood, M. D., Superintendent 

T. W. Fisher, M. D., Boston. 

George F. Jelly, M. D., 69 Newbury St, Boston. 

Henry R. Stedman, M. D., South St, Brookline. 

N. Emmons Paine, M. D., The Newton Sanatorium, West Newtoo. 

Alice Bennett, M. D., Wrentham. 

G. H. M. Rowe, M. D., City Hospital, Boston. 

Walter E. Fernald, M. D., Waverley. 

Lowell F. Wentworth, M. D., State House, Boston. 



GEOGRAPHICAL DISTHIBUTION MEMBEBS AND INSTITUTIONS. 33 

Henry C Baldwin^ M. D., ia6 Commonwealth Ave., Boston. 

J. L. Hildreth, M. D., 14 Garden St, Cambridge. 

Herbert B. Howard, M. D., Massachusetts General Hospital, 

Boston. 
Lewis L. Bryant, M. D., Cambridge. 
Edward B. Lane, M. D., 419 Boylston St, Boston. 
Owen Copp, M. D., Boston. 
H. W. Page, M. D., Baldwinville. 
Emily Pagelson Howard, M. D., Boston. 
Edward B. Nims, M. D., Springfield. 
J. F. Edgerly, M. D., Newtonville. 
James B. Ayer, M. D., 518 Beacon St, Boston. 
Charles G. Dewey, M. D., 539 Talbot Ave., Dorchester. 
Arthur C Jelly, M. D., 69 Newbury St, Boston. 
Edward Cowles, M. D., Warren Chambers, 419 Boylston St, 

Boston. 

MICHIGAN— Michigan Asylum for the Insane, Kalamazoo. 

William A. Stone, M. D., Acting Superintendent 

Herman Ostrander, M. D., Assistant Physician. 

George F. Inch, M. D., Assistant Physician. 
Eastern Michigan Asylum, Pontiac 

E. A. Christian, M. D., Superintendent 

Jason Morse, M. D., Assistant Superintendent 

Irwin H. Neff, M. D., Assistant Physician. 

Homer E. Clark, M. D., Assistant Physician. 
Northern Michigan Asylum, Traverse City. 

James D. Munson, M. D., Superintendent 
Asylum for Dangerous and Criminal Insane, Ionia. 
Upper Peninsula Hospital for the Insane, Newbbrry. 

G. L. Chamberlain, M. D., Superintendent 
St. Joseph's Retreat, Dearborn. 

J. R Emerson, M. D., Attending Physician. 
Oak Grove Hospital, Flint. 

C. B. Burr, M.D., Medical Director. 

H. R. Niles, M. D., Assistant Physician. 

Chas. B. Macartney, M. D., Assistant Physician. 

E. H. Van Deusen, M. D., ICalamazoo. 

Chas. W. Hitchcock, M. D., 270 Woodward Ave., Detroit 

Walter P. Manton, M. D., 32 Adams Ave., West, Detroit 

MINNESOTA— St. Peter State Hospital, St. Peter. 
H. A. Tomlinson, M. D., Superintendent 
W. H. Darling, M. D., Assistant Superintendent 

Rochester State Hospital Rochester. 

Arthur F. Kilboume, M. D., Superintendent 
3 



34 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Fergus Falls State Hospital, Fergus Falls. 
G. O. Welch, M.D., Superintendent 
Franklin S. Wilcox, First Assistant Physician. 

Arthur C Rogers, M.D., Faribault 
G. A. Chilgren, M. D., Sauk Rapids. 
C Eugene Riggs, M. D., St Paul. 
Arthur Sweeney, M. D., St Paul. 

MISSISSIPPI— State Insane Hospital, Asylum P. O. 
Thomas J. Mitchell, M. D., Superintendent 
Nolan Stewart, M. D., Assistant Physician. 
O. M. Turner, M. D., Pathologist (Jackson). 
East Mississippi Insane Hospital, Meridian. 
J. M. Buchanan, M. D., Superintendent 

MISSOURI — St. Vincent Institution for the Insane, St. Louia 
State Hospital No. i, Fulton. 

J. W. Smith, M. D., Superintendent 
State Hospital No. 2, St. Joseph. 

C. R. Woodson, M. D., Superintendent 
State Hospital, Farmington. 

Lemuel T. Hall, M. D., Superintendent 
Colony for Feeble Minded and Epileptic, Marshall. 
Crrv Asylum, St. Louis. 

Charles H. Hughes, M. D., St Louis 
Charles G. Chaddock, M. D., St Louis. 
George C. Crandall, M. D., St Louis. 
John Punton, M. D., Kansas City. 
Frank R. Fry, M. D., St Louis. 
J. F. Robinson, M. D., Nevada, Mo. 

NEBRASKA — Nebraska Hospital for the Insane, Lincoln. 
Asylum for the Chronic Insane, Hastings. 
Norfolk Hospital for the Insane, N^/rfolk. 

NEVADA — Nevada Hospital for Mental Diseases, Reno. 

NEW HAMPSHIRE— New Hampshire State Hospital, Concord. 
Charles P. Bancroft, M. D., Superintendent 
Frederick L. Hills, M. D., Assistant Superintendent. 
Harold C. Goodwin, M. D., Assistant Physician. 
Geo. H. Maxfield, M. D., Assistant Physician. 
Highland Spring Sanatorium, Nashua. 

Albert Edward Brownrigg, M. D., Superintendent 



GEOGRAPHICAL DISTRIBUTION MEMBERS AND INSTITUTIONS. 35 

NEW JERSEY— New Jersey State Hospital, Morris Plains. 
B. D. Evans, M. D., Medical Director. 
Peter S. Mallon, M. D., Assistant Physician. 
Christopher C. Beling, M. D., Assistant Physician. 
Raymond D. Baker, M. D., Assistant Physician. 
Harry A. Cossitt, M. D., Second Assistant Physician and Patholo- 
gist 
New Jersey State Hospital, Trenton. 

John W. Ward, M. D., Medical Director. 

John C Felty, M. D., Assistant Physician. 

Paul Lange Cort, M. D., Assistant Physician. 

Giarles Lewis Allen, M. D., Pathologist and Assistant Physician. 

New Jersey State Village for Epileptics, Skillman. 
Henry M. Weeks, M. D., Superintendent 

L S. Hinckley, M. D., Newark. 
Eliot Gorton, M. D., Summit. 
D. M. Dill, M.D., Newark. 
Thomas P. Prout, M. D., Summit 

NEW YORK— Bloomingdale Asylum, White Plains. 
Samuel B. Lyon, M. D., Superintendent. 
Charles E. Atwood, M. D., Assistant Physician. 
Albert Durham, M. D., Assistant Physician. 

Manhattan State Hospital, Ward's Island, New York City. 
Emmet C. Dent, M. D., Superintendent. 
John T. W. Rowe, M. D., First Assistant Physician. 
Louis C. Pettit, M. D., Second Assistant Physician. 
Dwight S. Spellman, M. D., Assistant Physician. 
John Rudolph Knapp, M. D., Assistant Physiciaa 
Frank H. Magness, M. D., Assistant Physician. 
Qarcnce F. Haviland, M. D., Assistant Physician. 
Anna E. Hutchinson, M. D., Woman Assistant Physician. 

Central Isup State Hospital, Central Islip, L L 
George A. Smith, M. D., Superintendent 
Calvin B. West, M. D., Assistant Physician. 
Irving Lee Walker, M. D., Assistant Physician. 

Long Island State Hospital, Brooklyn. 
O. M. Dewing, M. D., Superintendent 
Paul G. Taddiken, M. D., Assistant Physiciaa 

Kings Park State Hospital, Kings Park. 

William Austin Macy, M. D., Superintendent 
De Witt C. MacClymont, M. D., Assistant Physician. 
John Irvine McKelway, M. D., Assistant Physician. 
George O'Hanlon, M. D., Assistant Physician. 



36 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Hudson River State Hospital, Poughkeepsix. 

C. W. Pilgrim, M. D., Superintendent 
Giarles H. Langdon, M. D., Assistant Physiciaa 
Thomas £. Bamford, M. D., Assistant Physician. 
Emma Putnam, M. D., Assistant Physician. 
Isham G. Harris, M. D., Assistant Physician. 
Frederick W. Parsons, M. D., Assistant Physician. 

Massball Sanitarium, Troy. 
Hiram Elliott, M. D., Superintendent 

Utica State Hospital, Utica 

Harold L. Palmer, M. D., Superintendent 

£. G. Stout, M. D., Assistant Physician. 

George H. Tomey, Jr., M. D., Assistant Physician. 

Theodore I. Townsend, M. D., Assistant Physician. 

BiNGHAMTON StATE HOSPITAL, BiNGHAMTON. 

Charles G. Wagner, M. D., Superintendent. 

St. Lawrence State Hospital, Ogdensburg. 
R. H. Hutchmgs, M. D., Superintendent. 
Caroline S. Pease, M. D., Assistant Physician. 
Elbert M. Somers, Jr., M. D., Assistant Physician. 
Roy L. Leak, M. D., Assistant Physician. 
Walter G. Ryon, M. D., Assistant Physician. 
Charles M. Burdick, M. D., Assistant Physician. 
Ethan A. Nevin, M. D., Assistant Physician. 

Matteawan State Hospital, Fishkill Landing. 
Robert B. Lamb, M. D., Superintendent 

Brigham Hall, Canandaigua. 

D. R. Burrell, M. D., Resident Physician. 

Willard State Hospital, Willard. 

Robert M. Elliott, M. D., Superintendent 
Chester Lee Carlisle, M. D., Assistant Physiciaa 
Erving Holley, M. D., Assistant Physician. 
Robert E. Doran, M. D., Assistant Physician. 
Wm. H. Montgomery, M. D., Assistant Physician. 

Rochester State Hospital, Rochester. 

Eugene H. Howard, M. D., Superintendent 
Eveline P. Ballintine, M. D., Assistant Physician. 
Ezra B. Potter, M. D., Assistant Physician. 
Charles T. LaMoure, M. D., Assistant Physician. 

Buffalo State Hospital, Buffalo. 

Arthur W. Hurd, M. D., Superintendent 

Henry P. Frost M. D., Assistant Physician. 

Helene J. C. Kuhlman, M. D., Assistant Physician. 



GEOGRAPHICAL DISTRIBUTION MEMBERS AND INSTITUTIONS. 37 

George G. Armstrong, M. D., Assistant Physician. 
B. Ross Nairn, M. D., Assistant Physiciaa 
Joseph B. Betts, M. D., Assistant Physician. 

liiDOLBTOWN State Homeopathic Hospital, Mibdijctown. 
Maurice C. Ashley, M. D., Superintendent. 

GowANDA State Homeopathic Hospital, Gowaitoa. 
Daniel H. Arthur, M. D., Superintendent 

Dannemoka State Hospital, Daknemoea. 

King's County Hospital, Broof(.yn. 

John F. Fitzgerald, M. D., General Medical Superintendent. 
Wm. B. Moseley, M. D., Assistant Physician. 

State Custodial Asylum, Rome. 

Craig Colony foe Epileptics, Sonyea. 

Wm. P. Spratling, M. D., Superintendent 
Wm. T. Shanahan, M.D., Assistant Physician. 

Daniel A. Harrison, M. D., Breezehurst Terrace, Whitestone, L. I. 
Peter M. Wise, M. D., S02 W. 143d St, Washington Heights, 

New York. 
Carlos F. MacDonald, M. D., ap East 44th St, New York. 
Ralph L. Parsons, M. D., Greenmont-on-Hudson, Ossining P. O. 
Frank Livingston Grosvenor, M. D., 32 Nassau St 
Alton L. Smiley, M. D., Amsterdam Eye and Ear Hospital, 230 W. 

Thirty-eighth St 
O. J. Wilsey, M. D., Long Island Home, Amityville. 
Frederick Sefton, M. D., The Pines, Auburn. 
William D. Granger, M. D., Vernon House, Bronxville. 
Frederick Peterson, M. D., 4 W. Fiftieth St, New York. 
Garence J. Slocum, M. D., Pleasantville, Westchester Co. 
Sidney D. Wilgus, M. D., 47 E. s8th St, New York. 
B. Sachs, M. D., 21 E. Sixty-fifth St, New York. 
H. Ernest Schmid, M. D., White Plains. 
Theo. H. Kellogg, M. D., Riverdale, New York. 
J. M. Mosher, M. D., 170 Washington Ave., Albany. 
J. Joseph Kindred, M. D., River-Crest Sanitarium, Astoria, L. I. 
Willett S. Brown, M. D., Sanford Hall, Flushing. 
Austin Flint, M. D., 60 E. Thirty-fourth St., New York. 
Walter R. Gillette, M. D., 24 W. Fortieth St, New York. 
Flavius Packer, M. D., River-Crest Sanitarium, Astoria, L. L 
Arthur H. Harrington, M. D., 616 Madison Ave., New York. 
Whitman V. White, M. D., 2016 Fifth Ave., New York. 
William Hirsch, M. D., 52 E. Sixty-fourth St, New York. 
Frank W. Robertson, M. D., 411 West End Ave., New York. 
Adolf Meyer, M. D., Ward's Island. 
George B. Campbell, M. D., 78 Irving Place. New York. 



38 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Edward A. Sharp, M. D., Physician-in-Charge Hillboume Farms, 
Katonah, N. Y. 

Percy Bryant, M. D., 134 Hawthorne St, Brooklyn. 

Wm. Mabon, M. D., President State Commission in Lunacy, 
Albany. 

A. R Macdonald, M. D., Columbia Court, 431 Riverside Ave., cor. 
115th St 

Wm. L. Russell, M. D., State Commission in Lunacy, Albany. 

H. L. Barnes, M. D., Contagious Hospital, Kingston Ave., Brook- 
lyn. 

Wm. E. Dold, M. D., Falkirk, Central Valley. 

J. W. Wherry, M. D., Medical Superintendent " Glenwood," Dans- 
ville. 

James R. Bolton, M. D., Physician-in-Charge, "Riverview," Fish- 
kill-on-Hudson, N. Y. 

NORTH CAROLINA— State Hospital, Raleigh. 

James McKee, M. D., Superintendent. 
State Hospital, Morganton. 

P. L. Murphy, M. D., Superintendent. 
State Hospital, Goldsboro. 

John F. Miller, M. D., Superintendent 

Isaac M. Taylor, M. D., Morganton. 

NORTH DAKOTA— State Hospital for the Insane of North Dakota, 

Jamestown. 
Dwight S. Moore, M. D., Superintendent. 

OHIO — ^LoNGviEw Hospital, Carthage. 

F. W. Harmon, M. D., Superintendent 

Dayton State Hospital, Dayton. 

Arthur F. Shepherd, M. D., Superintendent 

Columbus State Hospital, Columbus. 
Geo. Stockton, M.D., Superintendent 
Geo. T. Harding, Jr., M. D., First Assistant Physician. 
Wm. W. Richardson, M. D., Assistant Physician. 

G. H. Williams, M. D., Assistant Physician. 
Earle R Gaver, M. D., Assistant Physician. 
Isabel A. Bradley, M. D., Pathologist 

Athens State Hospital, Athens. 

Cleveland State Hospital, Cleveland. 
A. B. Howard, M. D., Superintendent 
James F. Kelly, M. D., Assistant Physician. 

T01.ED0 State Hospital, Toledo. 

H. A. Tobey, M. D., Superintendent 



GEOGEtAPHICAL DISTRIBUTION MEMBERS AND INSTITUTIONS. 39 

Massuxon Stats Hospital, MassiujON. 
H. C Eyman, M. D., Superintendent 
Caroline Colver, M. D., Assistant Physician. 
Edson C. Brown, M. D., Assistant Physician. 
D. R Harris, M. D., Assistant Physician. 
Jas. M. McGeorge, M. D., Assistant Phjrsician. 
John D. O'Brien, M. D., Assistant Physician. 

George F. Cook, M. D., Oxford Retreat, Oxford. 

R. Harvey Cook, M. D., Oxford Retreat, Oxford. 

Wm. Searl, M. D., Fair Oaks, Cuyahoga Falls. 

J. M. Lewis, M. D., Cleveland. 

J. M. Ratliff, M.D., Dayton. 

F. W. Langdon, M. D., s Garfield Place, Cincinnati. 

Charles L. Harmer, M. D., Philo, Ohio. 

OREGON — Oregon State Insane Asylum, Salem. 

Henry Waldo Coe, M. D., Medical Director Crystal Springs, Port- 
land. 

PENNSYLVANIA — Pennsylvania Hospital for the Insane, Phil'a. 

John B. Chapin, M. D., Superintendent 

A. R. Moulton, M. D., Senior Assistant Physiciaa 

Henry B. Nunemaker, M. D., Assistant Physician. 
Friends' Asylum for the Insane, Frankford, Philadelphia. 

Robert H. Chase, M. D., Superintendent 

Seymour DeWitt Ludlum, M. D., Assistant Physician. 
Philadelphia Hospital, Insane Department, Philadelphia. 
State Hospital for the Insane, Norristown. 

D. D. Richardson, M. D., Resident Physician Department for Men. 

Mary Moore Wolfe, M. D., Resident Physician Department for 
Women. 

Mary Christiancy, M. D., Assistant Physician. 
Pennsylvania State Hospital, Harrisburg. 

H. L. Orth, M. D., Superintendent 

W. E. Wright, M. D., Assistant Physician. 
State Hospital for the Insane, Warren. 

Morris S. Guth, M. D., Superintendent 
State Hospital for the Insane, Danville. 

Hugh B. Meredith, M. D., Superintendent 

Gilbert T. Smith, M. D., Assistant Physician. 
Western Pennsylvania Hospital for the Insane, Dixmont. 

Henry A. Hutchinson, M. D., Superintendent 
Pennsylvania Epileptic Hospital and Colony Farm, Oakbourne. 
Pennsylvania Training School for Feeble Minded^ Elwyn. 



40 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Asylum for the Chronic Insane, Wernersville. 

S. S. Hill, M.D., Superintendent 
Hospital for the Insane of Luzerne County, Retreat. 
; Charles B. Mayberry, M. D., Superintendent 

Harris May Carey, M. D., Assistant Physiciaa 

Charles K Mills, M. D., 1909 Chestnut St, Philadelphia. 

Jane Rogers Bak«*r, M. D., Embreeville. 

C. Spencer Kinney, M. D., Easton. 
f Edward R Mayer, M. D., Pittsburgh. 

Augustus A Eshner, M. D., 1019 Spruce St., Philadelphia. 
I Amo C. Voigt, M. D., Hawley. 

I George I. McLeod, M.D., 1225 Sansom St, Philadelphia. 

1 RHODE ISLAND — Butler Hospital, Provuxence. 

' G. Alder Blumer, M. D., Superintendent 

Henry C. Hall, M. D., Assistant Physician. 

Wm. McDonald, M. D., Assistant Physician. 

George Stimpson Hathaway, Assistant Physician. 
State Hospital for the Insane, Cranston (Howard P. O.). 

SOUTH CAROLINA — State Hospital for the Insane, Columbia. 
J. W. Babcock, M. D., Superintendent 
J. L. Thompson, M. D., Assistant Physician. 

SOUTH DAKOTA — South Dakota Hospital for the Insane, Yankton. 
L. C. Mead, M. D., Superintendent 
George Sheldon Adams, M. D., Assistant Physician. 

TENNESSEE — Central Hospital for the Insane, Nashvulk. 
John A. Beanchamp, M. D., Superintendent 
Albert R Douglas, M. D., Assistant Physician. 
Eastern Hospital for the Insane, Knoxvilix. 

Michael Campbell, M. D., Superintendent 
Western Hospital for the Insane, Bolivar. 
John P. Douglas, M. D., Superintendent 

William A. Cheatham, M.D., Nashville. 

TEXAS — ^HospiTAL FOR THE Insane, Austin. 

B. M. Worsham, M. D., Superintendent 
T. O. Maxwell, M. D., Assistant Physician. 
N<»TH Texas Hospital for the Insane, Terrell. 

John S. Turner, M. D., Superintendent 
Southwestern Insane Asylum, San Antonio. 
Marvin L. Graves, M. D., Superintendent 
Wilmer L. Allison, Assistant Superintendent 



GEOGRAPHICAL DISTRIBUTION MEMBERS AND INSTITUTIONS. 4I 

UTAH— Utah State Mental Hospital, Peovo City. 
Daniel H. Calder, M. D., Assistant Physician. 

VERMONT— Brattleboro Retreat, Brattleboro. 
Shailer £. Lawton, M. D., Superintendent. 
Vermont State Hospital for the Insane, Waterbury. 
M. Hutchinson, M. D., Superintendent. 
Clayton G. Andrews, M. D., First Assistant Physician. 

VIRGINIA— Eastern State Hospital, Williamsburg. 

L. S. Foster, M. D., Superintendent 
Central State Hospital, Petersbxtrg. 

William F. Drewry, M. D., Superintendent 

J. H. Garlick, M. D., Assistant Physician. 
Western State Hospital, Staunton. 

Benjamin Blackford, M. D., Superintendent 
Southwestern State Hospital, Marion. 

R. J. Preston, M. D., Superintendent 

WASHINGTON— Western Washington Hospital for the Insane, Fort 

Steilacoom. 
Eastern Washington Hospital for the Insane, Medical Lakx. 

WEST VIRGINIA— West Virginia Hospital for the Insane at Wes- 
ton, Weston. 
A. H. Kunst, M. D., Superintendent 
West Virginia Hospital for the Insane at Spencer, Spencer. 

A. J. Lyons, M. D., Superintendent 
West Virginia Asylum at Huntington, Huntington. 
L. V. Guthrie, M. D., Superintendent 

WISCONSIN— Wisconsin State Hospital for the Insane, Mendota 
Northern Hospital for the Insane, Winnebago. 

W. A. Gordon, M. D., Superintendent 
Milwaukee Hospital for the Insane, Wauwatosa 

M. J. White, M.D., Superintendent 
Asylum for the Chronic Insane, Wauwatosa. 

William F. Beutler, M. D., Superintendent 
Milwaukee Sanitarium, Wauwatosa. 

Richard Dewey, M. D., Physician-in-Charge. 

John B. Edwards, M. D., Maustoa 

William F. Becker, M.D., 604 Goldsmith Bldg., Milwaukee. 

Byron M. Caples, M. D., Waukesha Springs. 

Uranus O. B. Wingate, M. D., Milwaukee. 

Wm. G. Stearns, M. D., Lake Geneva. 

E. L. Bullard, M. D., 402 Camp Bldg., Milwaukee. 



42 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

WYOMING — State Hospital for the Insane, Evanston. 

PUERTO RICO— Insane Asylum, San Juan. 

CENTRAL AMERICA— Honduras. 

Arthur C. Delacroix, M. D., San Juancito. 



BRITISH AMERICA. 

ONTARIO — Asylum for the Insane, Toronto. 

Daniel Clark, M. D., Superintendent 
Asylum for the Insane, London. 

G. A MacCallum, M. D., Superintendent 

H. R Buchan, M. D., Assistant Superintendent 
RocKwooD Hospital for the Insane, Kingston. 

Charles K. Clarke, M. D., Superintendent 
Asylum for the Insane, Hamilton. 

James Russell, M. D., Superintendent 
Asylum for the Insane Mimico, Toronto. 

Nelson H. Bcemer, M. D., Superintendent 
Asylum for the Insane, Brockvillb. 

Thomas J. Moher, Superintendent 
Asylum for the Insane^ Cobourg. 

Eugene C. McNichoU, M. D., Superintendent 
HoMEwooD Sanitarium, Guelph. 

Alfred T. Hobbs, M. D., Superintendent. 

QUEBEC^Protestant Hospital for the Insane, Montreal. 
T. J. W. Burgess, M. D., Superintendent 
Carlyle A. Porteous, M. D., Assistant Superintendent 
Andrew Macphail, M. D., Pathologist 
Saint Jean de Dieu Hospital for the Insane, Longue Poinib. 
George Villencuve, M. D., Superintendent 

E. Philippe Chagnon, M. D., Montreal. 

David Alexander Shirres, M. D., 919 Dorchester St., MontrcaL 
Quebec Asylum for the Insane, Quebec. 

NOVA SCOTIA— Nova Scotia Hospital for the Insane, Halifax. 
W. H. Hattie, M. D., Superintendent 

Geo. L. Sinclair, M. D., Halifax. 

NEW BRUNSWICK— Provinoal Hospital, St. John. 
James V. Anglin, M.D., Superintendent 

George A. Hetherington, M. D., St John. 



GEOGRAPHICAL DISTRIBUTION MEMBERS AND INSTITUTIONS. 43 

PRINCE. EDWARD ISLAND— Hospital for Insane, Charlottbtown. 
V. L. Goodwill, M. D., Medical Superintendent 

NEWFOUNDLAND— Asylum for the InsXns» St. John's. 

BRITISH COLUMBIA— PuBuc Hospital por Insane, New West- 
minster. 
G. H. Manchester, M. D., Superintendent 

MANITOBA— Selkirk Asylum, Selkirk. 



44 AMERICAN ^EDICO-PSYCHOLOGICAL ASSOCIATION. 

HONORARY MEMBERS. 

T. S. Clouston, M. D., F. R. C. P., F. R. S. E., Edinburgh, Scotland. 

David Ycllowlces, M. D., F. F. P. S., LL. D., Glasgow, Scotland. 

A. Motet, M. D., Paris, France. 

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

Stephen Smith, M. D., New York, N. Y. 

G. Stanley Hall, Ph. D., LL. D., Worcester, Mass. 

Charles F. Folsom, M. D., Boston, Mass. 

James Rutherford, M. D., F. R. C P., F. F. P. S., Dumfries, Scotland. 

S. Weir Mitchell, M. D., Philadelphia, Pa. 

Victor Parant, M. D., Toulouse, France. 

Jules Morel, M.D., Mons, Belgium. 

Emmanuel R6gis, M. D., Bordeaux, France. 

Ren6 Semelaigne, M. D., Paris, France. 

James M. Buckley, D. D., LL. D., Morristown, N. J. 

Henry Hun, M. D., Albany, N. Y. 

James Beveridge Spence, M. D., R. U. L M. Ch., Bumtwood, England. 

Antoine Ritti, M. D., Charenton, pr^s Paris, France. 

Alexander R. Urquhart, M. D., F. R. C. P. E, Perth, Scotland. 

William Prior Letchworth, LL. D., Glen Iris, Portage, N. Y. 

Edouard Toulouse, M. D., Villejuif, France. 

Wesley Mills, A. M., M. D., Montreal, Que. 

D. R. Wallace, M. D., Waco, Texas. 



AMERICAN MEDICO-PSYCHOLOGICAL 
ASSOCIATION. 



CONSTITUTION. 



Article I. 
This organization shall be known as the American Medico- 
Psychological Association, this name being adopted in 1892 
by "The Association of Medical Superintendents of American 
Institutions for the Insane/' founded in 1844. 

Article II. 
The object of this Association shall be the study of all subjects 
pertaining to mental disease, including the care, treatment, and 
promotion of the best interests of the insane. 

Article III. 
There shall be four classes of members : (i) Active members, 
who shall be physicians, resident in the United States and British 
America, especially interested in the treatment of insanity; (2) 
Associate members; (3) Honorary members; and (4) Corre- 
sponding members. 

Article IV. 

The officers of the Association shall consist of a President, 

Vice-President, Secretary — ^who shall also be the Treasurer — ^two 

Auditors, and twelve other members of the Association to be called 

Councilors; all of these officers together shall constitute a body 

which shall be known as the Council. 

Note. — ^Thc Association of Medical Superintendents of American Institu- 
tions for the Insane was founded in 1844 by the original thirteen members. 
In 1891, when its membership had increased to more than two hundred, it 
was proposed, at the annual meeting of that year in Washington, to form 
a better organization of the Association — its work having previously been 
done under the somewhat unstable rules of custom and a few resolutions 
scattered through its records. The proposition was agreed to, and at the 
annual meeting in Washington, in 1892, th^re was unanimously adopted the 
following Constitution and By-Laws, with the change of name to the 
American Medico- Psychological Association. 



46 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Article V. 

The Active members of the Association shall include all past 
and present medical superintendents named in the official list pub- 
lished for 1892 of members of "The Association of Medical 
Superintendents of American Institutions for the Insane;" the 
Honorary members shall include those so designated in that list ; 
the Associate members shall include all the assistant physicians 
named in the same list; it being provided that said list shall be 
corrected by the Council, as may be necessary to carry out the 
intention of the Constitution as to the continuance of existing 
membership. 

Every candidate for admission to the Association hereafter as 
an Active member shall be proposed to the Council, in writing, 
in an application addressed to the President, at any annual meet- 
ing preceding the one at which the election is held. Honorary, 
Associate, or Corresponding members shall be proposed to the 
Council, in writing, in an application addressed to the President, 
at least two months prior to the meeting of the Association. 
Every application of whatever class must include a statement of 
the candidate's name and residence, professional qualifications, 
and any appointments then or formerly held, and certifying that 
he is a fit and proper person for membership. In the case of a 
candidate for Active or Associate membership, the application 
shall be signed by three Active members of the Association ; and 
by six Active members for the proposal of an Honorary or Corre- 
sponding member. The names of all candidates approved by a 
majority vote of members of the Council present at its annual 
meeting shall be presented on a written or printed ballot to the 
Association at its concurrent annual meeting, at least one session 
previous to that at which the election is made, which shall be by 
ballot at a regular session, and require a majority vote of the 
members present. Physicians who, by their professional work 
or published writings, have shown a special interest in the care 
and welfare of the insane, are eligible to Active membership. 
The only persons eligible for Associate membership are regularly 
appointed assistant physicians of institutions for the insane that 
are regarded to be properly such by the Council ; and they are 
eligible for such membership only during the time they are hold- 
ing such appointments. After holding such an appointment three 



CONSTITUTION. 47 

years, an Associate member may become an Active member by 
making application, in writit^, to the Council, and upon its 
approval, being elected in the manner heretofore prescribed. 

Article VL 

Physicians and others who have distinguished themselves by 
their attainments in branches of science connected with insanity, 
or who have rendered signal service in philanthropic efforts to 
promote the interests of the insane, shall be eligible for Honorary 
membership. 

Physicians not residents in the United States and British Amer- 
ica, who are actively engaged in the treatment of insanity, may be 
elected Corresponding members. 

Active members only shall be entitled to a vote at any meeting, 
or be eligible to any office. Honorary and Corresponding mem- 
bers shall be exempt from all payments to the Association. 

Article VII. 

Any member of the Association may withdraw from it on signi- 
fying his desire to do so in writing to the Secretary : Provided, 
That he shall have paid all his dues to the Association. Any 
member who shall fail for three successive years to pay his dues 
after special notice by the Treasurer shall be regarded as having 
resigned his membership, unless such dues shall have been re- 
mitted by the Council for good and sufficient reasons. 

Any member who shall be declared unfit for membership by 
a two-thirds vote of the members of the Council present at an 
annual meeting of that body shall have his name presented by 
it for the action of the Association from which he shall be dis- 
missed if it be so voted by two-thirds of the members present at 
its annual meeting. 

Article VIII. 

The Officers and Councilors shall be elected at each annual 
meeting. They shall be nominated to the Association on the 
second day of the annual meeting in the order of business of the 
first session of that day, by a committee appointed for that pur- 
pose by the President; and the election shall take place immedi- 
ately. The election shall be made as the meeting may determine. 



48 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION, 

and the person who shall have received the highest number of 
votes shall be declared elected to the office for which he has been 
nominated. 

The President, Vice-President, the Secretary and Treasurer, 
and Auditors shall hold office for one year or until the beginning 
of the term for which their successors are elected. The Secretary 
and Treasurer and one Auditor are eligible for re-election. At 
the first election of Councilors, four members shall be elected for 
one year, four for two years, and four for three years ; and there- 
after four members shall be elected each year to hold office three 
years, or until their successors are elected. The President, Vice- 
President, one Auditor, and the four retiring Councilors are 
ineligible for re-election to their respective offices for one year 
immediately following their retirement. All the Officers and 
Councilors shall enter upon their duties immediately after their 
election, excepting the President and Vice-President When any 
vacancies occur in any of the offices of the Association, they shall 
be filled by the Council until the next annual meeting. 

A quorum of the Council shall be formed by six members ; and 
of the Association by twenty Active members. 

Article IX. 

The President and Vice-President for the year shall enter on 
their duties at the close of the business of the annual meeting at 
which they are elected. The President shall prepare an inaugural 
address to be delivered at the opening session of the meeting. 
He shall preside at all the annual or special meetings of the 
Association or Council, or in his absence at any time, the Vice- 
President shall act in his place. 

The Secretary and Treasurer shall keep the records of the 
Association and perform all the duties usually pertaining to that 
ofl5ce, and such other duties as may be prescribed for him by the 
Council ; and under the same authority he shall receive and dis- 
burse and duly account for all sums of money belonging to the 
Association. He shall keep accurate accounts and vouchers of 
all his receipts and payments on behalf of the Association, and of 
all invested funds, with the income and disposition thereof, that 
may be placed in his keeping, and shall submit these accounts, with 
a financial report for the preceding year, to the Council at its 



CONSTITUTION. 49 

annual meeting. Each annual statement shall be examined by 
the Auditors, who shall prepare and present at each annual meet- 
ing of the Association a report showing its financial condition. 
The Council shall have charge of any funds in the possession of 
the Association, and which shall be invested under its direction 
and control. The Council shall keep a careful record of its pro- 
ceedings, and make an annual report to the Association of matters 
of general interest. The Council shall also print annually the 
proceedings of the meetings of the Association and the reports of 
the Treasurer and Auditors. 

The Council is empowered to manage all the affairs of the Asso- 
ciation, subject to the Constitution and By-Laws ; to appoint com- 
mittees from the membership of the Association, and spend money 
out of its surplus funds for special scientific investigations in 
matters pertaining to the objects of the Association, to publish 
reports of such scientific investigations; to apply the income of 
special funds, at its discretion, to the purposes for which they 
were intended. The Council may also engage in the regular 
publication of reports, papers, transactions and other matters, in 
annual volume, or in a journal, in such manner and at such 
times as the Council may determine, with the approval of the 
Association. 

Article X. 
Amendments to the Constitution and By-Laws shall be taken 
up for consideration at the first session of the second day of any 
annual meeting, and may be made by a two-thirds vote of all 
the members present: Provided, That notice of such proposed 
amendments be given in writing at the annual meeting next pre- 
ceding. It shall be the duty of the Secretary to send to all the 
members a copy of any proposed amendment at least three months 
previous to the meeting when the action is to be taken. 



50 AMERICAN MEDICO-J^SV^CHQI^OGICAL ASSOCIATION. 




H A ^^ 
"AfiTTCEE*'!. 

The meetings of the Association shall be held annually. The 
time and place of each meeting shall be named by the Council, and 
reported to the Association for its action at the preceding meeting. 
Each annual meeting shall be called by printed announcements 
sent to each member at least three months previous to the meeting. 

The Coimcil shall hold an annual meeting concurrent with the 
annual meeting of the Association ; and the Council shall hold as 
many sessions and at such times as the business of the Association 
may require. 

Special meetings of the Council may be called by the order of 
the Council. The President shall have authority at any time, at 
his own discretion, to instruct the Secretary to call a special meet- 
ing of the Council; and he shall he required to do so upon a 
request signed by six members of the Council. Such special 
meetings shall be called by giving at least four weeks' written 
notice. 

Article II. 
Each and every Active and Associate member shall pay an 
annual tax to the Treasurer, the amount to be fixed annually by 
the Council, not to exceed five dollars for an Active member, or 
two dollars for an Associate member. 

Article III. 
The order of business of each annual meeting of the Association 
shall be determined by the Council, and shall be printed for the 
use of the Association at its meeting. The Council shall also make 
all arrangements for the meetings of the Association, appointing 
such auxiliary committees from its own body, or from other mem- 
bers of the Association, and making such other provisions as shall 
be requisite, at its discretion. 



NOTE. 

The accompanjdng volume, containing the proceedings, papers, 
and discussions of the American Medico-Psychological Associa- 
tion at its Sixty-first Annual Meeting, is printed by the Council 
with the approval of the Association. 

E. C. DENT, 

Secretary. 
Wabd's IsLAZfD, New York City, 
October i, 190$, 



AMERICAN MEDICO-PSYCHOLOGICAL 
ASSOCIATION 



PROCEEDINGS OF THE SIXTY-FIRST ANNUAL MEETING. 

Tuesday, April i8, 1905. — First Session. 

The Association convened at 10 a. m. in the Convention Hall 
of the Menger Hotel, San Antonio, Texas, and was called to 
order by the President, Dr. T. J. W. Burgess, of Montreal, Can- 
ada. An invocation was offered by Rev. E. D. Mouzon, D. D. 

The President introduced Dr. Marvin L. Graves, Chairman of 
the Committee of Arrangements, who said : " Texas will extend 
to her friends from the East and the West, the North and the 
South, a cordial greeting to-day, and I introduce to you first a 
gentleman who has grown somewhat gray of head in fighting the 
battles of organized, legitimate medicine, but whose heart, like 
that of Dr. Oliver Wendell Holmes while living, is still young, 
and whose mental faculties, active and alert, present the unusual 
combination of maturity and wisdom with the sparkle and vigor 
of youth. I have the pleasure of introducing to you Dr. F. E. 
Daniel, President of the State Medical Association, who will 
welcome you for the three thousand doctors of Texas." (Ap- 
plause.) 

Dr. Daniel spoke as follows : 

Mr, President, Members of the American Medico-Psychological Associa- 
tion, Ladies and Gentlemen: 
It is my privilege, my great pleasure, and a distinguished honor to wel- 
come you in the name of my colleagues of the State Medical Association, 
and on their behalf I extend to you the right hand and greet you, friends 
and brothers, and welcome you to this Empire of the West Texas, though 
only a younger member of the great sisterhood of States, is famous the 
world over. Who, in the remotest part of the civilized world, does not 
know of the Lone Star of Texas, of the battle of the Alamo? We are a 
happy, prosperous people, proud of our State, proud of her splendid citizen- 
ship, of her history, and proud of her institutions, her great wealth and 
wonderful resources, as yet scarcely touched. We are proud of her strong 
men and beautiful women, and proud of our State institutions. Especially 



34 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATIOK. 

are we proud of our splendid psychopathic hospitals and their talented 
superintendents, who are an honor to the State; and doubly proud of the 
splendid provision the State has made for the care of the unfortunates. 

We welcome you to the famous city of the Alamo. So long as civiliza- 
tion shall endure, the names of Travis, Crockett, and Bowie will live in 
song and story, and the tale of the Alamo will sound down the ages to the 
remotest time, along with that of Marathon and Thermopylae. Here was 
poured out that " boon that heaven holds dear," 

" The last libation that Liberty draws 
From hearts that bleed and break in her cause." 

As from Daphne's virgin blood sprang the laurel, the emblem of honor 
and inmiortality, so the blood of our hero patriots enriched the soil of 
Texas and became the fruitful germ whence has grown a magnificent 
civilization which will ever honor their names and keep their memory 
green. 

Many of you gentlemen, perhaps, have not visited Texas before. You 
have had no experience in the delights of a sun-kiss'd, blossom-blest land 
like this. Your visit is as timely as it is welcome. You see the land at its 
best. You see the old Spanish city in her Easter attire, as gay and happy 
and blushing as a bride. Cybele has unlocked the storehouse of her treas- 
ures and scattered her jewels broadcast over the land. Our boundless 
billowy prairies, "as broad as the sweep of the tidal wave's measureless 
motion," were a little while ago the home of the buffalo and the hunting 
ground of the roaming savage. To-day they are brilliant with the bloom 
and fragrant with the perfume of the lily and the rose, as well as the wild 
foxglove and the gentian, the bluebells and the daisy. Dotted with flocks 
and herds and villages and hamlets and happy homes, the air is vocal with 
the hum of husbandry. The cheery "gee haw" of the plowman is every- 
where heard, as he prepares for that harvest that feeds and clothes the 
world; and as the mellow mould turns from his plow, see the eager, noisy 
flocks of blackbirds following in his wake, to catch the " early worm." 

"The down of the thistle and the bob-o-link's whistle 
Are blent with the vernal day's light and perfume." 

In our cities, too, the rattle of machinery, the noise of traffic, and the 
hum of industry are sweet, familiar sounds. Across the State from Tex- 
arkana to Brownsville and from Longview to El Paso— and across from 
Denison to the Gulf the State is ribbed with iron bands, and over broad 
plains and mountain steeps, and mighty rivers and purling brooks, and 
hill and dale, lumbering trains bear to the bosom of the ocean the 
products of our soil. It is a pretty sight to stand on Chatauqua Hill at 
San Marcos, "the loveliest village of the plain," and watch two splendid 
vestibule trains, the I. & G. N. "Flyer" and the "Katy" "Cannon Ball," 
racing in sight of each other for miles, to the quaint old city, laden with 
tourists to see the Alamo and the long line of missions founded two hun- 
dred years ago. One can but stand and wonder at the durability and 



PROCEEDINGS. 55 

beauty of the Moorish architecture, and towers and minarets of two cen- 
turies ago, and the quaintly carved doors and altars, the work of the 
fanatical Franciscan monks; and bearing health-seekers to bask in our 
soft southern sun and to breathe the balm of our fragrant air, and to 
drink in deep draughts of health. They are welcome. We dwell indeed 
in a favored land. The setting sun lingers to throw a last kiss "good- 
night" to Texas, and sinks to rest suffused in a halo of his own blushes. 
This is a land of the pomegranate and the fig, the magnolia and the olive. 

" Here rage no storms ; the sun diffuses here 
His tempered beams thro' skies forever fair; 
Here gentle airs o'er brakes of myrtle blow. 
Hills greener rise and purer waters flow. 
Here bud the woodbine and the jasmine pale, 
And every bloom that scents the morning gale. 
While thousand melting sounds the breezes bear 
In silken dalliance to the dreaming ear, 
And golden fruits mid shadowy blossom glow." 

But, gentlemen, you are not here alone for pleasure. You are not here 
for the gratification of the senses, however delightful. You are here to 
work for humanity and the advancement of that young science born but 
yesterday, of which you are the distinguished and honored exponents and 
apostles. There is no brighter page in the history of medicine than that 
wherein is recorded the birth, growth, and evolution of psychiatry, the 
scientific treatment of the diseased mind. It makes us shudder to look 
back and recall the cruelty and barbarity inflicted through ignorance upon 
the unfortunates, even one hundred years ago. It makes us sad to recall 
what was their sad fate before God inspired Pinel and Esquirol and Ray 
and Rush and Gait and Stribling and Woodward and Bryce, and that angel 
of mercy, ever blessed be her name, Dorothy Dix, through all of whose 
inspired and divinely guided labors we have reached the position of our 
splendid psychopathic hospitals and the rational treatment of diseases of the 
mind. High upon Fame's proud temple their names are inscribed in letters 
of living light and will endure forever. 

It makes us dizzy to recall the advances that have been made in the last 
quarter of a century, for within that time the new psychology has been 
bom. It was not evolved out of the old psychology, for that was such in 
name only. The immortal Locke, the father of the old psychology, had not, 
of course, the faintest conception of the wonderful truths and discoveries 
that have occurred, which show the mind in all of its multitudinous phases, 
of ideation, thought, memory, and consciousness itself, to be the function of 
the brain, evolved by chemical action — ^a force, a mode of motion, if you 
please — a specialized energy, transformed by the original dynamo — ^the 
brain — into what I believe is identical with electro-magnetic energy. 

Locke and his followers of the old school, and all the world, conceived 
of the mind as being the soul — something outside of, external to, inde- 
pendent of the organism, which entered the body of the babe at birth. 



S6 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

controlled the life of the man, shaped his destiny, and which at death was 
liberated and was immortal. That was a psychology of speculative pl^il- 
osophy, the "science of the soul" (psyche). We have now a new psychol- 
ogy, Professor James to the contrary notwithstanding, a science of the 
mind. All scientific men now recognize that the mind is purely a physio- 
logical process, independent of any external or supernatural causes. 

If it makes us dizzy to contemplate the advances of psychology in the 
past, it makes our heads swim to contemplate the possibilities of the future. 
We stand to-day, gentlemen, upon the shoulders of our immediate prede- 
cessors, and as we look into the opening vista of the twentieth century, the 
field opens, even broader and unending, and we are startled at the possibili- 
ties that await the further investigation of the brain cells. While much 
has been accomplished, there is much yet to be accomplished. Surely, it 
was thought that when Flechsig demonstrated the association centers, and 
the sensory and motor areas were clearly mapped out, we had reached the 
limit; but there are other problems. What is consciousness? How does it 
arise? Given the thought cells, how is thought produced? How is it dis- 
tilled from the elements of the food that float in the blood that bathes 
every other cell in the body? 

But, gentlemen, you are less concerned with psychology than with 
psychopathology and psychiatry. You are here to study your special branch 
of science and to devise means and methods for better construction and 
management of your institutions, and the care of your patients, but we 
have well-nigh reached perfection in that. You deal with the sick mind. 
It is yours to 

" * * * minister to a mind diseased. 
To pluck from the memory a rooted sorrow. 
To raze out the written troubles of the brain, 
And with some sweet oblivious antidote 
Cleanse the stufiPd bosom of the perilous stuff 
That weighs upon the heart" 

There is much work before you. You gentlemen, in your organized 
capacity, are an immense power for good. That power should be exerted. 
While science has advanced along this line, jurisprudence has stood still, 
and I say that it is a disgrace to the State of Texas that while 42 or 44 
forms of insanity are recognized by scientists, jurisprudence recognizes 
only two forms the " natural " and the " acquired," and the absurd test of 
knowing right from wrong, adopted in the McNaughton case two hundred 
years ago, is still the rule in our insanity trials. And unfortunates who are 
arraigned on a charge of murder, and where insanity is the defense, have 
not the benefit of a diagnosis by the light of modem science. 

Much could be said along this line. I would refer to the absurdity of 
having a jury of laymen to decide such a question. In our jury system, 
the more ignorant a man is, the better qualified he is to act, according to 
the practice of our jurisprudence. Experts testify and they always differ. 



PROCEEDINGS. 57 

and the courts call in twelve fanners, mechanics, tinkers and tailors and 
candlestick makers, day laborers, and what not to decide. 

But, gentlemen, I am occupying your time. There are many things you 
will have to consider. The jurisprudence of insanity has not progressed 
with science. You should have influence with Congress, but I am afraid 
in many of the States you will find that the most of the legislators ignore 
science and are moved solely by sentiment There is one problem before 
srou to which I wish to call attention. I refer to the alarming, terrible 
increase of insanity. What is the cause of it ? Dr. Graves, in his admirable 
address delivered at Galveston last month, made the startling assertion that 
the insane in Texas in the last 45 years have increased 6800 per cent, while 
the population has increased but 504 per cent, that is, nearly 14 to i. What 
is the cause of it? How can it be arrested? It is out of all proportion to 
the population and out of all proportion to the increase of crime* which is 
truly appalling. Something must be done, if possible. And it does seem 
to me, gentlemen, that our whole humanitarian system aims at and fosters 
the survival of the unfit and the propagation of the defective. It is race 
suicide. 

And now again, welcome. We set before you bread and salt, symbols of 
our most generous hospitality. We would send you home with a song in 
your heart and ask for ourselves a place there. We would say, "Rest 
you here. Bide with us awhile. We would do you honor." (Applause.) 

Dr. Graves. — ^Ladies and gentlemen, orators are indigenous to 
Texas soil, but none of them are more gifted than the gentleman 
whom I now present. His genial personality, his scholarly attain- 
ments, the melody and magnetism of his voice and thought equally 
charm whether in the pulpits of our country he is telling the old, 
old story of Jesus and His love, or upon the platform, showering 
gleaming sparks from his intellectual anvil, or placing a jeweled 
diadem upon the brow of America's uncrowned queen. I have 
the pleasure of introducing to you Rev. Homer T. Wilson, who 
will welcome you for everybody. 

Rev. Homer T. Wilson, D. D., spoke as follows : 

I do not really know whether I can speak after that speech of intro- 
duction. Some time ago, when I was invited by your committee to deliver 
a speech of welcome on behalf of the public of our city, I thought at 
first it would be well for me to give very careful, studious preparation to 
that address, and I began the study of the history of your honored pro- 
fession. But I found so many words that I did not understand (Laughter) 
and so many of them that I was afraid to try to pronounce before this 
body, that I gave the whole thing up, and I made up my mind to one 
thing — ^that you gentlemen are the smartest class of men in the world — 
next to the preachers. (Laughter). 



58 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

I assure you, my friends, that in the history of our beautiful Southland 
city of the Alamo I have never known a body of men assembled here in 
convention for whom I have personally higher regard, and on behalf of 
the public of our city it is indeed a pleasing task to bid you a hearty wel- 
come. I note with pleasure that some of you have brought your wives. 
Others seem to be here on a pleasure trip and have left their wives at home 
(Laughter and applause.) All of your anticipations will be fully realized 
and the sweet memory of your visit here will always be pleasant to recall. 

You represent, gentlemen, a very honored ancestry and the history of 
the human family is a history of the endeavor of the greater minds to 
relieve human suffering, and you have made the greatest progress of all 
the sciences known to man. There is a little difference, however, in the 
work of your hands and the work of other men of genius. If the artist 
places upon the canvas a beautiful picture, and perchance makes a mistake 
and leaves there the imprint of a finger, the world notes it If the sculptor 
produces a noble statue, but through a slip of the chisel makes a little 
mistake, the world notes it In the progress of invention, I was forcibly 
reminded at St Louis of the progress which has been made in the steam 
engine. How magnificently the mechanic has advanced in the line of his 
inventive genius, and there in that great Machinery Hall were samples of 
the work of the different ages and different minds, and it is beautiful to 
note how they have advanced, and how here and there, though making 
mistakes, have improved until you can see the mistake and the improve- 
ment side by side. It is a beautiful sight — ^wonderful to see the advance- 
ment so plainly portrayed. You have the advantage, gentlemen, in that 
whatever mistakes you may have made are covered with floral offerings, 
and when we join the white-robed hosts of heaven, how soon are we for- 
gotten here! 

It gives me pleasure, gentlemen, to pay a tribute to your profession. We 
recognize your power, not only in relieving human suffering, but you hold 
in your hands as no other class of men the destiny of the human soul. In 
the church to-day we have learned the lesson that when our missionaries 
go to heathen lands to present the Christ, that in every instance we have 
them prepare themselves to attend to the wants of the body as well as 
the soul, for we are coming to recognize the value of the uplift to intel- 
lectual and spiritual character through medicine, as well as through the 
pulpit I appreciate the glorious work in which you are engaged I want 
to say to you from the depth of my heart, there are no persons in the 
world who have such depth of appreciation as those who stand by the 
bedside of suffering and distress. 

As a father have I stood again and again and watched the face of that 
man we love better than all others, the family physician, and we have seen 
the moist eyes and could not gain a ray of hope, and we have seen when 
the hand was laid gently upon the fluttering pulse, and how perfectly 
charmed were that father and mother when they hear from the physician 
that there is hope! 

My dear friends, your position in this world is great. Your influence in 



PROCEEDINGS. 59 

shaping the destiny of mankind is greater than that of any other profession 
engaged in the material forces of this world, and if you are not the 
highest class and type of Christian manhood, you ought to be, for the 
development of character and the welfare of mankind are often placed in 
your hands. You are dealing not only with the physical, but the mental. 
You have gone a little higher and are dealing with that most difficult 
problem, the human brain, and I commend you for the splendid influence 
you exercise over humanity. 

On behalf, then, of this public, the people of San Antonio, I bid you 
one and all a cordial greeting. As the mouthpiece of the public I say, 
may God's richest blessing rest upon you in your visit here, and when you 
are gone, may we have the pleasant memory of your visit, as you, I trust, 
will carry with you the memory of this beautiful place, and what is more, 
the memory of kindly words and the hand-grasp that is prompted by the 
heart of loving sympathy. And may this convention to you and your 
profession be a long step upward and onward, and while you are with us 
in the enjoyment and pleasures that I trust will be yours, I pray that 
heaven's blessing may rest upon you in your deliberations, and when this 
convention is closed, we may all feel, "It was pleasant to be together." 
(Great applause.) 

Dr. Graves. — ^This is the greatest and best of Texas munici- 
palities. This is the home of hospitality. It is the nursery 
of Texas liberty and independence — a liberty that is not license, 
an independence that is not exclusiveness. I have the pleasure of 
presenting to you the Hon. F. C. Davis, our excellent City Attor- 
ney, who represents the Mayor of San Antonio, the City Beau- 
tiful, where flowers bloom all the year around and where every 
heart is yours. 

Hon. F. C. Davis spoke as follows : 

Ladies and gentlemen of the American Medico- Psychological Asso- 
ciation — is that right, Mr. President? (Laughter.) At the request of the 
mayor of our city, ladies and gentlemen and members of the Association 
and friends, it is my great pleasure to welcome you to the city, not as 
strangers, but as friends and as guests whom we are delighted to entertain 
and proud to honor. The gentleman who preceded has welcomed you to 
Texas, and the gentleman who has just sat down took the liberty to wel- 
come you to San Antonio, but, gentlemen, that is our business; you are 
our guests. When the mayor requested me to make this address, I asked 
him what I was to say to you. He said to tell them that San Antonio has 
no keys while they are in the city. Every door is unlocked. 

About these insane people — Dr. Graves says that there has been an 
increase of 14 per cent to i per cent increase of population in this State 
of Texas, but, gentlemen, they were not raised here ! (Laughter.) When 



. I 



6o AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

we try that class of people, if any of them get in here, I have always had 
one of these experienced doctors to testify. Seriously, we have had but a 
single one in my experience who did not come from another State. 

I desire simply to state that San Antonio feels flattered at your pres- 
ence and we hope you will feel at home. We feel proud of our city. 
Nature has done much and public generosity has added to this. Expres- 
sion has been exhausted in extolling the purity of this healthful climate, 
and what nature has failed to do the skillful hand of your noble profession 
has done to assist nature, and for this great credit is due our local physi- 
cians. We arc the most distinguished community in the world for health. 
(Applause.) 

Dr. Graves. — ^There is a tradition to the effect that the word 
" Texas " is derived from an old Indian word, " Tehas," which 
means "welcome." I am not an etymologist, so I cannot say 
whether this is true or not, but I do stand sponsor for the senti- 
ment here to-day. In behalf of the local Bexar County Medical 
Association, which is the best of the county societies in Texas, I 
have the pleasure of introducing to you Dr. L. L. Shropshire, 
genial and eloquent, representing the local medical society, who 
will spell for you hospitality with a large H, and welcome with a 
large W. 

Dr. Shropshire said : 

Mr, President and Gentlemen of the American Medico-Psychological 
Association: 

I feel that great injustice has been done me, in being called upon to 
follow such medical, legal, and spiritual prodigies. (Laughter.) I do not 
claim to be an orator, but I will give you as cordial welcome as they. 

On behalf of the Bexar County Medical Association it has become my 
pleasant duty to welcome you as our guests at this, your sixty-first annual 
meeting. In doing so, gentlemen, I beg to assure you that I welcome you 
with all the zeal and fervor which that word implies. 

From all over this great American continent you have assembled in your 
annual meeting to-day for the accomplishment of a great, good, and scien- 
tific work, and at the request of the local profession I extend to you a 
most welcome and hearty greeting. 

We welcome you, gentlemen, to our historic city, the cradle of Texas 
liberty. You meet to-day almost at the threshold of that grand old Alamo, 
made famous by the daring deeds of our countrymen, whose walls have 
been again and again baptized with the blood of our heroes. As citizens 
of this great Empire State we look upon it with awe and reverence and 
remember with admiration and love Travis, Crockett, Bowie, and others of 
that Spartan band, who so freely gave up their lives that liberty might 



PROCEEDINGS. 6l 

Kve. Here, almost in the shadow of that grand old battle-scarred building, 
made glorious by its baptism in the blood of heroes, who chose to die for 
the good of others; here upon ground held sacred by all who love liberty; 
we come to welcome you as representatives of our noble profession, which 
has faced death for the good of mankind as earnestly and as bravely as 
those who died in this historic building. Wherever pestilence or deadly 
scourge has smitten the human family, there can be found members of our 
profession faithfully and fearlessly facing danger in a more appalling form 
than that which follows the carnage of war. They take their lives in their 
own hands and fight back grim death, protect the living, and minister unto 
the suffering and dying. As the representatives of such a profession we 
are proud to welcome you to our city and to our homes. 

We recognize in this distinguished body of alienists and neurologists 
that branch of our profession which is especially deserving of the love and 
gratitude of the whole profession, as well as the public at large, for the 
great strides they have made in the successful care and treatment of that 
unfortunate class of individuals, who are from disease or otherwise about 
to be shut out from the light of the world by mental dethronement. Upon 
you, gentlemen, the world at large and society in general are very much 
dependent for your opinions in matters affecting the application of both 
our civil and criminal statutes. To your opinions must the courts of the 
commonwealth turn for the just application of the laws in efforts to dissolve 
wills where millions and millions of dollars are at stake. To you also 
must the jury of your peers look for the satisfactory evidence in deter- 
mining the fate of the criminal where the plea of insanity has been in- 
voked. "Since grim darkness felt the might of God and fled away," the 
path of the world has been one of advancement, and we of to-day live in 
a wondrous time; in a century instinct with the spirit of progress; in an 
era made radiant with the electric light of science; in a golden age made 
illustrious by the magnificent march of mind; but in no trade, calling, or 
profession has that progress been more manifest, has that march of mind 
been more apparent than in the one which you represent 

Again, gentlemen, in calling your attention to the sacred history of this 
hallowed spot upon which we stand, don't let me forget to remind you that, 
aside from the battle-scarred walls of our missions, made sacred by the 
blood of our heroes, whose memory we revere and love so well, the great 
Dispenser of natural gifts has blessed us with a climate unequaled by any 
on this continent If our climate could be used as assets, Texas would be 
the richest as well as the grandest State in the Union. You have doubtless 
all been impressed with the fact that we often send our patients to your 
climate for the benefits they may derive from the change, and to escape the 
heat of summer, and I want to impress upon you also, that if you once try 
it, you will always send your patients to our climate for the benefit to be 
derived from a change, as well as the escape from the rigors of the frozen 
North. Fresh air and sunshine, the parents of eternal Spring, are with us 
more days in the year than any other locality on this continent Ever 
abreast of the times, our specialists in your branch of the profession are 



62 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

rapidly supplying themselves with sanitaria for the better care of such 
patients who need fresh air and sunshine from January i to December 31. 

I trust that your visit among us may be enjoyable, that your deliberation 
may be fruitful of good work, and that in after years you may look back 
upon your brief sojourn in the Alamo City as a green spot in your memories. 

On behalf of the local profession, I again bid you welcome to the 
metropolis of the greatest State of the greatest nation under the sua (Ap- 
plause.) 

The President. — In the name of the American Medico-Psy- 
chological Association, I take pleasure in thanking you for the 
cordial welcome that has been extended to us on behalf of the 
State, the city, and the medical profession. 

We have long heard of your great State and rejoice to be now 
able to see it for ourselves. I say great State, for assuredly it is 
great — great in that it is the largest State in the Union, exceeding 
in size the v^rhole of New England with Maryland, New York, 
Ohio, Pennsylvania, and the two Virginias thrown in; great in 
that it has a larger number of miles of railway than any other 
State ; great in that it is the largest producer of cattle and cotton, 
and stands fifth of the States for population, with the prospect of 
outstripping all of them in this also. Nor is it only in these 
respects that it is great. What State can boast of older or prouder 
historical reminiscences? Over it have floated no less than six 
different flags, to each of which is attached a host of soul-stirring 
memories — ^those of France, Spain, Mexico, the Texan Republic, 
the Southern Confederacy, and the United States. On its soil was 
fired the last shot of the great Civil War, and in its capital stands 
a monument bearing one of the noblest epitaphs ever penned, 
" Thermopylae had its messenger of defeat ; the Alamo had none/' 

Though many of you may not be aware of it, there is a very 
close bond of union between the State of Texas and our Canadian 
Province of Quebec, in that both are indissolubly linked with a 
name dear to all Canadians, that of the intrepid explorer, Robert 
de la Salle. Somewhere in Texas soil were interred the remains 
of that great and heroic man, buried by his faithful adherent. 
Father Douay, after his foul murder by his mutinous followers, 
and less than three miles from the hospital over which I have the 
honor to preside are the ruins of La Salle's Canadian home, the 
home which he built and in which he lived for some four years 



PROCEEDINGS. 63 

of his early Canadian life, the home in which were planned the 
great schemes for the extension of New France, which engrossed 
his remaining days. 

Not less rejoiced are we that in visiting your State for the first 
time, our meeting place should be the ancient and beautiful city 
of San Antonio, the birthplace of Texan liberty, the scene of 
heroic deeds, the place where Travis, Crockett, Bowie, and all 
their valiant band fought their last fight and gave their lives that 
Texas might be free. 

But, gentlemen, it is not alone as sightseers and hero-worship- 
pers we are here. We have in addition a serious purpose in view — 
the discussion of problems connected with our particular branch 
of medicine, and the practical matters associated therewith. The 
noble and Christ-like work of ministering to the mind diseased, in 
which we are engaged, will, we trust, receive an added impetus 
from our meeting in your midst, and the close of our sessions 
will, I feel assured, see each of us the better prepared and the 
more resolute to devote himself with all his strength to the tasks 
assigned him. There is much, very much, to be done in our spe- 
cialty, and I for one rejoice that it is so, with all my heart saying: 

"God be thanked that the dead have left still 
Good undone for the living to do- 
Still some aim for the heart and the will 
And the soul of a man to pursue." 

Again I thank you for your cordial welcome. We came as 
strangers but feel so no longer. You have already made us feel 
that we are at home, and that only friends surround us. (Ap- 
plause.) 

The President. — The next business on the programme is the 
report from the Committee of Arrangements. 

Dr. Graves. — The President has permitted us to make a change 
in the final pr<^amme, and I will call your attention to the cordial 
invitation extended to all visiting members of this Association and 
their friends to the reception to-night at the Southwestern Insane 
Asylum. It will begin at 8 o'clock and will consist of a musicale 
and dancing. The cars can be taken at 7.15 o'clock in front of the 
Menger Hotel. You then transfer to the Hot Springs line. 

To-morrow afternoon at 2.30 o'clock a ride throughout the 



64 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

city by carriage and to our historic missions has been arranged by 
the courtesy of the Bexar County Medical Association. It will 
be necessary for you to be ready to start on time. 

For to-morrow evening nothing special has been arranged, but 
there is a theatrical performance at the Grand. E. H. Sothem and 
Julia Marlowe will appear in Shakespearean productions, and un- 
doubtedly a large number will avail themselves of the opportunity 
to be present. 

Thursday night at 8.30 o'clock, in Turner Hall, the Business 
Men's Club of this city extends a cordial invitation to friends and 
members to be present at the Mexican banquet. This is a warm 
number in this climate. (Laughter.) 

On Friday morning a drive and luncheon is tendered to the 
ladies of the visiting Association by Mrs. Dr. Frank Paschal, and 
carriages will call at the Menger at that time. On Friday night 
at 10.25 the train leaves for the Mexican trip. Tickets are good 
for thirty days. You will arrive in Mexico City at 10.30 o'clock 
Sunday morning, in time to see the bull fight, which is the national 
amusement of Mexico. This will be a delightful trip. You are 
permitted to stop off at Monterey or at any place on the route. If 
those who wish to go will give me your names, I will see that 
sleeper accommodations are reserved. (Applause.) 

The President. — Not having the necessary books and papers 
before it at last night's meeting, the Council was unable to prepare 
its report, which will, therefore, be presented to-morrow. Dr. 
Hurd has also asked that the report of the editors of the Ameri- 
can Journal of Insanity be deferred until that time. 

My next duty is the appointment of the Nominating Com- 
mittee. As that committee I will appoint: 

Dr. Chas. W. Pilgrim, of New York. 

Dr. Wm. F. Drewry, of Virginia. 

Dr. M. J. White, of Wisconsin. 

There will now be a short recess for the registration of mem- 
bers and friends, after which we will take up the memorial notices 
of deceased members. 

The following members registered as being in attendance during 
the whole or a part of the meeting : 



PROCEEDINGS. 65 

Applegate, Qiatles F., M.D., Superintendent Mt Pleasant State Hos- 
pital, Mt. Pleasant, Iowa. 

Bentler, W. F., M. D., Superintendent Asylum for Chronic Insane, Wau- 
watosa. Wis. 

Buchanan, J. M., M. D., Superintendent East Mississippi Insane Hospital, 
Meridian, Miss. 

Burgess, T. J. W., M. D^ Medical Superintendent ProtesUnt Hospital for 
Insane, Box 2581, Montreal, Que., Can. 

Busey, Alfred P., M. D., Superintendent Colorado State Insane Asylum, 
Pueblo, CoL 

Caples, Byron M., M. D., Superintendent Springs Sanitarium, Wauke^a, 
Wis. 

Crumbacker, W. P., M D., Superintendent Independence State Hospital, 
Independence, Iowa. 

Dent, Emmet C, M. D., Superintendent Manhattan State Hospital, 
Ward's Island, New York City. 

Drewry, William Francis, M. D., Superintendent Central State Hospital, 
Petersburg, Va. 

Graves, Marvin L., M. D., Superintendent Southwestern Insane Asylum, 
San Antonio, Texas. 

Hancker, William H., M. D., Medical Superintendent Delaware State 
Hospital at Famhurst, Famhurst, Del. 

Harmon, F. W., M. D., Superintendent Longview Hospital, Cincinnati, 
Ohio. 

Hattie, W. H., M. D., Medical Superintendent Nova Scotia Hospital, 
Halifax, Nova Scotia. 

Hill, Charles G., M. D., Physician in Charge, Mt. Hope Retreat, Balti- 
more, Md., Station R 

Hill, Gershom H., M. D., Nos. 210-21 1 Equitable Building, Des Momes, 
Iowa. 

Hurd, Arthur W., M.D., Superintendent Buffalo State Hospital, Buf- 
falo, N. Y. 

Hurd, Henry M., M. D., Superintendent Johns Hopkins Hospital, Balti- 
more, Md. 

Hutchings, Richard H., M. D., Superintendent St Lawrence State Hos- 
pital, Ogdensburg, N. Y. 

Kindred, J. Joseph, M. D., President and Consulting Physician River 
Crest Sanitarium, Astoria, New York City. 

Lamb, Robert B., M. D., Supt Matteawan State Hospital, Fishkill-on- 
Hudson, N. Y. 

Lyons, A. J., M. D., Superintendent Second Hospital for Insane, Spencer, 
W. Va. 

Maxwell, T. O., M. D, First Assistant Physician State Lunatic Asylum, 
Austin, Texas. 

Macdonald, A. R, M. D., 431 Riverside Avenue, Columbia Court, New 
York City. 



66 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Mead. L. C, M,D., Superintendent South Dakota State Hospital for 
Insane, Yankton, S. D. 

Miller, Harry W., M.D., Pathologist and Assistant Physician Taunton 
Insane Hospital, Taunton, Mass. 

Murphy, P. L., M.D., Superintendent The State Hospital at Morgan- 
ton, Morganton, N. C. 

Orth, H. L., M. D., Superintendent Pennsylvania State Lunatic Hospital, 
Harrisburg, Pa. 

Page, Charles W., M. D., Superintendent and Physician Danvers Insane 
Hospital, Hathome, Mass. 

Palmer, H. L., M. D., Superintendent Utica State Hospital, Utica, N. Y. 

Perry, M. L., M.D., Superintendent Parsons State Hospital, Parsons, 
Kans. 

Pilgrim, Charles W., M. D., Superintendent Hudson River State Hos- 
pital, Poughkeepsie, N. Y. 

Preston, John, M. D., Superintendent State Epileptic Colony, Abiline, 
Texas. 

Punton, John, M. D., Superintendent Punton Sanitarium, Kansas City, 
Mo. 

Redwine, J. S., M. D., Medical Superintendent Eastern Kentucky Hos- 
pital for Insane, Lexington, Ky. 

Robinson, J. R, M. D., Late Superintendent State Hospital No. 3, Nevada, 
Mo. 

Rogers, Joseph G., M. D., Medical Superintendent Northern Indiana Hos- 
pital for Insane, Longcliff, Logansport, Ind. 

Searcy, J. T., M. D., Superintendent Alabama Insane Hospitals, Tusca- 
loosa, Ala. 

Smith, G. A., M. D., Superintendent Central Islip State Hospital, Central 
Islip, L. I., N. Y. 

Turner, John S., M. D., Medical Superintendent North Texas Hospital 
for Insane, Terrell, Texas. 

Villeneuve, George, M. D., Medical Superintendent St Jean de Dieu Hos- 
pital for the Insane, P. O. Box 1147, Montreal, Quebec, Canada. 

Wade, J. Percy, M. D., Medical Superintendent Maryland Hospital for 
Insane, Catonsville, Md. 

Wallace, D. R., M. D., Waco, Texas. 

White, M. J., M.D., Superintendent Milwaukee Hospital for Insane, 
Box A., Wauwatosa, Wis. 

Wilsey, O. J., M. D., Superintendent Long Island Home. Amityville. L. I . 
N. Y. 

Witte, Max E., M. D., Superintendent Qarinda State Hospital, Clarinda, 
Iowa. 

Woodson, C R., M. D., Superintendent State Hospital No. 2, St Joseph, 
Mo. 
Work, Hubert, M.D., Superintendent Woodcroft Hospital, Pueblo, CoL 



PROCEEDINGS. (fj 

Worsfaam, B. M., M. D., Saperintendent State Lunatic Asylum, Austm, 
Texas. 

The following visitors and guests of the Association registered 
their names with the Secretary : 

Applegate, Mrs. Charles R, Mt Pleasant, Iowa. 

Atkins, Mr. Fred., Fishkill-on-Hudson, N. Y. 

Atherton, Mr. Horace H., Trustee Danvers Insane Hospital, Hathome, 
Mass., Tangred, Mass. 

Beutler, Mrs. W. F., Wauwatosa, Wis. 

Breeding, J. £., M. D., San Antonio, Texas. 

Burg, S., M. D., City Health Officer, Chief of City Hospital, San An- 
tonio, Texas. 

Caples, Mrs. Byron M., Waukesha, Wis. 

Crumbacker, Mrs. W. R., Independence, Iowa. 

Crumbacker, Mr. J. Bowen, Independence, Iowa. 

Daniel, Mrs. F. E., Austin, Texas. 

Daniel, F. £., M. D., President State Medical Association and Editor 
Texas Medical Journal, Austin, Texas. 

Daniel, R. P., Hospital Steward City Hospital of San Antonio, Texas. 

Dent, Mrs. Emmet C, Ward's Island, New York City. 

Drcwry, Mrs. W. F., Petersburg, Va. 

Hadra, Mr. Frederidc, 119 Alamo Plaza, San Antonio, Texas. 

Harmon, Mrs. F. W., Cincinnati, Ohio. 

Hemert, T. B., M. D., Gait, Mo. 

Hill, Chas., M. D., Pine Island, Goodhue Co., Minn. 

Hopkinson, Mr. Lemuel W., Trustee Danvers Insane Hospital at 
Hathome, Mass., Bradford, Mass. 

Hutchings, Mrs. Richard H., Ogdensburg, N. Y. 

Jameson, Mrs. Nellie, P. and S. Hospital, San Antonio, Texas. 

Kindred, Mrs. John Joseph, 47 E. 58th St, New York City. 

Lyons, Mrs. A. J., Spencer, W. Va. 

McCormick, C A., M. D., Chicago, IlL 

McQuaid, Mr. George, The Daily Express, San Antonio, Texas. 

Punton, Mrs. John, Kansas City, Mo. 

Redwine, D. B., Jackson, Ky. 

Robinson, Mrs. J. F., Nevada, Mo. 

Scott, Mr. J. W., Eudora, Ark. 

Smith, Mrs. G. A., Central Islip, N. Y. 

Shropshire, L. L., M. D., San Antonio, Texas. 

Taylor, C. W., M. D, 18-19 Hicks Building, San Antonio, Texas. 

Ryder-Taylor, Mr. Henry, San Antonio Daily Light, San Antonio, Texas. 

Tipton, Mr. W. K, Secretary State Board Charities and Corrections, 
Mitchell, S. D. 

Turner, Mrs. J. S., Terrell, Texas. 

Wallace, Mrs. D. R., Waco, Texas. 



68 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

White, Mrs. M. J^ Wauwatosa, Wis. 

Withers, Robert Lee, M. D., Assistant City Physician, City Hospital, San 
Antonio, Texas. 
Wilson, Rev. Homer T., D. D., San Antonio, Texas. 

After the registration the Association was again called to order 
by the President. 

The President. For many years I have held that the memo- 
rial notices of deceased members should be read at the beginning 
of the meetings, as the least we can do to show our r^;ard for our 
departed brethren. To defer them to the dose of the sessions is 
to show very scant respect to those snatched from our ranks, and 
very scant courtesy to the writers of the articles. Accordingly, it 
has been arranged to have the obituaries take precedence of every- 
thing else. 

Dr. Robert B. Lamb then read an obituary of the late Dr. Henry 
E. Allison. 

The President. — Personally I had known Dr. Allison a great 
many years, and while I sometimes differed from him in his con- 
clusions, I certainly have never known a man I thought more 
thoroughly honest in all that he said and all that he did. 

A memorial notice of Dr. James F. Ferguson, prepared by Dr. 
William E. Dold, was read by Dr. A. W. Hurd. 

A memorial notice of Dr. F. Savary Pearce, prepared by Dr. 
George Stockton, was read by the Secretary. 

A memorial notice of Dr. Merrick Bemis, prepared by Dr. 
Ernest V. Scribner, was read by Dr. H. L. Palmer. 

A memorial notice of Dr. George F. Keene, prepared by Dr. 
Henry A. Jones, was read by Dr. H. W. Miller. 

The President. — ^As there is still some time left us before 
luncheon, I will call upon Dr. Hattie to read Dr. Kemp's paper. 

Dr. Hattie then read a paper written by Dr. Robert C. Kemp, of 
New York City, " Some Observations on the Relations of the 
Gastro-Intestinal Tract to Nervous and Mental Diseases.'* 

The paper was discussed by Dr. Oiarles G. Hill. 

On motion, a vote of thanks was tendered Dr. Kemp for his 
valuable and interesting paper. 

A recess was then taken until 2.30 p. m. 



proceedings. 69 

Second Session. 
The meeting was called to order by the President at 2.30 p. m. 

The President. — It has always been customary to have a vote 
of thanks tendered for the addresses of welcome given us, and 
certainly that custom should not be omitted to-day, because I 
think, in all my experience, I never heard better. I will, there- 
fore, call upon Dr. Macdonald to make such a motion. 

Dr. Macdonald. — I had it in mind to offer such a resolution 
this morning, but Dr. Burgess represented the Association so well 
in his response that I did not do so. As the gentlemen concerned 
are absent, I will not make any remarks, but simply move that the 
Secretary be instructed to convey the grateful thanks of this Asso- 
ciation to the gentlemen who gave the addresses of welcome this 
morning. Seconded by Dr. Pilgrim. Carried unanimously. 

In the absence of the Vice-President, Dr. Henry M. Hurd was 
called to the chair and the President then read his address, " The 
Insane in Canada," which was greeted with much applause. 

Dr. Hurd (in the chair). — ^The Association is to be congratu- 
lated upon this clear-cut and most suggestive address. It has 
not been customary to discuss the address of the President I 
shall be glad, however, to have some one voice the feeling of the 
Association. 

Dr. C. G. Hill. — I was going to do so before you made your 
suggestion. It was evident from the attention given to the Presi- 
dent that he touched a chord in the hearts of all here. I move 
that a vote of thanks be tendered the President for his very inter- 
esting and suggestive address. Seconded by Dr. Busey. Car- 
ried unanimously. 

The President. — In answer to your commendation of my poor 
efforts, I will but quote the " Master of Poets " and say: " I can 
no other answer make but thanks, and thanks, and ever thanks." 

Adjournment. 



to american medico-psychological association. 

Wednesday, April 19, 10.00 a. m. 

The meeting was called to order by the President, who intro- 
duced Mr. Wm. L. Stiles, President of the Business Men's Qub 
of San Antonio, as having an announcement to make in behalf of 
the Committee of Arrangements. 

Mr. Stiles. — We have arranged to entertain you at a Mexican 
dinner to-morrow night at the Turner Hall, and Dr. Graves ex- 
tended our invitation yesterday. I thought best, however, to re- 
peat the invitation here because we want to make sure that you 
are all there. This is an affair to which the ladies also are in- 
vited. It is entirely informal ; it is not a full-dress affair — in fact, 
a Mexican blanket would be much more appropriate for a Mexican 
dinner. We are going to have plenty of hot stuff, and plenty of 
cold stuff too. We are going to have music, etc., and we hope 
you will all be there. (Applause.) 

The President. — ^This beautiful bouquet of roses, which you 
see on the table before me, was presented to the members of the 
Association by Mrs. Dr. Breeding. 

I will now call upon Dr. Dent, the Secretary, to read the report 
of the Council, deferred from yesterday. 

The Council begs leave to submit the following report to the Associa- 
tion: 

At a meeting of the Council held April 17, it was moved by Dr. 
Drewry, seconded by Dr. Pilgrim that the Council appoint a committee 
to be known as the "Committee on Programme and Publication," whose 
duty it shall be to assist the Secretary in procuring papers and arranging 
the programme for the next annual meeting, and in having the Transac- 
tions of the Association printed and published. After full discussion, this 
was carried. The appointment of the committee was entrusted to the 
President 

At a meeting held April 18, Dr. Hill moved: "That it be the under- 
standing of this Association that the papers read before it are the property 
of the Association. With the permission of the Council, the author may 
be allowed to publish his paper elsewhere, it being understood that in 
such publication, due credit shall be given to this Association." Seconded 
by Dr. Turner and after full discussion passed. 

The Council recommends the following names for membership: 

For Active Member ship, —Geo. I. McLeod, M.D., Philadelphia, Pa.; 
Thomas J. Moher, M.D., Brockville, Ont; Henry M. Weeks, M.D., Skill- 
man, N. J. 

For Associate Membership,— Oizrlts M. Burdick, M. D., Ogdensburg, 
N. Y.; Jesse C Coggins, M. D., Catonsville, Md.; Harris May Carey, M.D., 



PROCEEDINGS. 71 

Retreat, Pa. ; R. Edward Garrett, M. D., Catonsville, Md. ; George Stimpson 
Hathaway, M. D., Butler Hospital, Providence, R. I.; DcWitt C. Mac- 
Oymont, M.D., Kings Park, N. Y.; Charles Belton Macartney, M.D., 
Flint, Mich. ; John Irvine McKelway, M. D., Kings Park, N. Y. ; Ethan A. 
Nevin, M. D., Ogdenshurg, N. Y. ; George C^Hanlon, M. D., Kings Park, 
N. Y.; Frederick W. Parsons, M.D., Poughkeepsie, N. Y.; Carlyle A. 
Porteous, M. D., Montreal, P. Q.; A. L. Skoog, M. D., Parsons, Kans.; 
Irving Lee Walker, M. D., Central Islip, L. I., N. Y.; Lewis M. Walker, 
M. D., Harding, Mass. ; Edward M. Green, M. D., Milledgeville, Ga. ; Geo. 
M. Kline, M. D., ML Pleasant, Iowa. 

Report of Treasurer, 

in account with the american medico-psychological asso- 
ciation, from may i, 1904, to april lo, i905. 

Receipts. 

Balance Last Report $ 937-69 

Dues from Active Members 1,140.00 

Dues from Associate Members 168.10 

Received from Interest 41.81 

Sale of Transactions i.oo 

Sale of Gummed Lists .50 

Sale of Blakiston's Autopsies 2.25 

Sale of Desk 12.36 

Total Receipts $2,303.71 

EXFENDITUXES. 

Clerical Assistance $ 122.30 

Ballots, Luggage, etc., St Louis 6.50 

Programmes and Envelopes, St Louis 20.30 

Expressage 7.92 

Freight 20.40 

Labor and Material for Boxes for Shipping Records 13.19 

Printing 23.88 

Receipt Book 3.75 

Rubber Stamps 1.48 

Mimeograph Supplies 2.60 

Appropriation American Journal of Insanity 150.00 

Total Expenditures 426.82 

Balance to New Account : 

N. Y. Produce Ex. Bank $1,068.89 

Emigrant Indus. Savings Bank 808.00 

$1,876.89 
Total $2,303.71 



JZ AMERICAN MEDICQ^PSYCHOUXSICAL ASSOCIATION. 

The expense for freight, crating, etc., was incident to tiie transfer of 
records from Flint, Mich., to New York City. 

Fifty dollars were i>aid the American Journal of Insanity on account of 
appropriation for previous year and $100.00 on the last appropriation of 
^naoo. The Journal has not yet drawn for the second $100.00 of last 
year's appropriation. 

As the Transactions have not yet been received from the printer, they 
have not been paid for, which accounts for the large balance. 

I would respectfully report that outstanding dues are as follows : 

Due from Active Members $470.00 

Due from Associate Members 76.00 

Total $546.00 

Respectfully submitted, 

E. C. Dent, Treasurer, 

Upon motion the report was received and referred to the Audit- 
ing Committee. 

The President then called for the report of the editors of the 
American Journal of Insanity, which was read by Dr. Henry M. 
Hurd. 

Baltimore, April 13, 1905. 
To THE American Medico-Psychological Association. 

Gentletnen^At the request of Dr. £. N. Brush, the Managing Editor of 
the American Journal of Insanity, who is detained from being present 
at this meeting by an imperative engagement at home, I present herewith a 
statement of the account of the American Journal of Insanity up to 
April 12, 1905, which shows a balance of $24a20 on hand. The April num- 
ber, however, has not been issued, and it is probable that when that is 
issued, the account of the Journal will be somewhat overdrawn. 

In view of this state of things, I can only urge that an effort be made to 
increase the subscription list of the Journal. Many members of the Asso- 
ciation do not take it, and many general practitioners, by a little effort, 
could be induced to subscribe. 

It will also be noticed that the receipts from advertising continually fall 
off. A determined effort should be made to increase the list of advertise- 
ments. Many members of the Association are so situated as to throw 
advertising into the hands of the Journal, and I would respectfully request 
them to do so. The Journal has grown in influence and scientific standing 
steadily for a number of years, and it ought to be self-supporting. 

Vouchers for the expenditures are herewith submitted, and I would 
respectfully request that they be referred to the auditors. 

Very respectfully, 

Henry M. Hurd. 



PROCEEDINGS. 73 

Thb Johns Hopkins Pbkss. 
Statsmsnt of Account op ths Amkucan Jouknal of Insanity. 

SECEIPTS since I^AST STATBHBNT. 

From subscriptions and sales, including reprints $1,690.94 

From advertisements (less commissions to agents) 641.64 2,332.58 

PAYMENTS SINCE LAST STATEMENT. 

1904, May 20, deficit at last statement 62.33 

Friedenwald Co. (printing account) A 62143 

B 400.00 

C 279.13 

D 441.44 

E 5.40 

J. M, Mosher (editorial expense) F 8.25 

Publisher's charges G 200.00 

Postage and express H 70.70 

Miscellaneous expense, stationery, etc I 3.70 2,092.38 

Balance to new account $ 240.20 

1905, April 12. 

This statement does not include the cost of No. 4 (April, 1905), not 
yet issued. This is needed to complete the annual volume. 

The President. — Gentlemen, you have heard Dr. Kurd's re- 
port, and I am sure that I voice the sentiments of all when I say, 
" We are quite satisfied." 

Upon motion, the report was referred to the Auditing Com- 
mittee. 

The President. — I would call your attention to the necessity 
of our backing up the Journal in every possible way. To me it 
seems almost a disgrace for any member not to take it. I for one 
am very proud to have such a valuable production on my private 
library shelves, and it is the duty of each of us, as stated in the 
report, to use his utmost efforts to extend the influence of the 
Journal I regret that Dr. Hurd should have ceased his active 
editorship, but I am glad that he remains consulting editor. He is 
the general in charge of the advance. 

Dr. Murphy. — I move that a committee be appointed from the 
members of the Association to solicit subscriptions from those who 
are not subscribers and to further the interests of the Journal in 
every possible way. I know little about it, but if this committee 



74 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

were appointed, it would tend to relieve the busy editors of this 
detail of the work. I think it would advance the interests of the 
Journal to have this committee act in connection with the Com- 
mittee on Programme and Publication. 

Dr. Hurd. — I would make the suggestion, in order to avoid com- 
plication, that the Committee on Programme and Publication be 
charged with this duty and responsibility. 

Dr. Murphy. — I accept the amendment and move that the Pub- 
lication Committee as appointed by the Council be also the com- 
mittee to assist the editors of the American Journal of Insanity 
to further the interests of the Journal in every possible way. 

The resolution was adopted. 

Dr. Page. — I move that the Association put on record an expres- 
sion of appreciation of Dr. Kurd's services as chief editor of the 
Journal for many years past. I think we all appreciate what he 
has done for the Journal and for the interests of the Association. 

The President. — It has been moved that a vote of thanks be 
tendered Dr. Hurd for his services as chief editor of the Journal, 
and I will add that I never put a motion in my life with greater 
pleasure. Carried unanimously. 

Dr. Hurd. — I wish to return my sincere thanks for this expres- 
sion of appreciation from the Association. 

The President. — Prior to balloting the Secretary will read the 
list of the names which have been recommended by the Council to 
the Association for active and associate membership. 

The Secretary read the list. (This list is given in the report to 
the Association from the Council.) 

Upon motion of Dr. Woodson the Secretary was empowered to 
cast the ballot of the Association admitting these gentlemen to 
active and associate membership in the Association respectively. 

The Secretary announced that the ballot had been cast and the 
gentlemen therein named had been duly elected. 

The President.— The ballot having been found favorable, I 
declare these gentlemen duly elected members of the Association. 

Dr. Page. — I made my motion with reference to Dr. Hurd on 
the spur of the moment without deliberation and without confer- 



PROCEEDINGS. 75 

ence. Since that motion was passed, I find that there is a general, 
spontaneous sentiment among the members of this Association that 
we must do something more than pass a resolution to express our 
esteem and affection for Dr. Hurd and our appreciation of his 
services, both in connection with the Journal and the Association. 
I therefore move that the President appoint a committee of three to 
obtain and present to Dr. Hurd a suitable testimonial as a token of 
the esteem with which he is regarded by us all. 

Dr. Macdonald. — Mr. President, I heartily second this motion 
that a committee be appointed to obtain a suitable and fitting testi- 
monial as an expression of our appreciation of Dr. Kurd's untiring 
efforts for this Association and for the success of the Journal, and 
as an indication of the esteem with which he is regarded by us all. 

The President put the motion and announced that it had been 
carried unanimously. 

The President. — I will appoint as such committee Dr. Page, of 
Hathome, Mass., Dr. Burr, of Flint, Mich., and Dr. Murphy, of 
Morganton, N. C. 

As chairman of the committee empowered to prepare a History 
of the Association for publication, I can report progress only. 

I would ask Dr. Macdonald, as chairman, for the report of the 
committee appointed at St Louis to formulate the opinions of the 
Association on the subject of Dr. Punton's paper, " Are the Insane 
Responsible for Criminal Acts? " 

Dr. Macdonald. — In regard to that committee, I have to report 
that Dr. Hurd, Dr. Punton, and myself are the only members in 
attendance at this meeting, and consequently we have not been 
able to secure a quonmi of the committee for a meeting. Under 
these circumstances, it seems best to us to ask leave to report 
progress, and also that the committee be continued. It has been 
suggested that perhaps joint action or consideration might be 
secured in the matter after conference with the American Bar 
Association, and I submit this suggestion to the Association for 
such disposition as may appear proper. 

Dr. Hurd. — ^We have, I think, only one man in our member- 
ship who is both a lawyer and a doctor, who has the degrees of 
M. D. and LL. B. Consequently I would move that this report 
be accepted and that Dr. Macdonald be appointed a committee to 



76 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

confer with the American Bar Association with reference to pos- 
sible joint action in this matter. Carried. 

Dr. Macdonald. — ^Another matter for report is my attendance, 
as your representative, upon the meeting of the Executive Com- 
mittee of the Congress of American Physicians and Surgeons, of 
which Congress your Association is one of the comp<Mient parts. 
I have a long report as to the relations of the Association to the 
Congress, but inasmuch as the meeting has been postponed and 
does not come imtil two years from now, and as the matters in- 
volved are somewhat serious, I beg to report progress, and to 
suggest that it might be well to have a committee of this Associa- 
tion, to consist of the Executive Committee member (myself), 
the alternate (Dr. Brush), the President of this Association, and 
two members to be named by the President, to consider the whole 
subject and report to the Association at its next meeting. I offer 
a resolution to that effect. 

The President. — Dr. Macdonald has moved that a committee 
of five, one of whom shall be the President, two others, himself 
and his alternate on the Executive Committee, Dr. Brush, with 
two to be appointed by the chair, be entrusted with the con- 
sideration of the relations of this Association to the Congress of 
American Physicians and Surgeons, to report at next meeting. 
Is it the will of the meeting that this should be done? Carried. 

Dr. Macdonald. — I have to report that as the delegate of this 
Association I attended the meeting of the Pan-American Congress 
held in Panama during the first week in January. I will not 
detain you now with a verbal report of the proceedings, but will 
submit a written report later. 

The President. — In this connection I might read a letter I 
have received from the 15th International Medical Congress, 
which meets at Lisbon in 1906. 

XV International Medical Congress, 

American Committee. 

March 20, 1905. 
T. J. W. Burgess, M. D., 

President American Medico-Psychological Association, 

Montreal, Canada. 
Dear Doctor— I am requested by the Committee to ask you to kindly 
name a member of your Association to prepare a paper for the Fifteenth 



ntOCEEDIMXSS. fj 

International Medical Gmgress, to be held at Lisbon in 1906; such paper 
or address to be a representative one of your Association. 

Yours very truly, 
(Signed) Rahow Guitkias, M. D^ 
Secretary. 

It would be in order for some one to suggest a member to rep- 
resent this Association and prepare a paper for the Congress, as 
requested. 

Dr. C. G. Hill. — I move that Dr. Macdonald be appointed to 
write the paper and to act as our representative at the Congress, 
as he has so well represented us on other occasions. Carried. 

Dr. Macdonald. — I thank the Association for your confidence 
and kindness in the matter. 

The Secretary announced that telegrams or letters expressing 
regret at inability to attend the meeting and extending greeting 
had been received from the following : 

George Stockton, M. D., Columbus, Ohio; C B. Burr, M. D., Flint, Mich. ; 
G. Alder Blumer, M. D., Providence, R. I. ; T. O. Powell, M. D., Milledgc- 
villc, Ga. ; B. D. Evans, M. D., Morristown, N. J. ; Richard Dewey, M. D., 
Wauwatosa, Wis. ; H. A. Tomlinson, M. D., St Peter, Minn. ; Thomas J. 
Moher, M.D., Brockville, Ont; Chas. K. Mills, M.D., Philadelphia; E. V. 
Scribner, M. D., Worcester, Mass.; Charles G. Wagner, M. D., Bingham- 
ton, N. Y.; C. H. Hughes, M.D., St Louis, Mo.; Bigelow T. Safiborn, 
M. D., Augusta, Me. ; Arthur F. Kilboume, M. D., Rochester, Minn. ; George 
F. Jelly, M. D., Boston, Mass.; A. B. Howard, M. D., Qeveland, Ohio. 

The Secretary stated that accident in the case of Dr. Burr 
and deaths in the families of Dr. Blumer and Dr. Powell had 
prevented the attendance of these gentlemen, and that telegrams 
of condolence had been sent to them. 

The President then called for the report of the Nominating 
Committee. 

Dr. Pilgrim, Chairman. — ^The Nominating Committee would 
respectfully report as follows: 

For President, Dr. C. B. Burr, of Michigan. 

For Vice-President, Dr. C. G. Hill, of Maryland. 

For Secretary and Treasurer, Dr. E. C. Dent, of New York. 

For Councilors, Dr. G. A. Smith, of New York; Dr. W. F. 
Beutler, of Wisconsin ; Dr. J. T. Searcy, of Alabama ; Dr. N. H. 
Beemer, of Canada. 



yS AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

To fill vacancy caused by Dr. Hill's election as Vice-President, 
Dr. M. L. Perry, of Kansas. 

For Auditors, Dr. A. W. Hurd, of New York, Dr. W. H. 
Hancker, of Delaware. 

Upon motion the report of the committee was accepted and 
adopted, and the new officers were declared elected. 

The President. — Prior to listening to the annual address by 
Dr. Searcy, Dr. Graves has asked me to announce that the ride to 
the Missions takes place this afternoon, and that carriages will be 
in front of the Menger at 2.30 sharp. This is perhaps the most 
interesting item in the list of interesting things provided for our 
entertainment, and I would impress it upon all, but upon the ladies 
especially, the necessity to be on hand promptly, as the ride is a 
long one. Dr. Graves also asks that the members who con- 
template going to Mexico give him their names, and the names of 
ladies accompanying them, as soon as possible, that he may make 
the necessary arrangements with the railroad company for accom- 
modation. 

I now have the pleasure of introducing Dr. James T. Searcy, 
of Tuscaloosa, Alabama, who will deliver the annual address. 

Dr. Searcy. — I have been very much embarrassed by the fact 
since I first received notice that I was to give this annual address. 
I have selected as my subject "Tripartite Mentality." I know 
this is a very unusual title, and, with considerable hesitancy, I 
recognize also that my presentation of the subject contains a great 
deal of a venturesome character. I hope, however, that it will 
explain itself satisfactorily as I proceed. One thing I think I can 
say is that you will not find it in the text-books. (Reads address.) 

Dr. Rogers. — I rise to express what I have no doubt is the 
sense of the Association, that the address which has just been read 
is certainly worthy of an expression of appreciation on the part 
of the Association. I move that a vote of thanks be tendered 
Dr. Searcy for this very interesting and thoughtful address. 

Seconded by Dr. Turner. Carried unanimously. 

The President. — Dr. Searcy, I take great pleasure in tender- 
ing you this vote of thanks. 



PROCEEDINGS. 79 

The President. — As Dr. Witte wishes to get away to-morrow 
morning, if there is no objection, we will change the order of the 
programme and listen to his paper now. 

Dr. Witte then read a paper, "As to Surgery for the Relief of 
the Insane Condition." 

Discussed by Drs. Woodson, Crumbacker, Robinson, Hutch- 
ings, Punton, Page, and H. M. Hurd. 

The President. — Dr. Graves wishes to make an announcement 

Dr. Graves. — ^As chairman of the Committee of Arrangements, 
I have been requested by a number of gentlemen to see if we 
could arrange for the drive and luncheon for the ladies on Thurs- 
day instead of Friday as originally planned. This is given 
through the courtesy of Mrs. Dr. Frank Paschal, and she has very 
kindly consented to this change of date, and I will ask the gentle- 
men to kindly notify the ladies to be ready at 10.00 sharp Thurs- 
day morning. This is to accommodate those who wish to go to 
Mexico Friday morning instead of Friday night. The train ac- 
commodations are the same. This will enable you to reach Mexico 
Saturday night It is desirable that all the members who are 
going, and I have reserved sleeper accommodations for all who 
have given me their names, shall go to the I. & G. N. ticket office 
for their tickets, and also for an exchange of American money for 
Mexican money. You can make the exchange here or anywhere. 
If it is the desire of all the members to go Friday morning, and if 
you can notify me to that effect, I will be glad to have sleeper 
arrangements made for Friday morning. 

Adjournment 

Menger Hotel, April 20, 1905. 

The meeting was called to order at 10.00 a. m., by the Presi- 
dent, who asked for the report of the Auditing Committee. 

Menger Hotel, San Antonio, Texas, April 20, 1905. 
To the American Medico-Psychological Association: 

Your Auditing Committee would respectfully report that they have ex- 
amined the books and vouchers of the Treasurer and compared them with 
the report submitted by him to the Association showing a balance of 
$1,068.89 in the New York Produce Exchange Bank and a balance of 
I808.00 in the Emigrant Industrial Savings Bank, a total balance of 
$1,376.89, and found the same correct as read. 



80 AMERICAN MEDICO-PSYCHOlXXTtCAL ASSOCIATIOV- 

We would also report that we have examined the report ar 
submitted by the Editors of the American Journal of Insanity 
the report correct as submitted. ^s 2«f«^l1 ! 

Arthur W.I Ij^ . ^-t?i--«: 
W. H. Hanc- \ll\^ 




iiii mm 




On motion the report was placed on file. 

The report of the Council was then read by the : 
Three gentlemen, Drs. David Alexander Shirres, Montrc 
T. O. Maxwell, Austin, Tex., and Wilmer S. Allison, 
tonio, Tex., were recommended to the Association for 
membership, and on motion the Secretary was instructs i 
a ballot for their election. 

The Secretary announced that the ballot had been 
found favorable. They were accordingly declared elect 

The Council also reported that it had selected St. Pat 
or St. Paul and Minneapolis combined, as the place for 
meeting of the Association, and announced that it had -en de- 
cided to combine the programmes for Thursday and Friday in 
order to complete the meeting of the Association on Thursday. 

The President. — ^With reference to the appointment of a com- 
mittee to confer and report regarding our relations with the 
Congress of American Physicians and Surgeons, it seems to me 
that, as the thing is a serious matter, the whole country should be 
represented on that committee. I will, therefore, in addition to 
Dr. Macdonald, Chairman, and Dr. Brush, alternate, appoint my- 
self for Canada, as required by Dr. Macdonald's motion. Dr. Work 
for the West, and Dr. Worsham for the South. 

Before proceeding with the programme, I could say that it will 
be necessary to enforce the rule limiting the time for the reading 
of papers to twenty minutes and for discussion to five minutes. 
Otherwise we will not be able to get through to-day. 

Dr. H. L. Palmer then read the paper, "The Prevention of 
Insanity in its Incubation by the General Practitioner," by Dr. 
J. T. W. Rowe, New York. Discussed by Dr. C. G. Hill and the 
President. 

The President then called for Dr. Wallace's address. 




PROCEEDINGS. 



8l 



Wallace. — 



he American Medico-Psychological Association: 

w, gentlemen, that I have anything worth the saying under 
es. Our good brother, Dr. Osier, our Anthropological Phil- 
ve, did not interdict the privilege of the old man to be gar- 
ore this body, I am reminded of the great dramatist's words : 

When to the sessions of sweet, silent thought, 
I summon up the remembrance of things past." 

light of other days, I see myself a generation ago in the city 
Tenn., when and where I looked in upon for the first time 
I member of this body, not then known as the American 
ological Association, but as the Association of Superintend- 
ican Institutions for the Insane. To say that I was surprised 
^raiel of the body would be expressing it very mildly. A gen- 
i that time I had looked in upon the American Congress. For 
)een accustomed to attending the American Medical Associa- 
ccurred to me as soon as I looked over the body of men com- 
pobu.^ vmerican Medico-Psychological Association that it sustained 

about the same relation to the American Medical Association as the Senate 
docs to the House of Representatives of the American Congress. Take out 
a few men that you could count on your fingers, such men as Benton, Cass, 
William H. Seward— neither Clay, Webster, nor Calhoun— I think the per- 
sonnel of this body— that is the American Medico- Psychological Associa- 
tion, would compare very favorably at that time with the United States 
Senate. The impression made on me was that I had never seen as fine a 
body of men together. 

The Comptons of Mississippi, Callender of Tennessee, Bryce of Alabama, 
Green of Georgia, Fuller and Grissom of North Carolina, Stribling of Vir- 
ginia, Nichols of the Government Hospital for Insane at Washington, Kirk- 
bride, Isaac Ray, and Curwen of Pennsylvania, the Macdonalds, Brown, and 
Gray of New York — I am glad one of them is here, though he was not pres- 
ent at Nashville — my good old friend Orpheus Everts of Indiana, Webb, a 
brother of Mrs. President Hayes, and Gundry of Ohio — I am sure I never 
looked into the faces of a finer body of men. I was astonished how such a 
body of men got together. There were only two ordinary looking men in 
the body, as I now recollect— one of the two was Isaac Ray, perhaps the 
most talented, and myself, the least of all of them. It is sad to reflect that 
there is not a single one of them now living. I was at that time about fifty 
years old and about as old as a bigger part of the body. Sad, these gentle- 
men all gone, " Precious friends hid in death's fadeless night." Why I 
should have been spared to survive so many noble men — ^what good I have 
done or am doing— I do not see. 
When my dear, good friend. Dr. Graves, invited me to deliver the general 



82 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

lecture upon this occasion, I replied that I learned from an old teacher^ 
when a boy, Flaccus Horace: 

" Sumite, materiam vestris, qui scribitis, aequam 
Viribus et versate diu, quid ferre recusent 
Quid valeant, humeri." 

From a very much younger authority, Thomas Jefferson, whose memorial 
edition I have just been looking over, in a letter inclosing his resignation of 
the American Philosophical Society, which he founded thirty years pre- 
vious, as you know, I find these words : 

" Nothing is more incumbent on an old man than to know when he should 
get out of the way and relinquish to younger successors duties he can no 
longer perform and honors he can no longer deserve." 

I hold in my hand a time-stained paper written eighteen or twenty years 
ago. I would like to read some extracts from it, though as time is pressing* 
I believe I will not do so. I thought it was a paper of some importance at 
the time; I see now it is very foolish. However, I leave it with you to 
make such disposition with it as you may desire. I presume there are others 
present who would like to occupy the time. 

The President. — Gentlemen, if the garrulousness of old age 
were always akin to that of Dr. Wallace, I am sure we would all 
say that Dr. Osier is away, away out I hope that if I ever attain 
to Dr. Wallace's age, I will not be less a disgrace than he is to the 
Association. 

Dr. A. W. Hurd then read his paper, " Korsakoff's Psychosis." 
Discussed by Dr. Miller. 

" The Therapeutic and Medico-Legal Features of Drug Addic- 
tions," by George P. Sprague, M. D., Lexington, Ky. Read by 
title. 

" Melancholia, the Psychical Expression of Organic Fear," by 
J. W. Wherry, M. D., Dansville, N. Y. Read by title. 

" Mysophobia, with Report of Gise," by John Punton, M. D., 
Kansas City, Mo. Read by the author. Discussed by Drs. Tur- 
ner, H. M. Hurd, Woodson, and G. H. Hill. 

" Cholaemia ; Its Relations to Insanity," by R. J. Preston, M. D., 
Marion, Va. Read by title. 

"A Case of Huntingdon's Chorea," by Harry W. Miller, M. D., 
Taunton, Mass. Read by the author. Discussed by Drs. A. W. 
Hurd, Punton, C. G. Hill, H. M. Hurd, the President, and H. W. 
Miller in conclusion. 

" The Liver and its Relations to Mental and Nervous Diseases," 
by Charles G. Hill, M. D., Baltimore, Md. Read by the author. 



PROCEEDINGS. 83 

The President. — ^As it is nearly time for luncheon, I think we 
had better defer discussion of this interesting paper until the 
afternoon. I would like, however, to ask Dr. Hill one question 
before we adjourn. He has suggested that William Shakespeare 
should have been a member of the American Medico-Psychologi- 
cal Association and I would ask him if he thinks Shakespeare 
considered biliousness and melancholia as always proceeding 
from the liver. In his " Twelfth Night *' he says : 

" She never told her love. 
But let concealment, like a worm i' the bad, 
Feed on her damask cheek; she pined in thought; 
And, with a green and yellow melancholy, 
She sat, like patience on a monument. 
Smiling at grief." 

Here is a clear case of biliousness and melancholia, and the 
question is, did Shakespeare regard this young lady as suffering 
from liver or heart disease? 

Dr. Hill. — I will answer later. 

A recess until 2.30 p. m. was then announced by the President 

The President called the meeting to order promptly at 2.30 p. m. 

A communication from R H. Allen, Secretary of the Interna- 
tional Pure Food Congress, asking that the Association pass a 
resolution urging Congress to enact a law to control the adultera- 
tion and misbranding of all products intended for human con- 
sumption, was read by the President. 

Upon motion, this matter was referred to the Council with full 
power to act. 

The President announced that Dr. Dent, the Secretary, had 
asked permission to add Dr. Drewry's name to the Committee on 
Programme and Publication. The request was granted by unani- 
mous consent. 

Dr. Murphy. — I move that we elect Dr. D. R Wallace an hon- 
orary member of this Association. He is ex-superintendent of 
the hospital at Austin and also the hospital at Terrell. In his 
time he was an honored member of this Association. He is now 
eighty years of age, and I think it fitting that the Association 
render him this honor. 



84 AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION. 

Dr. H. M. Hurd. — I am very glad, Mr. President, to second 
this motion. 

Dr. Wallace was elected unanimously. 

" A Case of Visual Hallucinations and Crossed Amblyopia with 
Vascular and Degenerative Lesions in the Calcerine Cortex and 
Other Portions of the Occipital Lobe; also with Atrophy of the 
Pregeniculae and Optic Tracts," by Chas. K. Mills, M. D., and 
C. D. Camp, M. D., was read by Byron M. Caples, M. D. 

" Observations on Some Recent Surgical Cases in the Man- 
hattan State Hospital, East," by John R. Knapp, M. D., Ward's 
Island, N. Y. Read by J. Percy Wade, M. D. 

The President announced that discussion of Dr. Knapp's paper 
would be deferred until Dr. Broun's paper was read, so that both 
could be discussed together, as each dealt with surgery for the 
insane. 

"A Preliminary Report of the Gynecological Surgery in the 
Manhattan State Hospital, West," by Le Roy Broun, M. D., 
New York City, was read by Robert B. Lamb, M. D. 

The papers of Drs. ICnapp and Broun were discussed by Drs. 
H. M. Hurd, Hutchings, G. H. Hill, Woodson, Dent, Punton, and 
the President. 

"Tuberculosis Among the Insane," by C. Floyd Haviland, 
M. D., Ward's Island, New York City. Read by Dr. Hutchings. 
Discussed by Dr. A. E. Macdonald. 

" Masked Epilepsy," by Gershom M. Hill, M. D. Read by the 
author. Discussed by Drs. Crumbacker and Punton. 

" Epilepsy as a S)rmptom," Everett Flood, M. D., read by title. 

Dr. Woodson. — I desire to offer the following resolution : 
" Resolved, That this Association extend a vote of thanks to 
the Committee on Arrangements, to Dr. Graves, the Board of 
Managers, staff, and officers of the Southwestern Insane Asylum, 
the Business Men's Qub, the Mayor, the Bexar County Medical 
Association, the State Medical Association, Dr. Moody, Mrs. 
Frank Paschal, the ladies, the press of San Antonio, and the man- 
agers of the Menger Hotel for their many courtesies and for the 
hospitality extended to this Association in this beautiful city of 
the Southwest." 



PROCEEDINGS. 85 

Dr. C G. Hill. — I think the resolution meets with our hearty 
response, and anything we could say to intensify and add expres- 
sion to what we feel would almost be superfluous. We feel more 
than we can express. We can never forget such hospitality as we 
have enjoyed in this place. 

The President. — I think that if we all live to be centenarians, 
we will never experience more genial and true hospitality than we 
have experienced here at San Antonio. 

The resolution offered by Dr. Woodson was then adopted unani- 
mously. 

The President. — Before retiring from the office your kind- 
ness bestowed on me, I wish to thank you for the patience and for- 
bearance you have shown to me in the discharge of my duties, 
and to express the hope that you will extend to the new President 
a like encouragement and kindness. With all my heart I wish 
he were here that I might call on him to take the chair and close 
the meeting as is customary. To introduce him to you would be 
unnecessary, because, as Secretary, he has so long occupied a seat 
on the dais at our annual gatherings that he is known to all. To 
attempt to describe Dr. Burr's qualifications for the occupancy of 
the presidential chair would be highly impertinent on my part. 
I shall, therefore, only say that I feel a pleasure in vacating this 
office in favor of one so well fitted to fill it worthily. 

I now declare this meeting adjourned to assemble next year at 
St. Paul, or St. Paul and Minneapolis combined, at a time to be 
fixed by the Committee of Arrangements, of which all shall have 
due notice. 



PRESIDENTIAL ADDRESS—THE INSANE IN CANADA.* 

By T. J. W. BURGESS, M. D.. 
Montreal, Canada. 

Gentlemen: My first duty is to reiterate my thanks to you for 
having called me to this chair, a distinction I can attribute only 
to the fact, that in honoring me you sought to honor, not me 
alone, but the Canadian members of the association. " No man 
is bom without ambitious worldly desires" says Carlyle, and 
surely there could not be a more laudable ambition than to be- 
come the president of this the oldest of American medical asso- 
ciations, a position of which Dr. John S. Butler said, on his ele- 
vation thereto, in 1870, " In my opinion, to be elected President 
of this Association, is the highest honor of the profession." 
Rarely, however, does gratified ambition bring peace of mind, 
and I, alas, have been no exception to the general rule. The 
thought of occupying a position that had been held by such intel- 
lectual giants as Woodward, Bell, Ray, Kirkbride, Butler, and 
Earle, all members of the ''glorious original thirteen," beside 
many other illustrious men, abashed me — ^made me fully con- 
scious of my inability to fill it properly. Nor did the sense of 
my demerit lessen as the days rolled by. On the contrary, the 
long list of presidents, whose names are familiar to us because of 
their attainments in psychological medicine, loomed continually 
before my eyes, added to which the task of to-day's address 
haunted me like an ever-lengthening shadow. I had but one 
thought to reconcile me to the greatness your generosity had 
thrust upon me. It was, that the kindness which prompted you to 
elect me as your president would be extended so far as to induce 
you to overlook my shortcomings, and that if, in the matter of the 

* Delivered at the sixty-first annual meeting of the American Medico- 
Psjrchological Association, San Antonio, Texas* Tuesday* April 18. 1005. 



88 PRESIDENTIAL ADDRESS. 

address, I could not like my predecessors in dfice clothe my 
thoughts in 

" Choice word and measured phrase, above the reach of ordinary men," 

you would at least take the kindly will for the imperfect deed. 

In my search for a topic upon which to discourse, I fully veri- 
fied the words of Terence *' Nullum est jam dictum quod non 
dictum sit prius." Everywhere I found the fields of medico- 
psychology so well harvested by my forebears that there was 
apparently nothing left for even a gleaner. Nevertheless, a sub- 
ject had to be selected, and I finally concluded that, as the oldest 
medical officer connected with the insane asylums of Canada, in 
point of length of service, I could not do better than tell you 
something about the development of our Canadian asylum sys- 
tem, the status of the insane in our Dominion, and what, in my 
estimation, are some of our most crying needs for the betterment 
of those so justly styled " the most unfortunate of all God's 
afflicted ones." 

Evolution of the Canadian Asylum System. 

Of the number or condition of the insane in Canada under 
the French regime, that is prior to its accession to England in 
1763, I have been able to learn little or nothing. Doubtless their 
treatment differed in nowise from the cruelty shown them in all 
other countries at the same period. That they were not totally 
neglected is manifested, however, by the fact that, in 1639, ^^^ 
Duchess d'Aiguillon, niece of Cardinal Richelieu, founded the 
Hotel Dieu of Quebec for the care of indigent patients, the 
crippled, and idiots. As here employed, the term idiot probably 
refers to all forms of mental disorder, acquired as well as con- 
genital, and the creation of this establishment is especially note- 
worthy inasmuch as it was not only the first move toward the 
proper care of the insane, but was the first hospital instituted in 
North America. Four years later, namely in 1643, Mademoi- 
selle Mance founded the Hotel Dieu of Montreal to meet the same 
requirements. 

For well nigh three-quarters of a century after the establish- 



T. J. W. BURGESS. 89 

ment of British rule, the conditicm of the insane in the various 
Crown Colonies, which now make up the Dominion of Canada, 
was deplorable in the extreme. Each county seems to have cared 
for its insane as best it could by confining them in almshouses 
and jails. The poor lunatic did not appeal to the sympathies of 
the public, — a workhouse was good enough for him if harmless, 
a prison his proper place if dangerous. The thought that he 
might be cured, and that no effort should be spared to cure him, 
occurred to few if any. Bereft of man's noblest attribute, the 
mind, lunatics were regarded as little better than brutes, and 
were too often treated accordingly. While falling short of the 
Napoleonic Code, published in 1804, which openly classed the 
insane with beasts, and ordered the punishment of those who al- 
lowed " the insane and mad animals to run about free," the Law 
in Canada deemed them at least on a par with criminals. In 
proof of this witness an act, in force as late as 1835, which au- 
thorized any two justices of the peace, without any medical cer- 
tificate, " to issue a warrant for the apprehension of a lunatic or 
mad person, and cause him to be kept safely locked in some secure 
place directed and appointed by them, and, if they deem it neces- 
sary, to be chained" 

The first of the old British North American colonies to make 
special provision for its insane was New Brunswick, by the con- 
version, in 1835, of a small, wooden building in the city of St. 
John, originally erected as a cholera hospital, into an asylum for 
lunatics. This institution, the first of the kind in Canada, con- 
tinued in operation for a little over thirteen years, under the medi- 
cal supervision of Dr. George P. Peters, a native of St. John but 
a graduate of Edinburgh University. 

Dr. Peters had no previous experience in the care of the insane, 
but, being energetic and deeply interested in the welfare of his 
charges, did exceptionally good work considering how he was 
handicapped. That he was in advance of his day, and fully recog- 
nized the importance of special training for the proper treatment 
of mental diseases, a fact so often lost sight of by governments 
and their appointees, is evidenced by his urging, though vainly, 
the Legislature to get a physician from England, one trained in 
the best schools of psychiatry, to take charge of the new asylum. 
The difficulties he had to encounter were many, not the least being 



90 PRESIDENTIAL ADDRESS. 

one that is equally common to most of us at the present day, that 
of finding suitable nurses. On this point he quaintly reports : "* I 
find it very difficult to secure proper attendants, especially for the 
female patients. Those who apply for the place are coarse and 
ignorant, their only qualification for the position being good mus- 
cular development, and absence of all proper sensibility." 

The following record preserved in the Sessions of the Peace 
minute-book gives a good idea of the results attained by Dr. 
Peters during the first thirteen and a half months of his incum- 
bency. Of the thirty-one admissions, it says, " there have been 
discharged — cured, six ; improved, five ; to friends, not improved, 
two; died, four. Of the remaining 14, one is much improved, 
two perceptibly improved, and 11 without any visible improve- 
ment" Some of the details of the itemized accounts, contained in 
the same volume, are highly suggestive of the times and of the 
methods of treatment, in which blood-letting and restraint 
must have played a considerable part, and bathing and light been 
luxuries. 

"W. McBay for twelve hogsheads of water (for one month), one 
pound, fifteen shillings. 

"W. Hammond, for thirty pomids rush lights, ten pence per lb., one 
pound, five shillings. 

"Harvie and Allen for eight tin bleeding cups and one tin pan, seven 
and six pence. 

" D. Collins ( Sadler), for three hand mufflers, one pound, fifteen shillings. 

"G. T. Ray, for twelve straight waistcoats at twenty shillings each, 
twelve pounds." 

In 1848, this temporary refuge, the pioneer Canadian asylum, 
was abandoned, the inmates, ninety in number, being transferred 
to the present institution, the erection of which had been begun 
two years previously. 

Ontario, or, as it was then called. Upper Canada, was the next 
of the provinces to make a movement toward providing for its 
insane, the old and recently abandoned jail at York, now Toronto, 
having been fitted up and opened as a temporary asylum in 1841. 
Prior to this, numerous attempts had been made in the House of 
Assembly toward the creation of an asylum, the Government 
going so far, in 1836, as to appoint a Commission to visit the 
United States for the purpose of obtaining information on the 
subject. The chairman of this Commission was Dr. Charles Dun- 



T. J. W. BURGESS. 9I 

combe, who afterwards, during the rebellion of 1837, became the 
leader of the rebels in the western part of the province, and only 
saved his neck from the hangman's noose, on the defeat of the 
movement, by making his escape, disguised as a woman, across 
the Detroit River into Michigan ; this despite the fact that a re- 
ward of ^500 had been offered for his apprehension. Dr. Dun- 
combe's report is particularly interesting to us, because he therein 
gives an account of his visit to Worcester Asylimi, Massachusetts, 
then under the superintendence of Dr. Samuel B. Woodward, 
who eight years later became the first president of this association, 
of which he had been also one of the originators. His institu- 
tion was the one, of all those inspected, that best met the approval 
of the Commission, and the one, the general plan of which, they 
advised should be followed. In concluding his report. Dr. Dun- 
combe thus interestingly outlines his views on the subject of 
lunacy and the object of the proposed structure. " The building 
is not designed for the cure of the ordinary diseases of the body, 
but ' to restore the disjointed or debilitated faculties of a fellow- 
creature to their natural order and offices, and to revive in him the 
knowledge of himself, his family, and his God.' The subject of 
lunacy has been until of late years less perfectly understood than 
any other complaint known to our country that is at this moment 
successfully treated, but thank Heaven that the disease of an organ 
of the mind is no longer considered a crime subjecting the unfor- 
tunate subject of it to imprisonment, punishment, and chains, 
and that with the exception of this Colony no other portion of 
America has their insane confined in their jails, and I am well 
satisfied this will not be the situation of these unfortunate persons 
longer than until their number and present cost of support is 
known, and the legislature have time to provide a suitable asylum 
for their relief." 

The make-shift asylum, into which the old jail had been con- 
verted, was placed in charge of Dr. Wm. Rees, who had long 
urged upon the government the necessity for such an establish- 
ment, and continued in use up to 1850. At that date the patients 
were transferred to the present Toronto asylum, which, for 
twenty-two years after, was the field of labor of the venerable Dr. 
Joseph Workman, to whose wisdinn much that is best in the 
present system of caring for the insane in Canada can be traced. 



92 PRESIDENTIAL ADDRESS. 

Kingston Asylum, generally known as Rockwood Hospital, was 
the second asylum born in the Province of Ontario. It had its 
birthplace in the stable of the old Cartwright mansion, which, 
in 1856, was fitted up for the reception of twenty-four female 
patients. Like its successor, the present structure, opened in 
1862, it was originally designed for a criminal lunatic asylimi, and 
as such the institution remained in charge of the Federal Grovem- 
ment, an adjunct to the penitentiary, until 1877. In that year it 
was purchased by the Local Legislature and became one of the 
ordinary provincial establishments. 

London Asylum, the third Ontario asylum in point of age, was, 
when opened in 1859, originally located in the old military bar- 
racks at Fort Maiden on the Detroit River, and formed a branch of 
the Toronto institution which had become congested. In 1870, 
the present hospital, at London, having been completed, the pa- 
tients were transferred there. 

Of the other five public asylums in Ontario, that at Hamilton 
was originally built for an inebriate asylum, but was never used 
as such, being utilized instead for the reception of the insane, and 
opened in 1879. Mimico Asylum was first occupied in 1890, 
Brockville Asylum in 1894, Cobourg Asylum in 1902, and Pene- 
tanguishene Asylum in 1904. The Cobourg institution, for fe- 
male chronic patients, was created by the conversion of Victoria 
College, the scholastic headquarters of the Methodist community 
prior to federation with Toronto University, into a hospital for 
the insane ; and the Penetanguishene Asylum, which is for chron- 
ics of both sexes, was formerly a reformatory for boys. 

Ontario also possesses an asylum for idiots. It is situated at 
Orillia, where it had its inception, in 1876, in a building originally 
designed for an hotel. This structure was replaced by a new and 
modern establishment in 1887. 

In the Province of Lower Canada, now Quebec, the Quebec 
Lunatic Asylum, formerly known as Beauport Asylum, is the 
oldest of the institutions for the insane, the progenitor of the 
present structure having been opened, during 1845, ^^ the old 
manor-house of the Seigneur of Beauport, which stood about a 
mile from the present establishment Its creation was due to Dr. 
James Douglas, an uncle of my immediate predecessor in this 



T. J. W. BURGESS. 93 

chair. Dr. Joseph Morrin and Dr. Charles J. Fremont, but it is 
now the property of the Sisters of Charity. 

The second of the Quebec asylums, L'Hopital St. Jean de 
Dieu, or, as it is usually called, Longue Pointe Asylum, is situ- 
ated a few miles east of Montreal, and also belongs to the Sisters 
of Charity. It originated in a very humble way in 1852, its 
capacity at that time not exceeding twenty-five patients. This 
being found quite inadequate to meet the ever-increasing demands 
upon their charity, the Sisters, with the sanction of the Govern- 
ment, determined to take up the work of caring for the insane on 
a greatly enlarged scale. The result was the erection of a new 
St. Jean de Dieu Asylum, which was opened in 1875. This in- 
stitution was completely destroyed by fire in 1890, no less than 
seventy-five patients and five Sisters losing their lives in the con- 
flagration. Undeterred by this disaster, the Sisters lost no time 
in beginning the erection of the third St. Jean de Dieu Asylum. 
This, the present establishment, which is fully up-to-date in con- 
struction and equipment, was opened in 1901. 

The third Quebec institution, rightfully called the Protestant 
Hospital for the Insane, though generally spoken of as Verdum 
Hospital, was founded by a number of the charitably disposed 
Protestant citizens of Montreal for the relief of their co-religion- 
ists then confined in Beauport and Longue Pointe asylums. It 
was opened for the reception of patients in 1890. 

Quebec has in addition two institutions which receive idiots as 
well as some aged and infirm paupers. These are L'Hospice St 
Julien, located at St. Ferdinand d'Halifax, and Bale St. Paul 
Asylum, situated at Bale St. Paul. Both belong to the Sisters 
of Charity, the former having been opened for the reception of 
idiots in 1873, the latter in 1890. 

Prince Edward Island stands fourth, and Nova Scotia fifth, on 
the list with regard to the date of beginning special provision for 
the insane. The hospital of the former dates back to 1847, ^^^ of 
the latter to 1858, since which time Nova Scotia has increased its 
accommodation for the mentally defective by the creation of a sys- 
tem of county asylums, and combined county asylums and 
poorhouses. An interesting point in connection with the Nova 
Scotia Asylum is that to it pertains the honor of having had its 
site selected by the well-known philanthropist Miss Dix, of whom 



94 PRESIDENTIAL ADDRESS. 

it is said in Tuke's "Dictionary of Psychological Medicine": 
" Although, in every country, men and women and the medical 
profession have been ready to promote the interests of the in- 
sane, the name of Dorothea L. Dix stands foremost among all. 
Her efforts in improving the condition of the insane were not 
confined to her native State of Massachusetts, but extended to 
other States and distant lands. Her life was devoted to their 
interests, and it is stated that no less than thirty asylums owe 
their establishment directly or indirectly to her persistent efforts." 

The first Manitoba Asylum, now located at Selkirk, was origi- 
nally established in 1871, at Lower Fort Garry, in connection 
with the penitentiary. One of the old stone storehouses of the 
Hudson Bay Company, formerly used for the confinement of 
Lepine, the notorious Louis Kiel's Adjutant-General, was fitted 
up for the purpose. The second asylum, situated at Brandon, 
began work in 1891. 

The year 1872 witnessed the birth of the British Columbia in- 
stitution, when an ancient wooden building on the Songhees In- 
dian Reserve, outside the city of Victoria, originally built for a 
small-pox hospital, was reopened to receive lunatics. The popu- 
lation having outgrown these primitive quarters, it was decided 
to erect a new asylum on the main land, close to the town of New 
Westminster. This was done and the patients removed thereto 
in 1878. 

Of the superintendents connected with the bygone struggles 
of these beneficient institutions much might be said, but the lim- 
ited time at my disposal forbids the eulogiums they so justly 
deserve, even were my pen equal to the task. No words of mine 
could do justice to such men as Dr. Workman, easily, '* primus 
inter pares/' and fittingly styled by Dr. Tuke, "The Nestor of 
Canadian alienists " ; Dr. Henry Landor, whose rare qualities of 
heart and mind fitted him so eminently for his position; Dr. R. 
M. Bucke, to whom is due the introduction of the non-restraint 
system into Canada ; Dr. W. G. Metcalf , who by his sad and un- 
timely death added another to the goodly list of physicians who 
have perished at the hands of those whom they sought to benefit ; 
Dr. J. R. DeWolf, who was foremost in the early care and treat- 
ment of the insane in Nova Scotia ; Dr. E. E. Duquet, who died 
worn out by his labors in striving to reform the Longue Pointe 



T. J. W. BURGESS. 95 

Asylum ; and Dr. A. Vallee, whose advanced views did so much to 
improve the Quebec Asylum. The blessed results of the labors 
of such men can never be fully estimated, their works being 
truly: 

"Deeds which are harvest for Etcmity." 

Status of the Insane. 

At the present time Quebec is the only one of the provinces of 
the Dominion in which there is no State institution for the care 
of the insane. Though vastly improved in every respect and much 
more strictly supervised by the Grovernment than when Dr. Tuke 
visited them, in 1884, and so graphically portrayed the then ex- 
isting evils, the two largest hospitals, St. Jean de Dieu and Beau- 
port, are still proprietary establishments and, as such, still open to 
the criticisms thus forcibly expressed by that distinguished alien- 
ist in his work, " The Insane in Canada and the United States " : 
" Far be it from me to attribute to these Sisters of Charity any 
intentional unkindness or conscious neglect. I am willing to 
assume that they are actuated by good motives in undertaking the 
charge of the insane, that they are acute and intelligent, and that 
their administrative powers are highly respectable. Their farm- 
ing capacities are, I have no doubt, very creditable to them. It is 
not this form of farming to which I have any objection or criti- 
cism to offer. In the vegetable kingdom I would allow them un- 
disputed sway. It is the farming out of human beings by the 
Province to these or any other proprietors against which I ven- 
ture to protest. ... It is a radical defect — 3. fundamental mis- 
take — for the Province to contract with private parties or Sis- 
ters of Charity for the maintenance of lunatics. Whatever may 
be the provision made by private enterprise for patients whose 
friends can afford to pay handsomely for them, those who are 
poor ought to have the buildings as well as the maintenance pro- 
vided for them by the Legislature. They are its wards, and the 
buildings in which they are placed should belong, not to private 
persons, but to the public authorities, with whom should rest the 
appointment of a resident medical officer." 

No less pronounced in his condemnation of the " farming-out " 
system is a later writer, one of our greatest authorities on all 
appertaining to insanity and the care of the insane, Professor 



96 PRESIDENTIAL ADDRESS. 

Kraepelin. This world-renowned alienist says of it, in an article 
published some five years ago : " It is not only unworthy of the 
State, but in the long run it is also dangerous to entrust the care 
of such institutions to promoters, who are working only on their 
own responsibility, be they laity or clergy. The best ordinances 
of State supervision cannot do away with the danger which at- 
tends the transference of the insane from the care of the public 
officials to that of private individuals. Even if State inspection 
were well carried out, which cannot be guaranteed, only the more 
apparent abuses could be guarded against The management of 
the institution would still be carried out in accordance with the 
particular views and wishes of those who were in charge and, as 
a rule, to the disadvantage of the patients." 

Following the publication of Dr. Tuke's article, the Medico- 
Chirurgical Society of Montreal held a meeting at which, among 
others, the following resolutions were unanimously passed : 

" That the ' farming ' or ' contract ' system either by private individuals 
or by private corporations, has been ever3rwhere practically abandoned, as 
being prejudicial to the best interests of the insane, and producing the 
minimum of cures. 

" That in the opinion of this Society all establishments for the treatment 
of the insane should be owned, directed, controlled, and supervised by the 
Government itself, without the intervention of any intermediate party." 

Spite of these and other vigorous protests the system remains 
unchanged, and before Quebec can be counted in the foremost line, 
where it ought to be, the Province must own as well as supervise 
its institutions for the dependent insane. 

One outcome of the furore excited was, however, the founding 
of the Protestant Hospital for the Insane, an incorporated charit- 
able institution, which, while paid by the Government for the 
maintenance of public Protestant patients, is safeguarded by the 
leading clause in its charter of constitution. This stipulates that 
the conduct of the establishment shall be vested in a board of 
management elected by the governors, and that all moneys re- 
ceived by the corporation, from whatever source, shall be ex- 
pended upon the institution and its inmates. As a matter of fact, 
ever since the opening of the hospital, the per capita cost of pub- 
lic patients therein has not been less than fifty per cent more 
than the Government allowance for their keep, the difference hav- 



T. J. W. BURGESS. 97 

ing been made up by the revenue derived from private patients 
and the bequests of the charitably disposed. 

The Province of Nova Scotia, though possessed of as well-man- 
aged a State asylum as could be desired, is yet behindhand in that 
it has since 1886, sanctioned the erection of cotmty asylums, and 
in many cases combined county asylums and poorhouses. To these 
can be transferred the harmless insane irom the provincial insti- 
tution, and to ttiem can be sent direct, idiots, non-violent epileptics, 
and cases of chronic insanity refused admission on statutory 
grounds to the State Asylum. At the present time there are 
eighteen of these structures, which, according to the Report of 
Public Charities for 1904, house sane adults, children, insane 
patients, imbeciles, and epilq>tics. Each is governed by a com- 
mittee, the immediate management being entrusted to a keeper 
and a matron^ and there is a visiting medical officer attached. 
These establishments have been erected in pursuance of a plan 
outlined by Dr. Reid, formerly Superintendent of the Provincial 
Asylum, though a Nova Scotia medical friend of mine, well ac- 
quainted with the system, contends that it was invented by the 
devil. The scheme was necessitated by the pressing need of ad- 
ditional room for the insane, and the financial inability of the 
Province to undertake the erection of another public hospital. It 
is only fair to Dr. Reid, however, to state that this was but one 
of four alternative suggestions made by him, and that it was the 
one he considered the least desirable, although the cheapest way 
to provide the required accommodation. 

That county care is cheaper I will not gainsay, but does it best 
meet the demands of humanity, which, after all, is the true stand- 
ard to be adopted by any right-thinking community? That it 
does not, seems to be the general trend of the most advanced scien- 
tific opinion, and the following resolution, adopted at the sixth 
meeting of this association, held at Philadelphia in 1851, stilT 
holds good : 

" Resolved, That it is the duty of the community to provide and suitably^ 
care for all classes of the insane, and that in order to secure their greatest 
good and highest welfare, it is indisputable that institutions for their 
exclusive care and treatment, having a resident medical superintendent, 
shotxld be provided, and that it is improper, except from extreme necessity, 
as a temporary arrangement, to confine insane persons in county poorhouses 
or other institutions, with those afflicted with or treated for other diseasefi 
or confined for misdemeanors." 
7 



98 PRESIDENTIAL ADDRESS. 

Not a few of the chronic insane are as difficult to manage as 
the acute, and such being the case, it is hard to imagine any plan 
of county care where abuses will not creep in as a result of the 
desire to lessen the per capita cost and the absence of constant 
medical supervision. As practised in the State of Wisconsin it 
seems to be as well conducted as it is possible for such a system to 
be, and yet Dr. Burr, our worthy vice-president, who is a just 
and honest man as well as a careful observer, after a personal in- 
spection of the system there, published, in the October, 1898, 
number of the American Journal of Insanity, a scathing de- 
nunciation of its inefficiency. 

Many of the worst horrors connected with the treatment of the 
insane during the last half-century were consummated within the 
walls of county almshouses. In New York, where the practice 
of transferring cases which failed to recover in a certain time 
from the Utica Asylum to the county poorhouses was in vc^^ue 
for nearly thirty years, and where the county asylum system 
flourished for over eighteen years, the abuses which seem to be 
inseparable from almshouse and county arrangement so aroused 
public opinion that both methods were abolished, by the passage 
of the State Care Act of 1890. 

The State of New Hampshire has also lately recognized the 
injustice of this method of caring for the insane, and, in 1903, 
passed an act revoking county care, and providing for the re- 
moval of all lunatics confined in almshouses to the State hospitals 
within a period of six years. 

That those connected with and so best qualified to judge of the 
working of the Nova Scotia system are not themselves enamoured 
with it may be judged from the 1903 Report of Public Charities. 
Therein, the inspector. Dr. George L. Sinclair, an alienist of re- 
pute and a former superintendent of the Provincial hospital, szys: 

"The plan of county care adopted in this province has many grave 
objections. In a properly equipped and well officered local asylum, reserved 
for the exclusive use of insane or imbecile inmates, the objectionable fea- 
tures are fewest The scheme of associating in one house both sane and 
insane persons is the most objectionable and unsatisfactory. 

"Unfortunately our law permits this to be done, provided the building 
is made suitable for both classes and for both purposes to the satisfaction 
of the Govemor-in-Council. The difficulties to be overcome to make such 
a plan of care unobjectionable pertain quite as much to the structure of 
the municipal mind as to that of the building. 



T. J. W. BURGESS. 99 

" It is most unfair to the sane members of such a household, whose only 
auction is poverty, to compel them to associate with the insane and imbe- 
ciles, who are not only irresponsible, but may be a source of positive 
danger to their companions in misfortune, and it is distinctly unjust to the 
insane inmates to attempt to care for them with the limited oversight and 
attention which the small staff of an almshouse can give. 

"I have yet to find a single keeper or matron of an asylum to which 
the mental defectives are sent to associate with the paupers, whose expe- 
rience in looking after the two classes is sufficient to give the opinion any 
value, who does not think the mixing of the two kinds of inmates most 
undesirable. When it is done there is either a dangerous amount of lib- 
erty granted the defectives, or they are isolated and secluded to an extent 
that means positive neglect, and leads to distinct deterioration and the 
formation of bad habits. It cannot be otherwise. The staff of an ordinary 
almshouse usually consists of a keeper and a matron. The former has 
charge of the farm and the latter of the housekeeping. When at his work 
the keeper must either take the insane men with him or leave them at home. 
The first is often impracticable, and the second unsafe unless the patient is 
locked up. This more or less frequent seclusion always has an evil effect 
in causing the insane person to fall into bad habits. Some times most objec- 
tionable and severe mechanical restraints are used, and nothing but harm 
results." 

In the Province of New Brunswick, it is much to be regretted 
that the Government, on account of the overcrowded condition of 
the Provincial hospital, is contemplating a resort to the Nova 
Scotia system. At the last session of Parliament legislation was 
passed providing for the examination of all patients therein by a 
commission composed of the Medical Superintendent and two 
other doctors. When the work of the commission, which began 
its labors in November last, is completed, a report is to be made 
to the Government with a view to the selection of those who, 
being supposed to be harmless, can be sent back to their friends 
or to the county almshouses. To carry out such retrograde l^s- 
lation will be to sully the record of a province which has here- 
tofore always steadfastly declared against the incarceration of 
limatics, even temporarily, in prisons or poorhouses, — ^a province 
which can boast with pride of having been the first of the British 
North American colonies to provide special accommodation for 
its dependent insane. 

At present, in New Brunswick, perhaps the gravest existing 
defect in connection with the insane is the method, or rather lack 
of method, of commitment to the Provincial hospital. The safe- 



too PRESIDENTIAL ADDRESS. 

guarding of the liberty of the subject seems to be little heeded, 
and a patient can be conveyed to it with only a line from a doctor. 
No thought is given to advising the hospital authorities before- 
hand that a patient is coming, and often no history whatever of 
the case is furnished. The Medical Superintendent, however, in- 
forms me that this matter is to be remedied at once, and that the 
present year will see the manner of commitment more in con- 
sonance with the modes adopted in other civilized countries. 

Ontario, as the wealthiest of the Provinces, has of course been 
able to outstrip the others, and in its care of the insane has always 
endeavored to keep up with the advance of science. Its asylums 
are State institutions in the fullest sense of the word. In the 
majority of cases the patients are maintained entirely at Govern- 
ment expense ; in other cases, where able to do so without hard- 
ship, the friends are charged a rate that covers the bare cost of 
keep. While all its hospitals are good, Rockwood is certainly 
the foremost, ranking to-day among the most advanced institutions 
for the treatment of the insane in America. Whether it be that 
its presiding officer has a more persuasive tongue and so can bet- 
ter influence the " powers that be " I cannot say, but assuredly 
it has accessories that are elsewhere lacking, — ^to wit, a beautiful 
nurse's home, and several small cottages for the segregation of 
tubercular patients. The varieties of employment provided for 
the patients there are, as they should be, ntunerous and diversified, 
and physical culture classes are one of the features of the esta1> 
lishment. In addition, those who have a taste for music are in- 
structed in it under a qualified teacher, and there is also a school 
modeled after that in the Utica Asylum. At Rockwood, too, it is 
worthy of record, was established Canada's first training school 
for asylum nurses, and the first separate building, or infirmary, 
on the continent, for the treatment of lunatics afflicted with addi- 
tional ailments. 

Prince Edward Island has a Provincial hospital for its insane, 
but idiots and imbeciles are sheltered in the Provincial poorhouse, 
those who become dangerous being transferred to the insane 
hospital. 

In Manitoba and British Columbia the asylums are State institu- 
tions and well conducted, though, at present, sadly hampered by 
the constant and pressing necessity of providing sufficient room. 



T. J, W. BURGBSS. lOI 

owing to the mass of immigrants that ha9 been flowing into those 
Provinces during the last two or three years. The Manitoba hos- 
pitals receive imbeciles, but idiots are sent to the Home for In- 
curables, also a Provincial institution, located at Portage la 
Prairie. British Columbia has no special provision for idiots or 
imbeciles. When utterly unmanageable at home they are re- 
ceived into the insane asylum. 

The Northwest Territories having no hospitals of their own, 
by special arrangement with the Dominion Government, all cases 
of insanity occurring in those districts are cared for in the pro- 
vincial asylums of Manitoba. 

Number of Insane. 

In 1901, according to the census of that year, there were in 
the Dominion of Canada 16,622 persons of unsotmd mind, being 
a ratio of 3.125 per thousand, or about one in every 319 of a popu- 
lation numbering 5,318,606 souls, exclusive of the unorganized 
territories. Of these 16,622 defectives, 10,883 were inmates of 
asylums or other institutions, making a percentage of .642 under 
care. 

The Provinces as regards the number of their insane stood as 
follows: Prince Edward Island 361, a proportion of 3.496 per 
thousand ; Ontario 7552, or 3.459 per thousand ; New Brunswick 
1064, or 3.213 per thousand ; Quebec 5297, or 3.212 per thousand ; 
Nova Scotia 1403, or 3.052 per thousand ; Manitoba 464, or 1.818 
per thousand; British Coltunbia 301, or 1.684 P^r thousand; 
Northwest Territories 180, or 1.132 per thousand. 

With respect to custodial care, British Columbia ranked first, 
having under care, at the close of 1901, no less than 94 per cent 
of the total number of those mentally incapacitated; Manitoba 
came next with Tj per cent in safe-keeping; Nova Scotia stood 
third with 71 per cent sheltered ; Ontario was fourth with 69 per 
cent in asylums; Prince Edward Island was fifth with 61 per 
cent provided for; Quebec and the Northwest Territories were 
equal with 58 per cent, under care; and New Brunswick was 
eighth with 52 per cent, housed. 

The following table shows the changes indicating increased cus- 
todial care, or otherwise, on the part of the several Provinces, in 
the decade extending from 1891 to 1901. By this it will be seen 



I02 PRESIDENTIAL ADDRESS. 

that there has been a marked advance in all with the exception 
of New Brunswick, which remains unchanged. 

ProTlnoet. ^'"iSi!""' ^""^1^ 

British Columbia 90 per cent 94 per cent 

Manitoba 55 " 77 ** 

New Brunswick 52 " 52 " 

Nova Scotia 36 " 71 *' 

Ontario 58 " 69 " 

Prince Edward Island 38 " 61 " 

Quebec SO " S8 " 

Northwest Territories (housed in Manitoba 

asylums) $8 ** 

Canada 54 percent 66 per cent 

Increase of Insanity. 

Spite of the provision made for the care of the insane, from 
every Province comes the cry for additional accommodation. 
Year by year the number of lunatics, imbeciles, and idiots to be 
supported and cared for by the State is being largely augmented, 
and it has become a burning question whether something cannot 
be done to lessen an evil which imposes upon the community an 
enormous load of taxation for the maintenance of a large and 
constantly increasing multitude of those mentally afflicted. Can- 
ada, in common with the rest of the civilized world, has of late 
years shown a decided increase in the percentage of her insane 
population. Of course it is easy to be led astray by statistics 
compared without just qualification. The very agencies created 
for the care of the insane lead to an apparent increase in their 
number. With well-appointed asylums conducted on enlightened 
lines, aided by Government grants and private charity, hundreds 
of patients who might otherwise be uncounted, leave their homes 
to swell the enumeration of the insane. Still, with all allowance 
made for this, it is the consensus of opinion that insanity is on 
the increase in Canada as elsewhere. That such is the case is 
fully borne out by the census returns, which, though lessened in 
validity by the fact that the figures they furnish are in great 
measure dependent on voluntary information, are yet in this case 
a fair index of the true state of affairs, because any false state- 
ments made would be in the line of lessening the number of de- 



T. J. W. BURGESS. IO3 

fectives. From this source we find, that while in 1891 there 
were 13,342 insane persons in a population of 4,719^3, in 1901 
there were 16,662 in a population of 5,318,606, being an increase, 
in ten years, of nearly twenty-five per cent, in the number of 
lunatics whereas the increase in the total population was less than 
thirteen per cent. 

The causes of this increase are manifold. The methods of 
modem life and the modem race for wealth undoubtedly play an 
important part in it Our high-pressure civilization does not 
come to us without attendant woes. With the change and in- 
creased comfort in the mode of life of the great bulk of the people, 
their susceptibilities have been augmented, and their nervous sys- 
tems have been laid more open to the unkind influences of ma- 
terial and moral forces. But while these and other causes play 
a part in the production of mental disorder, it is a small one in 
comparison with that played by heredity. From time imme- 
morial it has been recognized that the great predisposing cause 
of insanity is hereditary taint, and as time rolls on, and we are 
able to make more careful inquiry into the influence of hereditary 
predisposition, the tmth of this old-time belief becomes more and 
more evident. Unfortunately we are not in a position to say 
exactly what amount of the mental obliquity met with is due to 
transmitted weakness. The statistics of heredity vary widely, 
and this variation is chiefly in direct ratio to the prevarication 
practised by the relatives of the insane. Not one of us but is 
well acquainted with the way in which people, even in the lower 
ranks of life, endeavor by every means to keep us ignorant of 
what they consider to be a stigma on the family. Almost every 
authority on mental diseases has commented on this, one writer 
going so far as to compare the difiiculty experienced in getting 
at the truth in such cases, to that which might be expected in 
dragging from an erring woman a confession of her frailty. Why 
brain disease should be regarded as more disgraceful than dis- 
ease of the lungs or any other organ of the body, or why the fact 
of insanity being in a family should be looked upon by the public 
as tantamount to an acknowledgment of criminality, is hard for 
us to g^sp. Such, however, is the fact, and until the masses are 
educated out of such erroneous beliefs, friends will continue to 
lie about their antecedents most unblushingly. Often I have 



104 PRESIDENTIAL ADDRESS. 

known cases where the relatives have positively asserted that 
there was no trace of insanity in their family history; and often 
I have afterward discovered that it had been well marked for 
generations. I well remember a lady, widely known for her 
Christian principles^ coming to see me about receiving her daugh- 
ter as a patient A prognosis in the case was of importance, and 
I was asked to give as definite a one as possible. Naturally I 
asked as to any possible hereditary taint My lady was firmness 
itself in her denials. In the course of further conversation, how- 
ever, she happened to mention that her brother, who had been 
very fond of the insane girl, was dead, and added, "" Perhaps it's 
as well after all that he is.'' It struck me at once that there must 
be something behind this expression of opinion, and my question, 
"Why so. Madam?" elicited the answer, "Well doctor, you see 
for over a year before my brother shot himself he was always 
worrying about Mary's future welfare.". Needless to say the 
hospital registers showed heredity as a definite predisposing factor 
in the case. 

But it is unnecessary that I should dwell upon the question of 
heredity as a cause of the increase of insanity. It and the mar- 
riage question were fully and ably discussed by Dr. Blumer in 
his presidential address delivered at Washington two years ago. 
I shall but strengthen, if that be possible, what was then said, by 
a quotation. It is from an address on the prevention of insanity 
given by Dr. G. F. Blandford, as President of the Psychological 
Section of the British Medical Association, in 1894. On that 
occasion Dr. Blandford stated : " I have long been of the opinion 
that insanity is to be prevented chiefly by limiting the propaga- 
tion of this most fearful disease through the union of affected 
persons. I am convinced that the only way to really diminish and 
finally stamp out insanity is by so educating public opinion, that 
those who have been insane or are threatened with insanity, shall, 
in the face of such public opinion, abstain from bringing into the 
world children who must certainly contain in them the potentiality 
of insanity, and so will hand on the heritage from generation to 
generation till the race dies out" 

Instead, let me call your attention to another topic, briefly re- 
ferred to by Dr. Blumer, in the line of prevention of the increase 
of insanity — ^the exclusion of defective immigrants. I do so for 



T. J. W. BUKGESS. IO5 

two reas<His. Firstly, because during the past two years the in- 
flux of strangers into Canada has been so enormously increased ; 
and secondly, because Canadian immigration laws being much 
less stringent than those of the United States our land is being 
flooded by a class of degenerates, many of whom, if not already 
insane, soon become so. 

That a country so vast as ours should be much more densely 
peopled is a " consummation devoutly to be wished," but the ques- 
tion of number, desirable as it may be, is secondary to the char- 
acter of the people who are being added to our population. The 
sturdy agriculturists and artisans of the British Isles, healthy 
alike in body and mind, always furnish a welcome addition to 
our ranks, but unhappily quite a large ntunber of the immigrants 
brought to us are of a low standard of mentality, some of them 
even having been inmates of asylums before coming to this coun- 
try. Such a condition, amid new environments and under new 
conditions of existence, is almost sure to lead to mental strain and 
insanity. The result is that these incompetents, many of them 
consisting of the scum and dregs of an overcrowded European 
population, are crowding our Provincial hospitals, especially those 
of Ontario, Manitoba, and British Columbia, to which Provinces 
immigration has been largest, and those contiguous to large sea- 
ports, such as Montreal. Most of our institutions have a larger 
percentage of foreigners than is found among the native popu- 
lation, and while the greater number of the foreign-bom inmates 
are legitimately there, having broken down mentally after they 
had earned a residence, there is in every asylum a proportion 
who should never have been brought to our shores. Some of 
these have come of their own accord, but it is evident from the 
statements of the patients themselves that in certain cases paroch- 
ial boards, benevolent societies, municipalities, and even rela- 
tives, have sent out persons simply as the cheapest way of getting 
rid of them. The cost of a ticket is small compared to a life- 
time's maintenance in an asylum, a poorhouse, or at hcxne. The 
late Dr. R. M. Bucke in giving his evidence before a Commission 
appointed to inquire into this subject, thus forcibly and truthfully 
expressed himself: "There are associations formed in England 
for bringing out to Canada what are called gutter children from the 
slums of England, Scotland, and Ireland. Thousands are brought 



I06 PRESIDENTIAL ADDRESS. 

out by these organizations. This is scandalous and should not 
be allowed to go on. These people might as well collect small- 
pox and typhoid fever and send them out It is just adding so 
much more to the number for which we have to provide, because 
so many of them are degenerates." But a few months ago it was 
proposed in London to form an organization for the emigration 
on a gigantic scale of British pauper babies and young children, 
and a meeting was convened at Mansion House under the aus- 
pices of the Lord Mayor to discuss the subject Canadians gen- 
erally and naturally object to the establishment of British work- 
house farms in Canada under the control of the British poor law 
guardians for the reception of English foundlings, and, I am 
thankful to say, the Canadian Government withheld its approval 
of the scheme. 

As typical of the class of persons sent out by their friends to 
get rid of them, let me read you a description of a batch of these 
defectives who had become hospital residents and were deported 
to Liverpool. It is from a report of the asylum in British Co- 
lumbia, where this custom has been very common, I suppose on 
the principle that the farther away a ne'er-do-weel is shipped the 
less likelihood of his return. *' All these cases were illustrations 
of a practice too much in vogue in Great Britain, of shipping off 
to the colonies weak-minded young persons who are unmanage- 
able at home, and unable to make a career for themselves, or earn 
a livelihood there. ' He has continued his wild and reckless con- 
duct, and has now been shipped off to the colonies,' is a phrase 
made use of in the Journal of Mental Science, in a description of 
a case of the kind now in question. But if a patient of the sort 
here described is unable, with the assistance and supervision of his 
friends and relatives, to steer a straight course and make a posi- 
tion for himself in the Old Country, still less is he likely, when 
left to himself, to be able to cope with the struggles and difficul- 
ties of Colonial life. Of the five cases above mentioned, in one 
the patient was of feeble intellect and the insanity strongly heredi- 
tary, in another the patient was obviously weak-minded originally, 
a third was a pronounced epileptic with consequent mania, and 
two others, a brother and sister, suffered from strong family taint 
The brother had been previously for three years in an English 
County Asylum, and the sister had suffered from an attack of in- 



T. J. W. BURGESS. IO7 

sanity before coming out here. The brother had only been four 
days in the Province when he again became insane and was sent 
to the asylum. He was two years and one month in the Prov- 
ince, the whole of which time, except four days, he spent in the 
asylum at the expense of the Government 

'' It is hard upon the Colonies that the mother country should 
'ship off' these waifs and strays, these victims of 'borderland 
insanity,' to become, as they almost inevitably must do, when 
thrown on their own resources out here, confirmed lunatics, who 
have to be maintained at the expense of the community." 

That Canada is being made a " dtunping ground " for the de- 
generates of Europe it needs only a glance at our general and 
asylum statistics to show. Few, however, realize the extent of 
the burden thus imposed upon our charities. Only those whose 
duty brings them in contact with the defective classes can fully 
grasp how urgent it is that greater restrictions should surround 
the admission of undesirable immigrants. Even conservative 
England, which has always prided itself on being held wide open 
as a refuge for the poor and oppressed of all nations, is becoming 
aroused to the necessity of raising a barrier against unrestricted 
immigration. The evils have become so palpably evident there, 
during the past few years, that the average Briton, once heartily 
in favor of admitting any and every one to his country, is now 
cr3dng out against it, and the last Royal Commission on Alien 
Immigration, which was appointed in 1902 and presented its re- 
port last autumn, reccmimended the establishment of an immigra- 
tion department, similar to that of the United States, for the pur- 
pose of debarring and repatriating " undesirables." 

In proof that what I have said is no exaggeration of the ill 
effects attendant upon immigration insufficiently safeguarded, let 
me call your attention to some figures bearing on the subject. By 
the census of 1901 the population of Canada was 5,371,315, the 
number of foreign-bom being 699,500; the total of the insane was 
16,622, and of these 2878 were foreigners. From these returns 
it will be seen that a little over thirteen per cent, of the general 
population — ^that is to say the imported element — furnished over 
seventeen per cent, of so-called Canadian lunacy. Stated in an- 
other form, if the native Canadians alone are considered, there is 



I08 PRESIDENTIAL ADDRESS. 

one insane person in every 339 of the population ; while the {M'o- 
portion among the foreign element alone is one in every 243. 

If further evidence were needed I would say that during the 
year 1903 there were admitted to Canadian asylums 2;2i3 insane 
persons. Of this number 1726 were bom in Canada. The re- 
maining portion, 487, representing 22 per cent, of the admissions, 
was foreign-bom. At Verdun, 2048 patients have been received 
since the opening of the establishment, and of this number 40 per 
cent, were of foreign birth. In the same institution there are at 
the present time no less than thirty persons in a population of 460 
who, if subjected to anything but the most cursory examination, 
would never have been allowed to set foot in the country. 

The cause of this load being foisted upon us is not hard to find. 
It lies in the laxness of our immigration acts which do not de* 
mand a certificate of good bodily and mental health from each 
person landing, and which limit the period during which such par- 
ties may be deported to one year. 

No effort should be spared to relieve the Dominion of such an 
incubus, and the remedy is in our own hands. It consists in the 
passing of stringent laws providing for a full knowledge of the 
past history of every alien seeking our shores. The tme place to 
prevent the coming of the dangerous immigrant is not at the port 
of entry but at that of departure. Each person preparing to 
emigrate to Canada should be rigidly examined, by salaried medical 
officers appointed by the Dominion Govemment, as to his mental 
fitness at the time of examination, and should also show proof 
that he has never been insane or epileptic, and that his parents 
have never been affected with insanity. If found to fulfill all the 
legal requirements, a swom certificate, containing his full personal 
description and vouching for his mental and physical health, 
should be given him. Without such a certificate he should not 
be allowed to land, and the vessel bringing him should be obliged 
to take him back on its return trip at the expense of the owners. 
The health officers at our ports should, in addition, be clothed 
with authority to reject any immigrant on arrival if circum- 
stances developed during his passage should demand it, and in- 
stead of one year, the period of probation during which an immi- 
grant might be retumed to his own country if afflicted with in- 



T. J. W. BUBCBSS. 109 

sanity, unless surely due to causes arising after his arrival, should 
be extended to two or even three years. 

Doubtless such legislation would be bitterly opposed by steam- 
ship companies as tending to lessen the number of their steerage 
passengers, and by irresponsible emigration agents who send out 
every soul they can for the sake of the commission received on 
ocean and railway tickets. But the interests of the State should 
be paramount to such selfishness, and the Government should in- 
sist that Canada, while a hospitable refuge for the deserving poor, 
be not made an asylum for the diseased and defective. 

Our Requirements. 

Canadian requirements, speaking generally, are many. The 
most pressing, to my mind, are separate accommodations for 
idiots, epileptics, inebriates, and the criminal insane; proper 
means for the segregation of the tubercular; some provision for 
the temporary relief of friendless convalescents; and the aboli- 
tion of political patronge in asylum affairs. 

In the matter of proper and sufficient accommodation for idiots 
and imbeciles Canada is woefully behindhand, there being in the 
whole Dominion, not a single institution for these classes con- 
ducted on the lines that modem science and experience have 
found most satisfactory and successful. In all the Provinces, 
with the exception of Ontario, the feeble-minded, which is a 
generic term now used to include all degrees of idiocy and im- 
becility, if provided for at all, are housed in poorhouses and other 
establishments which provide for sane persons as well, or are 
mixed up with the insane population of the lunatic asylums. 
Ontario alone has attempted any adequate provision, and even 
she, from a spirit of false economy, has allowed a once promis- 
ing institution to drift backward. 

The care, training, and education of the mentally defective is 
an accepted public duty, and should be undertaken by the State 
at public cost, at least to the extent of providing the necessary 
institutions and schools for their care and teaching. Mere cus- 
todial care, even if provided in separate establishments, does not 
meet the requirements of the case, it being admitted by all who 
have made the interests of this class a life study, that any effort 
made in the direction of bettering their condition is useless unless 



no PRESIDENTIAL ADDRESS. 

a training school is combined with the custodial asylum. Surely 
it is just as essential to educate the imbecile as it is to educate 
the deaf-mute or the blind. To allow him to grow up without 
education or " habit-training/' is simply to allow him to degen- 
erate into a repulsive, helpless creature, often so brutal in his 
propensities that, for the protection of the public, he has to be 
placed in custody. Of the milder types, many of the boys com- 
mit crime and find their way to reformatories ; the girls fall from 
the paths of virtue, become mothers, and bring forth children 
more feeble-minded than the parent. The education, however, as 
well as the method of imparting it, must be made to suit the in- 
complete mental organization with which we have to deal. Even 
the least weak-minded are generally unable to profit, to any ex- 
tent, by the instruction of ordinary schools, and often they suflFer 
unmerited hardship at the hands of teachers, who, ignorant of 
the mental defect, attribute backwardness to laziness or perversity. 
So well is this fact recognized that the public schools of New 
York, Philadelphia, Boston, and Baltimore are organizing special 
classes for backward and feeble-minded children. Cognizant of 
the same thing, the Royal Gnnmission on the Care and Control 
of the Feeble-minded, recently sitting in London, England, ex- 
pressed the opinion that the provisions of the Defective Children's 
Act of 1899, by which the school authorities are permitted to 
ccmipel the parents of feeble-minded children to send them to 
special certified schools for suitable instruction, should be made 
compulsory. 

The ultimate aim and object in the teaching of the feeble- 
minded being to fit them, as far as possible, to become useful men 
and women, it necessarily follows that school teaching should be 
followed by manual training. Imbecile children, when they have 
acquired such elementary education as their limited abilities will 
permit them to assimilate, should be set to learn some useful 
trade, by the practice of which they may become at least partially 
self-sustaining. It is in the industrial departments of the large 
establishments for the training of imbeciles that one sees what 
the better class of these unfortunates is capable of learning, and 
what really good workmen many of them become under the super- 
vision of patient and intelligent instructors. 

It was the lack of manual training that constituted the great 



T. J. W. BURGESS. Ill 

barrier to further progression in the Ontario institution, to which 
I have alluded as the only one of the kind in the Dominion. As 
early as 1872, Mr. J. W. Langmuir, then Inspector of Asylums, 
urged the creation of an asylum for idiots which should consist 
of two distinct departments, one a training school for young 
idiots, the other a custodial department for the safe-keeping of 
adult idiots who were unsafe to be at large. By the adoption of 
the second portion of Mr. Langmuir's scheme the Ontario Gov- 
ernment established the first custodial asylum for idiots on the 
continent. Later a teaching department was added, and for sev- 
eral years Dr. Beaton, the superintendent, was enthusiastic in his 
praise of the good results attained. Ere long, however, he dis- 
covered that it would be impossible to secure any permanent 
benefit if manual training was not made to go hand in hand with 
mental and physical culture. Time and again he appealed to the 
Government for the provision of industrial instructors, but all in 
vain. In addition, his staff of teachers was reduced to such an 
extent that, in 1902, the training school had to be discontinued. 
In concluding his report for that year. Dr. Beaton says : " It is 
to be hoped that they (the schools) will soon be reopened with 
a capable staff of teachers and instructors, and that the institution 
and schools will not only be placed on the popular footing of 
years ago, but far in advance." I am sorry to say that this hope 
has not yet been realized. 

With the reports that many imbeciles, after training, are inde- 
pendently capable of earning their own livelihood, I am not pre- 
pared to agree. Without continuous supervision little can be ex- 
pected from them no matter how highly trained and educated they 
may be; their whole disposition and temperament, away from 
control, in the vast majority of instances completely negatives the 
supposition. A few improvable cases may be rendered capable 
of earning a modest competence, but a few, and only a very few, 
are successful. In nine cases out of ten when such patients are 
said to earn their own living, it will be found that they have some 
advantages in the line of continued supervision. There can be 
no doubt, therefore, that it is the duty of the State to provide 
some means of permanent guardianship for these cases if friend- 
less, and the need could be admirably met by the creation, in all 
institutions for the feeble-minded, of a separate department for 



112 PRESIDENTIAL ADDRESS. 

improvable cases, who, after having undergone their period of 
training, could be drafted into work-shops of various kinds, or do 
farm and garden work under the supervision of an inspector. In 
this way they could be made in a large measure self-supporting, — 
perhaps even a source of revenue to the State. The model insti- 
tution outlined by Dr. W. W. Ireland, than whom we have no 
higher authority, would consist of three separate departments ; a 
custodial department for the extreme and non-educable class ; an 
educational department for those capable of being taught and 
trained ; and a semi-custodial department for those whose educa- 
tion and training has been completed, these three departments to 
be distinct buildings at a moderate distance apart, but all under 
the same superintendence. 

As respects special accommodation for epileptics, Canada is 
even worse off than she is in that for the feeble-minded, because, 
up to this date, no separate provision whatever has been made for 
them. Like the idiot they have either been kept at home, con- 
fined in poorhouses, or scattered through the various wards of 
insane asylums. Every principle of justice and humanity is op- 
posed to the indiscriminate mingling of epileptics, lunatics, and 
paupers, and Ontario, to her credit be it said, has already taken 
steps to right this wrong by founding an epileptic asylum at 
Woodstock. This it is expected will be ready for occupaticm 
during the present year, certainly not before it is urgently re- 
quired, since, by statistics compiled by Dr. Russell of the Hamil- 
ton Asylum in 1893, there were at that date no less than 292 epi*- 
leptics among 4251 asylum residents, with probably more than 
double that number scattered through the country, a burden to 
their friends and a menace to the public. 

The peculiarities and requirements of epileptics are such as to 
characterize them as a distinct class, for whose well-being sepa- 
rate accommodation is necessary. Only under such circumstances 
can they receive that special care in the way of occupation, diet, 
and moral treatment that their condition demands ; only in that 
way can we spare our insane patients the annoyance arising from 
the paroxysms of their disease, their irritability and the violent 
outbursts of maniacal excitement to which many of them are 
subject. That the insane epileptic is properly a State diarge 
every person agrees, but the same cannot be said of tiiose who 



T. J. W. BUBGESS. II3 

are sane. Personally, however, I am of the opinion that all 
epilq>tics ought to be under proper care and treatment, and to a 
certain degree under control, and if these requirements cannot be 
supplied by the friends, then, both for the patient's sake and for 
that of the community in which he resides, provision should be 
made for him by the State. The boundary line between sanity 
and insanity in the case of most epilq>tics is a very narrow one, 
and our Provincial Governments would do well to follow the ex- 
ample of the United States, Germany, and other countries where 
timely care of the epileptic often prevents his passing into the 
category of the insane. 

According to the best modem authorities employment is a 
sine qua nan in the treatment of epilepsy. Those in touch with 
epileptics all maintain that the fits tend to disappear during work- 
ing hours. Dr. Spratling of Craig G>lony is strongly of this 
opinion and states : " On holidays and on rainy days, when pa- 
tients were compelled to stay indoors and could not engage in 
any occupation, the number of seizures was doubled." In this 
point of view the colony system undoubtedly offers the best mode 
of care for the victims of the "sacred disease/' In colonies a 
variety of trades can be carried on to advantage, and, if a suffi- 
ciency of land be secured, floriculture, fruit-growing, and market- 
gardenii^, all of which are among the best forms of occupation 
for epileptics, both male and female, can be made sources of 
profit In this way the colonists are enabled to contribute in 
some degree towards Itheir own maintenance. Probably the 
most promising plan to meet all requirements, at least expense, is 
that advised by the Manchester and Chorlton Joint Asylums Com- 
mittee whereby one portion of a large estate is set apart for the 
accommodation of sane epileptics, another portion for those who 
are imbecile or insane. 

The equity and wisdom of separating the criminal insane from 
those innocent of wrong-doing cannot be disputed. In Canada, 
however, we have no provision for such segregation, and the 
asylum authorities are obliged to receive not only all criminal 
lunatics but all insane criminals on the expiration of their penal 
sentences. The former evil, bad as it is, is dwarfed by the latter, 
because patients of this type, as a rule, retain all their criminal 
instincts and are among the most vicious and depraved of the 



114 PRESIDENTIAL ADDRESS. 

human race. The presence of such patients on the wards of an 
ordinary asylum is a standing menace to the peace and discipline 
of the whole institution. In their sane moments, they never had 
the most distant ideas of the rights of property, and seldom placed 
any value on human life when it stood in the way of the prosecu- 
tion of their criminal designs; when insane, these traits are in- 
tensified, because what little power of self-control they had is 
generally lost and the fear of further punishment for their mis- 
deeds is banished. The more an ordinary lunatic improves, the 
more easily he is managed, whereas the more rational an insane 
criminal becomes the more dangerous he is. If taunted by their 
fellow-patients, as is apt to be the case, such lunatics are prone 
to violence; in addition they are constantly making efforts to 
escape and safeguards have to be provided against their accom- 
plishing their purpose. In this way the innocent are made to 
suffer for the guilty, because we cannot fully carry out the mod- 
em idea which discourages the use of bars and locks, in fact 
ever3rthing that partakes of the nature of a prison. Many of the 
insane retain all their self-respect and object to associate with 
this class of patients, while their friends, quite rightly, fed it a 
grievous wrong to have their unfortunate relatives housed with 
men and women who have been deliberately guilty of crime, and 
who, while undergoing punishment for such crime, have been 
overtaken by insanity. Rockwood Hospital suffers most from 
this cause owing to its contiguity to die penitentiary, and its 
superintendent. Dr. C. K. Clarke, who has long and strenuously 
protested against it, forcibly concludes his report for 1903 in 
these words : " People outside of institutions do not care to asso- 
ciate with instinctive criminals — there is no reason why the non- 
vicious insane should be forced to accept a companionship that 
would be repulsive in everyday life." 

The following motion presented by Dr. Pliny Earle and adopted 
by this association in 1873 applies forcibly to Canada at the pres- 
ent day: 

"Resolved: That when the number of this class in any State (or in any 
two or more adjoining States that will unite in this project) b suflficient 
to justify such a course, these cases should be placed in a hospital specially 
provided for the insane; and that until this can be done, they should be 
treated in a hospital connected with some prison, and not in the wards or 
in separate buildings upon any part of the grounds of an ordinary hospital 
for the insane." 



T. J. W. BURGESS. II5 

The former is undeniably the better plan, and, if Ontario be 
taken as an index to the existing state of affairs in the Dominion, 
there is certainly a large enough proportion of the criminal 
classes of the insane to warrant the creation of a special asylum 
for them. In 1899 there were in the asylums of that Province no 
less than y7 criminal lunatics guilty of offenses but acquitted by 
the cotuts on the ground of insanity ; the number of lunatic crimi- 
nals would probably at least equal this ; and there must be a large 
number of like cases in the other provinces. For the Federal 
Government to erect an institution for the reception of these 
cases, taxing the various Provinces in proportion to the patients 
they send, would seem to me the best and most economical way 
to meet the requirements. Failing this, all such patients should 
be kept in the penitentiary asylums, which should be open not 
only to insane criminals whether their sentences have expired or 
not, but to the criminal insane as well. Criminality alone should 
be the criterion for the separation of these people from the ordi- 
nary insane.' 

For some years a conviction has been steadily growing in the 
minds of physicians and the general public that Canada is behind- 
hand in the lack of any provision for the care and control of 
inebriates belcmging to the lower ranks of society. In 1875 the 
Province of Ontario took steps toward providing for these un- 
fortunates, but the good intention was abandoned. To my mind 
there is no doubt that the custodial care and treatment of ine- 
briates is a question of the gravest importance, and that the estab- 
lishment and maintenance of a hospital for this purpose fall within 

*The following paragraph, published in one of the daily newspapers in 
January last, furnishes a striking example of the need of special provision 
for insane criminals : " Samuel Jarvis, who shot a Windsor policeman last 
week, escaped last summer from the Rockwood Asylum, where he had been 
placed after his release from the Penitentiary, on the completion of a third 
term. The greater part of the past 17 years has been spent by him behind 
prison walls. Until recently Jarvis was in the penitentiary insane ward. 
When the time of such prisoners has expired the law requires that they be 
placed in an asylum. This was done in the case of Jarvis, who was trans- 
ferred from the penal institution on one hill of Portsmouth to the institu- 
tion for the insane on the other. He had not been there more than a month 
before he decided to escape, and this he succeeded in doing. All attempts 
to locate him were futile." 



Il6 PRESIDENTIAL ADDRESS. 

the true sphere of the Government. The great barrier to the 
creation of such an institution has been the threadbare cry, the 
" liberty of the subject/' but the rights of the individual should 
be subordinate to tfie rights of society. We are told that the 
inebriate by his drunkenness violates no law, and this may be 
so. But, are we, therefore, justified in allowing him to continue 
his debauchery until he commits a crime, as so many of them do» 
while many more are only by the merest accident kept from so 
doing? If a lunatic threatens suicide or the life of a fellow- 
dtizen, we put the law in force and confine him, without, as a 
rule, waiting until he has made an attempt on his own life or 
committed a homicide. It should be the same with an inebriate. 
The distinction between drunkenness and insanity has fre- 
quently been the subject of forensic investigation, but it is daily 
beccKning more and more evident to the profession and to some 
extent to the laity, that inebriety and dipsomania are diseases of 
the brain, resembling, if not in some cases constituting, true in- 
sanity. That an individual should in all other matters appear to 
be of sound mind, but that at certain times he should be subject 
to a morbid desire to reduce himself below the level of the beast 
by means of drink, is hard to grasp, but none the less true. 
Equally true is it, as shown by recent German studies, that the 
continuous use of alcohol to excess produces certain molecular 
changes in the brain cortex, which are apt to be permanent. The 
result is a lowering of the moral tone, a dulling of the mental 
powers, and a weakening of the will which constitute an organ- 
ized, progressive degeneration. Nor is the ill effect of the ex- 
cessive use of alcohol confined to the individual himself. There 
is strong evidence to show that the children of intemperate parents 
inherit a marked tendency to intemperance, insanity, idiocy, epi- 
lepsy, or some other form of mental disorder. Such eminent 
authorities as Professor Kraepelin of Heidelburg and Professor 
Berkley of Johns Hopkins University agree in considering alco- 
hol as a powerful factor in the production of insanity, the latter 
going so far as to say, in his work on mental diseases, " Of all 
the varied inciting causes of mental infirmities, heredity and alco- 
hol are most important." Personally I would go still further and 
say that, in the majority of cases at least, inebriety itself is a 
mental disease, — a true psychological condition. If, as has been 



T. J. W. BURGESS. II7 

done, we define an insane person to be, " One who owing to per- 
verted or deficient mental powers, the result of functional or 
organic disease of the brain, cannot adapt himself to his natural 
environment, and whose conduct is not in a sufficient degree 
guided and restrained by the ordinary safeguards of society," we 
include a large section of those at present known as habitual 
drunkards. But whether prepared to go thus far or not, I think 
there are few who will not agree that alcohol does much more 
harm in the way of producing mental degradation in the many 
who are never placed under care, than in the few who now find 
their way into asylums. Everyone is acquainted with men and 
women whose mental powers are so shattered by long-continued 
indulgence in drink that they have reached the borderland be- 
tween sanity and insanity, even if they have not overstepped it. 

To try to reform this class by any other means than personal 
restraint is "wasting our sweetness on the desert air." They 
must be placed in custody in an institution, the superintendent of 
which is clothed with authority to detain his patients for an in- 
definite length of time. In other words, the same policy in re- 
spect to their personal liberty should prevail, as now prevails in 
respect of lunatics. It matters not what the form of commit- 
ment be, provided it is statutory and means a definite and pro- 
longed term of oversight and treatment. This treatment should 
be conducted in a special establishment where work of various 
kinds, — one of the best of remedies,— can be enforced after the 
necessary medical regimen has paved the way for it In this 
manner the cost of maintenance would be greatly lessened. 

As early as 1833, Dr. Woodward, soon after taking charge of 
the Worcester Insane Asylum in Massachusetts, urged that in- 
ebriates be regarded as insane and sent to the asyltim for special 
treatment, but this is manifestly wrong. To associate the ordi- 
nary lunatic with the inebriate, even if we consider the latter to 
be truly insane, is an injustice to both. In the words of Dr. 
Joseph Workman : " Inebriates are soon dissatisfied, and strongly 
disposed to magnify the causes of dissatisfaction which the dis- 
cipline of an insane hospital unavoidably presents, — ^this dissatis- 
faction becomes contagious. One inebriate can upset the quiet and 
comfort of a whole ward." 

In view of the declaration of modem science that tuberculosis 



Il8 PRESIDENTIAL ADDRESS. 

is a communicable, preventable, and curable disease, the non-pro- 
vision of proper means for separating the phthisical from the 
non-phthisical ufisane might almost be called criminal, and yet 
in only one of our Canadian institutions, Rockwood, is there any 
special arrangement for such segregation. In all the other hos- 
pitals the medical oflScers have to combat the plague as best they 
can by attention to cleanliness, disinfection, and the isolation of 
the affected as far as possible. So much, however, has been writ- 
ten on the subject of tuberculosis during the past few years that 
I shall not detain you with any detailed account of my own views 
on any of the points connected therewith, but content myself by 
saying that I doubt whether, owing to the rigor of our climate, 
the " tent treatment," so successfully practiced by Dr. A. E. Mac- 
donald at the Manhattan State Hospital East, would be practicable 
with us during the winter months. Instead, I would favor the 
erection of a separate, isolated building to be used for tubercular 
cases only, one portion of the structure being set apart for sus- 
pected cases, another for those in whom the presence of the 
malady in an active state has been positively established. Such 
a building should be frame and constructed as inexpensively as 
possible, so that, if its destruction on account of infection seemed 
advisable, the loss would be slight. 

An important problem confronts the superintendents of Cana- 
dian hospitals, as it does those of the United States, in the case 
of the discharge of friendless patients. This is the securing of 
homes and employment for them. Who of us but can call to 
mind cases where the discharge of patients, though fully war- 
ranted by their mental condition, has been delayed for weeks, 
even for months, because they had no friends who could or would 
take charge of them on their return to the world, no homes to 
go to, no employment awaiting them by which they could earn 
their bread? The average citizen seems to have a morbid dread 
of the poor unfortunate who has been insane, and utterly refuses 
to even think of hiring him, while his wife is equally resolute 
against engaging as a domestic any woman who has been an 
asylum inmate. To turn such persons adrift without means or 
help is virtually offering a premium for their return to the hos- 
pital, whereas, if given some slight assistance they might earn 
a fair living and not again become a charge on the public. 



T. J. W. BURGESS. II9 

" 'Tis not enough to help the fallen up, 
But to support him after." 

Criminals discharged from prisons and reformatories are 
helped and encouraged by Prisoners' Aid Societies, often indeed 
assisted by the State with gifts of clothing and money. Fallen 
wcMnen are taken in hand by societies with a view to their refor- 
mation. Orphans are housed, educated, and clothed by the char- 
itable. Only for the poor creatures who have emerged from 
the gloom of dethroned reason is there no helping hand, no assist- 
ance of any kind. The best remedy for this pitiful state of affairs 
is to be found in the organization of '' After-Care Associations 
for the Insane," such as exist in France, which country was the 
pioneer in this branch of philanthropy, Switzerland, Italy, Ger- 
many, and Great Britain. Such associations would have to be 
the outcome of private enterprise, because the Governments of 
the several Provinces have already as much as they can do to 
provide for those actually insane. Doubtless, however, if once 
started by private benevolence and brought to a successful issue 
State aid would not be wanting to help the good work along. 

Last, but certainly not least, of the wants to which I would 
call attention is the abolition of political patronage in the matter 
of hospital appointments and the administration of hospital af- 
fairs. The "spoils doctrine" which decrees that "office is a 
reward for political service " has done much to keep down the 
record of scientific work done in Canadian hospitals for the in- 
sane. Merit has had little weight, especially in Ontario, as 
against " political pull," and the consequence is that almost two- 
thirds of our existing asylums are directed by superintendents 
destitute of special training prior to their appointment. That: 
men taken from the ranks of the general profession do sometimes. 
prove themselves admirable asylum officials, I do not dispute.. 
But what I do maintain is that the principle is wrong. To sub- 
ject the care of the insane to political purposes is a flagrant in- 
justice to the patients, who should be afforded the best possible 
chance for recovery ; to the taxpayer, who should receive the best 
value for the money he pays for their support ; and to deserving 
jtmiors who are thereby debarred from all chance of promotion. 
Superintendents are made, not bom, and it requires years of con- 
scientious study to acquire a knowledge of how to deal satis- 



120 PRESIDENTIAL ADDRESS. 

factorily with the manifold problems of psychiatry. Moreover, 
assistants generally take their cue from the superintendent, and 
if the superintendent be not specially trained for his work and 
take no active interest in it, his subordinates will almost inevitably 
lapse into routine. Nor can we blame them much that such 
should be the case. With no example set them, no prospect of 
advancement to cheer and encourage them to put forth their 
best eflForts, what else could we expect? 

Were the " spoils system " confined to the appointment of the 
heads of asyltuns the resulting ills would be lessened. Unfortu- 
nately it is not. Every medical office connected with our asyltuns, 
from the highest to the lowest, is regarded as " political pap " to 
be administered where it will do most good for the dominant 
party. Governments are unable or unwilling to grasp the fact 
that the scientific study of psychiatry consists primarily in the 
study of mental phenomena, and that this can only be done to 
advantage by men specially trained for such study. As a re- 
sult, well-developed seniors, who have been failures in life, are 
often given the junior places that should be awarded only to 
young men who have shown interest in, and capacity for original 
research. This is manifestly unfair both to the inmates of our 
asylums and the superintendents thereof. " Responsibility and 
authority must go hand in hand " is a time-honOred axiom, but 
the system of Governmental appointment of assistants furnishes 
the anomaly of superintendents, held responsible for the success- 
ful management of their hospitals, and yet deprived of the au- 
thority to appoint the officers upon whom such success in great 
measure depends. Surely a superintendent should be best capable 
of judging of the fitness and competency of his assistants, and it 
comports with common sense that he will, if only through self- 
interest, endeavor to procure the best he can find. 

A vigorous editorial, " Insanity and Politics," recently pub- 
lished in the Montreal Medical Journal, deals so searchingly with 
the ills of political patronage in our asylum service that I may be 
pardoned if I quote a portion of it: 

"Most persons will admit, unless they are incapacitated by congenital 
perversion, or political prejudice, that a hospital for the insane exists — pun 
or no pun — ^for the purpose of extending hospitality to the insane, and not 
to the protegees of a political party. In short, it is mental not political 



T. J. W. BURGESS. 121 

degeneracy which entitles an entrance to the enjoyment of such hospitality 
as it can offer. In Canada, there are to-day eighteen hospitals for the 
insane, and all but six exist for the combined care of the insane and the 
politicians. In twelve the present superintendents owe their appointment to 
influences other than their attainments in psychiatry. 

** The answer which the politicians make to all protests is that the men 
who occupy the posts of assistants are not sufficiently qualified to become 
superintendents. This is partly true, and because it is partly true the case 
is the worse; because, if there are incompetent men among the assistants, 
it was the politicians who put them there. But the answer is inadequate, 
because, in spite of the politicians, there are enough good men in the service 
to fill every vacancy which may occur during this generation. The wonder 
is that there are any remaining, when they have seen themselves passed 
over time and again by men whose attainments were unproven. The 
rewards of the specialty of psychiatry are small enough, and should not be 
filched away. The injustice is not chiefly to the men who have spent a life- 
time in acquiring a knowledge of the insane, of their diseases and of their 
treatment; it is to the wretched insane themselves, who are deprived of that 
experience which might aid in their recovery. 

"We yield to none in our admiration of the general practitioner. We 
are aware of his energy, his resource and his fidelity, but not even the 
general practitioner will lay claim to a capacity for treating off-hand and 
to the best advantage grave lesions of the eye and ear, or of the more 
secret parts of the body. He should adopt the same attitude toward the 
brain. In time it will come to be a shameful thing for a general practi- 
tioner to accept a position for which he is not qualified, since thereby he 
is committing a wrong towards his colleagues and towards his patients. 

**The ideal service is that which prevails in New York. The superin- 
tendent is appointed by the board of management, and he must be selected 
from men who have served at least five years in an institution for the 
insane and have proven their capacity and instinct for such work. The 
assistants in turn are appointed by the superintendents and they obtain 
advancement according to their merits, no step in advance being made 
unless the candidate has had previous experience in the specialty, and 
proven his fitness by passing an examination before promotion." 

Nor is it solely in the way of appointments and promotion that 
our Provincial Governments have shown themselves remiss. The 
good men in the asylum service, and good men there be, are, in 
most instances, hampered by the want of proper equipment and 
the paucity of the medical staff employed. It is the duty of the 
State to aid in every way the attempts of its physicians to do 
scientific work. Only so can they be stimulated to keep pace 
with the trend of modem research in other countries,— only so 
can we guarantee that our patients will be under the care of ever- 



122 PRESIDENTIAL ADDRESS. 

widening experience. Hitherto the Governmental policy has been 
to provide little or no equipment for study, and so to limit the 
number of physicians that the greater part of their time is taken 
up with clerical duties. The nimibing effect of such routine 
work is great, and might well make the average assistant adopt 
the words of Mr. Mantalini and pronounce life ** one demd horrid 
grind." 

Before we can properly enter on the study of psychiatry, as we 
ought to do, our Governments must learn that to make a hospital 
a center of scientific research its physicians should be appointed 
from the best class of men; should be paid sufficiently well to 
free them from anxiety as to their future livelihood; should be 
certain of promotion if they prove themselves fitted therefor; 
should be assured of a retiring allowance, graduated on length of 
service as is the case in England and other trans-atlantic coun- 
trieJs ; should be freed from an overburden of routine work ; and 
should be provided with books, apparatus, and assistance to prop- 
erly pursue their researches. 

Much more might be said on this and other subjects relating to 
the care of the insane in Canada, for example, the necessity of 
separate hospitals for acute cases and of pavilions connected with 
general hospitals, of nurses' homes, and of retiring allowances 
for medical and other officers, but I fear you will already have 
applied to me the old Spanish saying anent a tedious writer: 
" He leaves no ink in his inkpot." I shall, therefore, no longer 
trespass on your forbearance, but content myself by sa3dng in 
conclusion, that while with respect to custodial care and ordinary 
treatment, moral and medical, Canada, generally speaking, is well 
up to the times, she is doing little toward the solution of the many 
problems connected with the scientific aspects of insanity. In 
this respect she presents but a sorry picture when compared with 
the good work being done in many hospitals elsewhere. To stand 
still is to fall behind. The universal motto should be: 

" Press on — * for in the grave there is no work 
And no device.' — Press on while yet ye may." 



ANNUAL ADDRESS— TRIPARTITE MENTALITY/ 

By J. T. SEARCY, M. D., 
Tuscaloosa, Alabama. 

Mr. President, Ladies, and Gentlemen : 

I have been very much embarrassed with the fact, since I first 
received notice, that I was to give this annual address. I have 
selected as my subject " Tripartite Mentality." I know this is a 
very unusual title, and, with considerable hesitancy, I recognize 
also that my presentation of the subject contains a great deal of a 
venturesome character. I hope, however, that it will explain itself 
satisfactorily as I proceed. One thing I think I can say is that 
you will not find it in the text-books. 

I prefer to use the word mentality. More readily than the 
word mind, it can be used to designate a property, a qualification, 
an accomplishment, a faculty, which can be scientifically observed, 
classified, and studied. 

Mentality varies normally and, sometimes, abnormally, in the 
course of the life of the individual ; and it very evidently differs 
in its capabilities and its accomplishments in different individuals. 

Mentality is normal when its exhibitions are such as are usual, 
natural, customary, and expected. It is abnormal when it varies 
from what is usual, natural, customary, and expected. 

An abnormal exhibition of mentality, of any grade, is a psycho- 
sis. 

When the abnormality of any kind of a psychosis reaches such 
a grade of deficiency or defectiveness as to bring the person with- 
in the cognizance and jurisdiction of the law, as the case may be, 
it is called "craziness," " idiocy," " lunacy," " insanity," and the 
like. I prefer to confine these terms to such grades as require 
legal attention. Indeed, the State reserves to itself the right to 
apply them. A court alone is authorized to declare a person 

' Delivered at the sixty-first annual meeting of the American Medico- 
Psychological Association, San Antonio, Texas, Tuesday, April i8, 1905. 



124 ANNUAL ADDRESS. 

disqualified on account of mental deficiency or defectiveness, and, 
on that account an " idiot " or " insane." 

All kinds and grades of mental abnormalities are, however, 
psychoses; and are every-day matters of observation, concern, 
and care on the part of medical men. 

Mentality is the most important of all studies. It is a matter 
of vital importance to the individual, because his welfare, safety, 
and degree of success depend upon the grade of its efficiency 
within himself; and no general subject concerns the public more. 
The average level of the mentalities of its citizenship determines 
the standing of the community, the race, or the nation. 

For these reasons, psychology, which is the study or science 
of normal mentality, is rapidly attracting more and more popular 
and scientific attention; and psychiatry, which is the study or 
science of abnormal mentality, is assuming more and more a 
scientific aspect. 

As our pathology is the study of deficient, defective, or dis- 
turbed physiology, so our psychiatry is the study of deficient, de- 
fective, or disturbed psychology. 

If I approach the subject of normal and abnormal mentality 
from a rather new direction, in this august presence of psycholo- 
gists and psychiatrists, from over a whole continent, I do it with 
extreme diffidence. My suggestions are, of course, only tenta- 
tive ; even by myself subject to ready change as they are altered 
by further instruction and information. 

Let me, at this point, express my appreciation of the high com- 
pliment included in the appointment of your Committee of Ar- 
rangements for me to make The Annual Address at this meeting 
of the Association. 

Three Natural Divisions of Mentality. 
In a broad sense, mentality may be said to be a property ex- 
hibited by all living things. For this reason, it can be observed, 
classed, and studied throughout the whole biologic world. 

In scientific philosophy, the usual method is, to accurately ob- 
serve and classify phenomena everywhere. When sufficient 
observed and classified data have been accumulated, we philoso- 



J. T. SEARCY. 125 

pfaize by using the more familiar and simpler to explain the unu- 
sual and more complex of the same class. This has been very gen- 
erally the rule in philosophizing about the inanimate world. It 
has, however, not so generally been the rule in philosophizing 
about the animate world ; of late, however, this method has been 
more generally adopted. We are beginning to use simpler men- 
tal phenomena to explain the more complex. 

All living things exhibit certain common phenomena which 
we look for to determine whether they shall be classed as living. 
First among these may be mentioned senHency, with which we 
observe the living thing recognizes impressions made on it from 
its environment; secondly, accompanying this faculty, as a part 
of it, the living thing receives into its sentient structures informa- 
tion of the impressions made on it ; thirdly, we observe the living 
thing emits motions in response to the information it has re- 
ceived; fourthly, we observe that, by an intermediate act of this 
same sentient faculty, the living thing has adjusted its emitted 
acts to its received ones, so as to conserve its welfare and safety. 

Viewed in this way, wherever exhibited, mentality shows itself 
as tripartite in character. It is readily divided into three depart- 
ments ; it receives, it adjusts, and it emits; or to use more com- 
plex psychologic terms, it learns, it reasons, it executes. 

Even the highest reaches of mental effort, I think, can be 
classed, with considerable eflSciency, into three such departments. 
The receiving department, for instance, can include, all the men- 
tal acts of appreciating, understanding, comprehending, acquir- 
ing, learning; the emitting department can include all the inten- 
tions, conclusions, wishes, purposes, decisions, — ^the results of the 
adjustments and ratiocinations made upon and out of the acquisi- 
tions ; the propositionizing of sentences lies in this department ; 
and the election or inhibition of the results of the reasoning 
department presented for emission — ^most of them, probably, are 
turned back for further preparation. The inhibitory part of 
mentality constitutes, on the emissive side, a large and important 
part of its work. Intermediate between the learning and the 
executing departments, lies the department of reason or adjust- 
ment ; made efficient in its complexity by the faculty of recollect- 
ing or remembering previous mental acts — ^probably by the ability 



126 ANNUAL ADDRESS. 

to perform tfaem again. This department can dissociate its acts» 
largely sometimes, from the immediate receptions and emissions, 
in the " flights " of imagination and abstract ideation. 

It is impossible here to follow into detail this classification of 
the highest phenomena of mentality into its three departmenta* 
I simply draw attention to it, hoping it may prove of value be- 
cause of its apparent naturalness. 

Every living thing, which is organized, is composed of in- 
numerable living cells. The cell is the unit of organised life. 
It is a living entity in itself. Like the whole animal, it has to 
work for its own defence and support, while it has functional 
work in its environment. For these purposes, it has its own 
grade of sentiency and its receiving, its adjusting, and its emit- 
ting structures and activities. 

Similar cells are aggregated and associated together in com- 
posing the structures of an organ of the body ; and each organ, in 
its aggregated capacity, has its receiving, adjusting, and emitting 
faculties; not only in accomplishing its special functicHi, but in 
adjusting its acts to those of other organs. 

Air (or oxygen), water, warmth, and food (not to mention 
light), may be classed as "the necessaries of life/* Every living 
cell within the body has to have these " necessaries " in order to 
live. To obtain from outside itself and convey within itself to 
the cells these necessaries is the first object of effort on the part 
of every living thing. All living things are organized, princi- 
pally, for this object ; and there are all kinds and grades of com- 
plexity in the organic construction of different living things for 
this purpose. 

Air and Tvater while most highly necessitous, are so abundant 
and easily obtained as not to be so much objects of effort and 
concern as the other two. To obtain warmth, in the shape of 
shelter, clothing, fuel, and heat-making food, is more a matter of 
concern and effort. Food for cell-heating and to repair cell 
wastes, because it is the scarcest and most difficult to obtain, is 
the highest priced and the object of most concern and effort. 

" To work for a living " is a common expression, illustrating 
the fact that man, primarily, has to work for " the necessaries " 
in order to live. " To accumulate wealth and property " prin- 



J. T. SEARCY. 127 

dpally means to secure an abundant provision of them for present 
and for future use. 

To go no further than to take "the necessaries of life" as 
objects of activity of the man within himself and without, it is 
easy to divide the body into tzvo general departments of organs 
and functi(His. The one department relates to the obtaining of 
the necessaries from the environment and the other to their 
preparation and distribution to the cells everywhere within. Man 
is highly organized for these two objects. 

Of course, other objects of external effort present themselves, 
as the man grows older, until the summation of all eventually 
becomes very complex. To improve himself, by improving his 
highest mental abilities and by the acquisition of knowledge, and 
to improve his environment by increasing the general store of 
knowledge are objects of effort. The improvement of his en- 
vironment by the removal of offensive, dangerous, and trouble- 
some agents, is another object as well as the encouragement and 
cultivation of things that contribute to his welfare and happiness. 
The improvement of his envircmment by the improvement of 
his fellow-men, physically, mentally, and morally, is another. 
These, with other matters, all make exceedingly complex that de- 
partment which relates to the external world. 

The internal department principally relates to the preparation 
and distribution of the " necessaries of life " ; though, in addition, 
there is the removal of waste material and of toxins from the 
system, and, in the female particularly, the caring for the coa- 
lesced product of the ancestral Hnes-of-descent Other objects of 
internal work could be mentioned. 

The division of the body into two general departments is well 
illustrated in sleep; when the highest and most important depart- 
ment which relates to the environment is suspended for repair. 
The high-brain, the cortex, with its lines of afferent action, from 
the organs of sense, and its efferent lines, which put in motion the 
'* voluntary muscles," all are dormant at that time ; while the 
internal department continues in action, distributing " the neces- 
saries of life " and removing wastes. 

The same division is aptly shown in the administration of an 



128 ANNUAL ADDRESS. 

ancBSthetic, The chemic action of the drug, distributed generally 
in the circulation, affects first the most delicate structures of the 
high brain and suspends their action. The consciously-sentient 
cortex, with its lines of reception and of emission, is stopped in 
function, while the less sentient sub-conscious, lower-^jrade, 
nerve-center structures, relating to internal action, are not 
affected so much, and continue to act. The administration of thef 
anaesthetic can ordinarily be safely held at that point. If, how- 
ever, it is carried further, so as to paralyze the adjusting centers 
that equilibrate and control the actions of the internal organs, 
the man is killed. 

About a hundred years ago. Sir Charles Bell discovered or 
more distinctly determined, the functions of "the sensory and 
motor roots of the spinal cord." This was not a very important 
discovery in itself, but it soon became so, because, like the dis- 
covery by Columbus of a small island in the West Indies, a whole 
continent of contingent discoveries have followed it. 

The posterior columns of the chord have since Been found to 
carry ascending, afferent, receptive, informing actions to the 
cortex, and to go posteriorly into it; while the anterior columns 
carry descending, efferent, mandatory actions to the muscles. This 
has been followed also by a mapping out of a large portion of 
the posterior cortex into receptive tracts; while anteriorly emis- 
sive actions are known to leave it. Decussating, connecting 
fibers, all along in the cord, anterior-posteriorly and laterally, 
make its tracts or centers of nerve cells into adjusting levels, for 
controlling the actions of parts below them. Such adjusting 
functions are shown to act with more and more scope and effi- 
ciency as they ascend in the cord, in the pons, in the lower, and 
in the higher brain. 

If we begin at the highest center, the cerebral cortex, and study 
down through the nervous system we find a descending grada- 
tion of sentient structures all with their receiving, their adjusting, 
and their emitting functions. 

The high brain, which is engaged in the highest and most com- 
plex work of adjusting to the environment, is immensely complex 
in structure, commensurate with its immensely complex work, 
and has, in part, been mapped over, as performing its receiving 



J. T. SEARCY. 129 

work posteriorly and its emitting work anteriorly; while over- 
riding, pervading, and subtending all are the adjusting functions 
for preparing out of the receptions and acquisitions the emissive 
conclusions, purposes, wishes, and designs. 

From the sense-organs, of seeing, hearing, smelling, tasting, 
and from the general sentiency of the whole body, along afferent 
nerve fibers, comes information, posteriorly, into the cortex; 
while, anteriorly, along efferent nerve fibers, go mandates putting 
into execution the results of the adjusting ratiocination. The 
transition of an act through the brain, from rear to front, may 
be '' as quick as thought " or as deliberate as a life-time. 

At the furthest extreme frcwn the cortex, in the periphery, a 
small vaso-motor ganglion, with the simplest function, for in- 
stance, of regulating the caliber of a capillary, receives, adjusts, 
and emits in its action; and so do the ganglionic centers of the 
sympathetic system, harmonizing and regulating some of the 
actions of the organs of the internal department; tracts in the 
chord, in the pons, and in the base of the brain, act similarly, 
though with different grades of sentiency and complexity. 

The man is an entirety from head to foot. There is no distinct 
line of separation between the departments for external and in- 
ternal adjustments either in the nervous system or in the other 
organs. Disturbance or shock in the one is promptly carried 
into the other. Suddenly or slowly, as the case may be, one 
department is impaired by disturbing action in the other. Still» 
there is a separateness. 

Pain may be said to be occasioned by the transition of disinte- 
grating cellular action, going on in the periphery, along afferent 
fibers to the conscious cortex. It may not stop at, but come 
through, centers of a lower grade, sense of whose actions does 
not usually reach the cortex, for they are ordinarily carried on 
within themselves with sub-conscious sentiency. 

I think it is interesting to study mental operations of the 
highest order, with this tripartite classification in mind. 

For instance: — From infancy to adult life, mental ability in 
each of the departments— of learning, of reasoning, and of exe- 
cuting — gradually improves. 



130 ANNUAL ADDRESS. 

To acquire information or knowledge is necessarily the first 
object of mental effort, requiring steady or continuous attention. 
For this reason the acquiring faculties start first in the growing 
child, and, as he grows older, precede, in their gradual develop- 
ment, the reasoning ,and the executive. In .our educational 
methods we take advantage of the fact that early life is the best 
acquiring age. We can do our teaching and training best during 
that period. Apparently the acquiring faculties in man develop 
fastest and reach maturity soonest. He does the best part of his 
learning and his training in the first third of his average life- 
time. The second part of his growing mentality, his reasoning 
faculty, his " best judgment," does not reach maturity until mid- 
dle life ; and the third part his emissive or his executive depart- 
ment, matures after his learning and his reasoning. Mentality 
naturally develops and matures in this order in life, and, I think, 
naturally declines, in the senescence of old age, in the same order. 
It is hard to teach new ideas or new methods to an old man, but 
in the lines in which he is practised, experienced, and long-ago 
instructed, his judgment and the output of his emitted opinions 
are often full of " wisdom." 

Of the scholars in a school, a goodly proportion, probably a 
third, generally exhibit excellent learning abilities ; in middle life, 
when reasoning abilities mature, a much smaller number of them 
exhibit good judgment; and a still smaller number exhibit ten- 
acity of purpose and good executive ability. The average man 
falls behind in excellence in this order as he takes part in competi- 
tive life. The fully rounded, excellent man exhibits a high order 
of abilities in all three departments. He starts out as a good 
scholar, and his good judgment and emissive work afterwards 
show themselves to be of a high grade. Ability to be excellent, 
in the second and third departments as well as the first, consti- 
tutes the successful man. The simply erudite scholar is excellent 
in acquiring abilities, but fails in judgment and execution. 

The teacher reaches principally the acquiring department of 
his scholar. The mental gymnastics, he makes the scholar do, 
principally improve the learning abilities. The reasoning de- 
partment and the executive are largely out of the teacher's reach, 
and mature later. They are bom into the man, not schooled 
into him. If not degenerated in him, they are at the level of 



J. T. SEARCY. 131 

ancestral, family, or race traits largely. " G»nmon sense," which 
means ability all through life, to learn, reason, and execute in 
a practical, prc^table way, is especially bom into the man. 

I have ventured to speculate this much in the line of the 
highest orders of mentality to show how far we can carry this 
tripartite division. In this direction I believe will lie the coming 
field of scientific investigation and generalization. 

As Psychologists, as we know more accurately the tracts in the 
cortex, we will be more able to observe and classify normal men- 
tal activities and abilities ; and, as Psychiatrists, this same natural 
method of making observations and conclusions, will the better 
enable us to determine the abnormal deficiency or defect — 
whether of a local or of a general character. 



MELANCHOLIA, 
The Psychical Expression of Osganic Fear.^ 

By J. W. VraERRY, M. D., 
Mtdkal Superintendent, The Glenwood, DansvilU, N. Y. 

In the very nature of things there can be no disease of the 
mind» and sooner or later so-called mental diseases must be recog- 
nized as simply states of mind which exist by reason of disease 
processes in some one or more of the organs of the body. There 
may be a derangement of the mental faculties ; there may be im- 
portant and radical changes in mental operations ; the mind may 
run riot in delirium, or weave itself into the fantastical and 
grotesque forms of delusional insanity, or vanish completely 
beneath the somber shadows of dementia, but it cannot become 
diseased, because in its very nature there is nothing upon which 
disease can fasten. 

Can pathological states be assigned to ideas? Is abstract 
thought subject to infection or degeneration? Reason may 
^ totter upon her throne " but does she ever *' languish upon a bed 
of sickness ? '* Then how can there be a disease of the under- 
standing, or a disease of judgment, or a disease of any other 
mental faculty? 

From one point of view it is not a matter of surprise that many 
are misled and adopt ideas regarding the relation of the mind to 
insanity entirely at variance with the facts of science. When the 
leading alienists of the country cry aloud, as with one voice, that 
all forms of insanity are due to abnormal bodily conditions, either 
located in the brain or elsewhere, while, at the same time, reports 
are published of various forms of insanity caused by disappoint- 
ment, or grief, or some other psychical state, is it to be wondered 
at that the vast army of '* lesser lights " become bewildered and 

^Read by title at the Sixty-first Annual Meeting of The American 
Medico-Psychological Association, San Antonio, Texas, April 20, 1905. 



134 MELANCHOLIA. 

revert to the original idea of a mind existing in the body, bat 
apart from it, and subject to its own peculiar diseases? Alienists 
must take one ground or the other in this matter if they wish to 
escape the charge of inconsistency. How many superintendents 
and assistant physicians in hospitals for insane report the condi- 
tion of a patient as follows : " He is becoming more and more 
impaired mentally but remains in good bodily health." How can 
such a statement be made to conform with present theories? If 
all insanity is due to disease of the body, or, as the more radical 
believe, is due to disease of the brain, how can a patient, who is 
becoming more impaired mentally, be in good bodily health? 
How would it sound to say, of a man afflicted with stomach 
trouble, that the ^* indigestion " is increasing but he is in good 
bodily health? If the function of any organ is impaired how 
can a man be in good bodily health ? The mind is either a func- 
tion of the brain or it exists independently of the body. If it is 
only a function it cannot be diseased in itself, either because of 
infection, or by contagion from its own psychical states. If it 
exists as a thing in itself, then are we indeed in the dark and far 
from the truth. This much we know, it cannot be a thing in itself 
and also a function of the brain. These theories are antagonistic, 
and the man who believes the one and advocates the other is 
inconsistent, to say the least. 

Disease is defined as, '' A condition of the body marked by 
inharmonious action of one or more of the various organs, owing 
to abnormal condition or structural change." If this definition is 
correct, and I believe it is sufficiently so for all practical purposes, 
there can surely be no disease of the mind because the mind is not 
an organ of the body, nor is it subject to structural change. It 
is the functional product of an organ itself, and there can no 
more be a disease of the mind than there can be a disease of the 
bile or a disease of the urine. 

Mental states or conditions, when abnormal, are only symptoms, 
and attest to the presence of bodily, not mental disease. What- 
ever the form these abnormal mental states may assume they 
point unerringly to the nature of the bodily disease or disorder 
from which they spring. All abnormal mental states are due 
either to intellectual derangement, or emotional derangement, or 
to a combination of these two. Idiocy, imbecility, and dementia^ 



J, W, WHERRY. I3S 

are the product of intellectual involvement. Idiocy and imbecil- 
ity indicate in varying degrees the absence of intellect through 
non-development of the brain; dementia points to a day that id 
done and marks the gradual sihking of the intellectual sun. On 
the other hand, delusional insanity has its origin in the emotions, 
and derives its form and structure from the character of the 
emotion which gives it birth ; while in imbecility with delusions, 
or dementia with delusions, we have the involvement of both the 
intellect and the emotions; the emotional involvement, however, 
being characterized by its evanescence, appearing and disappear- 
ing with the appearance and disappearance of the emotional state 
which produces it; while the intellectual conditions in imbecility 
and dementia, being due to organic brain alterations, persist 
steadily to the end. 

I have said that all abnormal mental states are due to intellec- 
tual changes, or to emotional changes, or to a combination of 
these two; that abnormal intellectual conditions are known as 
idiocy, imbecility, and dementia, and that abnormal emotional 
conditions are known as the various forms of delusional insanity. 
If this be true it may be well to turn our attention for a moment 
to the consideration of these intellectual and emotional states 
which determine the form of insanity present, but more especially 
to those emotions which give form and structure to delusional 
insanity and without which no delusive idea can originate* 

The field of discussion opened up by a subject of this nature 
is practically unlimited in extent, and I can do no more in this 
paper than lightly touch upon the following propositions, namely : 

1. That there are organic as well as ethical emotions. 

2. That the relation of the body to the mind is that of master 
to servant. 

3. That the influence of the brain has been overestimated in the 
production of abnormal mental states. 

4. That the organic emotion of fear has its origin in visceral 
conditions. 

5. That organic fear is a primitive instinct and necessary to the 
preservation of the individual. 

6. That abnormal organic fear is the basis of melancholia. 

7. That melancholia is but the expression of abnormal visceral 
conditions. 



136 MELANCHOLIA. 

It may be said in the beginning that intelligence and emotion 
are not limited to brain cells alone. While the highest form of 
intelligence and the most exalted emotions are peculiar to brain 
structure, it is none the less true that intellect finds its physio- 
logical counterpart in cell intelligence^ and that the higher and 
more ethical emotions find their physiological counterparts in the 
organic feelings, or in instinctive affinity and repulsion. 

Intellect, as expressed through reason and judgment, enables 
us to adapt acquired knowledge to the necessities of the body 
and leads us to adopt such measures as are most likely to preserve 
the body against injury or disease ; to select the food best fitted to 
purposes of nutrition ; and to adapt ourselves to our environment 
or, if necessary, to modify our environment to our needs; but 
cell intelligence, in a limited degree, does the same. It selects 
the beneficial and rejects the injurious. It adapts itself to changed 
conditions. It obliterates the ravages of injury or disease by 
reproducing itself if it can, or, if this is impossible, the breach is 
temporarily repaired with scar tissue. More than this, it, too, 
adopts such measures as are most likely to preserve the body 
against the onslaughts of its enemies. Products of decomposi- 
tion are both recognized and removed, while bacillary foes which 
escape the hygiene and asepsis of intellect, meet with stubborn 
and well-organized resistance at the hands of cell intelligence. 

Proposition i. — That there are organic as well as ethical emo- 
tions. 

The same parallelism noticed between the intellect and cell 
intelligence exists, and is observed, between psychical and organic 
emotions. The body cell hates, and desires, and fears. It in- 
stinctively cleaves to that which is good and rejects that which is 
harmful. It shudders with a presentiment of coming harm and 
recognizes dangers which are imperceptible to the mental eye. 
It feels the presence of a foe even while judgment pronounces 
him a friend. It hates without reason ; it desires without judg- 
ment; it lusts without a motive, and it trembles at dangers the 
mind knows not of. 

While all emotions are known only as they are recognized in 
consciousness, yet it is evident that, although tiiey have a common 
ground of recognition, they do not all have a common source of 
origin. Emotions such as joy, and sorrow, and hope, and grief. 



J. W. WHERRY. 137 

may have a purely psychical content; while such emotions as 
hate, and lust, and desire, and fear, are organic in their nature 
and have their origin in sensations of organic life. They are 
associated with, and have their basis in, the fundamental elements 
of existence. The man who, in expressing certain emotions, 
** lays his hand upon his heart," lays it much nearer their source 
of origin than if he placed it on his head. 

In certain forms of animal life all organic emotions are for 
the benefit and protection of the individual. Hate, or dislike, 
leads to instinctive caution ; lust, to reproduction ; desire, to that 
degree of self-assertion which secures the most possible good to 
the individual, and fear, to repulsion of objects of danger and 
consequent self-preservation. 

These instinctive emotions always have existed and always will 
exist, and their proper use has served to preserve and perpetuate 
animal life, and it is only when they become unduly exaggerated 
by reason of disease, or faulty heredity, that they assume the 
expression of pathological conditions. It is abnormal organic 
hate that characterizes the misanthrope; it is abnormal organic 
lust that distinguishes the libertine; it is abnormal organic desire, 
that marks the pathway of crime, and it is abnormal organic fear 
that grips the melancholiac. 

These organic emotions, indeed, are the basic elements of our 
natures. They are coexistent with life itself. They are the out- 
growth of those three fundamental principles, self-assertion, self- 
preservation, and reproduction, and, through all the vicissitudes 
of subsequent existence, they have preserved their identity and 
original characteristics, for they still cluster around the self as 
a body as they did around the self as a single cell. 

Psychical emotions are, in fact, but modified organic emotions. 
Psychical hate is organic hate modified by reason. Psychical love 
is organic lust tempered by judgment. Psychical desire is or 
ganic desire held in leash by a knowledge of subsequent punish- 
ment, and psychical fear is organic fear throttled by courage or 
fortitude. But reason, judgment, courage, and fortitude were 
bom but yesterday. They were acquired from others and were 
instilled into us through instruction and experience. They are 
the outgrowth of civil life and social requirements, while the 
emotions they seek to modify and control trace their genealogy 



138 MELANCHOLIA. 

back to the very beginning of things, and had their origin in the 
vital necessities of life itself. 

But nature is considerate during health, and the relation ex* 
isting between a normal mentality and normal organic emotion^ 
is one of harmony and tranquillity, and it is only under abnormal 
conditions of one, or the other, or of both, that we find the dis- 
harmony and internecine disturbance which characterizes the 
criminal and the insane. In their proper and due proportions 
they react beneficially upon each other. Mentality holds the 
organic emotions in check, and the organic emotions contribute 
life, and color, and personality to the mind ; while out of all these 
organic emotions, or, rather, out of all the organic sensations 
which we recognize in consciousness <is these emotions, the mind 
forms the personal Ego, 

But between the ethical emotions and the organic emotions 
there exists perfect peace and harmony only in the most favored 
individuals. With a large majority it is at best an unending 
struggle between protoplasm and ethics ; between cell intelligence 
and education ; between instinct and culture ; between self-preser- 
vation and brotherly love, and it only requires that the controlling 
faculties of the mind become weakened by disease of the brain^ 
or the organic emotions become intensified by reason of the per- 
verted organic sensations accompanying diseases of the viscera, 
and then will follow crime, or insanity, or both. 

Proposition 2. — That the relation of the body to the mind is 
that of master to servant. 

There is one feature in physiology of which we are woefully 
ignorant, and it transcends all others in importance, for it deals 
directly with the fundamental and vital elements of life itself. 
I refer to the relations existing between the brain and the visceral 
organs. Of the relation which the brain bears to these organs 
we have some small knowledge, but what of the relation whidi 
these organs bear to the brain? Do these organs, in which the 
essential and indispensable forces of life are continuously in 
active operation, have no influence upon the brain ? Is it possible, 
that these engines of existence which can make and unmake every 
cell in the body, which can unravel the nervous network of the 
brain itself and knit it up again, can exert no influence except 
through nutrition? Are there no sensations of organic life? 



J. W. WHERRY. 139 

Has the brain no knowledge of the conditions of these organs 
except through the quality of nourishment supplied? 

The mind is not the fountain head and primal source of all 
human action, nor is the brain the sole repository, as well as 
originator, of all that a man thinks, and feels, and does. It is 
well to consider, and to realize, that in all the abnormal acts of 
civil and social life the organic emotions must be reckoned with. 
It is the body that is the /, and not the mind. While the latter 
may be denied none of its highest and holiest attributes, it is this 
body of mine, this flesh, and blood, and nerve, and bone, that 
makes me what I am. The mind may supply the most exquisite 
ethical, religious, and intellectual experiences, but it is this mate- 
rial body that is the source of temperament, of moods, of char- 
acter, of a sense of well- or ill-being, of elation, of depression, of 
the organic emotions, of every fundamental expression of life. 
It moves, it breathes, it has its being, and, in spite of metaphysical 
teachings and religious dogmas, it holds the mind and all its 
attributes in the hollow of its hand. In health it is prime minister 
to the court of Mind, and in disease its influence over mentality 
is supreme. It is the chief arbiter of individual fate and, while 
we cry, All Hail ! to man's crowning glory, the Mind, we bow our 
heads in calm submission and stand or fall at the command of a 
body cell. From center to circumference, from coccyx to pha- 
langes, a thousand shuttles are weaving the web of destiny. They 
are forming hour by hour, and day by day, the warp and woof 
of existence, but the mind is wholly unconscious of what they do. 
Out of all this cellular work and turmoil, however, a flood of 
sensations sweeps over mentality, vagtie, uncertain, indefinite, but 
out of these is fashioned, in consciousness, the organic emotions. 

These organic emotions are often the real mainsprings of action 
and in abnormal conditions of the mind they are always to be 
duly considered. " In other words," says Ladd, in Philosophy of 
Mind, " what the individual man is, physically considered, either 
in respect to the whole course of his psychical development or in 
respect to the more general features of his psychical life at any 
particular period, is dependently connected with the character and 
development of the bodily organism. This principle, thus broad- 
ly stated, admits of indefinite illustration and proof. It is enough 
for our present purposes merely to refer to some of its more 



140 MELANCHOUA. 

important applications. The peculiarities which distinguish the 
sexes are especially worthy of note here. In spite of the modem 
effort, in a political and social way, to minimize or overlook these 
differences, the scientific study of the male and the female of the 
human species, in both physiologic and psychical aspects, only 
serves to multiply and emphasize these differences. Not in those 
respects alone which are obvious to all do men and women differ. 
In very blood and tissue, and in the most subtle ways and hidden 
comers of the physical and mental being of both, are they unlike. 
And the differences of a mental sort are, many of them, plainly 
assignable for their causes to original or developed differences of 
a bodily kind. In the same connection may be mentioned the 
dependence of transient or more permanent psychical manifesta- 
tions upon those bodily changes which belong to the different ages 
of life. That change in the sentiments which comes with the 
age of puberty, and the sudden and emphatic stress then laid on 
the psychical peculiarities of sex, are obvious enough. But psy- 
chology is just beginning successfully to investigate those im- 
portant mental changes which go on far more slowly and quietly 
in constant dependence upon the growth, the nutrition, the waste, 
and the decay of the various bodily tissues. The psycho-physical 
doctrine of disposition, or mood, as well as the physiological ex- 
planations of all matter of so-called diseased or abnormal mental 
conditions enforces the same principle." And Bastian says: 
'' Again, by reason of the direct or indirect connection of the 
viscera with the brain, the organic states of the various organs 
are capable of influencing the temper or mental state of the indi- 
vidual, either consciously or unconsciously. Visceral states may, 
independently of their conscious realization, prompt to automatic 
or instinctive acts; or, they may impress themselves upon the 
conscious life of the individual, and lead more or less directly to 
a series of voluntary actions." Ribot also says : " Organic feel- 
ings form the self; amnesia of the feelings is the destruction 
of self." 

I am afraid the tendency has been to exalt the brain pathologi- 
cally above its real position in the bodily economy, and to do so 
by underestimating the importance of other organs. We are 
inclined to think that the superior psychological position of the 
brain not only lifts it above its less fortunate neighbors, but rcn- 



J. W. WHERKY. 141 

ders it immune from the contaminating influences of its distinctly 
plebeian surroundings ; that it is a king in his castle, to whom the 
sickness or death of one or more of his subjects, among the count- 
less toilers in the field, signifies nothing; that he can close his 
eyes to their sufferings and turn a deaf ear to their entreaties; 
that if he does adopt any revolutionary ideas they must have 
originated in his own household, for he would hold no communion 
with the rabble; that, in other words, if the brain shows any 
vagaries of function they must have developed within its own 
domain, for they could not have arisen at the suggestion of any 
baser tissue. 

Under some circumstances it may be well to hold the brain 
strictly responsible for its own conduct and behavior, but, at the 
same time, it is also well to remember that it does not exist free 
and untrammeled, and that while its patron saint. Evolution, has 
done much for it in the way of culture and education, it still is 
encompassed by a horde of less fortunate friends and relatives, 
each asserting his kinship and pouring his tale of woe into a 
reluctant, perhaps, but not unsympathetic ear. Protoplasm has 
memory, and liver protoplasm has not forgotten when it and 
brain protoplasm lived together in a single cell, each equally help- 
ful to the other, and it does not propose that brain protoplasm 
shall forget it either. To rise from the ranks is a commendable 
thing to do, even for an organ, but it has its disadvantages, and 
even the brain cannot cut itself entirely loose from early associates 
and ignore old friends and acquaintances, without the latter tak- 
ing advantage of every opportunity to make their old companion 
realize that he is still dependent upon them for all that he is, and 
for all that he may be ; that with all his boasted glory he is still 
of the earth, earthy, and that the wonderful intellectual fabric he 
has so patiently reared is but the substance of a dream, which 
may be displaced at any time by another dream, or completely 
dispelled by a breath. 

No, the dominating influence of the sensations of organic life 
upon the brain must not be overlooked; nor must we ignore 
another fact While the brain is, in a measure, isolated from 
other organs and occupies a cavity by itself, there are, in the 
sympathetic nerves, millions of cells identical with its own, or, at 
least, next of kin, that dwell in the very midst of life's industrial 



142 MELANCHOLIA. 

hum ; that feel continuously the pulse and throb of energy ; that 
commune daily with tissue builders and blood makers ; and hear 
the grinding of the mills ; and see the elemental struggle at the 
making of a man; and know all the secrets of those marvelous 
laboratories which transform chemistry into energy ; and observe 
the mysteries of life and death within the very heart of nature. 
Do these cells tell nothing to the brain of what they see, and hear, 
and feel? Does none of this heat, and turmoil, and roar, and 
rumble, reach the master mind, even though it awakens no con- 
scious response? Does not the rumble and roar of machinery, 
after a time, fall unconsciously upon the workman's ear? But 
the rumble and roar is there, though he hears it not, and in the 
stillness of the night it will nmible and roar to the point of 
distraction. 

Proposition 3. — That the influence of the brain has been over- 
estimated in the production of abnormal mental states. 

It is possible that we have underestimated the influence of 
organic sensations in many mental conditions and have held the 
brain responsible for certain overt acts of mentality which reaUy 
had their origin in visceral sources. A blow on the abdomen 
will cause unconsciousness as quickly and as effectually as when 
it falls upon the skull. It is extremely doubtful if the exhilarating 
or depressing effects of intoxication from alcohol are due so 
much to its direct effect upon the brain as to its primary influence 
upon protoplasm in every part of the body, with only a secondary 
influence upon the brain centers. Alcohol produces its effect 
upon all tissue and not upon that of the brain alone ; indeed, the 
tissue changes caused by its excessive and protracted use are 
much more pronounced in the visceral organs than in the brain 
itself; and we cannot possibly conceive of alcohol, even when 
first introduced into the body, circulating freely in the blood but 
expending its force only within the cranium. 

Alcohol produces the same symptoms of intoxication upon man, 
with his well-developed brain ; upon animals with less brain ; upon 
insects with still less brain, as well as upon forms of life possess- 
ing no brain. Dr. Weir, in his Dawn of Reason, says : " I have 
repeatedly noticed the action of alcohol on rhizopods. When 
small and almost inappreciable doses were exhibited, the little 
creatures became lively and swam merrily through the water; 



J. W. WHERRY. 143 

but, when large doses were given, they soon became stupiiied and 
finally died." Thus single cells — ^protoplasm itself— can become 
lively and swim merrily and finally become stupified and die under 
the influence of alcohol. Can brain centers do any more than 
this? Here is a primitive single cell intoxication. The body is 
but an aggregate of single cells. Would it then be unreasonable 
to think that, in drunkenness, every cell in the body is intoxicated ? 
Would it not be more reasonable to say this than to say, that, 
although bathed in alcohol, every cell in the body is sober except 
those of the brain? 

With nerve and organic cells under the influence of alcohol 
the sensations of organic life carried to the brain would be pleas- 
ant indeed, and the fundamental tone of feeling would reflect the 
changed conditions. With every cell in the bodily fabric intoxi- 
cated and, perchance, as lively and as merry as a rhizopod under 
the same conditions, I can easily conceive of a flood of sensations 
being poured into the brain which could be elaborated into noth- 
ing but a sense of unusual exhilaration and of bodily comfort. 

In fact, is not this sense of bodily comfort strictly of bodily 
orig^? Is not the sense of bodily comfort following the use of 
morphine due to its effect upon individual nerve cells throughout 
the body, rather than to its isolated and limited influence upon 
the brain? The use of morphine certainly produces a sense of 
well-being, but because this feeling is present only in conscious- 
ness, and thus seems to reside only in the brain, it does not follow 
that it originates there merely as a result of the action of the 
morphine upon brain tissue. When, after long use, the mor- 
phine is withdrawn, the bodily sensations then occurring indicate 
the points where the influence of the drug was first felt. Not 
alone brain cells, but every cell in the body has been stupified, and 
stupified cells do not digest, or assimilate, or store up glycogen, 
or secrete, or excrete, in a normal manner, and this stupefaction 
of the agents of metabolism has more to do with coexisting mental 
conditions than any direct effect of the drug upon the brain itself. 
To be sure, opium will stupify a brain cell, as it does other cells, 
and this stupefaction will result in a sluggish mentality, but a 
sluggish mentality does not strike at the vital sources of exist- 
ence as does a sluggish liver, or a sluggish heart. 

For this reason opium has been discontinued as a remedy in 



144 MELANCHOLIA* 

melancholia. It was originally used because it was believed that 
it excited a directly "comfortable effect" upon the brain, and 
would thus dispel the morbid tone of feeling which permeated 
mentality. It was thought that the morbid feeling was due alto- 
gether and solely to mental derangement and that relief would 
come from a drug supposedly directed exclusively to the brain. 
The truth is, that the stimulating and cheerful effect witnessed 
in some cases was due only to the influence of the drug on the 
sympathetic nerve cells, and the modified sensations of organic 
life in consequence thereof. That this is true is evidenced by the 
fact that, while this benumbing of the visceral nerve cells gave 
some mental relief from the morbid sensations arising from 
pleuro-peritoneal sources, it also, at the same time, by reason of 
its similar benumbing effect upon metabolism, provoked and 
eventually increased the morbid tone of feeling which it was 
meant to assuage. 

That the sense of comfort and well-being experienced after the 
administration of morphine is due to its stupifying effect on the 
sympathetic nerves, which thus prevents the transmission of sen- 
sory stimuli from visceral organs to the brain, and, consequently, 
prohibits the occurrence of feelings of discomfort or depression, 
is shown by the fact that upon the withdrawal of the morphine 
the most disastrous results follow. "The most marked symp- 
toms," says Fisher, Nervous Diseases by American Authors, " arc 
observed upon the withdrawal of the drug (morphine). There 
is intense anxiety, a dread of some impending evil; the person 
may then become maniacal. There is marked insomnia and rest- 
lessness, with depression, and frequently suicidal intent." 

In other words, while the use of the morphine excites, in itself, 
general functional disorder in all viscera, the brain remains in 
ignorance of this universal calamity, because the influence of the 
drug on the end organs, located in the viscera, prevents the pas- 
sage of sensory stimuli and the consequent recognition" in con- 
sciousness of the deplorable condition. In the absence of all 
visceral sensory stimuli consciousness experiences a sense of ease 
and comfort. But when the drug is withdrawn; when visceral 
nerves, freed from the restraint of sedation, again awaken to their 
duty, what an overwhelming torrent of morbid sensory stimuli 
are carried to the brain. Practically every cell in the body has 



J. W. WHERRY. 145 

been pouring its tale of woe into an ear deaf to all entreaty, but, 
now that communication has been re-established, and every nook 
and cranny of the body is flooding the brain with the most direful 
stories of death and disaster, is it a matter of surprise that '' there 
is intense anxiety, a dread of some impending evil, and the per- 
son may even become suicidal ? " 

Brunton says : " From this producing a feeling of comfort and 
mirth cerebral stimulants are also called exhilarants. The func- 
tional activity of the brain depends upon the tissue change which 
goes on in the cells and fibers which compose it, and the amount 
of tissue change is regulated to a great extent by the quantity 
and quality of the blood supplied to the organ." This is all very 
true, but the application is incorrect. He forgets that the effect 
of the drug is to produce a thousand times more change in cells 
and fibers outside of the brain than inside. He forgets to take 
into account the very obvious fact that every individual cell 
in the pleuro-peritoneal cavity feels, and responds, to the influence 
of the drug just as much as the brain cells do. He forgets that 
this response of the brain cells, which he calls "comfort," is 
simply the summation of responses from cells elsewhere in the 
body. Comfort does not arise from the condition of brain cells, 
neither does mirth, or a sense of well-being. There are no sen- 
sory cells in the brain. Comfort and exhilaration come from 
visceral conditions. An increased circulation of blood in the 
brain, regardless of quality, does not in itself produce a feeling of 
comfort. Nitroglycerine causes a marked increase in cerebral 
circulation, but while it may stimulate the intellectual function of 
the brain, it certainly does not conduce to comfort. On the con- 
trary, the result is headache. No amount of cerebral stimulation 
will produce a feeling of comfort while there is acute pain in 
any part of the body. Whenever the drug, by means of in- 
creased circulation, and, consequently, increased secretion and 
excretion over a large area of the body, or by any other means, 
produces a condition of comfort in organic cells, then; and not till 
then, will the fact be recognized by the brain as a feeling." But 
because the condition of comfort is recognized by the brain does 
not indicate that it originates there, any more than that the ob- 
jects we see or touch have a cerebral origin. 

We find no difficulty in referring external sensations to their 

10 



146 MELANCHOLIA. 

proper objects; then why find the application to internal sensa- 
tions so perplexing? It is safe to lay down as a ftmdamental 
proposition that no sensation can originate in the brain. The 
brain receives and interprets sensations, but cannot originate 
them. All feelings of bodily comfort or discomfort, then, must 
come from sensations received by the brain but originating else- 
where. Accepting the proposition that their origin cannot be 
central, and that they must exist before this feeling of comfort 
can occur; then we are reduced to the simple statement, that 
before there can be a sense of well-being there are sensations, 
and that these sensations must have their origin either outside or 
inside the body proper. 

Of the sensations arising on the surface of the body nothing 
need be said, for these are quite well understood. The sensa- 
tions arising inside the body, however, are not well understood 
and, consequently, can only be approached theoretically, though 
experience has thrown considerable light upon the subject. That 
there is a conscious organic pain, no one will deny ; that there are 
also conscious organic sensations which are something less than 
pain will also be accepted ; but can we carry the argument further 
and say that still less intense sensations also occur, which do not 
rise above the threshold of consciousness, but exist in subcon- 
scious cerebration as a fundamental tone of feeling? The sense 
of touch may be so intense as to be painful, or, with decreasing 
intensity, it may awaken less and less response in consciousness 
until it may finally exist only in subconscious cerebration and 
exert its influence as in dreams, where the exposure of the body 
to cold air during sleep precipitates a dream of snowstorms or of 
icebergs. I can see no good reason for not believing that the 
organic sensations which exist at one time as pain, can likewise 
occur in less and less and still less intensity until it falls below 
consciousness and yet be active in the formation of that feeling 
which is known in consciousness as well- or ill-being, as comfort 
or discomfort, or, more properly, as a fundamental tone of feeling, 
which gives color to all mental operations. 

It is not necessary that we should be conscious of the actual 
sensations of organic life in order to testify to their existence. 
From every cell and organ of the body there is a flood of sensa- 
tions pouring in upon the brain, and especially is this true with 



J. W. WHERRY. 147 

reference to organs participating in the vital processes of life. 
That they are unrecognized in consciousness as real sensations is 
no evidence against their existence, for, while their intensity, as a 
rule, is such that they do not rise above the threshold of con- 
sciousness as an acute sensation, yet their presence is amply 
vouched for in consciousness as a general sense of well- or ill- 
being, which may become at any time a definite organic emotion. 

Itching, that is, an irritation of nerve filaments, is transmitted 
to the brain as a peculiar sensation. This sensation irritates 
consciousness and demands relief. But if the individual deter- 
mines not to yield to the call for relief, or, indeed, is, by force of 
circumstances, unable to do so, the irritation directed toward and 
received by the brain is none the less intense ; if, however, atten- 
tion is so completely engrossed otherwise that the individual is 
wholly unconscious of the situation, are we to conclude that the 
irritation projected against the brain cells is any the less intense 
because consciousness is too preoccupied to give it heed? 

Visceral conditions and organic states generally, furnishing, 
as they do, the material out of which emotions are fashioned, have 
more to do with mental states than we are inclined to believe, but 
the fact that the sense of bodily comfort ; the organic emotion of 
fear ; the depression of spirits ; the moods ; and all other mental 
states are known to us only in consciousness, and consciousness 
being associated in our minds exclusively with the brain has been 
the means of leading many an earnest seeker for truth astray. 
They have delved long and deep in this inviting but barren field, 
but hope and confidence have been so stroi^, and the quest has 
been so alluring, that many still believe that the pot of gold is 
buried at the rainbow's end and they have only to delve longer 
and deeper to secure the anticipated treasure; but so far as the 
emotions are concerned, or so far as it may involve the origin of 
emotional insanity, there is little hope for success. 

*' For these and other reasons," says Professor Ladd, of Yale, 
"the best evidence obtainable from pathological cases, when 
collected and sifted, appears surprisingly confusing and self- 
contradictory. . Brain pathology has, therefore, furnished the 
common fund of cases from which the most diverse and even con- 
tradictory theories have drawn at sight their stock of so-called 
proof. It has been used as the careless and false witness upon 



148 MELANCHOLIA. 

which either party, and all parties to the suit, could call for pre- 
cisely the testimony desired." While this is only too true it is 
not the intention to claim for it too wide an application, for the 
evidences of brain pathology in abnormal intellectual states, as in 
idiocy, imbecility, dementia, and general paralysis, are at least 
sufficiently established to call for further investigation, but in the 
emotional insanities, I believe it is useless to longer probe the 
brain for a secret it does not hold. 

Proposition 4. — That the organic emotion of fear has its ori- 
gin in visceral conditions. 

While it may be universally admitted that fear, as an emotion, 
exists, the statement that the emotion of fear has its origin in 
visceral conditions, and not in the brain, may not be so readily 
accepted. True, the feeling known as fear is recognized only in 
consciousness, but whence arise the sensations which give origin 
to fear in the absence of any conscious knowledge of danger? 
If all feelings must originate in sensations, from whence come the 
sensations which produce the feeling of fear? Must they origin- 
ate in the brain? Do organic sensations have no influence upon 
mentality? Are the relations existing between the body and the 
mind so remote and so indefinite that visceral conditions can have 
no effect upon psychical states ? 

I am slow to believe that morbid feeling must necessarily origi- 
nate in a diseased brain. Is the depression and irritability that 
comes with hunger dependent upon the hunger of brain cells 
alone? Is it not due rather to the hunger of visceral cells send- 
ing their protestations to the brain, which reproduces them as a 
feeling of depression and irritability? Does the feeling of hope- 
less and intense fear which accompanies angina pectoris originate 
in the brain, or does it originate in the heart itself, the brain 
standing only as mediator or interpreter between the organic 
sensations and consciousness, just as it stands as interpreter be- 
tween external sensations and consciousness? 

Ladd, Philosophy of Mind, says : " In all intense or emotional 
forms of feeling the presence of factors that have their origin in 
the condition of the peripheral parts of the bodily organism is 
obvious enough. The peculiar modifications of consciousness in 
which strong anger, fear, surprise, grief, etc., consist are un- 
doubtedly largely due to the condition into which the muscles, the 



J. W. WHERRY. 149 

vasomotor system, and the internal organs of the chest and abdo- 
men are thrown. Without using an unjustifiable figure of speech, 
we may say that these emotions are, to no small extent, feelings 
of the accompanying bodily conditons." "The emotions and 
passions have no centers in the brain," says Clevenger, " but arise 
in the body generally and later affect consciousness, as shown by 
your asking yourself why you grew so angry, why you should 
have done this, that, or the other impulsive thing." 

I believe this proposition can be safely laid down : That if the 
brain could exist and perform its psychical ftmction, separate and 
apart from the body, it would never know the feeling of fear. 
Dr. Lange, a Danish physician, first suggested that the organic 
conditions, with their various manifestations, are the primary 
elements in emotions, and that the emotion itself is nothing but 
the revelation of these things to consciousness. He says : " The 
nature of the interested organ determines the special character 
of the emotion which is produced, the intensity of the modification 
determines the agreeable or disagreeable tone of the emotions. 
The affective life is thus intimately related to the fundamental 
phenomena of organic life." 

" The most careful observers have remarked," says Ribot, " that 
the emotional faculties are effaced much more slowly than the 
intellectual faculties. At first thought it seems strange that 
states so vague as those pertaining to the feelings should be more 
stable than ideas and intellectual states in general. Reflection 
will show that the feelings are the most profound, the 
most common, and the most tenacious of all phases 
of mental activity. While knowledge is acquired and objective, 
feelings are innate." And here he points unmistakably to the 
source of these feelings. "Primarily considered, independently 
of any subtle or complex forms which they may assume, they are 
the immediate and permanent expression of organic life. The 
viscera, the muscles, the bones — ^all the essential elements of the 
body — contribute something to their formation." 

Fear is an instinctive emotion intended for the preservation of 
the individual, and must of a necessity spring from the vital pro- 
cesses of life itself. It cannot be dependent upon mentality; it 
cannot even be dependent upon the brain as the source of its 
origin. It must be equally active and efficient in man, with his 



I50 MELANCHOLIA. 

well-developed brain; in the animal, with a deficient brain, and 
in the amoeba, with no brain at all, and in order to be so uni- 
versally applicable it must reside in some tissue common to all, 
namely: Protoplasm, 

Professor James has emphasized with great skill and in an 
interesting way that organic changes are not merely an expres- 
sion of the mental state, but that they are its material cause and 
support. " What kind of an emotion of fear would be left," he 
says, "if the feelings neither of quickened heart-beats nor of 
shallow breathing, neither of trembling lips nor of weakened 
limbs, neither of goose-flesh nor of visceral stirrings, were pres- 
ent, it is quite impossible to think. Can one fancy the state of 
rage and picture no ebullition of it in the chest, no flushing of 
the face, no dilatation of the nostrils, no clinching of the teeth, 
no impulse to vigorous action, but in their stead limp muscles, 
calm breathing, and a placid face?" 

There can be no purely mental fear. The consciousness or 
recognition of danger without any bodily reaction would not be 
fear at all, indeed, there would be no especial feeling present; 
there would be simply a perception. Quickened heart-beats, 
shallow breathing, trembling lips, weakened limbs, goose-flesh, 
and visceral stirrings, are the essential ingredients of fear, and 
there can be no fear without them. This trembling of the lips, 
and quivering of the limbs, and stirring of the viscera, creates the 
feeling ; that is, we feel the stirring viscera and other phenomena 
and we call this peculiar feeling fear. Consequently, whenever 
there is this stirring of the viscera, etc., whatever the cause, we 
will experience this same feeling of fear, and these phenomena 
will always occur whenever there is an organic reaction to danger. 

It has been contended by some writers that fear is but the 
mental expression of a recognition of danger by the mind, but 
such a position is scarcely tenable, for it presupposes the posses- 
sion of a mental faculty. The fact is, if the feeling of fear was 
necessarily dependent upon a mind it could be felt by none of the 
lower animals, nor by man in conditions of imperfectly developed 
mentality, as in idiots, while, on the contrary, observation teaches 
us that this feeling of fear is more potent and more powerful in 
the lower animals and in idiots than in individuals with strong 
and active minds. The less dominating the mind may be the more 



J. W. WHERHY. 151 

intense this fear. It is felt alike, save in intensity, by all classes 
and all races of men ; by all species of animals ; by the very lowest 
forms of animated existence ; and this, too, under whatever name 
it may appear, whether as the instinctive repulsion of the amccba, 
the timidity of the animal or the dread and apprehension of the 
man. And this same fear, springing from "visceral stirrings," 
and morbidly increased by bodily disease, is the ground-plan and 
underlying principle of melancholia. In emotional insanity the 
architect and designer is some visceral disorder, the emotion is 
the foundation, and the subsequent delusion is the superstruc- 
ture, giving form and outline to the whole. 

" That the sensations of organic life," says Ferrier, Brain and 
Mind, " are represented in the cerebral hemispheres, directly or 
indirectly, is plain from the extraordinary influence which states 
of the viscera exercise on the emotional tone of the individual. 
Healthy states of the viscera produce pleasurable feelings, and 
morbid states of the viscera produce painful or depressing feel- 
ings. Visceral derangements are frequently the cause, and always 
the accompaniment, of melancholic depression." 

If a man was all mind and possessed no body he would never 
know what it is to fear. If there is any good reason for believ- 
ing that an angel is supremely and continually happy, it is that 
the separation from the body is complete, for the utter annihila- 
tion and eradication of fear would in itself be sufficient to make 
this earth a heaven and every inhabitant an angel of everlasting 
joy. 

Proposition 5. — That organic fear is a primitive instinct and 
necessary for the preservation of the individual. 

Among these organic emotions no one stands out so promi- 
nently as fear. Hunger, fear, and sexual desire, are the three 
fundamental protoplasmic principles, and on these three hang all 
the law and the prophets of biology. Hunger assures the main- 
tenance of life; sexual desire the reproduction of life, and fear 
the preservation of life. This organic, or instinctive, fear is 
inherent in protoplasm itself, and is older than the mind by mil- 
lions of years. It is not the result of ethics, or of culture, or of 
education. It originated with the primitive cell, and to this one 
emotion, more than to any other, is due the preservation, not only 
of the individual, but of the race itself ; and the fear of the single 



152 MELANCHOLIA. 

cell is reproduced and multiplied a million times by the aggfrega- 
tion of these million cells in a single body. Preyer says : " It is 
altogether wrong to maintain that a child has no fear unless it has 
been taught him. It is native and associated with all new im- 
pressions and is associated exclusively with the idea of injury to 
the individual." Fear is natural, inasmuch as it is a provision of 
nature, and it is organic because it is inherent in the body cells. 

The cause of the feeling of fear lies in organic sensations. It 
is the result of a reaction to danger on the part of body cells. 
The changes which occur in body cells in the presence of danger 
reach the brain as sensations, and these are represented in con- 
sciousness by the feeling which we call fear. That these organic 
sensations precede the feeling of fear is capable of demonstra- 
tion. In the presence of sudden and unexpected danger the 
muscular recoil, the respiratory spasm, the constriction of the 
heart, and the universal thrill which seems to proceed from every 
individual cell in the body, is oftentimes experienced before we 
become conscious of the feeling of fear. In other words, the 
cellular reaction to danger in these cases is so pronounced, and 
so intense, that we are conscious of the sensations of reaction 
before the brain can translate them into a feeling of fear. And 
this is why the individual, during this momentary period of time, 
is seemingly paralyzed and makes no effort to escape. He recog- 
nizes that the entire body is permeated with strange and unusual 
sensations, but, until the brain reproduces them in consciousness 
as a feeling of fear, he is unable to know their origin or what they 
portend. 

In the case of external sensations of danger coming through 
the special senses, there is some difference. In the reaction of 
body cells to internal danger we are unconscious of the source of 
the resulting organic sensations, and the mind can only translate 
them into the feeling of organic fear, without knowing what it 
dreads or where it will attack, but, in the presence of external 
danger, the mind cannot only recognize the source but can also 
comprehend the nature and extent of the peril. Consequently, 
there thus enters into the equation a mental faculty, judgment, 
which is not present in the fear arising from cellular reaction to 
disease. 

When a man sees an object of danger, or hears of one, or even 



J. W. WHERRY. 153 

thinks of one, this intelligence is conveyed through the sympa- 
thetic nervous system and every body cell is placed in a state 
of defense; this attitude of defense sends sensory stimuli to the 
brain and these are elaborated into fear. It is not the fear which 
causes the bodily condition — ^the intelligence of danger does this — 
it is the reaction of the body to this danger which causes fear. 
This bodily reaction to the presence of danger is as old as proto- 
plasm itself. The mind, however, is able to detect external 
danger where protoplasm would not, and the function of the 
mind is to report either known or foreseen danger — ^the body cells 
will do the rest, and this " doing the rest " will produce the feeling 
of fear. That this is true is shown by the fact that, although the 
mind recc^^zes a danger, every result of this recognition is in- 
voluntary, whether it be the action of the heart, or of the lungs, 
or the characteristic muscular phenomena. 

The bodily reaction to the presence of an external danger de- 
pends much upon judgment. If judgment can convince the body 
cells of their safety; can imbue them with a sense of security; 
then there will be no cellular reaction and consequently no fear, 
no matter how great the surrounding danger may be. But if the 
mind conveys this intelligence without the accompanying cellular 
assurance, the body reaction follows in spite of judgment, as 
during epidemics of disease or in panics; that is, if judgment 
acts at all in the latter instance. The facility, ease, and com- 
pleteness with which this assurance can be conveyed, and the 
degree of conviction with which the body cells receive it, deter- 
mines the individual's actions in the face of danger. A brave 
man is one whose judgment is able to perceive that the danger 
is more fancied than real, or, in the presence of real danger, can 
assure the body cells of their safety, and in either event he feels 
no fear. 

Knowledge of external danger that is made known by means 
of sight, hearing, taste, or smell, must come by way of the brain, 
but this knowledge must be conveyed to the body cells before 
there can be any reaction to the danger and, consequently, any 
feeling of fear. It is not the influence of the mind on the body : 
it occurs with equal positiveness in animals without mind. The 
purpose of the mind in this particular is to detect more readily 
the presence of danger ; more especially to convey the intelligence 



154 MELANCHOLIA. 

of foreseen or possible danger to the body cells, and to devise 
additional measures for escaping its consequences. As the mind 
succeeds in devising means for averting the danger, bodily reac- 
tion diminishes, and as bodily reaction diminishes fear disappears^ 
and caution, an acquired faculty bom of judgment, takes its place. 
Fear is instinctive and, when strong, dominates intelligence ; cau- 
tion is acquired, and is an aid to intelligence. Fear is weakening, 
enervating, paralyzing ; caution serves to steady and to strengthen. 
Fear is a product of the body ; caution an evolution of the mind. 
A man preserves himself from harm by caution; an animal by- 
timidity. And just as the mind or the body predominates ; just 
as the acquired or the physiological function controls; just so 
will a man show caution or timidity in the presence of danger. 

The brain, then, or the mind as its function, cannot originate 
the feeling of fear. Either of them can do no more than convey 
the intelligence of danger and, in some instances, an assurance 
of safety. If the mind really felt the fear before any bodily 
reaction had taken place, there never would occur such demoral- 
izing results as follow the sudden alarm of fire, or occur during- 
panics from any cause. It is in panics that we see the organic 
fear of the multitude so plainly in evidence. Every body cell in 
every individual, and every individual in the multitude, is blindly 
struggling for the preservation of life, as protoplasmic masses 
have ever struggled for existence since life began. In these 
instances few have any actual knowledge of the danger to be 
avoided, but they feel the fear, and they feel it without any intel- 
lectual assistance. If the mind originated the fear it would al- 
ways be in due proportion to the degree of danger, which is not 
the case. The mind would perceive the real significance of the 
danger, and, where no injury could possibly occur, would prevent 
the origin of this fear, instead of trembling with apprehension, 
the while it was quite convinced no harm could befall. 

The " nervousness," or " stage fright," or whatever it may be 
called, which attacks the actor, singer, or public speaker, is not 
the result of intellectual fear founded upon reason and judgment, 
but is this same organic fear, this same cellular reaction to fancied 
danger, and is absolutely beyond his control. It is the same 
organic emotion that causes the bird in the hand and the hare 
in the trap to tremble with apprehension. It is bodily, not mental. 



J. W. WHERRY. 155 

in its origin, and is not subject to mental control. The mind 
would not voluntarily create a feeling which it could not control. 
If its creation is involuntary, it must have its origin elsewhere 
than in the mind. Mental acquirements teach us to be cautious ; 
to avoid danger; to plan, or even improvise, new methods of 
escape, but they do not teach us to fear. 

We are not taught to fear. It was implanted in the primitive 
nature of the first cell. It is not a product of education, except 
those centuries and centuries of self-instruction which protoplasm 
has experienced since the first dawn of life. Mentality, as it 
further develops, may acquire more and more control over this 
bodily reaction to danger, but protoplasm has not yet delivered 
its safe keeping into the hands of any acquired function, no matter 
how high the latter may rise in the scale of morality or intellectu- 
ality. Protoplasm is neither moral nor intellectual, but it has pre- 
served its integrity through these millions of years without either 
morals or intellect, and the time has not yet arrived when it will 
unquestionably surrender itself into their care and keeping. In 
times of real danger protoplasm reacts, and it reacts exactly as 
it did a million years ago. Originally this reaction was simply 
a form of chemical repulsion, whereby elements without affinity 
were repelled. The chemical repulsion was the sum total of the 
phenomenon. But later, as the brain developed, this act of chem- 
ical repulsion was recognized in consciousness, and its associa- 
tion with the presence of danger became more and more evident. 
In the course of time, and because of repeated experiences, there 
finally came a mental reaction in response to the bodily reaction, 
and then whenever organized protoplasm reacted to the presence 
of danger the effect of such reaction was felt in mentality. Thus, 
the mental equivalent of the bodily reaction to danger was recog- 
nized in consciousness as a peculiar emotion which received the 
name of fear. And this fear, whether caused by bodily reaction 
to real or imaginary danger, or whether it be temporary or per- 
sistent in its nature, is the same fear, and produced in the same 
way, as the fear of the amoeba would have been had it possessed, 
in addition to its protoplasmic reaction to danger, the power 
to feel. 

The facility, ease, and completeness with which bodily cells 
react to danger depends upon habit and upon disease. The bodily 



IS6 MELANCHOLIA. 

cells of some people react upon slight provocation and they arc 
cowards in spite of all attempts to appear courageous ; while the 
f earf ulness and timidity of the sick man is the personal experi- 
ence of most of us, especially if the illness is of such a nature as 
to implicate all the organs of the body, and at the same time not 
so overwhelming in its toxicity or intensity as to exert a par- 
alyzing effect upon the sympathetic nerves, thus abolishing all 
sensory stimuli, or so benumbing in its action upon the brain as 
to prohibit its recognition of sensory stimuli or their elaboration 
into a conscious feeling. In the infectious diseases, as a rule, the 
action of the highly toxic blood upon the brain is such as to oblit- 
erate all consciousness of the bodily reaction to the danger, and 
no fear is felt, just as the melancholiac, during acute illness 
" forgets his fear," and is thought to be much improved mentally ; 
or the delusion gradually disappears under the disintegrating 
processes of dementia. 

Disease of the brain can prohibit the feeling of fear by a non- 
recognition of the sensory stimuli which produce it, but no dis- 
ease of the brain can originate fear. An excessive irritability of 
the brain may exaggerate normal bodily reaction to danger, but 
this normal bodily reaction can only come in the presence of real 
danger and, consequently, will not be continuous. A continuous 
feeling of fear can only come from abnormal bodily cells which 
are reacting to a disease whose toxicity is neither so overwhelm- 
ing as to prohibit the reception of sensory stimuli by the brain, 
nor so acute as to awaken the attention of consciousness to the 
fact of its presence. And this is why certain abnormal bodily 
states are so prone to precipitate a condition of melancholia, which 
would not follow or accompany the more intense manifestations 
of bodily disorder which are associated with the acute infectious 
diseases. 

Proposition 6. — That abnormal organic fear is the basis of 
melancholia. 

Having shown the important relation existing between visceral 
conditions and mental states, and having endeavored to establish 
fear as an organic emotion having its basis in cellular sensations, 
it now becomes necessary to consider the relation which fear bears 
to melancholia and, consequently, what connection, if any, exists 
between melancholia and visceral conditions. Melancholia is a 



J. W. WHERItY. 157 

condition of mind, characterized by a more or less intense feeling 
of abnormal fear, which may find expression in mild despondency, 
as in neurasthenia, or in a profound psychical depression, with or 
without agitation, as in emotional insanity. 

Practically all the delusions incidental to melancholia cluster 
around the feeling of fear. Clouston enumerates the delusions 
of 100 female melancholiacs taken at random, and the character 
of these delusions plainly indicate how closely and intimately they 
are associated with this primitive organic fear. There are delu- 
sions of persecution; of suspicion; of being poisoned; of being 
killed ; of being ruined ; of being conspired against ; of being de- 
frauded ; of being destitute ; of impending death ; of calamity ; of 
the soul being lost ; of having no stomach ; that she is to be mur- 
dered ; to be boiled alive ; that she is in hell ; being tempted by the 
devil; being possessed by the devil; having committed the un- 
pardonable sin; fear of being hanged; fear of being tortured; 
fear of living forever ; fear of taking food, and so on through a 
long list. Fear! Fear! Written in every lineament of the face 
and stamped upon every muscular movement. This is the heri- 
tage of the melancholiac. Struggling in an agony of fear with 
the nurses, who have become, by reason of her delusions, devils of 
destruction; shrieking for assistance to save her from a horrible 
death ; plotting and planning to outwit her persecutors ; stealthily 
secreting herself to await the coming of the mob ; arming herself, 
if possible, determined to defend herself to the death ; crouching 
in hidden and out-of-the-way places where she hopes to escape 
her enemies. Fear ! Nothing but Fear ! An emotion as primi- 
tive as life itself; founded upon organic sensations and bearing 
the most intimate relation to the fundamental elements of exist- 
ence. Fear ! An intense, abnormal, overwhelming fear. Learned 
men call it melancholia. 

It is not to be wondered at that an organic emotion, which has 
preserved the race through all the vicissitudes of animal exist- 
ence, and to which the individual, as well as the special organ, 
and, likewise, the single cell, have promptly responded whenever 
Ttcogniztd, should find the same ready response whenever felt, no 
matter whether its origin be normal or pathological or whether the 
cause of its origin be fancied or real. Education has been directed 
toward the restraint of this unreasonable fear, as society is pleased 



158 

to call it, but despite all education and all culture it rises to the 
occasion in supreme moments, and proves itself more effectual in 
the preservation of the individual than any methods devised by 
reason or judgment. For this reason, it is not surprising that 
during its pathological manifestations, whether in the form of 
momentary panic, or in frenzy, or in the more permanent condi- 
tion of melancholia, the individual should forget the lessons of 
yesterday, which taught brotherly love and self-sacrifice, and 
should revert at these times of greatest fear and apprehension to 
the original and eternal principle of self-preservation. 

The effect of this abnormal fear upon the melancholiac does not 
differ, except in the period of time involved, from the effect of 
uncontrolable fear upon any other individual. The man or 
woman who stands paralyzed with fear, gasping for breath, with 
a sense of constriction about the heart, face pale, eyes wide open 
with terror at the sudden and unexpected sight of a garter snake, 
eighteen inches in length, which could by no possibility injure 
them, differs in no particular from the melancholiac who feels all 
this terror but must invent some external object as its source. 
There is no actual danger in either case, and the man, recalling 
his experience with the snake, will laugh at the incongruity of 
the situation ; and so does the melancholiac, after recovery, laugh 
at the absurdity of his fears — but not at the reality of the experi- 
ence. After the feeling of fear has disappeared both can realize 
the absence of an adequate cause, but both will repeat the experi- 
ence under the same conditions. 

Organic cells will react to danger, and in times of disease and 
visceral irritation they respond with less and less apparent provo- 
cation, until in some bodily conditions, a state of panic is readily 
produced, which will continue as long as the conditions which 
give it birth persist. Heredity, likewise, plays an important role 
in these states of fear. Some individuals there are who from 
birth have been abnormally timid ; who scent danger from afar ; 
who feel an element of peril in the slightest touch ; who see death 
and disaster in every fleeting shadow. They react organically to 
every passing breeze of direful portent, and these organic sensa- 
tions keep them continually on the qui vive for anticipated danger. 
In some, indeed, this organic reaction is so abnormally developed 
that they may at any moment be grasped in the clutches of uncon- 



J. W. WHERRY. 159 

troUable fear without any external cause, and without any internal 
disorder, save the abnormal organic reaction itself. From these 
cases melancholia receives a long line of recruits. 

The feeling of fear is so closely associated with the idea of 
danger, that its mere presence leads the individual to sponta- 
neously take measures for protection; and if it is abnormally 
strong in the manner of its presentation it will find due recogni- 
tion in consciousness, whether or not there exists any known 
cause for its presence. It has been recognized for so long a time, 
and has so seldom betrayed its trust, that the simple fact of its 
presence is, to many, incontrovertible evidence that danger is 
near, despite all apptorances to the contrary, and the organic 
reaction finds a ready and willing ally in the intellect itself. 
Presentiments, and moods, and indefinite feelings of coming evil, 
have frequently taken possession of the man, but they have been 
mild and conciliatory in their manifestations, and, after a tem- 
porary occupancy, have, by means of counsel or cajolery, been 
dispelled. The absolute and all-compelling terror which takes 
possession of the man in melancholia is not to be dispelled so 
easily. On the contrary, it is so formidable in the method of its 
revelation, and so unquestionable in the manner of its conviction, 
that the intellect is enlisted in its cause and, instead of opposing 
its course, becomes at once its mentor and its friend. The degree 
of implication of the intellect depends upon the strength of the 
feeling and the success or facility with which reason and judg- 
ment can decide upon a possible cause or condition as the source 
of all this mental pain, for, until reason and judgment do adopt 
some object or condition as the cause, there can be no delusion, 
and the feeling remains vague and uncertain, though none the 
less real, until the physical conditions which gave it birth have 
I)assed away. 

Fear ! Fear for the self, the organic fear of protoplasm, is the 
essence and the all in all of melancholia. An abnormal fear 
which, in its very intensity, seems to be a reversion to the primi- 
tive instincts of protoplasm, and which sweeps away at a single 
stroke all the results of years of culture and education. A fear 
which drove the most timid wild animals to hide in gloomy cav- 
erns ; which now drives many men unceasingly to wander up and 
down the face of the earth ; which grips the heart, and blanches 



l6o MELANCHOLIA. 

the face, and, at times, makes abject cowards of us all. It is not 
a question alone of intellect or intelligence, but of organic reac- 
tion to the presence of danger, or to the irritability of body cells. 
It shows itself alike in the man who, without any reason for 
anticipating danger, is afraid to go out of the house at night, 
and the melancholiac who, without any good reason for so believ- 
ing, is afraid to eat for fear of poison in his food, save that the 
latter has known no peace until he has evolved some reason for 
the fear he feels. 

This disposition on the part of some to insist upon a mental 
reason for the fear which they feel, is the cause of delusions in 
melancholia. In neurasthenia the same feeling of fear is always 
hovering in the background, but in so mild a degree of intensity 
that the individual is content to regard it as a constant and annoy- 
ing source of depression, without attempting to account for its 
origin, but in its more powerful manifestations the sense of im- 
pending doom is so convincing and so all-pervading, that reason 
herself is aroused to the seriousness of the situation and the 
necessity of taking some measures to save the individual from 
destruction. 

It is at this point that the maneuvering of the intellect is first 
observed. Taking into consideration that this feeling of fear 
portends coming evil, and that it has hitherto possessed all the 
reliability of a primitive instinct, the intellect concludes that its 
mere presence may be conclusively accepted as evidence that 
something is going to occur. More than this, if the mere pres- 
ence of the feeling of fear can be received as an indication of 
danger, then, the unusual intensity manifested in the present case 
can only indicate that the danger is not only near, but extremely 
serious in its nature. The fact that the mind, at this point, can 
neither touch, nor smell, nor taste, nor hear, nor see, any object 
of danger, leads only to temporary doubt, if any, for the presence 
of so much fear with no discernible object as its cause only sug- 
gests a new idea, and that is, that the danger is none the less real, 
but that it will come in some mysterious and unusual manner; 
and from now henceforward imagination runs riot through all 
the probable and improbable causes, until one is found which 
seems to fit into, not only the present conditions, but into the 



J. W. WHEBRY. l6l 

temperament, teaching, and all the peculiar characteristics of the 
individual, and the delusion is bom. 

I have gone thus into detail because it is important to tmder- 
stand that the delusion in melancholia is the result of the exer- 
cise of both reason and judgment. It is not an idea which slips 
in, under the stress and strain of fear, only when reason and 
judgment have been abrogated by disease. The delusion comes 
in no clandestine manner. It is bom of a necessity, it is true, 
but its origin is legitimate, and it is stamped by the seal of reason 
and stands approved by judgment. Were it not so, reason and 
judgment would not voluntarily rally to its support, nor defend 
it so strenuously against subsequent attacks. Tme, if judgment 
and reason are weakened and impaired they will be less critical in 
their choice of a cause, but if the choice is made; if a cause is 
finally adopted ; the degree of intellectual refinement shown in its 
selection matters but little. The acceptance of some object or 
condition as the cause of the fear is the point. If the delusion 
is once bom, it matters little what the conditions of labor may 
have been. 

In the selection of a delusion in melancholia it should be no 
cause for surprise that it so frequently embodies the mysterious 
and undemonstrable, for, instead of indicating that the intellect 
has no part in its formation, it is additional proof that reason and 
judgment are involved in its creation. The fact that this feeling 
of fear can be accounted for in no ordinary way forces the intel- 
lect into the region of the mysterious for its solution. Besides, 
no average judgment would accept trivial and palpably impossible 
things as a cause. Reason would have to be weakened and im- 
paired, indeed, for a man to accept the proposition that a certain 
tree in the yard was going to pull itself up by the roots and come 
into the house and hit him on the head ; not that this proposition 
is too unreasonable alone, but that he can recognize, in the midst 
of all his mental turmoil, the transparency of the statement be- 
cause of his famdliarity with trees and their limitations. Thus it 
is that delusions will be found, as a rule, to have been gleaned 
from those sources with which the deluded one is least familiar 
for, while reason and judgment may be led astray by the pressure 
of circumstances, they will not voluntarily subscribe to self- 
evident error. 

II 



l62 MELANCHOLIA. 

A deluded patient seldom formulates into a false belief such 
propositions as these : Black is white ; eight times four is seven- 
teen; the square on the hypotenuse is equal to a right angle. 
Such statements are too obviously opposed to reason and judg- 
ment. Instead, he selects a cause of which he knows little or 
nothing, or which might be true, and the nearer he comes to 
selecting something of which he has no real knowledge, or some- 
thing which no one else can positively prove to be false, the more 
eagerly does judgment embrace it. If he finds the fulfillment of 
his fear in the conspiracies of enemies, which may or may not 
be true; or in secret societies, of which he knows little; or in 
electricity, of which he knows less ; or in everlasting punishment 
by a God, of whom he knows nothing ; or in the infidelity of his 
wife, which no one can disprove ; or in anjrthing else, which can 
not be demonstrated, the judgment encounters little difficulty in 
accepting it. 

The position occupied by this feeling of fear, whether above or 
below tiie threshold of consciousness, depends upon its intensity. 
This much we know : That there is a present sense of well- or 
ill-being; that in its normal tensity it forms a fundamental tone 
of feeling, which is known as temperament; that we recognize 
variations from time to time, and we call these moods ; that this 
feeling must have its origin in sensory stimuli ; that the elabora- 
tion of these stimuli into feeling lies outside of consciousness; 
that these sensory stimuli do not arise from external conditions, 
for if they did we would be conscious of both the source of these 
feelings and the cause of every modification they might undergo. 
More than this, I believe we may safely add : That this funda- 
mental tone of feeling has its origin in visceral conditions ; that 
these visceral conditions determine not only the normal tempera- 
ment of the individual but his moods as well ; that by reason of 
certain general abnormal conditions of the visceral organs, this 
tone of feeling becomes exaggerated and abnormal, resulting in 
depression of spirits and a universal sense of ill-being, known as 
neurasthenia; that further increase in the intensity of this ab- 
normal sense of ill-being eventually provokes the intellect to 
search for a cause; that this search for a cause develops a false 
belief ; that this false belief finds its expression in language, and 
thus perpetuates both itself and the accompanying feeling in 



J. W. WHERRY. 163 

memory, and that the adoption of this false belief begets new 
methods of thinking, and acting, which, in connection with the 
already present abnormal feeling, are resolved into a peculiar 
mental condition known as melancholia. 

Proposition 7. — That melancholia is but the expression of 
abnormal visceral conditions. 

For myself, I can see no good reason why there should be any 
doubt about the origin of melancholia in visceral conditions, 
rather than in a disease of the brain. In pure melancholia, un- 
complicated by dementia, I can see no such involvement of the 
intellect as to justify us in longer pointing the finger of suspicion 
at the brain. Disease of the brain will find its expression, if it 
finds it at all, in disorders of the intellect, not in any intensifica- 
tion of the emotions. Intensified emotions may find more free- 
dom of action in the presence of impaired intellect, as in dementia, 
but, nevertheless, the emotion is the basic principle and the mov- 
ing spirit in melancholia, and this emotion in itself would con- 
stitute melancholia regardless of the intellectual condition. In 
the idiot, in the dement, in one who is neither idiot nor dement, 
an almormal fear is the same. In the presence of the intellect 
it takes on the additional characteristic of a delusion; in the 
absence of intellect it exists as a profound depression without any 
delusive significance, but in either event the emotional mental 
condition is due to this same organic fear. 

One writer says : " Nutritive disturbances of the cerebrum 
being the principal causative factor (i. e., of melancholia) psy- 
chical distress and a sense of woe and uneasiness are the ways by 
which the brain expresses its lack of proper nourishment"; but 
this scarcely agrees with well-recognized facts in the case. In 
those mental conditions attended by the most pronounced insuffi- 
ciency of brain nourishment, " psychical distress and a sense of 
woe and uneasiness " are seldom present. In no other condition 
of the brain can there be a greater deficiency of nourishment than 
in advanced dementia, but " psychical distress and a sense of woe 
and uneasiness" are not characteristic of simple, advanced de- 
mentia. Idiots certainly represent the most pronounced lack of 
proper brain nourishment, both before and after birth, but no one 
associates " psychical distress and a sense of woe and uneasiness " 
with this condition. Psychical distress may come from lack of 



|64 MELANCHOUA. 

nourishment, but it is from lack of nourishment to organs outside 
the cranium. The brain cannot originate a feeling of psychical 
distress, nor of woe and uneasiness, no matter how adequate or 
inadequate its nourishment may be; it can only translate sensa- 
tions into feelings, and, as it has no sensory fibers of its own, it 
can have no sensations of its own, and, consequently, no feelings 
which arise from, or originate in and of itself. 

The brain has sufficient to answer for in the purely intellectual 
forms of mental unsoundness, that is, idiocy, imbecility, dementia, 
and general paralysis ; and the emotional mental condition known 
as melancholia must be charged up to visceral conditions — not to 
the brain. Melancholia is due to, and is the outgrowth of, organic 
fear, and organic fear has its origin outside the cranium, for it 
was in existence long centuries before the cranium was formed. 

The importance of the visceral organs, in any consideration of 
melancholia, cannot be overestimated — in fact, these bodily organs 
constitute the Ego itself. Ribot, Diseases of Memory, says : " It 
would seem, according to this view, that the identity of the Ego 
depended entirely upon the memory. But such a conception is 
only partial. Beneath the unstable compound phenomenon in 
all its protean phases of growth, degeneration, and reproduction, 
there is a something that remains; and this something is the 
undefined consciousness, the product of all the vital processes, 
constituting bodily perception, and which is expressed in one 
word — ^the ccmcesthesias. All observers are agreed that the early 
development of mental disease is indicated, not by intellectual 
disorder, but by changes in charctcter — changes which are only 
the psychical expression of the caenasthesias." That is, character 
is the product and outgrowth of the body, not of the mind. It is 
the result of vital processes and not of mental operations. He 
goes further : " So an organic lesion, often ignored, may trans- 
form the ccenaesthesis, substituting for the normal sensation of 
existence a condition of melancholy, mental distress, and anxiety, 
of which the patient is unable to discern the cause. This bodily 
condition, which is without the sphere of consciousness, because 
of its perpetuity, is the true bctsis of personality — ever present, 
ever-acting, without repose or respite, it knows neither sleep nor 
exhaustion, lasting as long as life itself, of which, indeed, it is 
only an expression." 



J. W. WHEUtY. 165 

How can melancholia, which is unquestionably an emotional 
condition, have its origin in the brain? There is no source of 
emotion there. Maudsley says: "So long as man has organic 
viscera he will have emotion enough, whatever his beliefs or dis- 
beliefs may be." And it is true that the emotions and the intel- 
lect have little in common. I quote again from Maudsley : " In 
truth these organic efforts of the physiological consensus of 
organs determine at bottom the play of the affective nature; its 
tone is the harmonic or discordant outcome of their complex inter- 
actions ; the strength of the force which we develop as will and 
the emotional color in which we see life have their foundation in 
them" Again, " Injury to the head and gross disease of the 
brain tend to cause intellectual rather than emotional disorder, 
while abdominal disease favors the occurrence of emotional de- 
pression; the organic conditions of the intellect being, as Mtiller 
remarked, mainly in the brain itself, and the elements which 
maintain the emotions or strivings with self, in all parts of the 
organism. It is clear as day that temporary bodily conditions, 
however they may have been brought about, will play their part ; 
and it may well be that future researches will discover the causes 
of the characteristic features of some varieties of mental derange- 
ment in the diathetic states and the actual bodily disorders which 
are associated with them. Without any change whatsoever hav 
ing taken place in his external relations, the presence of bile in 
his blood shall drive a person to regard his surroundings and 
his future in the gloomiest light possible ; carry this morbid state 
of nervous element to a further stage of depression and make it 
last, there ensues the genuine melancholia of insanity. There is 
the most perfect harmony, the most intimate connection or sym- 
pathy, between the diflferent organs of the body as the expression 
of its organic life, a unity of the organism beneath consciousness^ 
and the brain is quite aware that the body has a liver or a stomach 
and feels the efiects of disorder in any one of the organs, without 
declaring in consciousness the cause of what it feels." 

Melancholia must be regarded as a psychical expression of 
organic fear; a mental state due to visceral conditions. It has 
long been conceded that melancholia was the most curable form 
of insanity ; in fact, it has been almost the only curable form of 
insanity, but the reason why has only recently beg^n to dawn 



l66 MELANCHOLIA. 

Upon US. In the medical treatment of insanity we have regarded 
all forms of mental disorder as due to disease of the brain, but 
all our treatment has been directed elsewhere. We have known» 
and acknowledged covertly, that if it was true that insanity was 
due in every instance to disease of the brain, all treatment would 
be useless. Consequently, the course of treatment adopted was 
directed to the correction of bodily disorders. Attention was 
given to the stomach, the liver, the heart, the kidney, the blood, 
the lung, the skin, the bowels, and general systemic conditions. 
There is no special treatment for insanity, that is, there is no 
medicine for the mind, and little for the brain, because in those 
forms of insanity due to disease of the brain the very nature of 
the latter condition precludes recovery from any method of treat- 
ment. 

It was noticed, however, that by virtue of the treatment em- 
ployed in hospitals for insane a certain number recovered, many 
more improved, only to relapse, and in a large number there was 
no improvement except of the most temporary kind. Year after 
year passed by with the same methods of treatment employed and 
followed by practically the same results. After a time it was 
thought worth while to investigate the matter a little and it was 
discovered that practically all the cases of actual recovery were 
those of pure and uncomplicated melancholia, while the incurable 
were made up of imbeciles, epileptics, general paralytics, para- 
noiacs, and dements— especially dements. 

This opened up a field for study. If all forms of insanity were 
due to disease of the brain, and the same method of treatment 
was employed in each case, why should all the melancholiacs re- 
cover and all the rest refuse to do so ? It was evident that some 
feature of the matter had been overlooked, and the question arose : 
Is it possible that all forms of insanity are not due to disease of 
the brain? The results of the investigation and study carried 
on in response to the above query are embodied in this and a 
former paper, " Is Delusional Insanity Due to Disease of the 
Brain?" 

Melancholia and dementia do not differ in their curability be- 
cause dementia is due to a disease of the brain that is not curable 
and melancholia is due to a disease of the brain that is curable. 
No curable disease of the brain ever produced insanity. But, if 



J. W. WHERRY. 167 

such a condition did exist, curability and incurability is not the 
only difference between dementia and melancholia. Dementia is 
a mental condition implicating the intellect, while melancholia is 
a mental condition involving the emotions. Is it not possible 
that due consideration of this proposition may be of some service 
in the solution of the problem? Drugs, whatever their character, 
can have no direct effect upon mental states. There is no medi- 
cine for the mind per se. If any effect upon mental conditions 
is to be obtained by medical treatment it must be indirectly. It 
must be applied to the source of the disorder. It must be directed 
to the organ or organs from whence the mental state emanates. 
Treatment for melancholia and for dementia must be equally 
eflFective if the two conditions flow from the same source. Treat- 
ment for disordered intellect and for disordered emotions must 
find a similar response if both conditions draw their sustenance 
from the same organ. 

Then why do melancholiacs recover, while imbeciles and de- 
ments do not? Melancholia is a true emotional disorder; demen- 
tia is a true intellectual disorder. If the method of treatment 
employed relieves the emotional disorder but does not relieve the 
intellectual disorder, is it not possible that the treatment used 
reaches the seat of the disorder in melancholia more effectually 
than it does in dementia? May it not be true that treatment 
directed toward the bowels, or stomach, or liver, or heart, or 
kidney, or skin, does not produce any important or lasting impres- 
sion upon a diseased brain, but may be quite efGcacious in the 
relief of visceral disorders themselves? It is here, I believe, that 
we will find a solution of the problem, namely: That the intel- 
lect and the organic emotions do not have a common origin. 
That, while emotions are recognized in consciousness, and thus 
become associated in thought with the mind, and finally with the 
brain, they have their origin in visceral conditions. If thought 
and feeling both originated in the brain, then disease of the brain 
must produce both disorder of intellect and disorder of the emo- 
tions simultaneously, but, quite to the contrary, we have dis- 
orders of intellect, as in imbecility or dementia, without disorder 
of the emotions, and disorder of emotion, as in melancholia, with- 
out disorder of intellect. Imbeciles and dements can hate, and 
desire, and fear, even when the mind is so impaired as to be un- 



l68 MEX.ANCHOLIA. 

able to give any intellectual expression to the emotions felt ; and 
melancholiacs, while, apparently, so completely absorbed in their 
morbid feelings as to be indifferent and unconcerned regarding 
all external objects, are quite wide awake to their surroundings 
as they will tell you after the attack has passed away. In pure 
melancholia the intellect is in no way involved, except in the 
furtherance of the morbid design, and when, during an attack 
of melancholia, any intellectual involvement is observed, it is safe 
to conclude that the patient has both melancholia and dementia. 

If idiocy, imbecility, and dementia are due to disorders of in- 
tellect ; and melancholia is due to disorder of emotion ; then we 
must logically conclude that dementia and kindred mental con- 
ditions have their origin in functional or organic changes in the 
brain, while melancholia originates in functional or organic dis- 
eases of the viscera, for emotion, the organic emotion of fear, is 
the underlying principle in melancholia, and in whatever part of 
the bodily structure organic fear has its birth, there will be found 
the seed-bed of melancholia. Here is the secret of success in the 
treatment of melancholia and it explains the mystery over which 
so many of us have so long pondered, and the only source of 
wonder remaining is, that while we theoretically held to the fact 
that all abnormal mental conditions were due to disease of the 
brain, a position from which, until recently, we would withdraw 
under no consideration, we were led miraculously, or, perhaps, 
instinctively, to direct our treatment to the real seat of the dis- 
order, and that, too, in the one especially curable form of insanity. 

In the consideration of insanity we must now recognize two 
forms of disorder, namely: Intellectual, having its origin in 
disease of the brain ; and emotional, having its origin in diseases 
of the viscera. True, all injuries and diseases of the brain do 
not lead to intellectual disorder, nor do all diseases and injuries 
of the viscera lead to melancholia, but, whatever the special 
cause from which they spring, intellectual disorders must be 
referred to the brain and emotional derangements to the viscera. 

It may be well to add in this connection, what will be readily 
observed, however, that, while there are intellectual disorders 
and emotional disorders, and while a patient may have either one 
or the other in a pure and uncomplicated form, yet there is, at 
the same time, nothing to prevent or disqualify the patient from 



J. W. WHERRY. 169 

having both an intellectual and an emotional disorder at the same 
momenty without them bearing any intimate relation to each 
other, and without either being regarded as a syn^tom of the 
other. Bearing in mind the source of origin of each, there is 
little difficulty in understanding why they can both exist inde- 
pendently, or both exist in the same individual at the same time, 
without implicating each other, or of either being misinterpreted 
as bearing the relation of cause or effect to the other. A dement 
may have melancholia, or an imbecile may have melancholia, just 
as a man who is neither a dement nor an imbecile may have the 
same emotional disorder, or just as anyone else, sane or other- 
wise, demented or otherwise, who possesses viscera, may have 
melancholia. It is simply a question of visceral conditions and 
not of intellectual order or disorder. 

Probably 70 per cent of all patients admitted to hospitals for 
insane are subjects of some intellectual disorder, either idiocy, 
imbecility, or dementia in some of its forms. All incurable. 
The remainder are divided between toxic insanity, manic-depres- 
sive insanity, and melancholia, with prognosis good in nearly 
every instance. The reason that many cases of melancholia 
prove to be incurable is because we fail to discover in these 
patients another condition than melancholia hovering in the back- 
ground. I have said that there is nothing to prevent a dement 
from having melancholia, and if this dement is admitted to the 
hospital during this attack of emotional disturbance, as they 
frequently are, the latter condition quite naturally occupies the 
foreground, and the patient goes on record as a case of melan- 
cholia. In a week, or a month, or in six months, the patient 
recovers from the emotional disorder and then, the truth not yet 
having been discovered, the case is branded secondary dementia, 
and, not only this, it is ever afterward referred to as secondary 
dementia following melancholia. It may not be out of place to 
remark here that in all probability dementia is in every instance 
primary in its origin, so far as its relation to any other mental 
condition is concerned, and I am slow to believe that any case 
of melancholia ever had secondary dementia as a sequel. If 
dementia becomes observable upon the disappearance of melan- 
cholia it may be safely taken for granted that the dementia has 
been present all the time, or that, if it has developed in the mean- 



170 MELANCHOLIA. 

time, it has done so independently of the melancholia. If de- 
mentia is secondary to anything it is to the brain disease or malnu- 
trition which gave it birth, for it bears no such relation to any 
emotional disorder which may precede or accompany it This 
may seem to be a radical view of the matter but close observation 
will verify, I believe, the position taken. 

In conclusion I can only reiterate what has been already laid 
down, for if organic fear has its origin in visceral sensations, 
and if melancholia is a mental condition arising from a state of 
abnormal organic fear, then melancholia must of a necessity have 
its origin in abnormal visceral conditions. 



MYSOPHOBIA, WITH REPORT OF CASE. 

By JOHN PUNTON, M. D., Kansas Cmr, Mo. 
Professor of Nervous and Mental Diseases, University Medical College, etc. 

Gentlemen : 

The recent achievements wrought in the field of psychiatry 
easily take precedence of all other departments of medicine in 
point of scientific interest and value. Until within quite a recent 
period the study of mental diseases appealed only to those mem- 
bers of our profession whose tastes and opportunities led them to 
select this form of practice. A radical change, however, is now 
taking place in the form of a general enthusiastic scientific awak- 
ening or spirit of inquiry, relative to the nature and relationship 
of the various insanities, which is not confined to any special class 
of physicians, but permeates the ranks of the medical profession 
in all parts of the world As .a result there never was a time 
when so much good work was being done as now ; by not only the 
medical officers of our State and private insane hospitals, but 
also by the ablest alienists, neurologists, psychiatrists, bacteriolo- 
gists, clinicians, and other medical investigators, whose combined 
efforts are now engaged in unravelling the secrets associated 
with mental diseases. The tendency of modem medical progress 
therefore is such as to bring psychiatry into closer relationship 
with general medical practice, by furnishing the general medical 
practitioner with more accurate reliable knowledge concerning 
the clinical aspects of insanity and its allied neuroses. 

The chief practical clinical results of this marked psychiatrical 
activity has furnished us the means of making finer discrimina- 
tions in classification and diagnosis of the various insanities, as 
well as suggested methods for their more successful treatment. 
Moreover, it has also emphasized the important fact that while 
insanity is primarily a psychosis of the highest order, yet there 
are a niunber of morbid mental states, which, while showing a 
marked kinship to insanity, are not usually regarded as such. 



172 MYSOPHOBIA^ WITH REPORT OF CASE. 

These non-insane psychoses, however, as a rule, first come 
under the observation of the family physician, who imfortunatdy 
often fails to recognize their true psychological significance until 
the obsession-impulsion, or fixed idea, which accompanies them, 
becomes so very conspicuous and persistent as to render the 
patient at times exceedingly troublesome, and even unsafe to be 
at large. It is, therefore, both gratifying and complimentary to 
our profession to note the change which is rapidly taking place in 
our conception of the term Insanity, as well as our recognition of 
the close relation which exists between the psychoses and neu- 
roses, or those morbid mental states which formerly were not 
considered as belonging within the domain of the science of 
psychiatry. 

Those of us, however, whose professional duties bring us in 
daily contact with persons suffering from the various nervous 
and mental disorders, cannot fail to recognize the confusion 
which exists in general medical practice concerning the diagnosis 
of such conditions as neurasthenia, hysteria, and the different 
forms of insanity. 

The extreme relational importance of these neurotic states 
with insanity, while being duly accepted by us, are not sufficiently 
recognized by the general medical profession as their significance 
justly warrants, hence with a view of emphasizing the close kin- 
ship that exists between them and other practical features I am 
led to report the following case of mysophobia: 

Miss A — , aged 25 years ; single ; brunette ; occupation stenog- 
rapher ; was referred to me May 17, 1902, by her family physician. 

Family history. — Father of the patient was said to have been 
a dipsomaniac, while her mother died of tuberculosis. Nothing 
was known concerning the rest of her ancestors. Her only 
sister, however, was quite neurotic. 

Personal history. — Nothing unusual occurred in the life of the 
patient imtil about the 14th year, when her mother noticed she 
took a great dislike to one of her playmates, and after returning 
from school, where they met daily, she would wash her hands 
continually and sometimes her gloves. She also showed signs of 
stubbornness and was given to occasional hysterical outbursts. 
Her menstruation was irregular, but she seemed to be well other- 
wise. She was bright and intelligent and quite precocious in her 



JOHN PUNTON. 173 

Studies. Her general nervous condition, however, gradually in- 
creased in intensity as age advanced, and in addition to washing 
her hands constantly, her ablutions began to extend to other parts 
of her body. Upon being asked the reason for this marked 
desire to be cleanly, stated that she feared she was being con- 
taminated by her schoolmates and surroundings, and she in turn 
was contaminating her own family. 

Her general health remained fair, while her nervous condition 
was not considered of sufficient importance to need the services 
of a physician. Upon leaving school she studied stenography 
and soon secured a position, but did not remain long in any one 
situation, as her peculiarities, such as constantly washing her 
hands, clothing, etc., attracted her employer's attention and she 
was dismissed. Her conversation was perfectly rational, and 
while recognizing the absurdity of her dread or fear of being 
contaminated ; she claimed she was wholly unable to refrain from 
the habit. 

Associated with the fear of contamination she engendered a 
personal dislike for the article or person she thought contaminated 
her, which finally resulted in her tearing up her clothing or setting 
fire to the furniture of her room. Often in alighting from a train 
in some strange town or city she would be seized with the dread 
or fear that something had contaminated her, and no matter what 
inducements were offered she would leave immediately for other 
parts, but before reaching her destination would stop at a hotel 
long enough to wash everything belonging to her — ^nothing 
escaped, clothing, trunk, money, pocket-book, hat, shoes, indeed 
everything she had with her. At one time she worked in a large 
western city but soon became convinced that her associates in 
business as well as her surroundings had contaminated her, and 
soon after left for another dty to visit friends. While there she 
learned that there were some people in the same house that had 
just arrived from the city in which she had formerly worked, 
which made her very uneasy and restless, and under no circum- 
stance would she volunteer to meet the visitors, for fear they 
would contaminate her. Upon one occasion, while her mother 
was entertaining some visitors at her own home, during a meal in 
passing the food from one to the other the dress sleeve of a 
visitor happened to touch the vegetable dish, which was sufficient 



174 MYSOPHOBIA, WITH REPORT OF CASE. 

to make Miss A. become much worried and miserable until finally 
she left the table and went to her room, where she stripped her- 
self and took a sponge bath. 

She would not write letters to persons who lived in cities where 
she had been employed for fear that the reply would contaminate 
her, but when by chance she received such letters she would 
invariably wash them before reading. If while attending church 
she happened to see anyone she had formerly known in the cities 
where she thought she had been contaminated, she would leave 
the church immediately for home, and then wash all her posses- 
sions, as well as the furniture in the house, until stopped by sheer 
force or until she became exhausted. 

Often she takes a dislike to some article of clothing or furni- 
ture and immediately destroys it, and then bathes herself and all 
her belongings, including the bed, walls, pictures, doors, and very 
frequently will let certain articles of clothing, like her gloves or 
hat, remain soaking over night in water. 

When restrained from using water she will pick and pull des- 
perately at her clothing and other articles surrounding her, ever 
on a ceaseless hunt for the object or objects she believed con- 
taminated her. When reasoned with she acknowledges that she 
is unreasonable and that her fears are delusive in character, but 
cannot resist the impulse to either wash or destroy. 

Upon her admission to the sanitarium she had been suffering 
from mysophobia for about ten years, resisting all efforts of her- 
self and friends to overcome her ailment. For several years she 
had been under the observation of the family physician, who 
diagnosticated her condition as one of neurasthenia. 

She was somewhat anemic, small of stature, and badly nour- 
ished, but intellectually bright and rational, being perfectly con- 
scious of her serious condition, and voluntarily came to the 
sanitarium for treatment 

Examination revealed no organic disease of any kind, and her 
general health was fair. She ate and slept well and took kindly 
to all the rules of the sanitarium. She did not complain of any 
pain, although her menses were irregular, and the only thing 
noticeable was a marked tendency to despondency. She presented 
a well-developed beard, of which she was very sensitive, but kept 
it closely shaven by using a razor daily. During her stay with 



JOHN PUNTON. 175 

US she sought at times every opportunity to carry out her impulse 
to wash or destroy, occasionally becoming quite deceptive and 
even secretive to accomplish this purpose. She was, however, 
placed under rigid surveillance, and special attention g^ven to 
improvement of her malnourished condition. For this purpose 
tonics, electricity, massage, exercise, hydrotherapy, employment, 
and other agents were used, including large amounts of nutri- 
tious food and psycho-therapeutics. She gradually improved, 
and at the end of several months we thought we had fairly con- 
quered her besetment, she herself claiming that she was entirely 
well and wanting to go home to spend the Christmas holidays, 
which request was also urged by her friends. She promised 
faithfully she would refrain from her morbid habits, but no 
sooner did she leave Kansas City than the old impulse returned, 
and she stopped on her way home at a small station, went to the 
hotel, secured a room, and washed everything she possessed ; then 
resumed her journey. 

Soon after her arrival home she gave the entire premises a 
good scrubbing, including her own belongings, in fact continued 
until she became thoroughly exhausted. About two weeks later 
she returned to the sanitarium unaccompanied by any one, and 
after reaching Kansas City went at once to one of the hotels and 
had a general clean up before coming to the sanitarium. 

She regretted her conduct and the forfeiture of her pledge to 
me, but claimed she was unable to resist the desire to wash her- 
self, money, clothing, etc. She also stated that the only persons 
she knew who never incited these impulses or caused the fear of 
contamination to arise in her were her two brothers, who seemed 
in her mind to be free from such power. Upon one occasion, 
in speaking to me of her love affairs, she stated that while living 
in California she fell in love with a young man, but did not like 
to be with him often as she feared that should he make her 
angry the impulse to wash him, or herself, might suddenly arise, 
and nothing short of this would satisfy her. She is naturally 
affectionate and bore a most excellent character for kindness of 
disposition, yielding kindly and willingly to the dictates of friends, 
physician, and nurse. Her improvement again was so very satis- 
factory that by April i, 1903, her friends instructed me to send 
her to St Louis to visit relatives. While there she seemed to 



176 MYSOPHOBIA, WITH REPORT OF CASE. 

get along very well for a few weeks, but relapsed into her old 
state, and finally became so troublesome that she was legally 
adjudged insane and sent to the State Hospital for the Insane 
at Topeka, Kansas, where she remained for several months, but 
finally was discharged improved. A few days ago I wrote her 
friends to enquire after her present welfare and they reported 
as follows : 

" I consider L's condition much the same as when she left jrou. 
I don't think she is any worse, but she is certainly no better, 

''The same idea of contamination seems to haunt her. She 
never leaves the house even for a drive, and seldom meets any 
one who calls, for fear of being contaminated." 

In analyzing this case I think we can all readily agree with Dr. 
Dewey, when he states in his able paper on " The dividing line 
between the neuroses and psychoses," that so far as prevalent 
views are concerned, if there be a dividing line between the 
neuroses and psychoses, insanity exists on both sides of this line, 
hence the term neurasthenia, or nervous prostration, is often a 
polite misnomer for insanity. 

" Dana " has also recently emphasized the close relation which 
exists between the various neuroses and psychoses in his paper, 
entitled " The passing of Neurasthenia." To use his own language 
he says : " It is my contention that a large number of the so- 
called neurasthenias and all the hysterias should be classed as 
prodromal stages, abortive types or shadowy imitations of the 
great psychoses," " for in these cases it is the morbid mind that 
dominates the situation, not a weak eye muscle or a poor stomach ; 
a heavy womb, uric acid, arterial sclerosis, or even an exhausted 
motor nerve." 

" They are not often, to be sure, pure psychoses, for the body is 
also at fault, but the psyche is in main control and it gives the 
stamp to the clinical syndrone, directs the prognosis, and most 
acutely solicitates the treatment." 

The practical clinical value and significance of the attitude 
thus assumed by Dr. Dana cannot fail to appeal to all of us, while 
his claims are amply sustained and justified by my own college 
and hospital clinical experience, as well as by the case record of 
those admitted to my sanitarium. It is the rarest exception in 



JOHN PUNTON. 177 

our admission to find a pure unadulterated case of neurasthenia 
or hysteria, although so diagnosticated by the family physician. 

The vast majority, however, said to be suffering from these 
nervous affections, when admitted, are, upon strict examination, 
found to be afflicted with a true psycho-neurosis, which we some- 
times designate as psychasthenia, or which perhaps could more 
properly be termed psychosomatasthenia. 

While the so-called neurasthenias and hysterias may not con- 
form to the legal test of insanity, yet it is clear that the large 
majority of persons so diagnosticated are not endowed with 
normal minds, and that their maladies or sufferings are largely 
due to the mismanagement of their mental faculties, rather than 
their bodies, hence the morbid mentalization constitutes the chief 
paihological element of their ailment. 

We recognize, however, that associated with the psychical mani- 
festations of these conditions there are also found gross f tmctional 
and even occasionally serious organic somatic changes, requir- 
ing possibly at times surgical interference for their relief. Yet 
we contend that even when these purely local bodily complica- 
tions have been fully met, they often fail to relieve, much less 
cure, the mental agony of the patient. 

This would therefore indicate that in these morbid patho- 
phobic states we are dealing essentially and primarily with a 
true psychosis, and in order to treat them successfully we must 
of necessity apply the same rules or principles as those which 
belong to any other form of incipient insanity. Failure, however, 
to recognize the expediency of such stringent measures is largely 
the responsible agent for much of our present inability to cure 
such ailments. This discrepancy, therefore, forms the very climax 
of my theme, for if there be one principle more than another that 
has been universally endorsed and emphasized by you for the 
past quarter of a century in your medical reports, and to my 
mind justly so, it is the fact that insanity is more curable in its 
incipiency than at any other time. The longer its duration with- 
out appropriate treatment therefore the less the chance of recov- 
ery. Every alienist and neurologist responds to the logic of 
this dictum, for its truth is so very sensible and correct that it 
can readily be demonstrated by actual practical clinical experi- 
ence, and although hampered at times with the baleful influence 

12 



178 MYSOPHOBIA, WITH REPORT OF CASE. 

of a tainted heredity, yet it is the crowning glory of modem 
medical science to possess the means of overcoming even this 
great congenital bugaboo. 

If our united experience warrants the assertion that insanity 
in its incipiency is extremely curable, why allow it to become 
incurable before applying the legitimate means and measures 
that favor its cure? 

We are all, however, compelled to admit that the practical 
application of the great law of prevention, as related to so-called 
neurasthenia, hysteria, and allied states, is a very difficult one, 
even in spite of our united favorable opinion of their incipient 
curability. 

Herein, however, lies, in my judgment, our special responsi- 
bility to the medical profession, for as alienists, neurologists, and 
psychiatrists we must of necessity continue to sound the alarm, in 
the consciousness of our own undoubted favorable clinical evi- 
dence of such conditions yielding to early appropriate treatment, 
and in the presence of such universal mental and physical wreck- 
age and distress which results from error or neglect of its judi- 
cious adoption. 

While the morbid psychological manifestations in the case 
reported was present as early as the 14th year, yet practically 
nothing of a tangible therapeutical character was done for their 
relief until the 25th year, at which time their chronic fixity ren- 
dered the prognosis most unfavorable. It is, however, only rea- 
sonable to infer that had all the resources of modem medical 
science been brought into requisition early, and the principles 
which apply to the treatment of incipient insanity been rigidly 
enforced, the possibility of a cure would have been greatly en- 
hanced. 

If the present percentage of recoveries of insanity does not 
exceed thirty per cent, and there is universal agreement that the 
rate of recoveries could be raised, according to different authori- 
ties, from seventy-five to ninety per cent, provided all the re- 
sources of modem medical science were duly applied in their 
incipiency, it would seem our imperative duty to demand such 
legal and medical reforms as are necessary to meet this desirable 
exigency. 

" Kirchoff " has clearly shown that certain insanities, such as 



JOHN PUNTON. 179 

melancholia, mania, paranoia, and general paresis, may all de- 
velop upon a neurasthenic basis. While " Chapin," in his work 
on insanity, declares that "the larger proportion of admissions 
to the Pennsylvania Hospital received in an acute stage of insan- 
ity gives a history of neurasthenia." He therefore fitly styles it 
** the soil out of which insanity develops." 

That there is, however, a marked difference between true neu- 
rasthenia and insanity all will agree, but at present the differen- 
tiation of the various psychological manifestations which com- 
plicate neurasthenia and their separation into independent morbid 
entities are as yet not well defined, but it is safe to assume that 
the most important clinical sign of neurasthenia developing into 
true mental disorder is the manner in which the feelings, thoughts, 
and actions of the individual absorb his entire attention. This 
self-consciousness or morbid introspection is a marked feature of 
the more serious aspects of neurasthenia, and simply betrays the 
serious invasion of the higher mental faculties in the progress of 
the malady. Moreover, this asthenic neurotic weakness makes 
the patient vulnerable to morbid impressions of the Ego, which 
are usually expressed, clinically, in the form of anxiety, distrust, or 
suspicion. These morbid concepts have been variously desig- 
nated by different authors, as obsessions, besetments, impulsions, 
and fixed ideas, but clinically they are expressed either in the 
form of doubts, fears, or impulsive acts, which irresistibly force 
themselves upon the individual, dominating his every thought, 
word, and deed. In a limited degree they are commonly present 
in health, indeed very few of us escape the presence of doubts, 
fears, or impulses, as isolated sudden thoughts, but these are 
usually subject to the dominating power of inhibition. When 
they appear, however, as a complication of neurasthenia they 
often get beyond the control of the will and may therefore con- 
stitute the chief factor of a progressive insanity. Moreover, 
they are ably shown by " Regis " to be due to lesions of the will, 
or the offspring of a morbid heredity, hence there can be little 
doubt that certain crimes are due to such obsessions, impulsions, 
and nosophobic impulses, which may suddenly arise in the mind 
of those who are not ordinarily regarded as insane, but whose 
responsibility should always be duly considered. While the mor- 
bid fears present themselves clinically in every degree of inten- 



A CASE OF HUNTINGDON'S CHOREA. 

By harry W. miller, M.B. (Tor.), 
Pathologist and Assistant Physician, Taunton, Mass,, Insane Hospital 

The following case of chronic progressive chorea occurred in 
a family in which at least ten other members have already shown 
unmistakable evidence of the disease; three of whom have been 
patients in the Taunton Insane Hospital. 

The history of the individual members of this choreic family 
furnishes an interesting study on heredity and is of importance 
for a comprehension of the degenerative process associated with 
the disease. I have carefully investigated the life history of all 
the descendants of the one who is considered the choreic archetype 
of this group. One member has previously been reported by Dr. 
Frank Hallock in a paper read before the American Neurological 
Society in 1898. His case as well as mine is of rather special 
interest, as they both came under observation at a comparatively 
early stage of the process. 

Family history. — Paternal great-great-grandfather of the pa- 
tient was considered a robust normal man and died at the age 
of ICO. Reliable information can only be obtained regarding 
one of his children. I shall first briefly stunmarize the history 
of those who developed chorea and then refer to the mental and 
nervous peculiarities of the other members. 

The paternal great-grandfather of the patient, bom in Massa- 
chusetts, was considered a peculiar, irritable, eccentric man with 
an ungovernable temper, his eccentricities increasing in adult 
life. He died at the age of 68. Whether he had choreiform 
movements has not been positively ascertained. His descendants 
all report him as a very nervous man. He had eleven children 
and in only one of these (Case I), the fourth in order of birth, 
did the disease appear. Of the other ten children one inherited 
some of the father's neurotic traits, one died an accidental death 
in early infancy, the others were all regarded as normal and all 



184 A CASE OF Huntingdon's chorea. 

reached the age of 60. The history of the descendants of these 
collateral branches, the records of the majority of which I have 
investigated, is of negative value as far as chorea is concerned, 
nor is there any undue preponderance of mental or nervous dis- 
ease. These facts would seem to cast doubt upon the possibility 
of the existence of such a grave hereditary disease as Himting- 
don's chorea in their ancestry. 

In the original maternal line there is nothing of importance 
beyond the fact that the mother, the paternal grandmotiier, and 
paternal great-grandmother were all of healthy stock. 

Case I. — Paternal grandfather of the patient An excessive 
drinker; endowed with the mental traits of his father; onset of 
choreiform movements at the age of 47; never committed to an 
institution; developed the typical motor symptoms with mental 
deterioration of the characteristic kind. He died at 62. 

Case II. — Father of the patient. Excessive drinker. Had the 
same mental peculiarities as his father, namely, irritable, unrea- 
sonable, and quick tempered. These characteristics became accen- 
tuated before the onset of choreiform movements at 45. He 
showed gradual mental deterioration with increase of the invol- 
untary movements. Committed to the Taunton Insane Hospital 
in 1880, nine years after the onset of the motor disturbance. At 
that time much demented and with profound general movements. 
Death followed from exhaustion within two months of the date 
of admission. 

Case III. — Paternal uncle of the patient. Excessive drinker. 
Motor onset at 40. Mental stigmata of the disease prior to the 
onset of the choreiform movements. Admitted to the Taunton 
Insane Hospital in February, 1882, nine years after the onset 
On entrance he showed extensive involuntary movements 
throughout the body, characteristic speech. He was violent, abu- 
sive, imtidy in habits, with marked dementia. Death followed at 
50 years of age from exhaustion. 

Case IV. — Paternal aimt of the patient. Indications of the 
onset of the disease shown first by mental symptoms, chiefly delu- 
sions of persecution, increasing irritability, and "nervousness." 
Onset of choreiform movements at 50. Committed to the Taun- 
ton Insane Hospital in January, 1886, four years after the onset 
At that time she showed general gross choreiform movements 



HARRY W. MILLER. 185 

with characteristic speech and walk, persecutory delusions, mem- 
ory defect, dulness of comprehension, lack of insight. The dis- 
ease ran a gradual progressive course with increasing memory 
defect, childishness, and other symptoms of deterioration. Death 
in 1892, after a course of ten years, due to exhaustion and chronic 
diarrhoea. 

Case V. — Patient's sister. Has never been committed to an 
institution ; always of an irritable disposition, unreasonable, peev- 
ish, and selfish. Since the birth of her first child, 26 years ago, 
she has shown an accentuation of these symptoms and has been 
incapable of taking care of her home. Onset of muscular twitch- 
ings four or five years ago. At the present time she is in a more 
advanced stage than her brother — ^the patient — the movements 
are more extensive and the mental s3rmptoms more marked. She 
has not, however, shown the violent outbreaks which necessitated 
the patient's commitment. She can do no useful work around her 
home and it is only through the shrewd management of her 
mother, who has nursed three generations of choreics, that she 
is tolerated at home. 

Case VI.— The patient. {Vide infra,) 

Case VII. — ^Paternal cousin of patient. Daughter of IV. She 
died when 38 years old of puerperal eclampsia. For more than 
two years previous to that time she had shown mental symptoms 
with choreiform movements. Mental symptoms first noted. 

Case VIII. — Paternal cousin of patient. Daughter of IV. 
Died at age of 43. Onset of mental s)rmptoms five years before 
decided choreiform movements. Dr. Hallock's patient. 

Case IX. — Paternal cousin of patient. Daughter of IV. For 
years has been " ailii^," calls herself " nervous." Is very sensi- 
tive and has grown progressively more nervous and incapable in 
recent years. Refuses to be interviewed. Is reported as now 
showing motor symptoms. 

Case X. — Paternal cousin of patient. Son of V. Killed by 
accident due to incoordination of the disease when 36 years old. 
Mental symptoms present. Duratic^i of motor S3rmptoms two 
years. Duration of mental s3rmptoms unknown. 

Case XI. — Paternal cousin of patient. Committed suicide at 
43. At that time had well-defined motor and psychic symptoms. 
Mental symptoms noted for some time previous to the onset of 



i86 



A CASE OP Huntingdon's chorea. 



the choreiform movements. His mental peculiarities were such 
that his wife left him, and to this and his appreciation of his 
condition his suicide is attributed. 



g^bJUUOUl! 




Tht 9hoyt n)cn\bcrs I have indicated on the chart by double 
bold line*. 



HARRY W. MILLER. 187 

We have still to consider 17 descendants of Case I. In the 
first generation two did not have Huntingdon's chorea. A is 
72 years old, has no, children, is considered nervous. B died at 
the age of 60 of Bright's disease. She never had any choreiform 
movements, but had delusions of infidelity, was eccentric in other 
ways, but was never committed as insane. She was considered 
by the family to have mental symptoms similar to those observed 
in her sister (Case IV) during the early stage of her disease. 
C, D, E, G, and H all died in early infancy. F is over 4a 
years of age, is thought to be normal. He is divorced from his 
second wife, has no children. 

In the last generation are nine children. The oldest, I, twenty- 
six ; married at twenty ; has no children. Her husband recently 
left her without giving reasons. It is said that she is very irri- 
table, obstinate, in fact very similar to her mother of twenty years 
ago. No involimtary movements yet noted. 

Except K and O the other children have all shown neurotic 
tendencies. 

History of patient. — Male, born July 19, 1862, American by 
birth. During his mother's pregnancy the grandfather, then with 
a well-developed chorea, was living in the family. Patient was 
always stubborn and self-willed ; was an ordinary pupil in school, 
and did not complete his grammar school course. No previous 
serious illness. A moderate drinker, but an excessive tobacco 
chewer. For nine years previous to admission was a fireman in 
a city fire department; for the past four years captain at his 
station. He was married in 1888 ; had no venereal disease ; has 
three children, a boy fourteen, a girl twelve, and a boy two and a 
half years ; no miscarriages. 

The onset of the disease is difficult to define. The mental 
abnormalities antedate by five or six years the onset of the mus- 
cular twitchings, and consisted of marked irritability, outbreaks 
of anger, seclusiveness, indifference to the important affairs of 
life, and an increasing forgetfulness. No actual delusions or 
sensory hallucinations were noted. Suicidal tendency never sus- 
pected. 

As early as 1895 peculiar irregular involuntary movements 
were noticed, chiefly in the fingers, but sometimes the whole hand 



i88 A CASE OF Huntingdon's chorea. 

twitched and rarely the forearm was moved. These movements 
were infrequent, and were scarcely observed except by his wife- 
In 1900 the involuntary movements were first noticed in the 
muscles of expression. Later the legs became involved, and 
from that time the movements gradually increased until they 
have reached the stage I have described below. 

His irritability became accentuated, his outbreaks of anger 
more frequent, so that on account of his cruelty and brutality to 
his wife and children, who frequently had cause to fear for their 
lives, he became a terror to his household. Although out of sym- 
pathy his associates in the fire department overlooked his eccen- 
tricities; he was with them not so aggressive. He has lost in 
weight twenty pounds during the past year. His sleep for years 
has been poor. The movements ceased during sleep. He was 
committed November 30, 1904, on account of his destructiveness 
and his violence to his wife and children. 

Physical examination, — He is 5 feet 8 inches in height ; weighs 
147 pounds. Forehead low ; skull somewhat small ; no other stig- 
mata of degeneration. There is some arteriosclerosis. With the 
exception of a slight displacement of the heart to the right there 
is nothing abnormal outside of the nervous system. There is no 
disturbance of sensation. Pupils regular, equal, react to light 
and accommodation; knee-jerks exaggerated; very sharp elbow 
and tendo- Achilles reflex; skin reflexes all very sharp; organic 
reflexes normal. His face, when in repose, is rather dull, but this 
effect may be increased by a heavy drooping mustache. The 
most common facial movement is produced by a contraction of 
the frontalis muscle and a drawing back of the angles of the 
mouth, causing a peculiar quizzical, grinning grimace. He also 
smiles broadly involuntarily. Another peculiar movement of the 
face is a partial opening of the mouth, which is held so for two 
or three seconds, accompanied by a slight elevation of the brow, 
giving him a somewhat questioning look. He can control mo- 
tions voluntarily for a short time. He sat for one minute with 
his hands on his knees and his legs apart, and the only move- 
ments were a few slight excursions of the individual fingers and 
the thumb, which showed a greater movement than the fingers. 
The right thumb moved five different times in sixty seconds. 
There were also a few twitchings of the zygomatid and once a 



HARRY W. MILLER. 189 

slight twisting back of the head. His legs did not move except 
for two adductor movements. 

Sitting at ease without any special voluntary control his head 
is jerked back frequently, probably not more than an inch; his 
fingers move individually and collectively, but there is very little 
movement in the leg, and there it is chiefly a slight adduction 
with an occasional flexing of the foot. During conversation his 
movements are a little more extensive but by no means constant 
In walking, the movements in the arms and legs are increased; 
he holds his arms out from the body, his hands pronate and 
supinate irregularly, and his walk is of a peculiar kind of a 
swagger with a little reeling, as if partially drunk, his legs a 
little more apart than normal. His steps are about equal in 
length with some hesitation between each step. He lifts his heels 
well but comes down heavily on the whole foot. His walk is 
even more staggering when not under examination. He sways 
when standing with his heels together and was very unsteady 
with his eyes closed. There is no gross diminution of the gen- 
eral physical strength. He puts his tongue out without asso- 
ciated facial movements, but it rolls from side to side, and, while 
he is able to keep it out, it is in constant motion. There are no 
involuntary movements of the palate muscles. In holding the 
arms out at right angles to the body there are no greater move- 
ments than when they are in an easy position, except when his 
attention is taken from them when they are increased. There is 
sometimes a slight localized movement in some of the smaller 
facial muscles. 

The movement is more marked in the hands and face than 
elsewhere. Occasionally when sitting at ease his whole hand 
is flexed, pronated, or supinated, but this is rare. 

His speech is a little thick, like the speech of one partially 
drunk, but there is also an occasional halting before pronouncing 
certain words, and many words are indistinctly articulated. He 
recognizes this defect, and says that when he is observed this 
difficulty is more marked. His eye muscles are not involved. 
The trunk muscles show only occasional slight twitchings. There 
is the characteristic absence of fatigue. 

The handwriting, as shown by the specimen, reveals a little 



igo A CASE OF Huntingdon's chorea. 

tremor and an irregularity, also a carelessness in copying accur- 
ately, which is probably due to the attention disturbance. 

Mental symptoms. — On the psychic side we have the charac- 
teristic s)rmptoms in a mild form which go to make up the de- 
mentia intimately associated with the disease. Apart from the 
choreiform movements, one detects in his general attitude and 
manner, on superficial examination, very little abnormal. He is 
always neat and orderly; at times occupies himself in natural 
ways, such as reading, playing cards, and checkers, yet he is 
seclusive and prefers to remain alone, explaining that he thus 
feels less embarrassed. He has several times shown irritability 
without sufficient justification, though with the physicians he can 
always control himself. His orientation while not grossly dis- 
turbed is not normal. The defect seems explicable on the ground 
of a disturbance of the attention which was demonstrated experi- 
mentally. He is rather dull emotionally and has a general air of 
indifference. He grasps his surroundings in a superficial way, 
and although he has spoken of the nature of his disease and 
superficially comprehends its seriousness, he has shown no feeling 
of affect. He does not believe that he is mentally diseased and 
considers that he is just as capable of attending to his work as 
he ever was, though he will admit his increased irritability and 
his failing memory. There are no sensory hallucinations, per- 
secutory ideas, or other delusions. 

The most prominent symptoms of his mental inefficiency are, 
the forgetfulness, the superficial range of thought, the loss of 
the earlier school knowledge, and the defective judgment. 

His memory weakness is shown in many ways and involves 
both recent and remote impressions ; the immediate memory being 
more affected. In testing his ability for registering and repro- 
ducing memory impressions as ascertained by the giving of letters, 
numbers, and words, it is found that without intervening conver- 
sation he retained the impressions for intervals of one and two 
minutes, whereas with intervening conversation, even after 15 
and 20 seconds, his reproduction was very faulty. 

His range of thought is of quite an elementary nature; this 
has been recently commented upon by his relatives. He seldom 
takes the initiative in conversation, but it cannot be said that his 
voluntary production is incoherent or silly. 



HARRY W. MILLER. I9I 

His intelligence defect is demonstrable in the usual manner. 
He cannot give the capital of Massachuetts, nor of the United 
States ; cannot name any of the wars in which this country has 
been involved, and only recalls one previous president. In calcu- 
lations he makes numerous mistakes even with simple numbers. 

During his four months' residence in the hospital neither his 
mental or motor condition has undergone any striking altera- 
tion. 

To stunmarize briefly: We have from a choreic ancestor 
twenty-seven descendants. In the first generation three out of 
five were choreic, one had a psychosis, and the other is nervous. 
In the second generation seven out of thirteen were choreic, five 
died in early infancy, and one is supposed to be normal. In the 
third generation none have reached the age at which this form of 
chorea manifests itself, but seven out of the nine are neurotic. 

The defective hereditary endowment is well demonstrated in 
those members who fortunately escaped the disease. We find 
in these eleven cases of Huntingdon's chorea the classical triad 
of symptoms. 

(a) The uninterrupted heredity. 

(b) The associated insanity. 

(c) The manifestation of the disease only in adult life. 

The history of the family throws light upon a disputed point in 
the development of Huntingdon's chorea, namely, whether the 
mental symtoms or the motor phenomena first appear. In every 
member in whom the disease has appeared, where we have accur- 
ate information, the mental breakdown was clearly manifested 
before the onset of the choreic symptoms. The mental insta- 
bility is present in by far the greater majority of those who did 
not develop choreiform movements. Hallock draws particular 
attention to this point and considers that in the majority of cases 
distinct changes in the mental condition would be found at the 
time of onset if the mental side was thoroughly investigated. 
Rossi goes so far as to argue that the true coefficiency of the 
disease is the mental invalidity and not the chorea. 

This subject leads to the very practical sociological question 
of the part the medical profession should play in controlling by 
personal influence and legislation the marriage of individuals 
whose progeny will most assuredly show this morbid inheritance. 



192 A CASE OF HUNTINGDON S CHOREA. 

Here we have one of the few homeomorphic hereditary diseases 
whose influence on heredity is not theoretical. Preventive meas- 
ures ought at least to be attempted. If there was a more wide- 
spread recognition of the hereditary tendencies of such diseases 
as this among physicians there might be some hope of its extermi- 
nation, though unfortunately some cases do originate de novo. 

DISCUSSION. 

Dk. a. W. Hurd. — I think this paper is extremely valuable, not only 
from a medical but a sociological point of view. It teaches one lesson, 
viz., that we should make a very careful study of our admissions with 
regard to the history of nervous and mental diseases. The two arc very 
closely allied. If the State could have stepped in at number two or three 
on that chart and put a stop to propagation of the race you will see that 
twenty-seven individuals would have been cut off from the world, and of 
this number, two only were normal, five died in infancy, and the others 
have shown abnormal traits, such as chorea, insanity, suicide, etc 

A case occurred near Buffalo as follows: 

A young girl, employed as a nurse girl, whose sanity had never been 
questioned, while out one day with the children, without previous irri- 
tation threw both the children off a railroad bridge; one was killed, the 
other survived though badly injured. The purposelessness of the act 
caused a study of this girl's previous history, and it was then discovered 
that we had in the hospital the patient's aunt and two cousins. Dr. 
Krauss made an exhaustive study of the antecedents of this girl, who later 
became a patient in the hospital, and found no less than thirteen relatives 
out of twenty-five, of whom positive knowledge could be obtained, mentally 
deranged. 

The case was reported in the Journal of Nervous and Mental Diseases 
in 1891. Within a few months another cousin has been admitted as a 
patient to the hospital. 

This is but another illustration of the value and timeliness of Dr. Miller's 
paper, and it is to be hoped that sometime when we have collected a suffi- 
cient number of cases, we can take some action as an association, defining 
what should be the attitude of the State in this important matter. 

Dr. Punton. — Dr. Miller deserves credit for the careful manner in which 
he has studied this case. It illustrates the trend of modem science, which 
is toward preventive treatment rather than curative. When we have a 
case of this kind and learn that some prior member of the family has 
been afflicted, it ought to put us on our guard and make us doubly watchful 
for its occurrence in other members of the same family, and the taking 
of steps looking to its prevention in such persons is imperative. 

Dr. C. G. Hnx. — I would like to express my appreciation of the valuable 
paper of Dr. Miller, I cannot indorse, however, Dr. Kurd's extreme views 



HARRY W. MILLER. I93 

in regard to the making of laws restricting marriage. It would be very 
difficult to find one at the present day who is entirely free from any heredi- 
tary neurosis or psychosis, and if such laws were rigidly enforced the 
world would present the spectacle of a certain asylum town that was de- 
scribed as consisting of 300 lazy watching 600 crazy. There are unseen 
agencies of great potency that control the human race and contribute to 
its preservation and protection in peculiar but effective ways. They ac- 
complish results better than we could by meddlesome and short-sighted 
methods. One of the chief ways of accomplishing this is by shutting o£F 
the capacity for reproduction which affords an effective barrier to any 
further continuation of a diseased or degenerate family. 

This applies not only to insanity but to genius, its twin brother. The 
tendency in all faulty organizations is to die out and become extinct 

A tourist on his first visit to the Tower of London, on having pointed 
out to him the scenes of the many bloody executions that had taken place 
there in past centuries remarked, "if they had only left them alone they 
would have all been dead long ago without the trouble of their execution/' 
and we might say the same of neurotic and degenerate families, they will 
all die in good time if left alone. 

Dr. Henry M. Hurd. — It would be gratifying to adopt this cheerful view 
if we could, but look at the facts. Among these twenty-seven individuals, 
there was but one single normal individual who lived to maturity. 

Dr. Miller. — In closing I wish to impress especially the fact that here 
we have a disease which is homoeomorphous. Without entering into a 
discussion on the broad subject of heredity we all know that there are 
a great many forms of insanity which beget other forms, and also forms 
which may be considered as almost harmless, but in this particular disease 
we can say almost with certainty that the offspring are going to show in 
one way or another the defective heredity. If the children reach adult 
age, some of them we can say almost positively will develop the disease. 
I am not an extremist in legislation on this point, and it is far from me 
to suggest that the legislation spoken of in my paper should apply to all 
forms of insanity. Among the greatest geniuses in this country are many 
neurotics, and it has been asked if it was not feasible to breed for genius. 
I do not see that this would justify the perpetuation of neurotics. 

In this particular disease we have an altogether different question. The 
physician who had charge of this patient knew very little about Hunting- 
don's chorea. The patient has had three children. The wife knew nothing 
of the hereditary taint in the family when she married him, but since his 
detention in the hospital the fact has been presented to her that the chil- 
dren may inherit the disease, and I have been unable to comfort her with 
the thought that they were free from taint 

I presented this patient before a local clinical society for discussion, and 
none of the general practitioners in that society knew anything about 

13 



194 A CASE OF Huntingdon's chorea. 

Huntingdon's chor«a, in fact several had never heard of it I think it is 
our duty to bring such cases before general practitioners, otherwise how 
are they going to learn about the disease. It was because I was so im- 
pressed with this state of affairs that I brought this subject up for dis- 
cussion before this association. 



KORSAKOFF'S PSYCHOSIS— REPORT OF CASES/ 

By ARTHUR W. KURD, A. M.. M. D., 
Superintendent Buffalo State Hospital, Buffalo, N. Y. 

Several articles have appeared within the last few years de- 
voted to Korsakoff's " Psychosis " or Korsakoff's " Sjmdrome/' 
but of these only a small proportion have appeared in English 
journals. The question as to whether it is a disease entity or a 
symptom complex common to several different conditions has 
been under discussion and seems not yet to be settled. Additions 
and contributions to our knowledge on these points are still much 
to be desired, and it is with the hope of adding, even though 
slightly, to our knowledge of this condition that I present these 
five cases. 

In the bibliography following the excellent article on Korsa- 
koflF's " Psychosis," by Harry W. Miller, pathologist and assistant 
physician at the Taunton Insane Hospital, which appeared in the 
American Journal of Insanity for January, 1904, and to which I 
here acknowledge indebtedness, there are twenty-two articles re- 
ferred to ; of these there are but five in English. In the article in 
*' Brain," published in the autumn of 1902, by Sidney John Cole, 
entitled "On Changes in the Central Nervous System in the 
Neurotic Disorders of Chronic Alcoholism," there are in the 
bibliography thirty-eight articles referred to, of which but four- 
teen are in English, and many of these are devoted to multiple 
neuritis. Korsakoff published his first article in 1887 and char- 
acterized the disease as a polyneuritic psychosis, and suggested 
the name " Cerebropathica psychica toxemica," as a more fitting 
designation in view of the fact that the neuritic phenomena might 
not be prominent. A number of observers took issue with him 
in his view that the disease was a clinical entity and insisted that 
it was a clinical picture which might accompany other diseases, 
and that it was not individual and characteristic. 

^Read by Dr. A. W. Hurd, at the Annual Meeting of the American 
Medico-Psychological Association in San Antonio, Texas, April, 1905. 



196 Korsakoff's psychosis. 

In the mental field the most prominent symptCMns are memory 
weakness, persistent inability to retain impressions, loss of orien- 
tation, and falsifications of memory. That it is a toxic condition 
seems to be conceded ; that it may be a toxic condition operating 
upon the central or peripheral nervous system, or both, also seems 
established. Whether the toxaemia is the result of direct poison- 
ing, or is autotoxic, developed on the field prepared for it by other 
poisons, is open to consideration. That alcohol is by far the 
most frequent toxic agent is evident from a study of the recorded 
cases, but that other causes may be efficient would appear from a 
small ntimber of cases in which it seemed to follow typhoid fever, 
lead poisoning, arsenic, tuberculosis, and leukaemia. 

The clinical symptoms in the cases here presented, give, I think, 
a fairly definite mental picture of the condition, and it may recall 
to the minds of my hearers similar cases coming within their 
observation. 

Onset and Course. 

The symptoms may directly follow an acute intoxication, with 
delirium tremens, the symptoms of the latter persisting in a 
milder form with disorientation, fabrications of memory, occupa- 
tion delirium, memory weakness with or without evidences of 
polyneuritis. In some the long-continued delirium with some 
febrile reaction may suggest an acute encephalitis. Other cases 
may present first symptoms of neuritis with mental confusion and 
memory weakness coming afterwards. Others again, without 
evidences of an acute toxaemia, may develop mental symptoms 
first, to be followed by neuritic symptoms later, and some even 
have been reported as having the disease ushered in by symptoms 
of a toxaemia with even epileptiform convulsions, or an apparent 
apoplectic attack. The disease runs a comparatively long course 
if the patient does not, as is possible, die from the violence of the 
toxaemia in the initial delirium. The neuritis may run a course 
of weeks and months with recovery both mental and physical, as 
in two of our cases. Others pass through a long course of mental 
enfeeblement, delirium, and confusion, with pain, paralysis, and 
trophic ulcers, gradually to improve and even recover from the 
neuritis, but leaving a degree of dementia, weakness of memory, 
and confusion, which becomes a chronic condition. 



ARTHUR W. HURD. 197 

The abstracts of the histories of the following cases have been 
prepared for me by Dr. Henry P. Frost, first assistant physician, 
Buffalo State Hospital. 

Case No. i. — Man ; aged 71 ; widower ; occupation, brickmaker ; 
nativity, England. Admitted January 5, 1905. Said to have had 
locomotor ataxia for ten or twelve years ; pneumonia in 1901 and 
1903, and chronic dysentery since the Civil War. Contracted 
syphilis in early life. Married in 1863 ; wife bore no living chil- 
dren but four were still-bom. Has taken a wine-glass of whiskey 
before meals for years ; became intoxicated occasionally. Drank 
more than usual last fall after the death of his wife, and his 
present mental s)rmptoms date from that time. 

In the commitment paper it is stated his mind seems to be a 
complete blank, is wandering and disconnected in conversation, 
easily confused ; imagined that his nurse was his wife, also that 
his wife was in the next bed to him in the General Hospital. He 
looks for his revolver under his pillow, etc. 

On admission and during his stay (three months), he was quiet, 
tractable, pleasant in his manner, able to understand his surround- 
ings perfectly and to give a correct account of the remote past 
but with complete amnesia for everything recent. Constant fabu- 
lation ; would give a detailed account of what he had done the day 
before, often relating adventures, such as street fights, in which 
he punished his assailants. He invariably stated that he "came 
here this morning" and that he walked all the way. Admitted 
that he did not feel very well and excused it on the ground that 
he had been on a " little spree " the night before. Aside from 
these symptoms his mind was clear and his intelligence unim- 
paired. No hallucinations at any time while under observation. 

Physical Examination. — Patient emaciated ; in poor physical con- 
dition ; weak, requiring assistance in walking ; complaint of head- 
ache, dizziness, shooting pains in limbs, stomach, and chest ; numb- 
ness in all of the extremities ; prickling feeling in hip and spine 
and running down the legs. 

Eyes. — Pupils normal ; no strabismus. Nystagmus in extreme 
lateral positions, and also when the eyes are turned upward. 
Vision poor. 

Hearing, smell, and taste, all a little defective. 



198 Korsakoff's psychosis. 

Cutaneous sensibility, — Slight defect of tactile sense in legs 
and feet ; hyperaesthesia to painful impressions ; temperature sense 
normal. Localization of touch good in upper extremities; poor 
in lower. Muscular sense defective in feet — patient could not 
tell which toe was manipulated by examiner. Co-ordination good 
in arms ; fair in legs. 

Deep Reflexes. — Present in left arm; absent in right. Knee- 
jerk and Achilles reflex absent in both legs. 

Superficial Reflexes. — Plantar and abdominal normal. Cremas- 
teric absent. 

Motor Functions. — General impairment of strength; most 
marked in extensors of feet. Foot drop on both sides. Steppage 
gait ; uncertain station. Tenderness of muscles and nerve trunks, 
especially in lower extremities. Atrophy of thenar group in both 
hands. 

Slight tremor in tongue, lips, and hands. Fibrillary twitching 
of atrophied muscles in hands. Sphincters normal. 

Patient was discharged three months later. Condition the same 
as on admission except improvement in general physical condition. 

Case No. 2. — Woman; admitted March 15, 1903; age 27; 
prostitute ; history of gross intemperance for a long time ; drank 
whiskey principally. Some signs of derangement two months be- 
fore, when she appeared stupid and spoke of things disappearing 
mysteriously when she really misplaced them herself. About that 
time, two epileptiform (?) seizures. A week before admission 
here she had delirium tremens. 

On admission patient showed a good deal of confusion ; was dis- 
oriented in time and place; could not give a correct account of 
the journey to the hospital. She had no recollection of having 
seen imaginary objects, etc. 

She complained of pain in the eyes and in her feet, which she 
said were frozen a few weeks ago. There was divergent strabis- 
mus; pupils normal; accelerated and feeble heart action; much 
gastric disturbance, vomiting everything ingested; acute inflam- 
mation of tongue and mucous membrane of mouth, tongue being 
swollen, red, and shiny. Temperature 100°. Pulse 108. 

During the first few days patient seemed to be free from halluci- 
nations. She recalled things she had imagined and recognized 



ARTHUR W. HURD. I99 

them as unreal. She recalled seeing animals and figures 'Mike 
statues'' ranged round a hall; also a woman in black and two 
men who seemed to be mesmerizing her mother ; a girl with snakes 
twined about her ; various animals scattered about, etc. She was 
fairly composed during the day but restless at night, sleeping very 
little, taking only milk and beef juice in small quantities, occa- 
sionally vomiting. Then for several days and nights she was 
more confused and excited ; thought there were various animals 
and objects in bed with her ; would sometimes strke at these and 
cry out angrily. Said that some animal had bitten her ; she saw 
and heard people in the room ; felt worms crawling on her body 
and saw them on the bed. 

Temperature 99® to loi**. Heart very weak; pulse 130 and 
over. 

March 22, 1093. — Denies hallucinations, but says when left 
alone she " imagines all sorts of foolish things " ; picks at the 
bed-clothing, sometimes twitches all over, complains much of pain 
in her feet and legs which are very sensitive when handled. 

March 27. — More pain in lower extremities; complains that 
some one is screwing her feet to the bed. She can flex the 
ankles very little and move the toes but feebly. Has foot-drop 
on both sides. She often starts out of a doze and twitches vio- 
lently. There is coarse tremor of the arms. Patient is com- 
pletely disoriented; mood happy — orders drink and talks to im- 
aginary companions ; mumbles unintelligible answers. Her atten- 
tion can be held for a few moments only. 

April 6. — Still completely lost; talks incoherently; mistakes 
people about her, and has no correct idea of time and place. She 
reaches for imaginary objects and goes through the motion of 
winding thread, tying knots, etc. Is placid and happy except 
when disturbed by pain ; often whispers softly and laughs. 

She is very helpless, cannot turn over or raise herself in bed. 
Pulse continues very rapid, usually about 140. She is troubled 
with a cough and has a bad diarrhoea. 

May JQ. — Patient fabulates freely — says she came here yester- 
day; was out for a walk to-day; has been out for a drive, etc. 
Physically she is better ; digestion improved. 

June 30. — Marked memory defect. Does not know whether 
she was here last week or not. 



200 KORSAKOFF S PSYCHOSIS. 

The mental symptoms gradually disappeared until in Septem- 
ber it is noted that there only remains a difiiculty in estimating 
the lapse of time. Steady gain in weight and strength, gradual 
disappearance of paralysis and pain in the legs ; treatment — ^mas- 
sage and Faradism. 

For a long time after reaching a normal mental condition patient 
remained lame and had some pain and paraesthesia in the feet 
At the end of one year from the date of her admission she had 
practically recovered, showing only a mild weakness of the ex- 
tensor muscles of the legs and slight stiffness of gait. Normal 
mental condition. Good insight. Discharged recovered. 

Case No. 3. — Mother of last case. Admitted August 11, 1903. 
Age 49 ; married. Has been addicted to morphine and was said 
to have been moderately intemperate in the use of liquor. (This 
was afterward positively denied. There was no gastric derange- 
ment so the statement about abuse of liquor may have been 
erroneous.) 

She is committed from a general hospital where she had been 
for two weeks, during which time she was hallucinated — saw 
animals, imagined her children were being murdered, said her 
husband had died and she wished to attend his funeral, said bats 
came from the the ceiling and flew in her face, etc. 

On Admission. — She is in poor physical condition, weight 
100 pounds. Many scars from h)rpodermics on both arms. Tem- 
perature normal. Pulse 84. Heart and lungs negative. Tongue 
clean and steady. Pupils unequal, sluggish reaction to light ; ex- 
ternal strabismus of right eye ; some drooping of both lids ; verti- 
cal nystagmus in both eyes when looking upward. Gait unsteady, 
swaying. No Romberg. Knee-jerks normal. Complaint of pain 
in feet. Left foot and calf tender. 

Mental Condition. — Patient was completely disoriented ; thought 
she was in the postoffice in Toronto. She called the physicians 
and nurses by the names of people whom she had known pre- 
viously. She spoke of her husband's funeral as going on. She 
had no recollection of being in the other hospital. She was 
drowsy and slept most of the first day. 

On the following day she was more excited and restless ; was 
annoyed by hallucinations of hearing— thought her children called 



ARTHUR W. HURD. 20I 

for help and that her brother had been killed. When directed to 
look at the blank wall or the bed clothes, she saw snakes and fish, 
a child, a woman's face, a yellow woman, a sideboard with imita- 
tion drawers, etc. Visual hallucinations elicited by light pressure 
on eyeballs also. 

Hallucinations and confabulation persisted for three weeks, and 
during this time it is noted that " she can be recalled to a knowl- 
edge of her surroundings but her mind immediately wanders; 
she forgets in a few moments what is told her, never remembers 
the doctor's name though told daily. She fumbles with the sheet ; 
says it is a white silk dress with a yellow spot. Mood sometimes 
cheerful but usually a depressed condition. Complains of pain in 
calves and feet, and numbness of fingers of right hand." 

After one month she was clear. The memory defect had dis- 
appeared; she recalled her distressing hallucinations and delu- 
sions; had good insight Convalescence was rapid and patient 
was discharged recovered after four months. 

Case No. 4. — ^Woman. Admitted December 6, 1904. Age 46 ; 
married ; no children. 

Family History. — One brother died of tuberculosis and was 
insane for three months before his death. Another brother is a 
drunkard. 

The patient has been drinking to excess for at least twelve 
years, and last summer she began to take morphine to make her 
sleep. 

Present trouble began three weeks ago with delusions and con- 
fusion and complaint of " stomach trouble." 

Statements in the commitment paper are: " She said she was 
out in the country having an awful time; that her husband was 
down the river; that she was cooking a turkey and going to a 
dance; that her mother and father (both dead) are here. She 
soliloquizes in a loud whisper and her face shows disturbance and 
anger. She gets out of bed at night and wanders around ; sees 
crowds of people coming and going. Mistakes her surroundings. 
She is confused as to the day of week and time of day. Thinks 
each day is Sunday and that she has been to mass. Says she was 
at a funeral day before yesterday and worked at home all day 
yesterday (both statements untrue)." 



202 KORSAKOFF S PSYCHOSIS. 

On Admission. — The patient was completely disoriented in time 
and place and could give no account of recent occurrences. She 
made many contradictory statements, forgetting in a few moments 
what she had said before. She was emotional and occasionally 
wept. 

Physical Examination. — Patient was in poor physical condition. 
Tongue and hands tremulous. Pupils unequal but with normal 
reaction to light and accommodation. Knee-jerks absent. Heart 
rapid and feeble. Pulse 120. No murmur. Slight bronchitis. 

Since admission there has been gradual physical improvement, 
but a good deal of indigestion and much complaint of rheumatism 
(pains in legs). Knee-jerks still absent. 

Patient is usually cheerful. She understands her present sur- 
roundings and has no hallucinations but many falsifications of 
memory. She will answer quickly and confidently but her state- 
ments are contradictory as at first. She continues to relate im- 
aginary happenings of yesterday or last week, etc., forgets the 
doctor's name from day to day. Her mental condition four 
months after admission seems stationary. 

Case No. 5. — Woman. A dressmaker (U. S.) ; divorced; age 
38; mother of two children. Intemperate in habits. 

Admitted June 18, 1901, with a history that she had had two 
previous attacks of mental excitement which were short in dura- 
tion and maniacal in character, from both of which she recovered. 

Present trouble began about three weeks before admission. It 
was characterized by a lack of interest in her surroundings and a 
restless, uneasy condition. She talked in a rambling, foolish way 
and made remarks something like the following : " I am deter- 
mined to know why people are crazy and in the asylum. I am 
investigating their conditions." She said she heard beautiful 
music, the sound of flowers and the spray of water. 

On Admission. — She was excited and in a playful mood; she 
seemed to be elated and rather pompous in her conduct, but at 
times became irritable and made insulting remarks to the attend- 
ants and physicians. She imagined much of the time that she was 
travelling on a train or steamer. She remained in this half-mani- 
acal condition until April, 1902, when she had a very severe cold 
and complained of much pain in her head. She was quite drowsy. 



ARTHUR W. HURD. 203 

Following this she had very severe headaches with much vomit- 
ing, and in consequence lost 20 pounds. After a few weeks she 
was somewhat improved physically but mentally much worse, be- 
ing more confused, restless, and talkative. Shortly after this 
she became quite delirious and remained so for a week, and later 
had a remission and seemed in about the condition she was on her 
admission. 

In July, 1902, she became suddenly ill again. She vomited 
much and was unable to retain liquids at all, but could retain solid 
food to some extent. She again complained of great pain in her 
head and eyes, and continued to get worse until, in November, 
1902, she was in a critical condition. Her pulse was very weak 
and irregular. She was very stuporous and could not be aroused. 
Pupils were unequal. She was constantly wet, not being able 
to retain urine at all. Bowels were constipated. 

When she came out of the stupor and improved a little phys- 
ically, she was very silly. Talked "baby talk"; mistook the 
identity of everybody, although occasionally she would address 
them by their correct names. She began to complain of queer 
sensations in her chest and knees. She said they felt cold and 
heavy, but there was no paralysis at that time. 

She was able to be out of bed in December, 1902, but at this 
time she was unable to walk or lift her legs at all. She did not 
complain of pain in her legs but there was a " feeling of numb- 
ness " and she had areas of anaesthesia on the outer side of both 
legs. The knee-jerks were abolished. 

In June, 1903, she was still unable to walk and there was con- 
siderable atrophy of the calf muscles. Mentally she was quite 
silly and childish, sometimes noisy, talking incessantly about 
events in her past life, some of which were real, but mostly fabri- 
cations ; for instance, when asked where she was, she said : " This 
is the State House in Buffalo and Cleveland — ^the Half-Way 
House, they call it. When we made the Pan-American, it brought 

the two cities together — ^in art and in every way My father 

is living out West; has several villas. They are up from the 
valleys and so they are villas." 

She could not tell the day. Says : " I am well taken care of. 
What do I care what day of the month it is? " 

To questions, she will elaborate at great length about her child- 



204 KORSAKOFF S PSYCHOSIS. 

hood and youth, romancing about her having been an actress and 
that she is constantly travelling, imagining that she is on a steamer 
or taking part in all sorts of theatrical productions, etc. 

She shows marked memory defect and cannot remember a 
number from one day to another, and when this is given her as a 
test she attempts to deceive the physician by scratching the num- 
ber in the varnish of the wood-work so that she can refer to it 
when asked again. 

At present she is able to walk a short distance, and shows no 
sensory disturbance. The knee-jerks are still abolished and there 
is a slight tenderness in the calf muscles. 

The appearance of neuritis so long after admission to hospital 
is worthy of note. 

In order to have a symptom complex assigned to the dig^ty 
of a disease entity, there are certain conditions which it seems 
should be met. First, there should be a fairly definite and con- 
stant etiology. Second, there should be a reasonably clear, defi- 
nite, and distinct clinical picture, which does not (more than is 
usual in medicine), overlap or appear in other disease conditions. 
Third, the pathological findings should be fairly consistent, char- 
acteristic, and distinct. As to the etiology, a study of the cases, 
it seems to me, indicates that the condition is clearly a toxic one, 
of which poisons alcohol is by all odds the most constant and 
frequent. As regards the condition, it also seems that the picture 
of " Chronic delirium tremens," as it has been called, loss of 
memory especially for recent events, fabrications of memory, 
inability to retain impressions, loss of orientation, with evidences 
of an acute infection, mental confusion, and frequent appearance 
of polyneuritis, constitute a fairly consistent and distinct picture, 
though it is admitted that some of these manifestations are also 
seen in senile and general paralysis. As regards the pathology, 
I must quote briefly from some of the studies post mortem, made 
by pathologists. First, I am indebted to Dr. F. Robertson Sims, 
from whose article entitled " Anatomical Findings in Two Cases 
of Korsakoff's Symptom-Complex," appearing in the March Jour- 
nal of Nervous and Mental Diseases (1905), I give the summaries 
of two cases : 

First. — " Slight arteriosclerosis. Hypostatic pneumonia. Fatty 



ARTHUR W. HURD. 20$ 

infiltration of the liver. Acute degenerations of many of the 
peripheral nerves. Axonal reaction in cells of the anterior horns, 
Clarke's columns, and many cranial nerve nuclei. D^enerations 
in the posterior columns, direct cerebellar tracts, and the root 
bundles. Moderate ' acute alteration ' of the cortical cells." 

Second. — ^''General arteriosclerosis involving the aorta and 
coronaries. Fatty degeneration of the heart, liver, and kidneys. 
Acute bronchitis. Acute degenerations in the peripheral nerves 
of the lower extremities, and also in the vagi. Axonal reaction 
in cells of the anterior comua, in Clarke's columns, some cranial 
nuclei, and the Betz cells of the cortex. 

"Vascular changes in the cord and cortex, with numerous 
microscopical hemorrhages throughout the cerebrum. Acute de- 
generation of the cortical radiati(Mis, and of both motor and 
sensory systems of the cord, as well as degenerations of the cord 
not easily reconcilable with the systemic changes." 

I would make use also of some of the work of Dr. Cole who 
has given, in the article on " Brain " before referred to, a detailed 
account of the findings (post mortem) in three cases— one acute, 
two chronic. In the two chronic cases fibrosis of tibials is found, 
vascular changes of nerves, and in one vascular changes in the 
cord. Changes in the cells of the anterior comua of the cord, 
and spinal ganglia; changes in the cells of the posterior comua, 
Qarke's columns, in the direct cerebellar tracts, in the cells of 
the cranial nerves, in the pyramidal tracts, of the Betz cells of the 
cortex, and in the frontal thalamic fibers. The findings, as will 
be seen, were much like those in the cases reported by Dr. Sims. 
The one acute case showed acute degenerations of the nerves, not 
found in the others, but taking into consideration the difference 
in duration, the findings were fairly similar. Of course, the 
number of cases is small, but it is significant that there is such a 
correspondence in the lesions of these five cases. 

In studying the fact that some lesions seem to be found in the 
peripheral nerves, and some in the central nervous system. Dr. 
Cole recognizes the difficulty of reconciling these differences, 
except on the theory that it is an entire neurone with its cells and 
fibers which are affected, and that in peripheral cases the disease, 
while a general one, may be manifested in the periphery of the 
nerve ; as in arteriosclerosis senile gangrene may be a manifes- 



^o6 Korsakoff's psychosis. 

tation of the disease far removed from the centers of circulation, 
without evident changes between. The possibility of sites of 
selection on the part of toxins is also pointed out, and reference 
IS made to such selective action as in the case of diphtheria where 
the poison seems to be manifest in the nerves presiding over de- 
glutition and respiration, and in lead poisoning where the toxine 
seems to be by preference manifested in the nerves supplying the 
extensors of the wrists, and in alcohol where the poison, if mani- 
fested in a peripheral neuritis, is usually seen in wrist- and foot- 
drop. Also pointing out that the previous view, that alcoholic 
neuritis consists in an inflammatory infection of the nerves only, 
is now rarely held. That it consists in a degeneraticm of the 
nerve fibers in spite of complete, or nearly complete, absence of 
changes of the sheathes, connective tissues and vessels. That, in 
fact, there are fewer vascular interstitial changes, the more severe 
the changes in d^eneration, thus showing that they cannot be the 
<:auses of the fiber degeneration. In other words, that fiber de- 
generation is the primary element of the neuritic process. 

In an article by Dr. Turner, in the Journal of Mental Science, 
he quotes Chotzin as saying that women are more susceptible 
than men, and that the recovery ratio is as one to thirty-eight in 
both sexes. SoukenhoflF and Boutenko found that in one hundred 
and ninety-two cases collected, one hundred and twelve were in 
men, and eighty in women, and that about seventy-five per cent 
were alcoholic in origin. In nine per cent, only, was multiple 
neuritis absent in the men. In about half of those not dying, 
mental defects persisted. Complete recovery was put down as 
occurring in about two per cent. In another series, fourteen 
women out of seventy-six recovered, or eighteen per cent, and 
twenty-one died, the rest showing more or less defect, and de- 
mentia persisting. Eleven out of fourteen recoveries were alco- 
holic cases. Of Turner's twelve cases, an analysis indicates that 
four recovered ; three were discharged recovered, but with some 
memory defect; three were not considered recovered but per- 
sisted with more or less marked mental defect, and two died. 

Our experience inclines us to believe that the low percentage 
(two) of recoveries given by some is, or will be found in a study 
of a larger number of cases, entirely too low, and that we may 
feel encouraged to hope for a favorable outcome in suitable cases. 



ARTHUR W. HURD. 20/ 

Whether a disease entity or not, I believe the picture is a more 
or less clearly cut and recognizable one to those engaged in the 
actual practice of psychiatry, and my experience leads me to be- 
lieve that in this, as in many other diseases, an encouraging 
measure of success is obtainable by persistent, constant, and intel- 
ligent care and treatment 

DISCUSSION. 

Dr. H. W. MnxEK. Mr. President— I wish to express my appreciation of 
Dr. Hurd's very timely and instructive article. We all understand how 
difficult it is for a busy superintendent who is overburdened with executive 
duties to prepare such a presentation as he has given us to-day. 

I think this is an extremely interesting psychosis or symptom-complex. 
Whether it is a psychosis or whether it is a symptom-complex is debatable, 
but every careful clinician cannot fail to observe certain characteristic symp- 
toms which strongly suggest a distinct clinical entity. Although it may be 
somewhat similar to senile dementia, as has been suggested, I do not 
think an acute observer would often be led astray. The aetiological factors, 
the characteristic disorientation, the memory disorder, the Merkfahigkeit 
defect, the romancing, etc, with the frequent association of neuritic dis- 
turbance, make to my mind an impressive picture. 

I think it is well to be a little cautious, and I would rather prefer to apply 
the name Korsakoff's syndrome or Korsakoff's symptom-complex, because 
in outlining and designating a clinical entity we have to take into considera- 
tion the aetiology, the course, the outcome, and the pathologico-anatomical 
changes. 

G>nsidering the aetiological factors of these cases we find that excessive 
alcoholism is predominant in the majority. In some cases it is morphine, 
in some tuberculosis; in one of my cases it was a post-typhoid condition. 
Thus we find in the great majority of the cases a toxin either formed 
without or produced within the organism, or we have the combination of 
both. We perhaps unfortunately, find this symptom-complex produced by 
brain injury, which fact Kalberlah recently reported in an article (Korsa- 
koff's symptom-complex after brain concussion). He also carefully re- 
viewed the literature on this subject 

Of the pathological changes in this condition there is considerable dis- 
cussion. It is claimed by some that there is always what is known as cen- 
tral neuritis with the concomitant changes. Again we find nothing but the 
axonal reaction in the spinal cord without significant changes in the cortex. 

The close association with polioencephalitis superior hemorrhagica, in so 
far as anatomical changes are concerned and even from a symptomological 
standpoint has led many to consider it part of the same process. Thus 
we find certain differences of opinion as to the pathological changes. 

Now considering the course and outcome, the majority and the con- 
sensus of opinion is that the condition leads to an irreparable mental 



2o8 Korsakoff's psychosis. 

defect, which in some cases is very slight Dr. Hurd is rather more hopeful 
of it than I am with my limited experience. I cannot recall a permanent 
recovery in any of my cases. 

Now we may ask the question, are all these apparent discrepancies suffi- 
cient to invalidate our conception of this process as a disease? Is it not 
possible that there is a common cause underlying the whole disease, and 
can this common cause produce all the symptoms and the anatomical 
changes which have been described? It is to be hoped that future study 
will elucidate these apparent discrepancies. 

BonhoefFer calls the condition chronic alcoholic delirium, but he does 
admit that it may be caused by other toxins than alcohol. Korsakoff gives 
a whole series of aetiologies, but there is no doubt that alcohol is by far 
the most important aetiological factor. We see it is present in every case of 
Dr. Kurd's but one. Of the four cases which I reported, three were alco- 
holic, and of the six cases which I have had in my service since that report, 
every one was alcoholic. I might add that of my reported cases two are 
still in the hospital and show practically no change ; one has gone home and 
is earning a living, but could not, even for statistical purposes, be considered 
a recovery. He is emotional and has a very defective memory. 

The question of association with peripheral neuritis has been well dis- 
cussed by Dr. Hurd, and I do not consider that it is of fundamental im- 
portance whether the toxic effect is concentrated upon the peripheral or 
upon the central neurones, or upon both. 

I came prepared to discuss the pathology of the disease, but I find that 
my time is up, so I will not further burden you. I wish again to thank 
Dr. Hurd for his very interesting reports. 



A CASE OF VISUAL HALLUCINATIONS AND CROSSED 
AMBLYOPIA WITH VASCULAR AND DEGENER- 
ATIVE LESIONS IN THE CALCARINE CORTEX 
AND OTHER PORTIONS OF THE OCCIPITAL 
LOBE; ALSO WITH ATROPHY OF THE PREGEN- 
ICUL^ AND OPTIC TRACTS.* 

(From the Laboratory of Neuropathology The University of Pennsylvania,) 

By CHAS. K. mills, M. D., 

Professor of Neurology in the University of Pennsylvania, Neurologist to 
the Philadelphia General Hospital, 

AND 

C. D. CAMP, M. D., 

Assistant in Neuropathology in the University of Pennsylvania, Assistant 
Neurologist to the Philadelphia General Hospital, 

The case briefly recorded below is of much interest from several 
points of view. It throws some light upon the question of the 
organic basis of visual hallucinations, and affords some valuable 
data regarding the pathological anatomy of the insanity of arterio- 
capillary sclerosis. It also furnishes an illustration of a somewhat 
irregular form of crossed amblyopia, apparently due to lesion of 
the occipital cortex and subcortex. 

The patient, a woman sixty-three years old, had suffered with 
impairment of vision in both eyes for nearly two years before 
coming under observation. This dimness of sight was attributed 
to glaucoma, for which a double iridectomy was performed. 
After this operation her vision was good in the left eye, but only 
fair in the right eye. She was not, however, blind in either eye and 
was able to do considerable near work, although she was careful 
in this respect. The following is a brief record of the state of 
her vision and of her fields shortly after the iridectomies, for 
which we are indebted to Dr. Geo. C. Harlan under whose care 
she was at that time and by whom the operations were performed. 

At this time the vision in the right eye was 20/40 and the 

^Read at a meeting of the American Medico- Psychological Association, 
San Antonio, Texas, April 18-21, 1905. 

14 



2IO VISUAL HALLUCINATIONS AND CROSSED AMBLYOPIA. 

field practically normal with a slight peripheral cut in the tem- 
poral side; the disc was cupped, 1.50 D; vision in the left eye 
was 20/50 ; the field and the ophthalmoscopic examinations were 
the same as in the other eye. 

In September, 1904, one of us (Dr. Mills) was called to Vir- 
ginia to see this patient A few days before she was seen she 
had had a cerebral seizure in which the right eye became totally 
blind and vision in the left eye was greatly impaired. Examin- 
ation showed this complete loss of vision in the right eye, and so 
great a contraction of the fields of the left eye as to give the case 
the appearance of one of so-called barrel vision. At the time of 
her attack she lost the power of coordinating her movements 
sufficiently to stand and she was slightly delirious. She was 
mildly excitable, talking rapidly and somewhat inconsequentially. 
The members of her family regarded her as simply excited over 
her loss of sight and inability to stand, but her condition was one 
suggestive of hypomania. From the first it seemed that active 
mental disorder was imminent. 

After a few days she was brought to Philadelphia where she 
was attended until her death by Dr. Harlan and Dr. Mills. 
Shortly after her arrival Dr. Harlan made a careful examination 
of her eyes. In the right eye she had scarcely more than light 
perception. The fundus was the same as in the previously re- 
ported examination, except that the cupped nerve had filled up 
to the level of the retina which equalled a swelling of plus 1.50; 
tension was normal. In the left eye vision was reduced to 5/40. 
The field was peripherally contracted to 40 degrees on the mesal 
side and to 20 degrees on the temporal side. The color propor- 
tion of the field was normal. The disc was slightly cupped, the 
fundus was otherwise normal. 

On account of the patient's nervous condition it was not con- 
sidered wise to make a minute outline of the fields. 

Early in the history of this case there was something hard to 
describe in her mental state and attitude. She talked and acted 
as one somewhat emotionally exalted and lacking in inhibition. 
As she had not at first any hallucinations or illusions, some of 
those around her were inclined to regard her as not suffering from 
any mental unbalance, she normally being vivacious and inclined, 
on slight cause, to excitement. At first she was not able to stand 
or walk, but in the course of ten days she became able to walk 



C. K. MILLS AND C. D. CAMP. 211 

without support for a few feet How far her inability was mental 
and how far physical, it was difficult to say, as under strong 
encouragement she stood and walked better. 

Two weeks after arriving in Philadelphia she suddenly became 
violently delirious during the night, talking and screaming and 
showing signs of visual hallucinations. She leaped from the bed 
and beoune difficult to manage. From this time on until a few 
days before her death, when she became quieter through weakness, 
she was acutely maniacal. 

A record of a few of her hallucinations will be of interest. 
Four days after she had given clear evidences of the existence of 
acute mania, she saw men in the room with knives and pistols 
assaulting her son and husband as well as herself ; she said that 
her own life was in danger but she did not care for that if only her 
son and husband were saved. At about this time she also saw 
fire occasionally, but she still continued to recognize those around 
her, and talked with them more or less rationally. She also 
now and then spoke of some dead relatives. Up to this period 
she had shown no fever, although her temperature had occasion- 
ally arisen to 99 or even to lOO degrees. 

About one month after coming under continuous observation 
she developed a glandular swelling on the under right side of the 
face which disappeared in a few days. She died about three 
months after coming under care in Philadelphia. During most of 
this time illusions and hallucinations of sight were the most 
marked features of the case. She would, for example, suddenly 
cry out that she saw persons or objects threatening her or passing 
before her. She sometimes mistook the nurse or the doctor for 
someone with evil designs against her. With an effort her 
attention could be temporarily fixed, but she would suddenly cry 
out with great fear, pointing in the direction of some imaginary 
person or object. The hallucinations and illusions of sight kept 
up until a state of thorough exhaustion came on a few days before 
her death, They were not associated with hallucinations of sound, 
and there was no involvement of other senses unless the state- 
ments which she made at one time early after the development of 
visual hallucinations, that her legs were being or had been cut off, 
might be so considered. 

Examinations of her urine were frequently made and on one 
or two occasions showed a few casts and on one or two others a 



212 VISUAL HALLUCINATIONS AND CROSSED AMBLYOPIA. 

trace of albumin ; otherwise there was nothing of special import- 
ance. The blood examination made about ten weeks before her 
death showed : red cells 4,280,000 ; white cells 8700 ; hemoglobin 
85 per cent. 

Her mental condition grew steadily worse as shown by incoher- 
ence mingled with wild hallucinations and illusions, chiefly of 
terror, and steady mental reduction. A week or two before her 
death the optic discs, which were cupped, began to present the 
appearance of an optic neuritis, but this did not fully develop. 
About this time her evacuations became involuntary. Later she 
became stuporous and developed Cheyne-Stokes breathing. She 
died of all the evidences of cerebral and general physical ex- 
haustion. 

Dr. Cadbury, one of the internes at the Pennsylvania Hospital, 
has kindly furnished notes of the case. 

The necropsy was performed by Dr. Geo. S. Crampton, one of 
the resident physicians to the Pennsylvania Hospital. The results 
of the gross examination summarized were, chronic interstitial 
nephritis ; chronic mitral and aortic endocarditis ; acute vegetative 
aortic endocarditis ; cardiac hypertrophy with fatty degeneration 
of the myocardium ; congestion of the lungs with acute broncho- 
pneiunonia ; fatty degeneration of the liver, and a high degree of 
atheroma of the vessels at the base of the brain. The brain was 
sent to the laboratory of neuropathology of the University of 
Pennsylvania where it was examined both macroscopically and 
microscopically by Dr. C. D. Camp under the supervision of 
Dr. Wm. G. Spiller, professor of neuropathology. 

Further macroscopical examination of the brain showed the 
convexity and other regions of the brain apparently normal. 
The arteries at the base, as already stated, were intensely sclerotic. 
The pregeniculae were much atrophied on both sides. No areas 
of softening were found in the thalamus, other basal g^glia, 
optic radiations, or in any part of the cerebrum. 

After hardening in ten per cent formalin solution, pieces of 
tissue from various parts were examined histologically with the 
following results : 

The preparacentral regions on each side were normal by the 
hematoxylin, acid-fuchsin, and Weigert-hematoxylin methods, 
though the blood-vessels here as elsewhere in the cortex, were 
slightly thickened and the perivascular spaces enlarged. There 



C. K. MILLS AND C. D. CAMP. 213 

was no round-cell infiltration of the pia or about the blood- 
vessels. The Betz cells, studied by the thionin modification of 
the Nissl method, were intensely pigmented, occasionally almost 
filled with pigment. The tigroid substance appeared to be normal, 
except where it was invaded with the pigment. The contour of 
the cell was preserved, but the dendritic processes of many of the 
cells were indistinct. 

Sections from the cortex of various parts of each hemisphere, 
selected with a view to their functions, such as the posterior para- 
central convolutions, the midprecentral opposite the second frontal 
convolution, the frontal poles, the quadrate lobules and angular 
gyres were found to be normal by the acid-hematoxylin, acid- 
fuchsin, the Nissl, and Weigert-hematoxylin methods. 

In sections from the calcarine fissure from each side was seen 
to be an intense congestion, with the formation of numerous very 
fine new capillaries. They were mostly in the second and third 
layers of the cortex, and the pyramidal cells in their vicinity ap- 
peared degenerated on examination by the Nissl method. Sec- 
tions from the cortex of the lateral surface of each occipital lobe, 
near the occipital pole, showed areas not involving the whole 
section of a similar vascular appearance, as in the calcarine fissure, 
and probably a part of the same pathological process. The nerve 
cells in the location of these areas were of the pyramidal variety, 
but they had lost their normal shape and structure completely. 
The white substance beneath these areas appeared degenerated 
by the Weigert-hematoxylin method, and full of small holes as 
though nerve fibers had dropped out. 

Sections from the white matter in the interior of the frontal 
lobes appeared perfectly normal by the Weigert-hematoxylin 
method, but sections of the white matter from the interior of the 
occipital lobes did not stain so well. 

Sections from the oblongata appeared normal by the acid- 
hematoxylin, acid-fuchsin, and the Weigert-hematoxylin methods. 
The cells of the nuclei of the hypoglossal nerves appeared normal 
on examination by the Nissl method of staining. 

The left optic nerve was about one-third of the normal size of 
an optic nerve, and surrounded by a greatly thickened sheath. 
There was much connective tissue overgrowth between the nerve 
bundles, which were small and degenerated. 



214 VISUAL HALLUCINATIONS AND CROSSED AMBLYOPIA. 

The chiasm appeared to be degenerated by the Weigert-hema- 
toxylin method, but there was no round-cell infiltration about it. 

It is most interesting to note in connection with this case that 
the patient was a sister of a lady, the record of whose case was 
presented to the Medico-Psychological Association in 1897; and 
also in a fuller report, to the Section on Neurology and Medical 
Jurisprudence of the American Medical Association in 1898." 

In this case the patient was a woman sixty-four years old at 
the time of her death. At a comparatively early period after the 
birth of one of her children she had an attack of mania from which 
she recovered. She had also suflFered from chorea during adult 
life, and when about thirty-five years of age began to show some 
signs of mental change and peculiarity which gradually increased. 
During the third year before her death she became so unreasonable 
as to make living with her almost impossible. Later she had 
attacks resembling grippe. She became bed-ridden and was the 
subject of persecutory delirium or outbreaks of excitement and 
of hallucinations of various sorts. 

Her chief symptoms during the last eighteen months of her 
life were: vertiginous attacks; difficulty in orientating herself; 
marked amnesia, not only for names, but for recent events. She 
gradually became feebler mentally and, during the few months 
preceding death was in a state of decided dementia, with occasional 
spells of excitement. Her attempts at conversation were childish, 
and she had numerous transient, unsystematized delusions. 

The necropsy in this case showed on gross examination wide- 
spread evidences of arterial disease. The vessels at the base were 
atheromatous ; the precommunicans was the seat of an aneurism, 
and numerous miliary aneurisms were found in the pial vessels in 
different locations. The dura was thickened and the pia arachnoid 
somewhat opaque. An extensive and careful microscopical in- 
vestigation of six different regions of the cortex was made by 
Dr. Mary A. Schively, who used the thionin, methylene blue, silver 
phosphomolybdate, hematoxylin and eosin, hematoxylin, picric 
acid and fuchsin, and also the Weigert-Pal methods of staining. 
The results were recorded in a condensed but valuable report with 

"American Journal of Insanity, vol. 56, No. 2, 1897. The Journal of 
the American Medical Association, No. 15, vol. xxx, April 9, 1898. 



C. K. MILLS AND C. D. CAMP. 215 

numerous illustrations of the pathological appearances found in 
nerve cells, glia cells, vessels, meninges, and brain substance. 
One of the most interesting illustrations was a photo-micrograph 
of a long pyramidal cell from the ascending frontal convolution, 
showing roughening of the cell corpus and of the apical den- 
drites ; also moniliform swellings of some of the basal dendrites. 
The patholc^cal features of the case were summarized as internal 
and external changes in the neuron ; changes in the protoplasmic 
glia cells; changes involving the cortical pial vessels, also the 
vessels at the base of the brain ; multiple areas of softening in the 
ascending parietal region ; and myelin degeneration. 

A close scrutiny of the pathological changes found in the brain 
recorded in the present article will show that the pathology of the 
two cases was fundamentally the same. In the first case recorded, 
however, the disease was much more extensive and more ad- 
vanced as would be expected from the clinical history of the case, 
the evidences of mental disorder and deterioration having ex- 
tended over many years, while in the case of this patient's sister, 
now put on record, active disease had only been present for a year 
or two at most. In this case, as in the other, the vessels at the 
base were highly atheromatous. The cortical vessels were every- 
where slightly thickened and the perivascular spaces enlarged. 
The giant pyramidal cells were in some places almost filled with 
pigment; and the dendrites, although preserved, were often in- 
distinct. The cortex and subcortex examined in various regions 
as stated in the full report, showed comparatively little disease. 
The calcarine cortex, however, and other parts of the occipital 
lobe were the seat of recent vascular and less recent degenerative 
changes. The intense congestion and the formation of new capil- 
laries were pathological findings of particular interest in connection 
with the conditions of excitement and the striking visual hallucina- 
tions shown by the patient. The degenerative changes in the 
pyramidal cells were similar to those found by Dr. Schively in 
widespread areas in the other case. The pyramidal cells in both 
cases had lost their normal shape and structure and the adjacent 
white substance was degenerated. Whether the very marked 
atrophy of the left optic nerve and the accompanying changes 
were primary or secondary it is difficult to say. In any case it is 
probable that the visual hallucinations present were due to the 
cortical and subcortical vascular alterations. 



2l6 VISUAL HALLUCINATIONS AND CROSSED AMBLYOPIA. 

The case reported in this paper and the one placed on record 
in the Proceedings of the Association in 1897, in addition to other 
points of interest, constitute valuable contributions to the sympto- 
matology and pathological anatomy of the insanity of arterio- 
sclerosis. The vessel changes of arterio-sclerotic insanity as 
recorded by others are, thickened and much altered walls ; dilated 
or occluded lumina ; and aneurisms, both miliary and macroscopic. 
In connection with the intense congestion and formation of new 
capillaries recorded in our case, it is interesting to note that other 
cases with similar changes, including capillary hemorrhages, have 
been recorded. Advanced intracellular, dendritic, and neurogliar 
changes were also present in our case as in others. It is also 
worthy of note that in the case here first recorded arterio-sclerotic 
changes were found in other organs as in the kidneys, heart, and 
liver. 

Whether the complete blindness in one eye and the serious loss 
of vision in the other were to be regarded as constituting a genuine 
case of crossed amblyopia such as has been reported by Ferrier 
and Gowers, and attributed to lesion of the angulo-occipital region 
or of the macular bundle may perhaps be regarded as doubtful. 
If due to the lesions undoubtedly present in the calcarine cortex, 
this crossed amblyopia is of much interest in connection with the 
question of the existence of a separate macular representation in 
the primary or lower cortical visual centers of the calcarine region 
and in the higher angulo-occipital visual areas. 

Dr. Harlan agreed that the final amblyopia in this case could not 
be attributed to the preceding glaucoma, at least not to the periph- 
eral conditions which were present. With the exception of the 
cupped nerves, the fundus of each eye was normal and the filling 
up of the nerve cup seemed to indicate the occurrence of some in- 
tracranial lesion. The attacks of sudden loss of vision which 
occur in chronic glaucoma may, in some instances be due to intra- 
cranial lesions affecting the cerebral, and especially the macular, 
bundles or centers. It is possible of course that the atrophy of 
the left optic nerve and tract may have accounted for the g^eat 
loss of acuity of vision and contraction of the visual field in the 
left eye, but in any case the sudden amblyopia in the right eye 
was doubtless due to a sudden vascular lesion in the left 
hemisphere. 



THE PREVENTION OF INSANITY, IN ITS INCUBA- 
TION, BY THE GENERAL PRACTITIONER. 

By J. T. W. ROWE, M. D.. 

First Assistant Physician, Manhattan State Hospital, East, Ward's Island, 

New York City. 

Within the limitation of a ten-minute paper I shall attempt to 
express my views on a subject that alienists and psycho-patholo- 
gists have for many years striven to shed light upon, viz., a means 
or method for preventing the occurrence of insanity. 

I expect to be received with due acclaim by superintendents 
of overcrowded institutions whose greatest efforts are in the direc- 
tion of keeping out the incoming patients and getting rid of those 
on their hands, and by industrious students of asylum financial 
budgets. Constantly renewed volumes of psychiatry have not 
aided us in the least. The annual reports of superintendents 
only deplore the steady increase of insanity with no relief in 
sight. The ratio of recoveries is no better, and assigned causes 
for the disease are the merest generalizations. Then the question 
arises, what means are we taking to keep the overcrowding of 
our hospitals within bounds or to prevent in the slightest degree 
the occurrence of insanity? 

The State hospital has acquired such an enviable reputation 
nowadays for its luxurious appointments that its freely yielding 
doors have invited all sorts and conditions of defectives, coming 
like those in the nursery rhyme, " some in rags, and some in jags, 
and some in velvet gowns," who might well be kept outside the 
walls. 

The poor relations, "lightly touched," have been unearthed 
from back rooms and qualified for the journey to their Mecca. 
And, as well, the old fatuous chronic whose alcoholic periodical 
qualifies him for the workhouse instead of a State hospital. The 
increasing number of degenerate types and imbeciles which, by 
an easy stretch of the examining powers, receive the imprimatur 
of insanity, impel us not only to scan vigorously the doubtful 



2l8 THE PREVENTION OF INSANITY. 

cases presented for our acceptance, but also to speed the parting 
guests who complaisantly settle down to the amenities of asylum 
life and share with relatives the fear only that they may be dis- 
charged to the short commons of their family circle. 

We perhaps do not appreciate the importance of a frequent 
rounding up of the population for chronic harmless dements who 
should be discharged to their friends. Many of these cases could 
be liberated without danger to themselves or others ; at any rate, 
the patient should have the benefit of the doubt or be turned over 
to his local department of poor. 

We are all doubtless familiar with cases where the relatives 
refuse to be comforted because we object to discharge the patient 
upon their first request, and later, when notified to remove him, 
promptly discontinue visits to patient and hospital and invoke 
political and charitable aid to have him retained in the institution, 
alleging fear of personal harm, or perhaps, newly-formed out- 
side attachments. It is needless to say that no consideration 
should be shown except to relieve the hospital of its incubus. 
Too lengthy treatment is not always best for these cases. 

Our Argus eyed inspectors at the very foot of Liberty's statue 
bid fair to give an account of the undesirable classes from 
abroad, but the State has done such wonders with its maternal 
care and coddling that the hospital is now a veritable hospice 
toward which is directed any and everybody who shows the 
slightest aberration. The policeman marches the mumbling 
rounder promptly to the nearest reception hospital, and an alacrity 
is always shown by interested parties in diverting to us the harm- 
less old mendicant prayerfully haranguing the sun, while the 
profane and lusty tramp of violent speech, begotten of frequent 
ejectments, is especially the object of their solicitude and, inci- 
dentally, of State hospital care. 

The question arises, Do we check the flow at the fountain head, 
or are we content merely to exhibit vis inertur and receive the 
flotsam and jetsam brought to us by the scores of small streams, 
scavengers of the country side? The flood comes from the sup- 
ply already domiciled here. If it was dependent only upon 
foreign supply, we could easily avoid the consequences by de- 
manding a certificate of sound mental health at the port of entry. 



J. T. W. ROWE. 219 

or, if necessary, at place of embarkation, or, to reach out still 
further, from the native town or village of each immigrant. 

But our asylums are not filled by the sharply challenged immi- 
grant, who is not always as black as he is painted, and we have 
a knotty problem to solve in devising a way to check the increas- 
ing stream of insanity in all degrees and stages. After a long 
association with the classes received at probably the largest 
hospitals for the insane in existence, I can but conclude that the 
remedy must be applied before the patient is submitted to the 
examiners in lunacy. 

Theories and opinions, fortified by new classifications and fur- 
ther buttressed by many a foreign ipse dixit of academic sound- 
ness, give rise to very agreeable and interesting scientific discus- 
sions, but they lessen the incoming tide or relieve the hospitals 
of their burdens, not one jot. Our patients come, we must agree, 
from the field, the factory, and the office ; and must, as a matter 
of course, in the large majority of cases come first to the notice 
of the family doctor. Therefore, to the general practitioner, and 
not to the trained alienist, must we look to relieve us of our in- 
creasing burden. That he has been more or less delinquent in 
this respect is apparent to us all, for who of us has not been 
frequently impressed by the shameful neglect of proper medical 
treatment for patients prior to their commitment to a hospital for 
the insane ? 

To minister to a mind diseased is perhaps not the daily routine 
of the general practitioner, but he will find scores of incipient 
cases in his daily rounds whose progfress he can arrest, and the 
responsibility rests upon him to guide the patients into a safe 
haven. The physician could do an immense deal of good to his 
patients and to the hospitals if he had a better knowledge of the 
nature and phenomena of mental disease. We see every day 
patients arriving who, if taken in time, need never have sought 
the protection of a certificate of insanity. We see case after case 
showing toxsemia following abeyance of function, the result of 
too close application and overwork amid unsanitary surroundings. 
Such cases, taken in time, unquestionably would have responded 
to proper medical treatment. Hundreds of patients are com- 
mitted to our asylums yearly, a large portion of whom have the 
conviction that they need never have been certified as lunatics 



220 THE PREVENTION OF INSANITY. 

had they received timely medical advice in the stage of incuba- 
tion, and their functions and physical condition bear them out in 
their lamentable statement of neglected health. 

The medicine of the future will be largely one of prevention of 
disease, insanity in particular, and the preservation of health. 
The general practitioner should exercise vigilance and should 
be urged to stop the downward course, and the subsequent filling 
of asylums. If a man is obviously a lunatic, is suicidal or dan- 
gerous to others, he should properly be placed in a hospital for 
the insane, but such a place is not for cases of neurosis or ex- 
hausted states due to neglect or lack of medical care. The family 
doctor is the first to see the cases in the stage in which alone the 
disease is curable. Many of these patients can be treated at home 
and cured. 

In his daily rounds the practitioner sees the departure from 
normal health in a hundred forms. He has the opportunity to 
check its progress and give sound advice, and can manage to 
see every member of the family at one or other of his visits. 
The parents, or some of the family, can be encouraged to confide 
in him regarding the mental condition of any one of them, and 
by treatment for the declining bodily health upon which it de- 
pends, the patient can be restored in mind and body. The work- 
ing classes should be taught to seek a physician's advice much 
more frequently than they do. It might be brought home to them 
through their pockets, if in no other way, for the dullest intellect 
will comprehend that the weakling cannot bring g^st to the mill, 
and that fact being impressed, the doctor undoubtedly will be 
called in without delay. 

In these days when our social and economic systems are dis- 
turbed by disorganizing factors, industrial upheavals, and strenu- 
ous competition between those well and those poorly equipped 
for the struggle, a large number of old and young are to be 
found on the verge of physical and mental breakdown. They 
dare not give in, for the pace has been set and they strain every 
nerve to respond to the demands. While able to drag along 
neither they nor their families will consult a physician. The 
laborer, in his ignorance of the laws of nature, sweats in the 
darkness. The workers in the factory and the slums; the pro- 
fessional man, over confident in his intellectual powers and well 



J. T. W. ROWE. 221 

ordered nervous system ; the lad at school, weighed down by too 
close application and not enough open air exercise ; the shy retir- 
ing boy, just yielding to evil inclinations; the worried business 
man and father, bearing a heavy load and seeing no way of 
lightening it — all these patients are very near the borderland of 
mental affection and this is the very time when proper medical 
advice could avert disaster. A large number, the condition recog- 
nized, if taken from their work and sent to the sea, or moun- 
tains, or even advised to do half time, could ward it off. The 
family doctor sees such cases every day. 

The neurasthenic with trepidation consults his physician. The 
alcoholic with his fleeting delusions, and the railroad man com- 
plaining of nervous exhaustion and fearing that his nerve is fail- 
ing him, are cases which require close watching. The mother 
with her dangers of the climacteric, bending under the monotonous 
drudgery of household cares, the young girl with her period of 
evolution, ungratified longings, and hypochondriasis, and the 
man who has his sleep broken and begins to hear voices at night, 
demand medical attention. This is the period of initiation and 
incubation. These are the varieties of ailment becoming insanity. 
This is the doctor's golden opportunity. A few days in bed with 
" rest " treatment, and perhaps nothing more is required. A 
short time in a general hospital or under observation would ena- 
ble a large number to clear up sufficiently to resume work and the 
care of family, the physician's advice helping along to recovery. 

Thirty per cent of admissions to hospitals for the insane are 
cases due to neuroses, drug, and drink habits, toxaemias of adoles- 
cence and states incident to the menopause. A few days off 
from the farm and the carking cares of the house, and the results 
will be astonishing if the doctor shows determination to nip the 
symptoms in the bud. 

An early diagnosis is of the utmost importance, and the advisor 
has a boundless opportunity to check the downward course by 
sending his patient away, even in the face of a threatened poverty, 
which is preferable to certain poverty with the additional burden of 
the sick or insane father or brother. The inclination to send to the 
medical certifiers should be resisted to the last. It can always be 
the dernier ressort. An asylum is not by any means the best 
place in the world for him. It is not the solution of the problem. 



222 THE PREVENTION OF INSANITY. 

Comparatively few require such extreme measures as being locked 
up from family and consigned to the discipline of an institution 
for the insane, with the loss of personal liberty and dissolution 
of family ties. A timely word to the patient, a hint to the family, 
even if it is unheeded, and there is time to defer this regrettable 
action. Send him abroad if his circumstances permit, or to the 
sea or mountains. For those long immured in the country, the 
diversion of a densely populated city may be beneficial, but not 
the discipline and rules of an institution. 

The overcrowding of State hospitals has become a necessary 
€vil through the ready complaisance in writing out a certificate 
of insanity, and many have been taken to asylums against their 
will, their families inflicted with horrible doubt, and the patients 
themselves subjected to suspicion ever afterwards. It is true, 
although to be deplored, that the knowledge of a former asylum 
residence militates seriously against a man, for there is always 
a doubt about his mental restoration. The pilot experiences diffi- 
culty in getting back his old post, the engineer may obtain sym- 
pathy, but seldom the charge of his train or yacht, and the business 
firm is decidedly averse to placing responsibility in the hands of a 
man with an asylum history. 

No one appreciates this handicap more than the patient him- 
self and, therefore, he does his best to keep the fact of failing 
physical or mental strength concealed when his daily bread is at 
stake. Proper and early recognition by the doctor may enable 
the patient to avert what must be a blot upon him for the re- 
mainder of his days, while under proper medical supervision he 
would be infinitely happier outside asylum walls. 

If the physician will pay less attention to the mental condition 
and treat the failure of bodily health upon which it depends, 
for he should know that functions are not slow to become dis- 
ordered, he frequently may effect a recovery in mind and body. 
Indeed, many most unpromising cases benefit so much by change 
of scene and occupation that they scarcely would be recc^nized 
as having narrowly escaped the restrictions of a hospital for the 
insane. Every day it is more forcibly impressed upon us that a 
large number of cases of degeneration can be arrested before be- 
coming fully developed. 

The care of fully established cases of insanity is not in ques- 



J. T. W. ROWE, 223 

tion. Such should go to the alienist — ^but the physician has it in 
his power to prevent the full establishment of insanity. He can 
shed light upon the darkness begotten of ignorance regarding 
syphilis and its inclusive list of general paralysis, tabes, and all the 
disastrous consequences to immediate sufferers, including the 
neuroses of degeneration resulting from it. He has it in his 
power to assist the asylums and benefit his patients who time and 
again lament the fact that they received no medical attention be- 
fore admission. Their friends, when questioned, admit that no 
physician was consulted, until pronounced mental s)rmptoms were 
exhibited and the patient became unmanageable. 

The school curriculum in each practitioner's neighborhood may 
well arouse his concern, its absurdly high standard being fre- 
quently out of all proportion to the mental and physical strength 
of the pupil. He may see many a growing and promising lad 
whose precocity is mistaken by his proud parents for unusual 
mental endowments, winning prizes and scholarships at the ruin- 
ous price of his mental and physical stamina. The writer has 
seen such cases end in complete bodily wreck, mental enfeeble- 
ment, and, frequently complete dementia, rendering the subjects 
fit only for an asylum for the rest of their days. 

That the family doctor can do much for us if he cooperates 
heartily is brought home by the astonishing length of time some 
discharged patients, not considered favorable cases, remain at 
large when placed under his surveillance. There is no doubt 
that the facilis descensus of the defective and the delinquent with 
the resultant crowding of asylums, can be materially relieved by 
the efforts of the family physician. 

DISCUSSION. 

Dr. Hn-L. — This paper is too important to pass by without a word. We 
all appreciate it very highly. I would like to express my hearty approval 
of the paper and to suggest that some friend of the doctor's remind him 
that it should be published in the medical journals. We are all aware of 
these facts, but the general practitioner does not understand them so well 
as he should. 

The President. — I think myself that Dr. Hill's suggestion is an ad- 
mirable one, and I hope Dr. Palmer will convey it to Dr. Rowe. I am sure 
the council would endorse Dr. Rowe's publishing that as broadly as 
potsible. 



' CHOLJEMIA— ITS RELATION TO INSANITY/ 

By R. J. PRESTON, A. M., M. D., Mawon, Va. 

Ex-President Virginia Medical Society; Ex-President American Medico-- 
Psychological Association. 

Cholaemia, from its etymology (chole, bile, and aimae, blood), 
and for the purposes of this discussion, may be considered a con- 
dition in which the poisonous elements of the bile, not eliminated 
or excreted by the liver, are circulated in the blood. The liver 
was regarded by the ancients as the chief cause of insanity, and 
some of the older writers were wont to say that " Liver Disease " 
was the black pit into which all diseases that could not be diag- 
nosed were thrown. The liver being the largest excretory organ 
in the body, excreting on an average of 500 grs. of bile per day 
(which is partly excretory and partly secretory in its functions), 
any derangement or obstruction of it must necessarily greatly 
affect not only the nervous and mental system but the well being 
of the entire body. 

The presence of icterus and of gallstones in the insane, the 
changes in the quality and quantity of the bile, the obstruction 
of the portal circulation, the well known despondency attending 
hepatic affections in general, and the serious systemic conditions 
resulting from organic disease of the liver, have all been noted 
by many writers. All practitioners of medicine, and in fact all 
laymen, know and appreciate the depressing effect of what is 
called a bilious attack; in fact, the writer himself, before ap- 
proaching this complex subject, resorted to a mild course of 
cholagogue treatment to remove the hepatogenous poisons re- 
sulting from sluggish liver action and imperfect elimination of 
same. 

Cholaemic psychoses, or mental disturbances following icterus 
or jaundice, are comparatively rare, and are ordinarily hypo- 

*Rcsid by title before the American Medico- Psychological Association, 
San Antonio, Texas. 

IS 



226 CHOLiEMIA — ITS RELATION TO INSANITY. 

chondriac-melancholic type that gradually pass away with the 
elimination of the poison from the body, but more rarely in the 
severer forms, as in acute yellow atrophy of the liver, the great- 
est mental disturbances are manifested, terminating mostly in 
coma and death. 

The severer mental disturbances accompanying toxaemic jaun- 
dice, or toxic states of the blood dependent upon various poisons, 
which either act upon the blood itself or in some cases on the 
liver cells (formerly improperly called haematogenous jaundice), 
or more rarely dependent upon hepatogenous jaundice with ob- 
structive changes in the bile passages, are of obscure patho- 
logical origin. Some later writers term the group of sjrmptoms 
" Cholaemia or Cholesteraemia," on the supposition that choles- 
terin is the poison, but its true nature has not been determined. 

" There are a number of other somatic diseases in which this 
autotoxis is met with, and poisonous substances are engendered 
that act upon the nerve tissue and cause such disturbances in 
the nervous elements that storms of variable violence result," and 
various mental disturbances occur. " It is not surprising," says 
Dr. Peterson, " that deleterious agents in the blood which bathes 
every cell and fiber in the nervous system, carrying thither the 
nutritive elements, and removing thence the waste products, 
should readily overstimulate, retard, pervert, or destroy its high 
function." Accumulation of carbonic add and the poisons of 
diabetes and uraemia in the blood have long been known to 
medical science as deleterious agents affecting the nervous system 
and sometimes producing insanity; but the more mysterious 
poisons produced by disease in the various parts of the body, by 
fermenting or putrefying substances, in the alimentary tract, and 
by some of the acute infectious fevers, have only of late taken an 
important place in the etiology of psychoses. We do not know 
yet how frequently autointoxication from absorption of intestinal 
and other poisons determines insanity, but facts collected point 
to a niunber of cases from this cause. These autotoxines, pro- 
duced by deleterious agents from diseases of different organs and 
parts of the body, are doubtless similar in character and pathology 
to those of the liver now under discussion, and similarly produce 
various mental disturbances and can probably be brought into 
this discussion. The ancients were not wholly wrong in their 



R. J. PRESTON. 227 

black bile theory of melancholia (fiiXa^-, black and /oAi^, bile), 
but there are many other toxines, as has been and is now being 
demonstrated by later researches, equally if not more deleterious 
in the production of insanity. The autotoxines generated in the 
system consequent upon typhoid fever, malaria, influenza, la 
^ppe, acute articular rheumatism, tuberculosis, nephritis, dis- 
eases of genital organs, etc., are noted by many writers as pro- 
ductive or causative of melancholia and other serious neuroses. 
Surgical operations upon the liver and the gall-bladder, like oper- 
ations upon other organs of the body, are known to produce post- 
operative insanities. As before said, these forms of insanity fol- 
lowing upon icterus or toxaemic jaundice are usually of the 
melancholy t}^, but in some forms of liver trouble, as in atrophic 
cirrhosis, or more rarely in the fatty cirrhotic liver, a noisy hallu- 
onatory insanity may develop; but usually even here stuporous 
coma and convulsions supervene with symptoms often mistaken 
for uraemia, which Osier thinks cannot be attributed to cholaemia. 
The nature of the toxic element is not yet settled. With the 
many ardent workers of late years in this field of pathology, and 
the researches into the minute cell structure of the nervous sys- 
tem, and into the nature and pathology of these various auto- 
toxines produced in diseases of different organs and parts of the 
body, brilliant results have already been achieved, and we hope 
in the near future for further elucidation of these complex prob- 
lems and for important discoveries along these lines of investi- 
^tion. 



SURGERY FOR THE RELIEF OF INSANE CONDITIONS. 

By Max R Wrrre. M. D., 
Superintendent Clarinda State Hospital, Clarinda, Iowa, 

Medicine and what thereunto belongeth is a science in theory 
only ; its application in practice is an art and as such is not sub- 
ject to closely and clearly drawn rigfid laws according to which it 
moves and has its being. Even theoretically as a science it, or 
our knowledge of it, lacks the comprehensiveness and definiteness 
which would warrant us in expressing it under the form of an 
equation. Our judgments are chiefly qualitative and then often 
imperfect, and it is rarely we can apply quantitative standards of 
measurements. And this imperfect status of our profession should 
occasion no surprise or painful chagrin when we remember the 
incomplete, or even frequently rudimentary, condition of the 
subsidiary or fundamental sciences on which medicine is based. 
While only vanishingly slight certain knowledge obtains in the 
domains of physics and chemistry, so that even the nature of its 
subject is not known but a matter of dispute or fancy, the diffi- 
culties and obscurities in the way of our understanding multiply 
as we ascend the ladder of the sciences in our quest on the trail 
of matter evolving onto higher planes. In the expansion of the 
various biological sciences, we can see things as through a glass 
darkly; can conjecture and note trends and dispositions, and 
occasionally break out a solid block for our certain knowledge 
and place it under the reign of law, but in much we must be con- 
tent to approximate reality as closely as we may. Complete 
evidence is lacking to form just such judgments, or, mathemati- 
cally speaking, too many unknown quantities for which we as yet 
have no equations enter into the problem. We deal with the 
phenomenon, but phenomena are illusive and modified by the 
individual observing and interpreting mind. But this should not 
engender in us a paralyzing pessimism to annul our efforts, but 
on the contrary should arouse our combativeness, spur us on to 
search for the missing equations, and to victorious achievement. 



230 SURGERY FOR THE RELIEF OF INSANE CONDITIONS. 

At the same time we should be careful to abstain from prejudice 
in matters still under judgment, to eliminate the personal equa- 
tion, and above all avoid a fossilizing dogmatism to blind us ; but 
on the contrary, we should cultivate a critical and conservative 
mental attitude, ever ready to accept the true and reject the false, 
until the touchstone of experience in time clarifies our knowl- 
edge. Amongst the problems of this character, I would classify 
that of surgical intervention in alienated mental conditions. 

So much controversy, so many claims for and against, so much 
partisan acrimony, so many discordant statistics, based appar- 
ently on diametrically opposed experience, envelopes this subject^ 
and this a subject on which one would on first cast expect cer- 
tainty, since coming under objective experience, that we, locddng 
at the matter philosophically and unbiased, cannot avoid the con- 
clusion that these various claimants have been hasty and have 
formed hard and fast conclusions on insufficient evidence and 
that at best their dicta merit no greater consideration than pro- 
visional opinions, and should be so considered. One source of 
error in the claims of those who believe in the vast beneficence of 
surgery in the insane is, in my opinion, the omission of the 
element of time. This is an important omission, and I have been 
particularly impressed that this is true in a number of cases to 
the point in my own experience, to which I shall refer later on. 

Again, I am convinced that in certain cases wherein surgical 
procedures were beneficial and followed by amelioration and per- 
haps restoration in the mental condition, this happy result is not 
so much due to the premeditated and planned removal or cor- 
rection of foci of irritation as to the operation per se and its 
consequent crisis in the organism, with its attendant changes in 
innervation, circulation, nutrition, and metabolism. Improve- 
ment in many cases in whom I operated for the relief of morbid 
conditions other than mental, bear me out in this ; moreover, we 
find similar experience in other fields of surgical work. I may 
mention only the good results following simple abdominal section 
in tubercular peritonitis. 

Again, it is a matter of sufficiently frequent observation of 
those who have had considerable experience with the insane, that 
crises other than of surgical origin play a remedial role. I well 
remember the case of a woman, some 35 years of age, who had 



MAX E, WITTE. 23I 

been subject to chronic mania for a dozen years or more, who 
was much disordered and disturbed, with extensive and appar- 
ently constantly increasing mental deterioration, who for years 
had had no even comparatively quiet or lucid intervals, but who 
was continuously noisy, disorderly, destructive, and slovenly, un- 
able to comprehend her condition or situation in time or space or 
to frame an intelligent reply to a simple question, who had been 
considered hopelessly insane and incurable for years, who was 
attacked by acute lobar pneumonia and for a number of days 
was gravely ill. This woman, with the development of pul- 
monary inflammation, became quiet and orderly, and not only 
this, but completely rational and clear mentally. She remained 
sane after convalescence from the pneumonia, and after a suffi- 
cient period of observation, during which she manifested no 
mental disorder or even observable impairment, she was dis- 
charged recovered. She remained well some four years after- 
ward, and so far as I know is well to-day. In this case mental 
restoration was so closely connected with the pneumonia that the 
conclusions seems inevitable, that it was propter hoc and not 
post hoc. 

In another instance, in the days of airing courts surrounded by 
high enclosure, a man sought to escape over a fourteen-foot, tight 
fence by climbing a large silver maple growing near and letting 
himself down on the other side by the overhanging branches. 
Instead of bending, the branch broke and the patient fell head- 
long a distance of thirty feet and broke his arm. Now the 
strange feature of the case comes in. This patient, who had been 
considered hopelessly insane for years, recovered promptly, not 
only from the fracture of the humerus, but also mentally. 

Now a few swallows do not make spring, and llie lessons 
drawn from the aforementioned cases should not induce us to 
adopt pneumonia and the forcible precipitation from a height into 
our remedial armamentarium for the treatment of the insane. I 
have simply referred to these cases out of a number to illustrate 
my contention. They no doubt can be easily duplicated by others 
in the experience of my auditors. 

Now as to surgery in the treatment of the insane, we may 
premise the discussion of the subject with the axiomatic state- 
ment that it should be employed under precisely the same con- 



232 SURGERY FOR THE RELIEF OF INSANE CONDITIONS. 

ditions and circumstances in the insane as in the sane. When or 
wherever the life of the patient can be prolonged or his health or 
comfort be promoted by surgical intervention, it is our solemn 
duty to aid him in this manner. Anything less is remissness; 
anything more, rashness. I think we are all agreed on this, and 
no one should find fault with this position. Should we, there- 
fore, find in the insane morbid or abnormal conditions calling for 
operative or other surgical measures, we should employ them, 
primarily in the hope to benefit and improve the patient's general 
health, and secondarily, to thereby increase his chances for mental 
improvement. 

This is " safe and sane " practice, and I may say, only by way 
of parenthesis, that the insane are entitled, justly entitled, to the 
benefit of the same diagnostic and surgical skill, antiseptic pre- 
cautions, care, and nursing as the sane. 

There are, however, two fields of surgical endeavor to which 
psychiatrical importance has been attached and wherein the ex- 
perience of observers diverge and opinions differ. These sub- 
jects at issue are cerebral as the one and pelvic in the female as 
the other, for the relief of insane conditions. And since the views 
are so discordant touching these matters it seems to me to be 
the part of prudence to suspend definite judgment until time and 
trial shall bring in more extensive and reliable evidence. At 
least let our conclusions for the present be only provisional and 
capable of being modified and changed by subsequent develop- 
ments bearing on this question. For the further elucidation of 
the subject it will be important, nay necessary, that we should 
carefully observe and faithfully report cases having bearing, in 
order that our own experience may be enriched and interpreted 
by that of our fellow-worker in the field. Above all, let us be 
fair and impartial and avoid partisanship. It is so human to take 
sides, to color and exalt testimony on the side we advocate, and 
to neglect evidence against it. 

It is in the field of cerebral, or rather cranial, surgery that we 
perhaps most frequently encounter importunities of friends to do 
something, and this whether or not there are indications in the 
way of old fractures of the skull with depression, or even a well- 
defined history of cranial injury. Scarcely a week goes by that 
I am not urged by some solicitous friend to examine Mr. X. with 



MAX E. WITTE. 333 

a view of having something done in an operative way for his 
relief. The request is usually explained that he once upon 
a time when a small boy fell on the ice, or had been crowded 
against the stall by a horse, or that the doctor had made the 
statement that his insanity is due to " clot on the brain." Now 
these people no doubt feel considerable disappointment in me 
because I cannot fall in with their views and refuse to operate or 
sanction operation without marked and well-defined indications 
for the same. It is very natural that friends should be anxious 
for the relief of their patient, and like a drowning man grasp at 
straws. Their feelings override their judgment, especially as the 
latter is uninformed on the matters at issue, and led astray by 
highly colored and sensational reports finding their way into the 
lay press, of brilliant achievements, by some bold operator, bor- 
dering on the miraculous, in the cure of insanity. Akin to this 
is the frequently heard clamor for vertebral readjustment, having 
its origin in the osteopathic intellectual occultation. 

However, we meet sufficiently often with cases of unmistakable 
cranial or cerebral traumatism, with fracture and perhaps depres- 
sion of fragments of the skull. Usually the injury occurred long 
ago and insanity developed subsequently and is, indubitably or 
reasonably certain, consequent or dependent on it. Mental dis- 
order increases and the friends or the patient himself is very 
urgent to have the source of his mental derangement, as they 
believe, removed by operation. 

Now what can we say to these people ? What does experience 
justify us in advising? What can we promise? What hopes 
hold out? 

It is indeed a question of vast moment that stares us in the face 
for our solution. On the solution depends tfie weal or woe of a 
human being, and not only one but many may be vitally affected 
by it. The ruin or salvation of a human life is no small matter, 
but, to those concerned, of the greatest importance. It behooves 
us, therefore, to bring forward to the solution our best efforts and 
all the light we can obtain in experience or otherwise, so that we 
may decide justly and do what is needful. I have been much 
interested in the subject, and during the many years of my service 
in behalf of the insane have observed the results not only of my 
own work in this line, but also that of others ; and amongst these 



234 SURGERY FOR THE RELIEF OF INSANE CONDITIONS. 

were some of the deservedly most famous surgeons of our coun- 
try. As a result there has been bom and grown within me a pro- 
nounced and critical conservatism in thought and action, if not a 
despondent pessimism in all cases of mental disturbance where a 
considerable period has elapsed since the receipt of the injury. 

I may be pardoned if, as partly illustrative of the subject, I 
briefly outline from memory the history of two cases operated 
by me, and two cases operated by other surgeons, but subse- 
quently coming under my care. These cases have been selected 
from quite a number, partly as typical of a class and partly as 
illustrative of some things I have said, and to serve as a text for 
a somewhat more minute consideration of the question involved. 

Case I. — ^A young man, some 21 years old ; occupation, farmer ; 
strong physique ; vigorous bodily health. Some eleven years be- 
fore admission was kicked in the head by a vicious horse. He 
was unconscious many hours after receipt of injury, but gradually 
rallied and regained consciousness and what appeared to be his 
normal condition, with the exception that at times he appeared 
confused, also irritable in temper, and suffered pain in the head 
He, however, learned readily at school and in intelligence was up 
to the average. However, as he advanced in years, mental pecu- 
liarities became more prominent and for some time preceding com- 
mitment mental disorder was practically continuous and he was 
subject to periods of active disturbance, maniacal in character, 
with violent and dangerous tendencies. When he came under my 
observation his condition mudi resembled the restless, active stage 
of certain forms of dementia praecox, with an already marked 
degree of mental enfeeblement. While restless and mischievous, 
he was oriented and still had some interest in his affairs and 
matters generally and could converse quite well for a time. His 
mental condition rapidly deteriorated and he became careless and 
untidy about his clothing and in his personal habits, indifferent to 
matters of ordinary concern, vicious and irresponsive to mental 
stimulation, and apparently drifting rapidly into terminal de- 
mentia. There was a marked depression of skull due to fracture 
at the site of the old injury in tfie frontal region. No focal sjrmp- 
toms indicating involvement of the motor zone were present At 
the urgent solicitation of the friends, although no promises were 
made or definite hopes held out, the operation of trephining and 



MAX E. WITTE. 235 

raising the depressed portion of the skull was performed under 
strictly aseptic conditions. The fractured and depressed bone, an 
irregularly elliptical segment some i>^ inches wide, beginning just 
above the middle of right superciliary ridge and extending up 
and backward over frontal eminence some 3}^ inches to the 
coronal suture and overlying in part first and second frontal con* 
volutions, was elevated. Rough spicular projections into brain 
and membranes were removed completely and dura mater sepa- 
rated from adhesions. The dura was atrophied and attenuated 
under depressed spicules and permitted examination of pia mater 
which seemed rather anemic, but was not extensively coalescent 
with dura or otherwise markedly abnormal ; neither was anything 
found justif3dng deeper invasion by knife. The recovery from 
operation was uneventful and from a surgical standpoint all that 
could be desired. 

And psychically now developed the strange features of this 
case. Onto the operating table had laid down an appearing ter- 
minal dement, uncouth, indifferent to all interests, careless, filthy, 
untidy, silly in manner, and vacant in expression. Issuing from 
under the influence of the ether this same patient at once mani- 
fested mental changes for the better. His expression was brighter 
and more animated, he recognized and spoke to his father intelli- 
gently, and from day to day thereafter improved mentally, became 
clearer and more active, neat and orderly about his person, took 
interest in and conversed rationally on home affairs and general 
subjects of common concern. In fact, at the end of a month 
after the operation he was so well and nearly normal in every 
mode of psychical activity that his friends and all interested re- 
joiced at his apparent restoration. Had his case been reported 
at this time, it could justly have been claimed as brilliant an 
achievement as any of the sensational stories occasionally chron- 
icled in the lay press. But, alas! the high-flying hopes were 
doomed to be extinguished in bitter disappointment. He grad- 
ually g^ew more confused and listless, careless, disorderly, and 
by the end of six weeks he was as much demented as before, and 
so far as I know has remained so ever since. The only difference 
observable has been that after operation the dementia has not been 
interrupted by periods of more active disturbance with vicious 
and destructive tendencies, such as were quite common prior to 
the operation. 



236 SURGERY FOR THE REUEF OF INSANE CONDITIONS. 

Case II. — Aged 38; intemperate; formerly a private in the 
regular service of the U. S. Army. Some years before, during a 
drunken brawl, he was struck on back part and right side of head 
by a large stone in the hands of his drunken opponent. Ever 
since he had been subject to epilepsy and this for some time 
complicated by insanity. When he came under my care, patient 
was in strong and vigorous health, but subject to epileptic attacks, 
coming on at irregular intervals, usually in a series of three or 
four, with active disturbances during which he was vicious, 
violent, and homicidal, and withal a dangerous and difficult sub- 
ject. Then he would ordinarily have an interval of three or four 
weeks of freedom from convulsion and during this time patient 
was orderly and industrious, and, since dementia had not pro- 
gressed extensively, rather a bright and companionable patient, 
without the irritable epileptic disposition being well marked. He 
complained, however, of pain in the head and soreness at the 
seat of the injury in the posterior right parietal region where scars 
and an irregular large depression in the skull, evidently due to 
fractured and depressed bone, were very marked. He attributed 
his strange feelings and distress in the head as well as his epilepsy 
to this cranial fracture, and he undoubtedly was right in this. He 
furthermore requested an operation for the relief of this condi- 
tion, although he had been told that nothing definite could be 
promised him as to results. Being a man of good intelligence, he 
concluded to take all risks, since his condition could not be made 
worse but might perhaps be bettered. An irregular triangular 
deeply depressed section of bone was raised some 4 inches long 
by nearly 2j^ inches wide, extending from apex near the middle 
of the right parietal bone near vertex of skull obliquely backward, 
outward, and downward to base at lambdoid and masto-parietal 
suture and involving the furrow for the right lateral sinus in part 
and overlying the occipital cerebral lobe. The meninges were 
found tightly adherent to fragments of skull projecting down- 
ward deeply into the brain, besides the lateral sinus was sacculated 
and insinuated deeply into cerebral fissure, probably due from 
pressure by the depressed bone below the dilatation. I may say, 
parenthetically, patient had no psycho-sensory disturbance, but 
had complained of strange sensations in the head. The operation 
wound healed kindly, and the result surgically was satisfactory. 



MAX E. WITTE. 237 

Patient generally improved ; became better-natured and less irri- 
table, and the queer feeling in the head which had given him 
considerable distress before disappeared altogether. No sign of 
epilepsy was observed either by himself or others for a period 
of some six months, a longer period than had ever intervened 
between attacks since receipt of the injury. Patient was in high 
hopes and exuberant spirits in consequence of what appeared his 
recovery. One evening, however, he had a well-marked attack 
of grand mal. The convulsion was not as severe as had formerly 
been the habit, neither was it followed by mental obscuration and 
disturbance. He remained under observation a few months longer, 
doing nicely and having no further recurrence of epilepsy either 
masked or open. He then passed from my observation by escape 
and I have no further knowledge of him. Whether he continued 
to do well, with perhaps further improvement, or whether he again 
became more epileptic and deteriorated is a matter of conjecture. 
I fear the latter, on account of his former predilection for alcohol, 
if for no other reason. Attention may be drawn to a few points 
in this case. The sacculation of the large vein appeared to enter 
more deeply into cerebral tissue than any projections of the frac- 
tured skull, and in my opinion was the more potent and capable of 
cerebral irritation, oppression, and disturbance. I think that the 
disappearance of the " queer feelings " after operation was either 
really due to removal of the obstruction in the venous channel or 
removal of pressure from psychic centers of sensation. Again, 
from the brain region involved one would expect some sensory 
disturbance or hallucinations; especially in the interpretation of 
visual, muscular, and common sensations in consciousness, but, 
although patient was gifted with fair descriptive ability, this could 
not be made out. The " queer feelings " of which he complained 
were local and there was no evidence of objective projection. My 
opinion is that the psycho-sensory centers on the injured side had 
become functionally inoperative through neglect, and that the cor- 
responding centers on the opposite side compensated. May it not 
be that these higher psychical centers, like the speech centers, 
functionate on one side only as a rule? 

Case IH. — Aged 20; white; slight in build; in good bodily 
condition. Patient's father, paternal and maternal grandfathers 
died of paralysis (apoplexy) and the latter had been a hard 



238 SURGERY FOR THE RELIEF OF INSANE CONDITIONS. 

drinker. At age of 8 he sustained a severe injury by being struck 
on the head by a baseball bat in its descent, after it had been 
flung by one of his mates as high as possible; he was knocked 
down, but did not become unconscious. Four years later, at the 
age of 12, the first epileptic convulsions occurred. (It is said, 
however, that he had convulsions in infancy attributed to worms.) 
Three months after the establishment of the epilepsy, during which 
he had weekly attacks, on the advice of the best medical counsel 
obtainable in his city, he was operated on by that past master in 
surgery, the late Dr. Christian Fenger, assisted by the advice of 
an eminent neurologist. They found some depression of skull at 
the site of the former injury, namely, one irregularly circular lyi 
inches in diameter at juncture of sagittal with coronal suture, and 
the other of same size and similar shape 2 inches back in sagittal 
suture near vertex, both over superior longitudinal sinus. Both 
depressions encroach a little more on right side. The name of 
the surgeon is guarantee that the work was well done, but both 
Dr. Fenger and his counsellor gave a guarded prognosis, stating 
that they were not certain that the operation would relieve the 
epilepsy. Patient had slight convulsions three months after the 
operation and then the seizures came on weekly as before. Be- 
tween attacks he appeared bright enough, was industrious and 
fond of music. Five years ago, t. e., 3 years after the first epi- 
leptic convulsion and 7 years after receipt of the injury, insanity 
became manifest. He became dull and confused and was strange 
and irrational for days; conceived strange ideas to which he 
adhered with stubborn pertinacity, was very irritable, quarrel- 
some, and disposed to contradict others. If aroused in any way, 
would fly into a passion and be disposed to assault others with 
whatever was nearest to his hand; would say strange and un- 
called-for things; in fact his conduct, disposition, and general 
manner has been typical of epileptic insanity. There is evidence 
that a gradual mental deterioration has been going on as the 
result of the epileptic condition. Much dementia is now present 
and evidently increasing. Whatever mentality remains is un- 
stable and either much obscured and dulled or explosive in char- 
acter. 

An undoubtedly well-advised and well-done operation was of 
no benefit, and the fears expressed in the prognosis were well- 



MAX E. WITTE. 239 

founded. However, it must be borne in mind that the operation 
was performed four years after the injury was received, and 
after the epileptic habit had become firmly established. Again, 
while the injury to the head apparently was at the basis of the 
epilepsy and subsequent insanity, it is not unlikely that the patient 
was constitutionally predisposed to the disorder. His father and 
paternal grandfather died of apoplexy; maternal grandfather 
also died of apoplexy after he had been a hard drinker for years, 
and we know intemperance favors epilepsy in subsequent genera- 
tions. The patient himself had some convulsive disorder in early 
childhood, so that it seems reasonable to surmise an inherited 
neurotic encumbrance which embarrassed the prospects. 

Case IV. — Age 19. Female. In latter part of August, 1904, 
attempted to drive across a railroad track in front of a train 
running at 60 miles an hour. She was struck by the train, car- 
ried 1000 3rards, and thrown into a ditch at the side of the track. 
She was picked up unconscious, and consciousness was only par- 
tially regained. She was taken to a general hospital, and was 
then very violent, it requiring the united eflForts of two persons 
to keep her in bed. Her movements were convulsive, pupils con- 
tracted, sphincter ccmipletely relaxed, cutaneous sensibility and 
planter reflexes lost. In September, Dr. Fairchild, of Des Moines, 
assisted by the hospital physicians, trephined, with the expectation 
of finding fracture of internal plate of cranium at site of injury to 
head in left parietal region ; found none, but found hemorrhage ; 
punctured membrane and put in cat-gut drainage. After opera- 
tion she began to scream, sphincters closed, but no gain in sensi- 
bility (intelligence?) could be noticed. Movements lost convul- 
sive appearance and were apparently influenced by volition ; could 
swallow, but refused food ; was fed by tube ; would scream for 
hours at a time. 

At time she came under my observation, September 29, 1904, 
she was in a state of active delirium. She could see and hear, but 
was utterly confused and deranged and had no conception of her 
situation or surroundings; at the same time she was extremely 
restless and agitated, biting and tearing everything she could 
reach. She made no effort to speak and it was impossible to 
attract or hold her attention. There was apparently complete dis- 
organization of mentality. 



240 SURGERY FOR THE RELIEF OF INSANE CONDITIONS. 

Patient had gained a little physically by October lo, and took 
nourishment better, but no important change had occurred men- 
tally. She remained much impaired, with greater motor activity, 
legs were in almost constant motion, so that it was impossible to 
keep her covered. Pupils were extremely dilated and she now 
was unable to see ; could hear loud sounds ; attention could not be 
attracted ; uttered cries similar to cephalic cry, or the cry heard in 
idiocy. By middle of month improvement had advanced so she 
could repeat parrot-like a few words, and in another week could 
speak some and recognized physician and nurses, still repeated 
words, scanning speech. She maintained that her mother was in 
Kansas City (mother really was there at time of accident). She 
had no recollection of the accident. She had still much motor in- 
coordination. She could see, but only indistinctly, and objects 
appeared double. By the end of October improvement had ad- 
vanced and she had better control over movements and could 
stand alone; complained of tingling sensations in extremities, 
especially on the right side; was brighter and began to relate 
events of her early life prior to accident and to releam what she 
formerly knew. 

She continued to gain in every way so that by early December 
she had become a bright and intelligent young woman, with much 
brightness and sprightliness of thought, as shown in manner and 
conversation. Some motor impairment remained at time of parole, 
January 4, 1905, especially in walking, but she had regained good 
use of arms and hands. Since she has continued to improve. 

In this case operative intervention was justified by signs of com- 
pression even in the absence of fracture and well-defined focal 
symptoms. In my opinion, the mental disorder was due to cor- 
tical molecular injury and disturbance by the violence encountered 
in the accident. No doubt cortical malnutrition by pressure from 
the clot aided. It is evident from the defined motor symptoms that 
this influence extended to motor zone in Rolandic fissure. 

These few cases mentioned more at length, selected from quite a 
number coming under my observation, illustrate not only my own 
experience in cranial surgery, but also that of others in this line 
of work. I think Dr. Burr's paper, read before the 1903 meeting 
of the American Medico-Psychological Association, on this sub- 
ject, corroborates this. 



MAX E. WITTE. 24I 

The one lesson I think we can safely derive from this joint ex- 
perience is the maxim : Operate early, before the insane condition 
has become fully developed and fixed. And a little thought will 
reveal to us that this position is just and reasonable, and consonant 
with rational surgical procedure elsewhere than the brain. The 
disturbing influence of a simple depressed fractured cranial seg- 
ment is either due to pressure with consequent mechanical anaemia 
of either the underlying brain tissue, or of the cerebral parts sub- 
ject to counter pressure elsewhere or to irritation from cranial 
projections and penetrating spiculae, or to both causes. In either 
event we expect a gjave disorder, not only functionally, but mor- 
phologically. We can justly look for malnutrition from lack of 
blood in the cortex involved with attendant loss of function in the 
cortical neurons, with whole groups and constellations of cells 
inoperative, and the mentality depending on the region defective ; 
moreover, mental processes elsewhere wherein the involved region 
entered by association, are gravely disturbed. If the basal con- 
dition is not soon relieved, degeneration of cell and connecting 
fiber ensues from disturbance of nutrition and functional disease. 
The irritating spicula or cranial projection may not only cause 
mechanical injury by disruption of cortical tissue, but may initiate 
vasomotor disorder and consequent irregular cerebral vasculari- 
zation, perverted nutrition with disturbance of function, and, if 
the disturbance endures, organic changes take place which are 
perpetuated, and the mental disorder based thereon proves per- 
manent, whether the original cause of irritation is removed by 
operation or not. Of course, still graver is the situation when 
cerebral tissue itself is more profoundly involved and gross de- 
structive or disruptive effects have occurred in the brain by the 
trauma. Here in my opinion early surgical interference is still 
more urgently indicated for fear of future mental alienation if for 
no vital reason, provided always that we can improve the exist- 
ing conditions and leave the parts in a more natural state with less 
danger from subsequent loss or irritation. 

I, personally, have felt reluctant to carry the knife into cerebral 
tissue in the absence of well-defined indications for it. We can- 
not hope to leave anything but scar tissue in our wake, which per- 
chance may prove more troublesome in the cerebral system than 
the resultant of the trauma. Of course, each case must be judged 

16 



242 SURGERY FOR THE REUEF OF INSANE CONDITIONS. 

on its merits, and our actions based thereon. There are usually 
other vital considerations which may help us to decide. The r^ion 
of the brain involved will have a bearing. Aside from the uncertain 
and problematical prospects from operation in cases of long 
standing, it has occurred to me that the usual technique in the 
opening and replacement of depressed parts of the cranium may 
in a measure at least be at fault in the production of unsatisfactory 
results. And especially is there danger of the formation anew of 
adhesions about the trephine opening or site of operative proce- 
dure, involving the meninges or even perhaps the subjacent cor- 
tical tissue, with proliferation of connective tissue, subsequent 
contraction and disturbance and irritation structurally and func- 
tionally of the brain. The marked improvement following opera- 
tion in Case I, and the mental deterioration soon afterward might 
be considered as pointing to this. Others have come to the same 
conclusion. Dr. M. L. Harris discusses this question at length 
in a paper — ^Joum. Am. Med. Association, March 19, 1904. Dr. 
Harris commends sterilized silver foil to prevent adhesions. The 
foil should be aseptic, free from openings, and its edges extend 
beyond the limit of adhesions. He prefers a replaceable bone- 
flap to opening by trephine. Hemorrhage must be checked and 
clots removed before the foil is gently and smoothly put in place. 
I consider his views and recommendations sound ; at all events, 
our eflForts in the future must be towards the improvement of the 
mechanical part of the work, in order that we leave the parts in 
as natural condition as possible, and thus more favorable for heal- 
ing and the achievement of more perfect results structurally. It 
goes without saying that the operation should be performed under 
strictly aseptic conditions only. It would be well-nigh inexcusable 
to set up a meningitis by infection. 

What can we say to friends or patients who urge operative 
measures for the reUef of the insane condition? My practice, in 
which I am more and more confirmed as time goes on, is this: 
I tell them freely and frankly in cases of long-standing trouble, 
and they are usually of this character, that I can promise them 
nothing, and that the operation itself is grave and not free from 
risks to life ; that if they, however, wish to assume such risks in 
the hope of possible improvement, I am always ready to operate 
and do what in my judgment may be deemed necessary, or, if 



MAX E. WITTE. 243 

they prefer some other surgeon, I will have no objections, and 
will do what I can to further their wishes. 

I do not know what more I can say with the present status of 
the subject. I certainly do not think it right to raise illusive hopes, 
as is frequently done by members of our profession who are sur- 
geons merely with the furor secandi strong upon them. 

On the other hand, it must not be overlooked that cases of recov- 
ery do occasionally occur after operation ; as witness some enu- 
merated in Dr. Burr's list, and a case recently reported by Dr. 
Hedges in Medical Record, January 28, 1905. I am quite cer- 
tain, however, that these cranial operations are more frequently 
performed than we suppose, but the results not being satisfactory, 
are not reported. We can readily expect this, for it is only human 
to publish our successes and neglect mention of our failures. 

The other g^eat surgical field for which psychiatric importance 
is claimed is that involving the female pelvis and its contents. It 
is not my purpose to burden these pages with the report of cases 
or even statistical figures gathered from a rather extensive series 
operated either by myself or others, but coming under my. imme- 
diate care and observation. Suffice it to say that my views touch- 
ing the subject have quite early crystallized into the following 
maxims, which are the guides in my practice to-day : 

1. Do not expect relief in the mental condition from operative 
interference, in the absence of actual disease of the pelvic organs 
requiring surgical aid. 

2. In pelvic diseases complicating insanity often much good, in 
the way of improving general health and comfort and thereby aid- 
ing and promoting mental restoration, may be accomplished by 
less heroic measures than surgical. 

3. In the insane, as in the sane, pelvic disease disturbing or im- 
pairing patient's health, or even seriously the comfort or threaten- 
ing life and remediable by surgical intervention only, should re- 
ceive surgical aid promptly and efficiently. 

4. To benefit coming generations, surgical measures to annul 
procreative power are indicated and justified in certain types of 
insanity, deficiency and degeneracy depending on an inherited and 
inheritable constitutional tendency or abnormality. 

In amplification of my first proposition, I may say that I am 
well aware that it is diametrically opposed to the views of some 



244 SURGERY FOR THE RELIEF OF INSANE CONDITIONS. 

Other and no doubt competent and honest observers. We remem- 
ber the claims made by some, of brilliant results from operative 
gynecological work achieved in the cure, or at least great improve- 
ment, of the insane. This was some year ago. I do not hear 
much, if anything, from the field nowadays. Has more recent ex- 
perience not borne out the earlier claims? I will confess that I 
was also infected with the enthusiasm then in vogue on this sub^ 
ject, and expected much from oophorectomy and artificial meno- 
pause in patients who were more disturbed and the mental disorder 
aggravated during the menstrual period, but in whom no positive 
pelvic diseases or organic alteration could be demonstrated. My 
hopes and labors for relief of the insane condition were in these 
cases doomed to bitter disappointment. Not that I even now 
regret the sacrifice of all these ovaries, since in many of these cases 
whatever good I have done will redound to the welfare of future 
generations in accordance with proposition 4, and in others there 
was marked relief of sexual visceral irritation, and no doubt in- 
creased comfort to the patient. 

Upon due and mature reflection, we cannot reasonably expect 
recovery or even material amelioration in the mental condition by 
the forcible ablation of a physiological function, especially when we 
consider that these people are usually afflicted with dementia 
praecox or some other form of mental alienation or obliquity de- 
pending on blight and structural or molecular changes in the 
cerebral cortex. There is no achievement without proportional 
sacrifice, and without doubt the burden of this fell heavily on the 
female of our species, when man abandoned the horizontal for the 
perpendicular plane and walked upright in the image of the Deity. 
Yet, when all is said, there has been an inclination to exaggerate 
the influence of the genetic function in the life of the woman. With 
woman in health, the accent lies on the second syllable and not on 
the first. On the other hand, in actual disease of the generative 
organs, causing distress, or discomfort merely, tfie general health 
suffers and restorative powers are diminished. Even when patient 
is not conscious of disease, more or less continuous nervous im- 
pulses emanate from the site of disease and cause derangement of 
the nervous mechanism by irregular reflection or they even gravely 
affect for ill the prevailing states of feeling by the registry of 
tidings of evil below the threshold of consciousness. All the more 



MAX E. WITTE. 245 

is this true when the pelvic disease is sufficiently grave to cause 
pain or conscious discomfort. It may then be the locus of irrita- 
tion which causes or perpetuates insanity, and the latter cannot be 
relieved until the source of trouble is removed. 

That this often may be done by non-operative measures goes 
without saying. Topical medication, massage, baths, electricity, 
heat and cold, all have important remedial functions in the treat- 
ment of these cases in bringing about secondarily either restoration 
or great relief in the disordered mental condition. Where, how- 
ever, the pelvic disease is of such a grave organic character that 
the aforesaid agencies fail, surgery has a place, and that an exalted 
place. The insane, as the other citizens of our great country, have 
the inborn right to liberty and the pursuit of happiness. If this 
undeniable right can be restored to them by the use of the knife, 
we are indeed remiss to duty if we do not use it. 

Now as to the employment of surgical measures to remove gen- 
erative power in certain types of mental involution, I would not 
restrict it to the one sex. But, as Kipling says, " this is another 
story." 

DISCUSSION. 

Dr. Woodson. — I desire to compliment Dr. Witte for his conservatism 
and the manner in which he has treated this subject; also to approve most 
heartily of the work he has done. It has not been many years since a 
few of our members came to the Association meetings and declared they 
cured everything with the knife; and those who were inclined to differ 
with them were criticised harshly in other societies by gynecologists, and 
we were regarded as not being up-to-date because we entertained different 
views. 

There is no question but patients suffering from mental diseases and epi- 
lepsy are often improved after undergoing surgical operations; however, 
the improvement is too often only temporary. The time to operate in 
cases of trauma to brain is soon after the injury. 

I remember about nineteen years ago being called to see a young woman 
who had shot herself. By carefully removing the ball, fragments of bone, 
blood-clots, etc., she soon became rational. Before these were removed 
she was unconscious. I heard from this woman a few years ago and there 
had not been up to that date the slightest manifestation of mental aber- 
ration. 

I remember a boy who had been struck with a buggy-shaft, above the 
supraorbital ridge. The skull was fractured extensively. He had been 
treated by two physicians and there had been no effort made to remove 
the fragments of bone. The wound had been packed with gauze to pre- 



246 SURGERY FOR THE RELIEF OF INSANE CONDITIONS. 

vent hemorrhage. I saw the lad about six hours after the injury, found 
him unconscious, and he had been having convulsions. I removed the 
gauze, all pieces of bone, clots, and wounded brain and instituted proper 
drainage. The boy regained consciousness before I left the house. It has 
been my pleasure to see this boy every few months since the injury, and 
aside from the loss of an eye he recovered without an untoward symptom 
and there has been no manifestation of insanity or epilepsy. 

In our institution a few years ago, a man suffering from acute mania, 
was struck by a fellow patient with a heavy teacup above the supraorbital 
ridge causing a fracture or a rent in the frontal bone two inches long and 
one-eighth of an inch wide. He had been the most troublesome patient in 
the institution. The wound was properly dressed, he at once became con- 
scious and remained so. He had no elevation of temperature, never com- 
plained of the slightest pain or headache, and recovered thoroughly from 
the injury. While he has never been restored mentally he has not at any 
time been so troublesome as before he received the injury. 

Dk. Crumbacker. — I wish to compliment Dr. Witte on the thoroughness 
of his paper and the conservatism with which he handles the subject I 
cannot add much, if anything, to what has already been said on the sub- 
ject During the past year, however, it has been my good fortune or bad 
fortune, as the case may be, to have been persuaded to operate upon the 
cranium in two cases of mental disorder, and to have advised and wit- 
nessed the operations. 

One case was observed in our hospital at Independence. The patient had 
been an inmate of the institution for a number of years. He was very 
badly disturbed, and some years ago, with suicidal intent, he had butted his 
head against the wall in such a way as to cause fracture of the cranium. 
The fragments of bone, as well as the osseous tissue adjacent thereto, had 
become necrosed, and operation was deemed advisable and resorted to, for 
the purpose of removing this necrosed bone. At the operation a portion 
of the cranium a little larger than an old-fashioned copper cent was re- 
moved. This did not cure our patient of his mental disability; we did not 
expect it would; but he was much less disturbed from the time of the 
operation, and after the lapse of a few months he presented material im- 
provement He then escaped from the institution, and we have not heard 
of his whereabouts since. We have also lost trace of his family and rela- 
tives and have thus been unable to locate the patient 

The other was a case in which the injury had happened only a few 
weeks prior to the operation. A man working on a derrick was struck on 
the vertex by a large beam, near the junction of the lambdoid and the 
sagittal sutures. A slight indentation could be recognized on palpation^ 
and we felt confident that the man had a slight fracture of the cranium. 
His disposition had changed a great deal. Instead of being profane, ener- 
getic, and of an aggressive character, he had become calm; he cried; he 
did not prosecute his work at all; he even talked of suicide. In this in- 
stance the cranium was trephined, and a small spicula of bone about as 



' MAX E. WITTE. 247 

large as the nail of the little finger, imbedded in the cerebral cortex, was 
removed, and the slight adhesions which had formed between the dura and 
the pia were broken up. He came out of the operation nicely, and next 
morning his profanity was as evident as ever. Since recovery from the 
operation he has seemed much more natural. I recently saw him driving 
a team, and apparently acting normally. Of course, a good deal of time 
is required to manifest the eventual outcome in such a case as this. The 
immediate effects of the operation in the two cases mentioned were satis- 
factory enough, however, to stimulate a further study of this subject, and 
they warrant us in giving this matter even more serious consideration than 
it has ever yet received. 

Ds. Robinson. — I have been very much interested in this paper of Dr. 
Witte's and the discussion following. We usually look upon men discuss- 
ing a paper as showing great wisdom when they agree with us and the 
opposite when their conclusions differ from our own. I have had some 
observation of cases in private practice. I received a young lady some 
years ago who was injured in a cyclone. The house was blown over while 
she was seated at the dinner table. There was a fracture of the skull and 
she was in a comatose condition. I thought she would die. I removed the 
fragments of bone and she never had elevation of temperature and made 
a good recovery. 

Another case was that of a young man kicked by a mule in the supra- 
orbital region. There was a discharge of perhaps one or two teaspoonfulls 
of brain substance. This was treated in the same manner. I never noticed 
any elevation of temperature and the patient made an uneventful and full 
recovery. 

I merely refer to these cases to show the importance of operating in the 
beginning. I have in long years observation in hospitals seen quite a num- 
ber of physicians who had some surgical experience, but not much obser- 
vation in these cases, who wished to operate and the friends would consent, 
but I am sorry to say that I have never seen one case that was benefitted. 
They would invariably be brought back in a much worse condition. In 
epilepsy large sections of bone have been removed and the cases have re- 
turned in worse condition than before. Even some slight cases of epilepsy 
were greatly aggravated by the operation. I am sorry to say that I have 
never seen a case prove successful. I appreciate this paper very much and 
desire to commend the gentleman for his conservative stand. 

Dr. Hutchings. — I compliment Dr. Witte on the good judgment shown 
in the preparation of this paper. It is quite a contrast to the extreme views 
which have sometimes been expressed here. 

There is one point we should never lose sight of in prognosis, and that 
is that there is something more required to cause insanity than trauma 
affecting the brain. In other words, that there is a predisposing as well 
as an exciting cause, and when we have before us a case of insanity fol- 
lowing trauma we must consider not only the injury but the predisposition. 



248 SURGERY FOR THE REUEF OF INSANE CONDITIONS. 

and while one individual of a sound nervous system may withstand severe 
injury, another may lapse into dementia, though the injury may be skill- 
fully treated. 

As to the other department of Dr. Witte's paper, the pelvic operations, 
my experience has been that we are more frequently consulted in regard 
to them by women who are hysterical or of the extreme neurasthenic 
type, who have heard that some cases have been cured by pelvic operations. 
The general practitioner should assume an extremely conservative posi- 
tion in such cases, and while recommending any operation which seems to 
be required for the improvement of the general health, should disabuse 
the patient's mind of the idea that all their nervous S3rmptoms will dis- 
appear upon the correction of some minor uterine lesion. 

Another point we should emphasize is that the so-called cures of this 
class have been reported, as a rule, too early. It has been my experience, 
and doubtless the experience of many others, that the so-called cures of 
this class are not infrequently readmitted into hospitals for the insane after 
one or two or more years. 

Dr. Punton. — ^While surgical treatment for insanity has been carried 
out with varying results by different authorities and from time to time we 
have received reports both in this Association and those of others, I think 
that we have at least passed the experimental stage and we can now begin 
to formulate some conclusions with reference to results. Dr. Witte's 
first case should have at least offered some results from a purely surgical 
standpoint, on the ground that all cranial fractures should be elevated, 
but it failed to do this. 

Again, as a matter of fact, while we are never quite satisfied with the 
results obtained by operation, we often see some results that are beneficial. 
It seems to me, however, that we are about ready to conclude that unless 
these conditions are operated upon much earlier than is customary that 
very little can be expected from a surgical operation. I have, therefore, 
come to the conclusion that surgery of the brain offers very, very little 
results when the lesions are chronic. Of course there are exceptions to 
this rule. 

I very much fear that the same state of things holds true with reference 
to operations in the pelvis when associated with insanity. Even if there 
is an organic lesion, the insane condition may have come on after the 
lesions were organized, as this paper indicates they may have done, hence 
Dr. Witte's conclusions agree with my own. 

Dr. Page. — I wish to express my appreciation of the conservatism ex- 
pressed by the doctor and for his rational conclusions. I have had simi- 
lar experience with reference to epileptics. The friends of an epileptic 
young man were anxious for an operation, which I strongly advised 
against, but they removed the patient to his home and operated upon his 
head. About six months subsequently they brought the patient back to 
the hospital to show us the wonderful results of the operation. A cure 



MAX E. WITTE. 249 

was claimed, and both patient and surgeon were in an enthusiastic frame 
of mind. While not admitting all they claimed, I had to congratulate them 
upon their apparent success. 

But within a year this man was reconmiitted to the hospital and subse- 
quently died there, having many epileptic seizures, the character of which 
was even much worse than that formerly exhibited. 

It was my privilege recently to attend a meeting in Boston and hear the 
local surgeons discuss the question of cerebral surgery. The records of 
some twenty-eight cases operated on for cerebral tumor were given, but 
only two were wholly successful. Operations upon the head for epilepsy 
were a little more successful, but there was only a very small percentage 
of recoveries in these cases. For spinal tumors the records were decidedly 
better. The conclusions drawn from the records considered was that 
about all you could promise in a case of cerebral tumor was relief of 
pressure. If you had pressure symptoms, you could operate and afford the 
patient some temporary relief. But in such cases, it was best to avoid 
operating over the motor centers. 

At the Danvers Insane Hospital ninety-four autopsies were held last 
year and in nine cases cerebral tumors were discovered. The character 
and location of these tumors were such that successful removal would 
have been possible in only one case and the actual location of that tumor 
could not have been discovered during the life of the patient 

Dr. Henry M. Hxnu). — Granting all that has been said, is it not better to 
cure one or two than to let all such patients die without any prospect of 
relief? I believe in these desperate cases we are justified in operating 
with the hope that some relief may accrue and that there may be a faint 
hope of a cure mentally. 



EPILEPSY AS A SYMPTOM. 

By EVERETT. flood, A. M., M. D., 
Superintendent Massachusetts Hospital for Epileptics, 

Dr. Schafer's experiments in irritating the cortex, have clearly 
shown how convulsions may be caused though it cannot show that 
this is the only method of causing convulsive attacks. 

To do justice to the subject would be to separately consider the 
etiology of every case, going over all the causes from a slight 
irritation of the cortex, which with predisposition is sufficient to 
produce a fit and successive fits through the whole of thousands 
of possible causes and degrees of abnormality to actual trauma. 

It seems desirable, if possible, to show that epilepsy is always 
a mere symptom as we know it to be in some cases, in order that 
we may be able to attribute the diseased condition to its ultimate 
location and group symptoms correctly. 

It will readily be allowed that convulsions occur as a symptom 
of many different diseased states and that to be satisfied with 
this name as a diagnosis would be shortsighted. 

Almost any simple symptom may be analyzed into several and 
a final elemental symptom will be hard to find. Each symptom is 
made up of parts. We use these s)mdromes as symptoms. 

Epilepsy is a more complex symptom. A combination of symp- 
toms is necessary to produce the syndrome epilepsy. 

Fever consists of increased activity of the heart with a cause 
for this increased action, consequent hastened combustion, aug- 
mented frictional heat, heightened color, hastened respiration, 
etc. 

When a fit occurs, it consists of a number of conditions, e. g. : 

The paleness. 

The unconsciousness and fall. 

The convulsive movements. 

The recovery. 

The weakness. 

Some or all of these conditions in varying degrees will be 



252 EPILEPSY AS A SYMPTOM. 

present and according as the variation from a typical condition 
is more or less, the difficulty of distinguishing the group diminishes 
or increases. 

A certain modification of phenomena often proves very mystify- 
ing whereas another and more common synthesis of elements 
will show epilepsy as a clear and definite syndrome. 

The other symptoms usually associated with epilepsy, such as 
vertigo, asphyxia, inhibitory disturbances, etc. may be present or 
absent, or present in almost any degree and the complete syndrome 
therefore very obscure. 

Conditions of many of these sorts are commonly called Sympto- 
matic Epilepsies especially when dependent on " Gross organic 
brain lesions, such as trauma, abscess, tumor, thrombus, and in- 
fantile hemiplegia ; " but to be able to positively diagnose any <Mie 
of these states and assign the epilepsy as a symptom would 
surely be desirable. 

The exciting causes of epilepsy are nearly all positive condi- 
tions which may from one point of view be said to be evidenced 
by the convulsion, e. g. : 

Insolation may be the exciting cause of the first convulsion, 
but an obscure molecular change has probably occurred. 

Epilepsy is often associated with enfeeblement of mind. To say 
epilepsy is a symptom of feeblemindedness would be no more cor- 
rect than to say that feeblemindedness is a symptom of epilepsy. 
They are concomitants. 

Other conditions very often associated with epilepsy are paraly- 
ses and resulting deformities. 

The epilepsy of the cerebral palsies is a mere symptom. 

" One of the most common and distressing symptoms is the 
occurrence of convulsive seizures usually confined to the paralyzed 
side but tending to become general." — Osier. 

" Hemiplegic or post-hemiplegic epilepsy affects, sooner or later 
a considerable proportion of the cases." — Osier. 

Osier also cites six cases of children who had convulsions re- 
peatedly before the onset of the hemiplegia and thinks it possible 
that they caused the lesion on which the paralysis depended. It 
seems that the condition back of the convulsions ought also to be 
reckoned with. 

One of the most constant symptoms in severe onset of exanthems 



EVERETT FLOOD. 253 

is the occurrence of convulsions. Following the same line of 
reasoning we must conclude that the fit following scarlatina or 
other eruptive state is due to an intoxicated center or an oppressed 
area. Beyond this we would probably be unable to penetrate. 

Walter B. Bogges of Louisville, Kentucky, says: "While 
strictly speaking a convulsion is only a symptom and not per se 
a well-defined disease, yet as this symptom is the only prominent 
one in the majority of cases and the etiology and pathology so 
varied and oftentimes so obscure that we cannot but feel that the 
subject is one of so much import in the life of infants and early 
childhood that it should and can be treated as a separate and dis- 
tinct disease." 

If we have a convulsion repeated at intervals it constitutes 
epilepsy. 

Dr. W. N. BuUard of Boston writes, " Epilepsy is not a disease, 
it is properly a symptom." 

Following is a case in which cerebro-spinal fluid constantly 
dropped from the nose and in which convulsions developed late. 

The report which Dr. Meyer kindly sent the father is below : 

" We have just opened the brain and find that the tumor seems 
to have started from the region of the pineal gland. It is about 
the size of a big walnut and burrows backward into the mid- 
brain and forward into the third ventricle ; it seems to occlude the 
ventricle completely, and this would account for the necessity of 
another escape for the cerebro-spinal fluid. I find that the anterior 
end of the right ventricle dips down into the frontal lobe and 
opens on the orbital surface, very much as in the case of Wollen- 
berg where there was also a communication between the anterior 
end of the lateral ventricle with the nasal fossa. It is a pity that 
the passage into the nose was not definitely established, but there 
is no doubt about the fluid having followed the olfactory fibrils. 

We shall make drawings of the specimen or photographs, 
and shall make them accessible to you. 

The twitchings in the face and the anaesthetic spot seem to be 
accounted for by destruction of the mid-brain root of the fifth 
nerve. The early eye symptoms which made me suspect a lesion 
in the chiasma should evidently have been used with some cau- 
tion for the diagnosis. 

I send you this preliminary account because you must be 



254 EPILEPSY AS A SYMPTOM. 

anxious to know, and I shall inform you of the further investigja- 
tion as soon as things are ready." 

Convulsive attacks occur in Adams Stokes disease as illustrated 
by a single case from this hospital. 

Epilepsy occurs in many cases in tumors of the brain. At 
Taunton Insane Hospital, a patient is reported in the report of 
1904. " A tumor in the left frontal lobe was found in a patient 
who for years was reported as an epileptic." 

There are many states physical or mental which seem to burden 
the life of the individual and come near the point of disturbing the 
nicely adjusted physical and psychical equipoise. 

We have frequent examples of convulsions occurring from im- 
perfect aeration of the blood, as in pertussis, and other more 
positive degrees of asphyxiation, and I believe it is quite possible 
that convulsions may occur in cases of dyspepsia, from toxaemia, 
if not from the actual irritation and bad nutrition, as a symptom 
of hypsonosus, of Graves disease, or as a symptom of mere ex- 
haustion ; and no doubt the list can be lengthened to include dozens 
of distressing and disturbing influences when acting upon a pre- 
disposed subject. 

If we could carry out such a line of reasoning, we must con- 
clude that there is no disease properly called epilepsy and that the 
combination of symptoms manifested in a convulsion or a recur- 
rence of convulsions can always be attributed to a distinct cause. 

There is no doubt that the number of fits can be reduced by the 
administration of bromide. Every charlatan knows this but is 
it justifiable to treat a s)rmptom and rest satisfied if we can ccmtrol 
it? 

I do not believe that we should classify on a symptom and push 
epileptics off by themselves as if they are hence diflFerent from 
the rest of mankind. 

Dr. C. L. Dana in " Psychiatry in Its Relation to Other 
Sciences " says, " We do not want to know alone that a child is 
nervous, excitable, easily febrile, a bad sleeper and a noisy drea- 
mer: but what are the special s)rmptoms which may lead us to 
foresee a dementia praecox about eighteen, or a hysteria, or a 
mania, melancholia before adolescence, or paranoia at maturity? *' 

I would like to add, or an occasional convulsion which has no 
significance to the average parent and often causes no apprehen- 
sion. 



EVERETT FLOOD. 255 

In a case which can be paralleled every day the record is that 
the child fell over in a high chair, struck on the occiput, turned 
pale, became unconscious, stiffened, regained its balance, and 
never had any further trouble. How near the child has come to 
a permanent disability no one but the physician can appreciate and 
not even he unless the accident has happened to his own child. 
After such an occurrence the apprehensive parent is alive to every 
sudden start, to a possible starting spell, to the danger of over- 
eating, to innocent and usual childish pranks, fearing the initial 
symptom of a positive fit and knowing that such a convulsion often 
means epilepsy. 

In Dr. Dercum's case of a lesion of the foot of the second fron- 
tal convolution the patient had epileptic seizures, general in char- 
acter, not focal. 

As a symptom of drug action, e. g. : 
Camphor. 
Tobacco. 
Lead, etc. 

Convulsions are prominent and it is not unusual for these to 
become established. 

In acute alcoholic neuritis as a S3rmptom of uremia and eclamp- 
sia (" Leubes Special Medical Diagnosis " considers the separa- 
tion of eclampsia from epilepsy an artificial one). 

As a symptom of dementia praecox and general paresis, the con- 
vulsive state is a pretty constant factor. It may very properly be 
argued that hundreds of other conditions, e. g. chorea, etc. are 
mere S3rmptoms of lesions which are equally obscure and this 
may be fully substantiated. What we need is to reduce the total 
number of disease entities and learn to group the symptoms so as 
to positively indicate their cause. 

Adams Stokes Syndrome Combined Angina Pectoris. 

Case No. 699. M. A. H. C. Female. Age 76. 

Patient was admitted to the Hospital November i, 1902, with a 
history of having had fainting attacks for the past year. 

Examination revealed the following points : 

Adams Stokes Syndrome, consisting of a bradycardia of 30 to 
58 beats a minute and fainting spells occurring several times a 
day. 



256 EPILEPSY AS A SYMPTOM. 

There was a considerable amount of arterio-sderosis. Patient 
also suffered from a chronic bronchitis and from interstitial 
nephritis. 

Patient had six or eight attacks of angina pectoris during her 
hospital residence ?ind finally died in one of these, May 2, 1904* 
Most of her convulsions were of the nature of fainting spells; 
although she had two or three of an epileptiform character. 

Meningitis or Polioencephalitis. 

Case No. 976, F. G. Female. Age 37 years. 

When about six years old, patient had brain fever which re- 
sulted in partial blindness and left-sided sensory hemiplegia. She 
commenced to have convulsions about seventeen years ago. The 
exciting cause she claims is overeating. 

Hydrocephalus. 

Case No. 865. H. C. M. Female. Age 24 years. 

Patient was admitted to the hospital about one year ago. She 
has had epileptiform convulsions for the past twenty-three years. 
The shape of her head is typical of hydrocephalus. Her lower 
extremities are very spastic and she has little use of them. Her 
mental development is about that of a child eight years old. 

Hydrocephalus. 

Case No. 651. M. K. Female. Age 30 years. 

Patient was admitted to the hospital about two years ago. The 
shape of her head was typical of hydrocephalus. There was a 
considerable amount of exophthalmos. There was an external 
strabismus and ptosis of the left lid. Her lower extremities were 
very spastic and she had little use of them. She had had convul- 
sions, epileptiform in character, for the past fourteen years. She 
had suffered for several years with mitral stenosis and died from 
this cause. May 21, 1905. 

Little's Disease. 

Case No. 780. A. W. Male. Age 19 years. 

Patient had convulsions when three years of age. Cause, 
rickets. After this they ceased for about five years and began 
again at about eight years of age. 



EVERETT FLOOD. 257 

Patient's gait is very spastic; reflexes are all plus; Babinski 
present This condition according to his people has been present 
since infancy. 

Disseminated Sclerosis. 

Case No. 241. C. B. P. Male. Age 22. 

Family history negative as far as can be ascertained. Patient 
was always well until about eighteen years of age when he began 
to complain of weakness of the legs and at this time there seemed 
to be considerable muscular rigidity. These symptoms increased 
until he came imder observation when he presented the following 
s)rmptoms: Intention tremor, scanning speech, spastic paretic 
gait, lateral nystagmus, epileptiform attacks. Patient's mind is 
very weak and apathetic, his voice is monotonous, breaks easily, 
and hoarseness is present. After he became confined to the bed, 
he began to have attacks of purposeless laughing and crying. 
The other symptoms grew worse and he died from exhaustion. 

Cerebral Tumor and Amyotrophic Lateral Sclerosis. 

Case No. 563. S. A. R. Female. Age 40 years. 

Patient was admitted to the hospital February 29, 1902. 

Upon admission patient had had convulsions for the past six 
years. During patient's hospital residence the following symptoms 
were noted. Upon admission there was considered spasticity of 
the lower extremities. This gradually increased and extended 
to the arms. Soon after admission, atrophy of the muscles of 
the legs, the shoulders, arms, forearm, and hands began. This 
gradually increased until at the time of patient's death, May 6, 
1904, it was very pronounced. The muscles of the face were also 
atrophied to some extent. There was a fine tremor of the mus- 
cles of the left cheek and lips. During the last eighteen months 
of patient's residence pronounced bulbar s)rmptoms made their 
appearance. She had great difficulty in swallowing and articu- 
lating. Aphasia of amnesic character made its appearance soon 
after patient's admission to the hospital and this combined with 
patient's convulsions made a diagnosis of cerebral tumor evident. 
After patient had convulsions, the aphasia, bulbar symptoms, and 
spasticity seemed more pronounced. 

Patient died of respiratory failure. May 6, 1904, and at autopsy 

17 



2S8 EPILEPSY AS A SYMPTOM. 

a cystic tumor was found near the center of the left frontal lobe 
about 11/2 in. long, i in. wide, and i in. thick. 

There are a large number of cases remaining in which no gross 
lesions can be demonstrated. These cases have for want of a bet- 
ter title been classified as idiopathic epilepsy. A derangement of 
metabolism, an autointoxication affecting a weakened area is often 
the real condition and the fit is a combination of symptoms result- 
ing. This may be imagined to be the equivalent of an actual 
lesion though it will never become demonstrable, passing away 
as a congestion of blood might pass. The occurrence of the fit 
or any of its premonitions ought to cause us to look for a condition 
back of it which may be treated. 

During the past few years a number of observers have found in 
patients, dying of status, microscopical changes in the cells of the 
cortex, such as chromatolysis and nuclear changes. It seems 
probable that in time we may be able to classify these cases of 
idiopathic epilepsy as chronic encephalitis or chronic degenera- 
tion of the cortical cells, etc., with epileptic convulsions as a symp- 
tom. 



THE THERAPEUTIC AND MEDICO-LEGAL FEATURES 
OF DRUG ADDICTION. 

By GEORGE P. SPRAGUE, M.D. 
Director Dr, Sprague^s Sanatorium, Lexington, Ky, 

The belief that the treatment of drug addictions has been made 
needlessly obscure by many writers, and the belief that to most 
physicians the drug habitue is the victim of a vice, merely, and 
not a sufferer from a diseased condition, prompts the presentation 
of this brief paper. 

It should be understood, at the outset, that a large number of 
drug users are such, because their nervous systems are below par 
in resistance to what may be called the normal pains and discom- 
forts of life ; often below par in judgment, and can never stay well 
while they live an unrestrained existence. It naturally follows 
that this class of drug users is more apt to commit abnormal acts, 
after being poisoned by the drug, than are those with normal 
organizations. 

It may be accepted without argfument, that the gradual reduc- 
tion method, in cases of morphin addiction, is the method of selec- 
tion, and that the patients must be under the complete control of 
the physician. 

The simple rule for the reduction is to remove the drug as 
rapidly as can be done without causing the patient to suffer. This 
requires from five to fifteen days, for the average case; in fact 
the writer has seen but two cases in fifteen years experience with 
this class of patients, who required a longer period. One was a 
divorced, syphilized, hysterical woman ; the other was thought to 
have a cerebral abscess, and died under treatment, without autopsy. 

Each case is a law unto itself, but the average patient will 
be comfortable on the first day of treatment, on from J4 to ^ 
of the amount of morphin he had been taking. It is best given in 
doses of equal amounts, just before each meal, at bedtime, and at 
about 2 a. m., making five doses in twenty-four hours. The 



26o DRUG ADDICTION. 

morning dose is then decreased rapidly, each day, until the point 
of tolerance has been reached, after which, the doses for each day 
are decreased not more than i/io grain at a time, beginning with 
the morning dose, until the last day not more than i/io of a 
grain is given, after which strychnia for two or three additional 
days will suffice. 

If elimination is carefully carried out, if the patient is fed all 
he can assimilate, and be given a tactful, companionable nurse, 
he will be free from the drug, and comfortable in the time men- 
tioned, without having had pain, prostration, diarrhoea, and with- 
out any suggestion of delirium, so common in the hyoscine treat- 
ment. These statements liave been sneered at by competent men 
who disbelieved simply because they had not tried the method. 
Any method will be useless if the nurse is not absolutely true to 
the physician. The patient should never be left alone, and should 
come in contact with the smallest possible number of persons; 
even then, the physician is justified in being suspicious of the 
patient, and with everyone with whom he may converse. It is 
easy to remove the drug ; easy to have the patient feel within two 
weeks, that he is well, but the treatment is then only well started, 
for complete recovery, additional weeks of thorough elimination, 
of correct living, of being taught to bear ordinary pains that may 
arise, without a drug to relieve them, with frequent explanations, 
warnings, and suggestions from the physician, are necessary. 

It is probable that in many cases, the recurrence of the habit, 
the moral lapses and the foolish excuses for wrongdoing are 
all due to a weakness of judgment, which is the larger part of a 
mental change as definite as the logical, coherent state from which 
the epileptic emerges without recollection. In other words, there 
seems to be abundant evidence to prove that (in many cases, at 
least) the habitual use of morphin produces a co-incident change 
in the victim's judgment, desires, and memory, so subtle that 
his intimate friends often fail to recognize it, and yet so real that 
nearest dependent relatives are disinherited, marriages unwisely 
consummated, fortunes dissipated, and crimes committed because 
of it. Of course such acts committed while the patient is known 
to be constantly using morphin would not be noteworthy, but 
these things and many others occur when morphin has not been 
taken for days previously, and when the patient appears even to 



GEORGE P. SPRAGUE. 261 

the alienist, called in to observe him, to be absolutely sane. Or 
they may be cc»nmitted by those who have so carefully concealed 
their use of the drug that no one suspects them, although when 
suspicion is once directed toward them, it may be seen that mental 
changes have occurred. Thus a prominent lawyer carried a filled 
hypodermic syringe in each pocket of his trousers, to use while on 
the bench, and in at least one case, convicted a man, accused of a 
serious crime, because, as he said, he knew he was guilty, no 
matter what the witnesses said. A trained nurse remarked that 
she had omitted doses of medicine, and at other times given mul- 
tiple doses just to see if they would have the eflFect the physician 
said they would have. A physician, besides having the tendency 
(which is common) to give morphin to his patients, needlessly, 
would recklessly experiment on his patients with other drugs, 
particularly with drugs of a poisonous nature. Each of these 
patients did not, for a moment, think that he had done wrong, 
although the lawyer said, when his attention was called to the 
matter, that he thought no habitual user of morphin was exactly 
normal, even if not under the acute effects of the drug. In 
another case, a brilliant lawyer, after having used morphin for 
over twenty years, was thought to have stopped its use for more 
than five years before his death, at which time it was found that 
he had left a large sum of money to a young servant girl, and had 
disinherited his only child, a widow. 

It cannot be too plainly stated that such abnormal acts as those 
just mentioned, are not the deeds of degraded persons, careless 
of the known rights of others, or of the sure reaction upon them- 
selves, but are committed because the patient cannot see that they 
are wrong; cannot follow cause to effect and see the reaction, 
and cannot always dissociate his hallucinations of special senses 
frOTti the words and acts of those about him. As Crothers has 
well said ("Morphinism and Narcomania from other Drugs")* 
"The medico-legal relations of morphinism are practically un- 
known, and every year it is becoming more and more apparent 
that some authoritative studies should be made along the medico- 
legal lines of this subject/' It is surprising that such a rich field 
should so long have been neglected, for these abnormalities are 
found to be quite common, when once our attention has been 
called to them. 



A PRELIMINARY REPORT OF THE GYNECOLOGICAL 

SURGERY IN THE MANHATTAN STATE 

HOSPITAL WEST. 

By LEROY BROUN, M. D., New York City, 

Surgeon to the Manhattan State Hospital; Assistant Surgeon to the 

Woman's Hospital; Fellow American Gynecological Society; Fellow 

N, Y, Academy of Medicine and of the N. Y. Obstetrical Society. 

Modem psychiatric science, my alienist friends tell me, has 
undergone many changes within a comparatively short period of 
years. Aside from new classifications and advanced modem 
methods of treatment applicable to all, the necessity of individual- 
izing — of treating each patient according to his or her especial 
needs — is becoming strongly impressed upon those responsible 
for the welfare of large aggregations of insane people. The 
value of the study of the individual and of the rendering of such 
physical assistance as may be needed with each patient is shown in 
the higher percentage of mental recoveries in the various institu- 
tions, and in the more contented and useful community of each. 

This is exemplified strongly in the present method of treating 
the tuberculous insane by isolation, protecting thereby the re- 
mainder, and in the tent life and the properly constructed, airy 
wards for the direct treatment of the tuberculous unfortunates 
themselves. What an advance over the old custom in which noth- 
ing of note was done for the protection of the rest of the patients 
or toward decreasing the mortality of those already infected. 

This same spirit of advance can be noted along all other lines, 
and the insane patient of to-day is treated as one who, though by 
the laws is confined with others of like disease, is however, subject 
to physical diseases and abnormalities which are now being sought 
out and remedied wherever they interfere with the general health 
of the individual. If from the improved physical state as a result 



264 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 

of this line of procedure, the mental status of the individual is 
benefited, the result is doubly gratifying. 

To be in a position to treat such pathological conditions in a 
proper surgical manner, Dr. Emmet C. Dent, as Superintendent 
of the Manhattan State Hospital West, in 1902, requested that I 
should take charge of the gynecological surgery of that institution 
and add to the equipment already on hand such necessaries as 
should place the facilities for modern surgery on a plane equal 
to that of other general hospitals. Through the far-sighted lib- 
erality of the State Board of Commissioners and the hearty en- 
dorsement of Dr. Dent this has been done, and this hospital is 
to-day equipped for surgery of the most advanced character. 

Before the report of the gynecological surgery done in this 
institution is considered, it will be of interest to review what 
is being done elsewhere, and to note the frequency of the exist- 
ence of pathological pelvic and abdominal conditions among 
insane women. 

Ripping states that in the asylum under his charge in Germany 
thirty-three per cent of diseased pelvic organs were found in one 
hundred consecutive autopsies. 

Hergt speaks of almost sixty-six per cent of diseases of the 
sexual organs of women being found in the autopsies for two years 
in the Heidelberg Institute. 

Isabella Davenport, of the Illinois Eastern Hospital for Insane, 
states that during 1898 to 1900, 431 female patients were ad- 
mitted; of this number 387 were examined g)mecologically and 
361 pathological pelvic conditions were found. Danillo reports 69 
per cent out of 200 patients examined, Rohe reports 74 per cent, 
Manton reports 81 per cent out of 100 patients examined. Hobbs 
reports 93 per cent. Pique, surgeon to the Alien Hospitals of 
the Department of the Seine, reports 89 per cent. Anna Hutchin- 
son, of the Manhattan State Hospital West, where my operations 
on the insane are being done, reports that during the year ending 
October, 1904, 700 women among the admissions of that year were 
examined by her ; 543 or seventy-seven per cent had pathological 
pelvic or abdominal conditions. 



LEROY BROUN. 265 

This large percentage of physical abnormalities existing in the 
sexual organs of the women inmates of the insane asylums 
throughout the country cannot be said to indicate that 75 to 80 
per cent of such patients have given birth to children, and that 
these departures from the normal state are the result of par- 
turition. As an evidence that this is not true, during the last 
sixteen years there have been admitted to the Manhattan State 
Hospital West, almost thirteen thousand women of whom forty 
per cent were single and sixty per cent married. Many abnormal- 
ities are, however, the result of child-bearing, and cause, by their 
neglect in many instances, suffering and a train of nervous dis- 
turbances undermining the general health of the patient. 

For the better understanding of the physical necessity of reliev- 
ing the pathological pelvic and abdominal disturbances in women, 
let me cite in brief a few prominent symptoms and conditions 
following in the train of each class. 

Fibroid Tumors of the Uterus. — ^At times contant pain; 
hemorrhages ; malignant degeneration ; disease of the kidneys 
by pressure on ureters ; sloughing. 

Ovarian Tumors. — Constant pain ; malignant changes. 
Purulent Diseases of Tubes and Ovaries. — Constant 
marked pain; incapacity for physical effort; invalidism; 
death. 

Tears of the Cervix and Perineum {severe) and Displace- 
ments. — ^Well-marked nervous disturbance, irritability, hys- 
teria, backache on slight exertion. 
Endometritis. — Irritability ; pain. 
It will be seen that all of the above conditions give rise to 
symptoms of sufficient gravity to cause women in the ordinary 
walks of life to seek assistance and to be willing to undergo 
surgical operations for their relief. The same relief is now 
recognized as the right of patients confined in insane asylums, and 
as a result they are being made, when it is given, happier and 
more contented members of the community in which their un- 
fortunate mental state has placed them. Of such importance is 



266 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 

the rendering of physical assistance to insane patients esteemed 
in France, that a large, well-equipped surgical pavilion has been 
for some years erected in connection with the department of the 
Seine. To this pavilion all patients needing surgical treatment 
are sent from the four asylums, St. Ann, Vaucluse, Villejuif and 
Ville Evrard. 

It is hardly necessary to speak in detail to the members of this 
Association of the operations of Manton in the Eastern Michigan 
Asylum, or of Hobbs in the London, Ontario, Asylum, or of the 
late Dr. Rohe in the Second Hospital for the Insane of Maryland. 
The work of each is a matter of record and one familiar to all — 
nor is it necessary to remind the Association of the unrelenting 
stand taken by Dr. Russell of the Hamilton Asylum of Canada 
in opposition to the views advanced by Rohe and by Hobbs. 

The operations of Rohe were done with the sole view of in- 
fluencing the mental state of the patients. They were thirty-four 
in number. An ablation of the tubo-ovarian adnexa was done in 
thirty-two instances. It would seem that a diseased state of the 
tubes and ovaries was not a prerequisite for their removal among 
the cases operated on. The indications for operation with him 
were hallucinations referable to the pelvic organs, and which were 
accentuated at the menstrual epoch. He reported eleven mental 
cures and nine mental ameliorations. The views of Rohe were 
unreservedly condemned by conservative alienists and surgeons. 

It is only necessary to quote an extract from a paper of Dr. 
Alexander Skene, read before your association in 1902, to indicate 
the opinion of all gynecologists upon this subject. He says, 
" The slow destructive action of the ovaries prepares the organi- 
zation as it were, for the menopause and at the same time occupies 
the nervous system with disturbances, which come from diseased 
ovaries, and hence their removal is a relief to the nervous system, 
whereas the removal of the normal ovaries is, figuratively speak- 
ing, an outrage to the nervous system which often overwhelms it." 

Raimann in the Chrobaks Festschrift of 1903, presents an ex- 
tensive article, " On the Causal Relations between Female AflFec- 
tions and Mental Disturbances." He reports in full eleven cases 



LEROY BROUN. 267 

in which the hallucinations were referable to the pelvic organs 
and accentuated during menstruation. In all the tubo-ovarian 
adnexa were removed though in some instances they were not 
diseased. There were no mental cures ; in three only was there 
any diminution of the previous hallucinations and in these the 
mental improvement was only slight. 

The results reported by Raimann are in accord with what would 
have been anticipated from a gynecological standpoint. It is 
contrary to all surgical experience to expect that the removal of 
the normal ovaries and tubes in a woman during her active sexual 
life can result other than disastrously to the nervous system even 
in women having no mental alienation — how much more so with 
those who have a weakened nervous potentiality as Tomlinson 
admirably expresses it, or in those already insane. 

In some instances the mental recovery of patients is hastened 
by the physical relief experienced, when an operation that is 
needed has been performed. Of this there is no question since 
there are well authenticated reports of such instances from many 
hospitals. The operation has not, other than in exceptional in- 
stances, been the means per se of the patients' mental recovery. 
It has, however, restored the patients' physical health, by the 
restoration of which the patient is able to profit to a full extent by 
the moral and therapeutic treatment given her in the institutions. 

The gynecological surgery at the Manhattan State Hospital 
West has been done with a view of improving the physical con- 
dition of the patient only. In every instance the relief of the 
local condition alone and the ordinary symptoms resulting have 
been considered; no cognizance has been taken of the mental 
state excepting as it precluded for the time any form of surgical 
operation. In other words, no operation has been done with a 
direct view of its possibly affecting favorably the mental disease 
for which the patient has been admitted to the hospital. 

While the relief of the physical suffering alone has been the 
object of these operations, the subsequent progress of the mental 
disease of these patients has been carefully noted with a desire 
to determine, if possible, whether the improvement of the general 



268 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST, 

health through the operation has exercised a beneficial effect on 
the favorable progress of their mental state. 

Reliable conclusions upon this question are extremely difficult 
to draw, since so many other factors enter into the mental im- 
provement of patients. 

Deductions to be decisive should be drawn from the result of 
systematic surgical work, extending over many years. In tab- 
ulating my own operations I have arranged them under three 
heads in order to better to analyze them. As stated, no operations 
have been undertaken with the direct object of influencing the 
mental status. The physical status alone has been considered. 
As a result of adopting this course fully three-fourths of the 
patients operated on were sufferers from forms of mental disease 
recognized as unfavorable and for whom little can be expected 
in the way of ameliorating their mental state. 

The unfortimates of this class had, however, as much claim 
for physical relief as those with more amenable forms of mental 
disease. 

The three classes into which I have divided these operations are : 
Major Operations which include all abdominal sections. Oper- 
ations for displaced uteri which include also, when present, a 
repair of cervical and perineal injuries ; finally. Minor Operations, 
including a restoration of injuries of the vagina and cervix and 
uterine endometrium. 

These divisions have been made, since it has been claimed by 
some, notably Rohe and Hobbs in the report of the results of 
their operations, that the greatest mental improvement has been 
noted in those operations involving the removal of diseased 
adnexa. Some authors also express the opinion that malpositions 
of the uterus are of considerable importance in the mental disturb- 
ance of women, while others believe that such conditions have 
very little bearing on their mental state. 

The daily population of the female division of the Manhattan 
State Hospital is about 2500 patients. The yearly admission of 
new patients is between 900 and 1000. As revealed by the pelvic 
examination of these patients admitted, fully seventy-five per cent 



LEROY BROUN. 269 

have some form of pelvic trouble. Operations have been done 
only in instances where the patient's life was imperilled, or to 
remove tumors, or in instances where the condition was such as 
to give rise to constant pain and ill health, or to a train of nervous 
symptoms. 

Two hundred and forty-two patients have undergone some form 
of g3mecological operation which is a little less than 5 per cent 
of the total number of women in the hospital during the period 
covering the operations. Of those operated on there have been 
sixty-two abdominal sections, fifty-one operations for displaced 
uteri and one hundred and twenty-nine minor plastic operations. 

As a result of all the operations done (242) one hundred and 
twelve patients have been physically benefited in a marked degree, 
one hundred and seven have been noticeably improved, though not 
to such an extent as in the previous number. 

Of the remaining patients five died, of which number two 
deaths were attributable to the operation and three to natural 
causes. 

When we bear in mind that in no instance was the mental 
condition of the patient made worse, either directly or indirectly 
as a result of the operations, the importance of rendering such 
surgical assistance as is needed to these tmfortunate members of 
our society becomes evident. In some instances lives have been 
saved ; in others, patients who had been bed-ridden or semi-inva- 
lids for a long period of time, were restored to excellent physical 
health. With the exception of a very small percentage all were 
made more useful and contented members of the community in 
which they live. 

The statement made by some writers that operative measures 
for remedying diseased conditions at times aggravate the insanity 
of the patient is not in accord with my experience. No instance 
of such aggravation exists among patients I have operated on. 
The same statement is made by Manton concerning his own 
operations in the Eastern Michigan Asylum covering a period of 
twenty years, and by Picque who has been operating for twelve 
years among the insane of Paris. 



270 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 

The collection of one hundred and nine operations brought 
together by the Italian alienists, Angelucci and Pierraccini, in 
which they state that twenty-three patients were made mentally 
worse I cannot analyse, having been unable to obtain the original 
article. If, however, these operations deal with castration for 
the cure of insanity, and I infer that this is the case, since the 
article seems to have been inspired by the widespread attention 
brought to this subject through the publications of Rohe and of 
Hobbs, it can readily be understood that the removal of com- 
paratively normal ovaries could accentuate the psychoses of these 
patients. 

The rare occurrence of true psychoses following gynecological 
operations upon women not previously insane, has been brought 
out by Rohe in the New York Medical Journal of October, 1893. 
Here he states that as a result of communicating with all the 
asylums of the United States and Canada he found that in the 
course of the ten years prior to 1893 only twenty-five patients 
had been registered in all of these asylums, as having become 
insane after gynecological operations. 

Kelly in his " Operative Gynecology " states that in an exper- 
ience of something over two thousand abdominal sections he has 
had eight patients who have become insane after operations. 
Piqu6 who has devoted much attention to this phase of insanity, 
draws a line between intoxication psychoses as the result of 
sepsis, the anesthetic, alcohol, or iodoform so largely used some 
years ago, and true psychoses following operations. 

He gives as his experience that the latter class includes only 
old people in whom the senile change in the brain is taking place, 
or those mentally weak in whom there exists an intense fear and 
dread of operations. 

This opinion, as expressed by Picque, appears to be that of most 
alienists of the present day. The only cases of insanity following 
operations coming under my care have been those of septic origin 
in which a relief of the sepsis has brought about a slow but steady 
improvement in the mental state. 

The late Dr. Bucke, Superintendent of the London, Ontaria, 



LEROY BROUN. 2/1 

Asylum, presented in a paper before your Association at its 
meeting in 1900 a full report, up to the time of his writing, of 
the gynecological operations of Hobbs in that institution. This 
report included two hundred patients. 

The results were from a mental standpoint: 83 women re- 
covered, 45 women improved, 68 women unimproved. 

Of sixty-three general surgical operations he reports only one 
patient recovering mentally. In analyzing the different char- 
acters of gynecological operations and their effects, he finds that 
the largest number of mental recoveries have been among those 
on whom operations were done for diseased ovaries and tubes; 
next in order he ascribes importance to relief of diseases of the 
uterus, and last, to relief of injuries to the pelvic floor. 

Pique in his " Surgery among Aliens " cites eighteen selected 
cases of his own, of which he reports ten mental recoveries and 
four mental improvements. In examining his report he does 
not show any larger number of improvements as resulting from 
removal of diseased uterine adnexa, in fact the greater number 
follow a cure of an endometritis with an eroded and lacerated 
cervix. 

In stud)ring the histories of the patients upon whom I have 
operated I find that of the two hundred and forty-two patients 
one hundred and thirty-eight still remain in the institution and 
one hundred and four have been discharged. Of those discharged 
forty-three are recorded as recovered mentally. Twenty patients 
of the forty-three discharged as cured have had their mental 
recovery materially hastened as a result of the physical improve- 
ment arising from the operations done upon them. 

While in the majority of these patients there had been some 
mental improvement before the operation was done, yet in all of 
the twenty of which we speak the psychic improvement following 
the operation was marked, as also was the steady progress toward 
recovery. 

I would not have it inferred that this change for the better was 
an immediate result of the operation. Such could not be ex- 
pected, nor did it exist. The marked improvement commenced 



272 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 

generally at the time that the patient began to experience her 
physical improvement and the relief from her former pelvic or 
abdominal discomfort. 

In this connection it is of value to note the moral eflfect of the 
operation. In not a few instances during my operations in this 
hospital patients in need of surgical work would be transferred 
from other wards to the hospital ward in such an excited state 
that it would be a question whether the operation should be done 
on account of the possibility of the patient injuring herself while 
recovering from the operation. If the physical condition was of 
sufficient gravity to warrant us in disregarding the mentally ex- 
cited state, the operation would be done and sufficient nurses 
supplied to protect the patient In not a few of such conditions 
it was surprising to find that additional nurses were not needed, 
since the patient had at once become docile, free from all excite- 
ment, and showed a willingness to do everything she was told. 
None of these patients, however, were among those discharged 
as recovered, hence it cannot be stated that the mental benefit 
accruing was a moral one. 

The diagnosis of the form of the mental alienation of the twenty 
patients whose recovery appeared in a great measure to be due to 
an improved physical condition as a result of the surgical operation 
is as follows: Melancholia, chronic in 5 patients; melancholia, 
acute in 7 patients ; mania, acute in 4 patients ; dementia, primary 
in 4 patients. 

It is seen that the beneficial effect of a surgical relief eventually 
resulting in a mental recovery is confined in my own experience 
to those patients whose mental disturbance might be largely 
influenced by the presence of pathological conditions. 

Through the earlier reports of operations that were done for 
the relief of insanity, the opinion among asylum physicians became 
prevalent that such efforts involved the removal of the tubo- 
ovarian adnexa of patients, and that a disease of these organs was 
not a necessary prerequisite. As a result a strong opposition 
was created among the physicians in charge of these institutions 
against all gynecological work, and it has only been within a 



LEROY BROUN. 273 

comparatively few years that this opposition has given way under 
the influence of a correction of this inference. 

Among my own operations it has been my effort to preserve one 
or both ovaries if consistent with the physical welfare of the 
patient. This course has been followed, in accordance with the 
now well established fact in pelvic surgery, that leaving even 
a part of an ovary, provided that part is in a healthy state, so 
modifies the necessary phenomena of the menopause as to relieve 
the patient of many of the more acute and depressing symptoms 
attendant thereon. 

From among the sixty-two abdominal sections performed for 
various pelvic and abdominal disorders seven had their mental 
recovery hastened through the beneficial physical effect of the 
operation. The character of these operations is as follows : 

2 myomectomies with suspension of the uterus, mental 
diagnosis, melancholia chronic and mania acute. 

2 suspensions of the uterus in one of which the right 
ovary and tube were removed. Mental diagnosis, melan- 
cholia acute in both instances. 

2 supravaginal hysterectomies for fibromyomatous tumors 
of the uterus, both ovaries and tubes were removed in 
each instance. Mental diagnosis, melancholia chronic and 
dementia primary. 

I Bassini's operation for inguinal hernia. Mental diag- 
nosis, melancholia chronic. 
It will be seen that the beneficial mental effect is not confined 
to abdominal operations of any especial character. In five of these 
cases the ovaries and tubes were not diseased except in one 
instance, necessitating the removal of one ovary. In two it was 
necessary on accoimt of disease to remove ovaries and tubes 
together with the tumor. 

These results are not in accord with those obtained by Hobbs 
of the London, Ontario, Hospital, who states that the best results 
obtained in that institution were in operations on the uterine 
appendages. Especially is this difference perceptible when in 
examining the total number of abdominal sections it is seen that 

i8 



274 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 

in twenty-three instances both tubo-ovarian adnexa were removed 
for disease, in only two of these were there mental recoveries. 

Not being an alienist, I hesitate to venture an opinion on this 
subject. I am, however, in full accord with the opinions of 
Tomlinson, that the mental benefit accruing is not dependent on 
the character of operation done, but more upon the nervous 
potentiality of the individual patient and her ability to respond to 
the stimulus of increased physical health. 

It matters not by what character of operation or by what other 
means the physical well-being of the patient is restored. 

Of the one hundred and twenty-nine plastic operations, ten of 
those discharged as cured began to give evidence of rapid mental 
improvement after recovery from the operations. While there 
was some improvement before the operations the rapid improve- 
ment was, however, subsequent. 

The only legitimate conclusion to be drawn is that the improve- 
ment was due to a relief from the previous ever acting, depressing, 
nervous disturbances resulting from these injuries. The char- 
acters of these operations were the repair of a torn perineum, to- 
gether with a diseased cervix, and the cure of an endometritis. 

The forms of mental disease were: Melancholia, acute in 4 
patients; melancholia chronic, in 2 patients; mania acute, in 2 
patients ; dementia primary, in 2 patients. 

Of the fifty-one operations for displaced uteri associated with 
a repair of the cervix and perineum where indicated, three patients 
had their mental recovery hastened by the correction of the pelvic 
abnormalities. 

Upon two of these patients a curettage and a shortening of the 
round ligaments by Alexander's operation was done, upon a third 
the peritoneal cavity was entered through an anterior vaginal 
incision and through this opening the rotmd ligaments were 
shortened ; the torn perineum was also repaired. 

The mental condition of these three patients was mania acute, 
melancholia chronic, and dementia primary. 

The length of time in which I have been conducting these 
operations is too short to draw conclusions of very great value. 



LEROY BROUN. 2/5 

Such systematic work must extend over a number of years before 
positive lessons can be learned. Operations done in most of the 
hospitals other than by Manton in the Eastern Michigan Hospital 
and Picque in the splendid surgical pavilion of the asylums of the 
Department of the Seine, and in the Manhattan State Hospital 
West, are of a character too transitory to permit of drawing 
conclusions which we can feel are not subject to future modi- 
fications. 

There are, however, some facts which I regard as well 
established. 

1st. If the operation when needed has been properly done and 
the patient is not mutilated by an uncalled-for castration the mental 
condition is never aggravated by such a procedure. This, as 
stated, has been the experience of Manton who has been oper- 
ating for over twenty years ; also that of Picque whose operations 
have extended over a period of twelve years, and of myself in the 
entire range of my surgical work among the insane. 

2d. There exists among the patients confined in the various 
insane asylums many pathological conditions which can and do 
give rise to symptoms detrimental to the patients' physical well- 
being and mental recovery. Those, with such conditions, have a 
right to be given relief irrespective of their mental state. 

3d. Under the stimulus of the improved somatic state resulting 
from surgical relief some of the patients show greater mental 
advancement imder the moral and therapeutic care than were 
shown before such relief was given. At times this improved 
mental state continues to one of recovery. 

The primary object of surgical operations upon the insane 
should be to improve the physical status of the patient with one 
end only in view, of relieving them of physical suffering and 
nervous disturbances. 

If as a result of this relief they are mentally improved, it is a 
sequel not primarily sought, yet welcomed. 



276 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 
MAJOR OPERATIONS 









i 


1 




Duration of 








1 


1 




8 


^l| 


Mental 
dia^osis 


mental 

disease 

preylous to 


Pelvic condition 


Date of 
opera- 
tion 


Opermtktt 


5 


1 

82 


III 




entering 
hospital 






C.S8-02 


9540 


M. 


Fair 


Mania, acnte 


2 wks. 


Multiple fibroids of 


1^26-02 


Snpra-Taginal 1 




B. H. 












uterus 




tereetomy 


10-14-02 


9829 
S. G. 


44 


S. 


Poor 


Melancholia, 
chronic 


8 to 4 yra. 


Retroyerted uterus 
with small fibroids 


10-80-02 


Curettage, mya 
tomy, TentrsI 
pension 


2-28-08 


10141 
H. L. 


21 


M. 


It 


Melancholia, 
acnte 


2 days 


Double adnezal 
disease, retro- 
version, adhesions 


8-4-08 


IntrmabdoraiBsl 
shortening of 
round ligameo^ 
ngnt tube, n 
ovary removd 


2-12-08 


10120 
M. S. 


89 


M. 


Fair 


Dementia 
paralytica 


■ . « • 


Ovarian cyst and 
retroflexed uterus 


5-7-08 


Removal of eyil 
and suspenskM 
uterus 


5-20-08 


9458 

N. G. 


80 


8. 


It 


Melancholia, 
chronic 


SKyrs. 


Retroversion with 
adhesions 


8-12-02 


Double salpiDff 
oophorectomy; 
suspension of 
uterus 


8-24-01 


8862 
H.W. 


48 


M. 


ti 


Melancholia, 
acnte 


8 to 4 wks. 


Right inguinal 
hernia 


11-80-^02 


Baasini's open! 


10-80-02 


^860 
C. G. 


40 


S. 


t( 


Melancholia, 
chronic 


2yrs. 


Retroflection with 
fibroids 


2-26-08 


Myomectomy;! 
seirs operatioi 


10-12-01 


8958 
B. R. 


54 


w. 


iC 


Dementia 
paralytica 


4 mos. 


Umbilical hernia 


8-19-08 


Repair of nipt« 


2-27-08 


10152 
M. F. 


28 


(1 


ti 


Melancholia, 
chronic 


8 yrs. 


Retroversion and 
ovarian cyst 


4-9-^8 


Curettage, snta 
vaginal sectios 
Shortening roa 
ligaments, nm 
of right ovsriti 
cyst 

Abdominal aectii 


4-15-08 


10802 


28 


8. 


Poor 


Dementia 


8 wks. 


Cyst of left ovary 


4-80-08 




M. P. 








precox 








left ovarian e; 
removed 


4-8-08 


10285 
A. R. 


32 


M. 


tt 


Melancholia, 
acnte 


6 mos. 


Retroversion, 
laceration of cer- 
vix and perineum 


5-9-08 


Curettage, hy«- 
terorrhspby 


5-14-08 


10877 

D. 
McL. 


84 


8. 


tt 


DepreeBiye 
hallncinoBis 


8 yrs. 


Acute appendicitis 


5-17-08 


Appendectomy i 
evacuation of f 


4-4-08 


10288 
A. L. 


26 


M. 


tt 


Melancholia, 
acute 


1 wk. 


Adherent retro- 
version, double 
pyosalpinx 


&-21-08 


Excision cerrix 1 
perineorrhspby 
suspension ntei 



LEROY BROUN. 
MAJOR 0PBRATI0N8 



277 



mltof 
intion 



■factory 



Fhysioal im- 
provement 
followinir 
operation 



Rapid 



\ Aug. 18 
Ifiutory 

itisfactory 
■factory 



Marked 

Slight 
ti 

Rapid 

Slight 
Marked 



Mental im- 
provement 
apparently re 
xerable to 
operation 



None 
Marked 

Very marked 

None 



Gradual but 
very marked 



None 
Slight 

None 

Slight 

Very marked 



Diaoharged 



Marked 



10-15-02 
8-80-08 

<M-08 



Transferred 
to E. hospital 



ld-36-08 



Discharged 
5-22-03 

Discharged 
4-28-04 

Discharged 
8-4-08 



Result 
mental 



Recovered 



Died 4-2-04 
Tuberculosis 

Discharged 
7-11-08 

Discharged 
10-19-08 



12-1-08 



Unimproved 



Recovered 



Unimproved 



Remain- 
ing in 
hospital 



None 



Improved 



Improved 



Remarks 



Patient had almost re- 
covered before opera- 
tion 

Patient had begun to 
improve before opera- 
tion; after operation 
improvement more 
rapid 

No improvement prior 
to operation. 



Hallucinations 15 mos. 
prior to operation. No 
hallucinations subse- 
quent to 4 mos. after 
operations. 



At time of operation 
patient greatly excited. 
Active hallucinations. 
All disappeared after 
operation. Discharged 
apparently cured, yet 
having same hallucina- 
tions 

Improvement does not 
appear to be due to 
operation 



. I 



278 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 



MAJOR OPERATIONS 



^ 






1 


1 




Duration of 








1 


1 


1 

85 


III 


Mental 
diagnosis 


mental 

disease 

previous to 

entering 

hospital 


Pelvic condition 


Date of 
opera- 
tion 


OpeiattOB 


5-21-08 


10895 


8. 


Fair 


Mania, acnte 


4 mos. 


Adherent retro- 


7-21.08 


Myomectomy; 1 




L. C. 












version, small 
fibroids 




pension nteru 


8-11-02 


10205 
M. C. 


80 


8. 


(t 


Melancholia, 
acnte 


6 wks. 


Retroversion 


7-21-.08 


Hysterorrhaphj 


^28-08 


N. 
10475 

M. 
McG. 


45 


8. 


u 


Paranoia 


6 mos. 


Right ovarian cyst 

Intestinal obstmc- 
tion 


7-28-08 
9-28-08 


Salpingo-oopbo 
tomy 
Intestinal reeeci 


11-1M)1 


9024 
M.G. 


85 


8. 


Poor 


Melancholia, 
chronic 


10 yrs. 


Multiple flbro. 
myoma 


9-9-02 


Supra- vaginal 1 
terectomy 


4-1-08 


10268 
M. B. 


81 


8. 


Fair 


Paranoia 


10 mos. 


Impacted fibro- 
myoma, nmbllical 
hernia 


6-11-08 


Supra-vaginal ^ 
terectomy, hen 
tomy 


8-17-08 


10689 
L. H. 


82 


M. 


it 


Epileptic 
psychosis 


2 wks. 


Double hydrosal- 
pinx retroversion 
(adherent). Lacer- 
ated cervix and 
perineum 


11-12-08 


Anterior vaginal 
section, shorts 
ing round liga- 
ments and sal- 
pingectomy 


1-6-08 


11094 
M. J. 


28 


8. 


<t 


Dementia 
primary 


2 yrs. 


Adherent retro- 
version dysmenor- 
rhoea, oophoritis 


11-14-08 


Hysterorrh^hy 
and oophoreci 
(right) 


7-4-08 


10497 
F. D. 


28 


M. 


(C 


Dementia 
prsecox 


18 wks.. 


Salpingo-oophori- 
tis, retroversion, 
lacerated cervix 
and perineum 


12-10-08 


Salpingo-oopboi 
tomy, faysteroi 
rhaphy and pel 
orrhaphy 


1-6-08 


10021 


28 


M. 


tt 


Mania, acnte 


.... 


Fibro-myoma 


12-81-08 


Hystero-salptsg 
oophorectofli}| 




L. P. 
















6-5-08 


10428 
M. 8. 


45 


M. 


Poor 


Melancholia, 
chronic 


4 yrs. 


Mnltiple-fibro- 
myoma, anteflex- 
ion, laceration of 
cervix and peri- 
neum 


1-14-04 


Anterior vafin 
section — mys 
tomy— Goffsl 
ration— exeiil 
cervix and p« 


12-28-02 


9098 
C.8. 


21 


8. 


it 


Dementia 
prsecox 


1 mo. 


Pelvic abscess 


1-28-04 


neorrhaphy 
Complete bysU 
tomy 




1-28-04 


11140 
J.B. 


86 


W. 


Fair 


Melancholia, 
acnte 


6 wks. 


Adherent retrover- 
sion 


4-14-04 


Hysterorrbspfe] 




2-1-04 


11170 
H. F. 


22 


M. 


ti 


Dementia 
prsecoz 


5 days 


Retroversion 


4-28-04 


CcBllotomy uA 
palrofpunetl 
uterus 

CompleUhysH 




4.22-04 


11884 


21 


M. 


Poor 


Mania, acnte 


15 days 


Puerperal septic»- 


4-28-04 






V. A. 








(deUrions) 




mia (Pelvic ab- 




tomy 
















scess) 




. 






















1 
J 





LEROY BROUN. 
MAJOR OPERATIONS 



279 



Besnltof 
opentloii 


Phjraical 

improyement 

foUowliiff 

operation 


Mental im- 
provement 
apparently 
referable to 
operation 




Reeult 
mentol 


Remain- 
ing in 
hospital 


Remarks 


(bktUfaetory 


Marked 


Marked 


11-17-08 


Recovered 


.... 


Slight mental improve- 
ment before operation 


(i 


t( 


II 


4-5>-04 


It 
Died Sept 


.... 


Slight mental improve- 
ment before operation 
Slight mental improve- 


^ Died 








28-08. Shock 




ment before operation; 
recovered from first 
operation, 2 mos. later 
intestinal obstrnction 
developed 


^tlsfaetory 


Marked 


Marked 


10-10-04 


Recovered 




Slight mental improve- 
ment before operation 


I 

i 


it 


None 


8-28-04 


Improved 


.... 


Slight mental improve- 
ment before operation 


i( 


Blight 


II 


1-6-04 


II 




Improvement does not 
appear to be due to 
operation 


It 


ii 


Slight 


7-2<M)4 


II 


.... 


Improvement begun be- 
fore operation 


i 


li 


II 


2-8-04 


II 


.... 


Some improvement be- 
fore operation 


(« 


Marked 


II 


4-19-04 


II 


.... 


Some improvement fol- 
lowing operation. 
Patient re-admitted 
Oct. 6-04 


«c 

1 


c< 


II 


4-15-04 


11 




Improvement before 
operation 


(< 


II 


II 


5-1^04 


II 


.... 


Marked improvement 
after operation; 
patient re-admitted 
May. 04 


4( 


II 


II 


6-10-04 


Recovered 


.... 


Some improvement be- 
fore operation 


it 


II 


<i 


7-1-04 


Improved 


.... 


Some improvement be- 
fore operation 


Died 


None 


None 




Died 4-80-04 




Died 2 days after opera- 
tion, of ezhanstion 
from puerperal sepsis 



280 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 



MAJOR OPERATIONS 











1 




Duration of 










< 


SES 


1 


|l 

M. 


If! 


Mental 
dlaffDosis 


mental 
disease 
previous to 
entering 
hospital 


Pelvlo oondltlon 


Date of 

opera- 

fion 


OperaOoo 


6-7-00 


7379 


84 


Poor 


Mania, acute 


5 days 


Tuherculons perito- 


2-11-04 


ExploratoiT cttM 




B. C. 












nitis 




tomy 


8-2M)4 


11818 
P. H. 


88 


M. 


Pair 


Dementia 
precox 


2 mos. 


Multiple flbro- 
myoma 


5-5-04 


8upra-vaglna] hfi 
terectomy 


5-5-04 


11435 
P. H. 


82 


8. 


tc 


Paranoia 


10 days 


Adherent retrover- 
sion salpingo- 
oophoritis 


6-9-04 


Hysterorrbapby- 
lef t salpingo- 
oophorec tony- 
right salpingee- 
tomy 


11-17-95 


48851 
L. 8. 


82 


8. 


Poor 


Mania, 
chronic 


.... 


Fibro-myomata 
uteri 


8-19-02 


8upra-vagiDtlliji' 
terectomy 


11-14-98 


5094 
L. L. 


40 


8. 


II 


Melancholia, 
chronic 


8 yrs. 


II II II 


9-8-02 


Supra-vsginsl lij»- 
terectomy 


d-13-03 


9190 
C.S. 


89 


8. 


II 


Dementia 
terminal 


5yrs. 


II II II 


9-28-02 


Supra- vaginal hyfr 
terectomy 


9-11-03 


0782 
L. 8. 


84 


M. 


II 


Melancholia, 
chronic 


8>^ yrs. 


Retroflexion, lacera- 
ted cervix and peri- 
neum 


11-5-02 


HyBterorrbiphj- 
excision cerrli- 
perineorrhapby, 
curettagei 


2-13-00 


7028 
J. N. 


82 


•• 


Pair 


Melancholia, 
chronic 


lyr. 


Right inguinal her- 
nia 


11 20-02 


Herniotomy 


10-20-00 


8180 
L. G. 


48 


M. 


II 


Melancholia, 
chronic 


Ijr. 


Umbilical hernia 


11^-19-02 


<c 


8-37-97 


5191 
8. L. 


89 


M. 


II 


Mania, 
chronic 


10 yrs. 


Multiple flbro- 
myomata retrover- 
sion 


3-5-08 


Myomectomy; bj» 
terorrbaphy 


10-8-97 


5257 
A. H. 


86 


•• 


Poor 


Melancholia, 
chronic 


8 yrs. 


Ovarian cyst 


2-13-08 


Excision of oTftriA 
cyst 


3-7-08 


10105 
F. 8. 


45 


M. 


Fair 


Melancholia, 
chronic 


lyr. 


Fibro-myomata 
uteri salpingo- 
oophoritis 


4-16-08 


Supra-vagintlliy*- 
terectomy 


3-37-08 


10154 
J.J. 


39 


M. 




Paranoia 


1 wk. 


Fibro-myomata 
uteri ovarian cyst 


4-28-08 


Supra-vaginal hys- 
terectomy 


1-7-08 


10022 
E. B. 


49 


M. 




II 


8 yrs. 


Fibro-myoma uteri 
impacted in pelvis 


7-2-08 


Supra- vaginal hyi- 
terectomy adnexa 
removed 


4-5-97 


5029 
R. P. 


23 


M. 




Mania, 
chronic 


5 mos. 


Fibro-myoma uteri 


7-14-08 


Supra- vaginal hys- 
terectomy rifM 
ovary left 


8-34-99 


5882 
A. V. 


40 


•• 




Dementia, 
secondary 





Incarcerated femo- 
ral hernia, left 


7-24-03 


OperaUon-redttc- 
tion 


3-8-08 


10498 
N. H. 


85 


W. 




Paranoia 


lyr. 


Adherent retrover- 
sion lacerated cer- 
vix and perineum 




Suspension ntenit; 
left tube and otu 
removed; exclri<« 
cervix and repair 
of perineum 



LEROY BROUN. 
MAJOR OPERATIONS 



281 



Baanlt 
operation 


Ph jaioal im- 
provement 
followiniT 
operation 


Mental im- 
provement 
apparently 
referable to 
operation 


Dlaoharged 


Reault 
mental 


Remain- 
ing in 
hospital 


Remarks 


fuatiafactory 


None 


None 


Died 4-4-04 


None 


.... 


Died of pulmonary and 
peritoneal tubercnlo- 
sis 2 mos. after opera- 
tion 


aatisfactory 


Marked 


Marked 


»-17-04 


Recovered 


.... 


Slight improvement be- 
fore operation 


»« 


• • • • 




Died 7-28-04 


None 


.... 


Died 14 days after 
operation of pulmo- 
nary emboli 


«< 


Marked 


None 


.... 




2-1-05 


No mental improve- 
ment before or after 
operation 


•* 


ti 


11 


• • • . 




ti 


No mental improve- 
ment before or after 
operation 


4t 


tt 


tt 


* * * ■ 




t« 


No mental improve- 
ment before or after 
operation 


<t 


None 


tt 


.... 




tt 


Slight mental improve- 
ment before operation 


ii 


Marked 


Slight 


.... 




tt 


Slight mental improve- 
ment before operation 


(C 


tt 


None 


.... 




tt 


Slight mental improve- 
ment before operation 


ti 


tt 


it 


.... 




It 


Slight mental improve- 
ment before operation 


t( 


Very marked 


ti 


.... 




tt 


Slight mental improve- 
ment before operation 


it 


Marked 


It 


.... 




«t 


Slight mental improve- 
ment before operation 


ti 


it 


Slight 






tt 


Mental improvement 
before operation 


ii 


tt 


None 


.... 




It 


Slight improvement 
before operation 


ti 


tt 


tt 


.... 




it 


Unchanged 


ii 


tt 


it 


.... 




tt 


Much improved before 
operation 


it 


It 


tt 






tt 


Slight improvement 
before operation 



282 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 



MAJOR OPERATIONS 









^ 


e 




Duration of 








1 


o 




!3 


If! 

Fair 


Mental 
dla^noila 


mental 

diseaae 

previous to 


Pelvic condition 


Date of 

operar 

tlon 


Operation 


< 


^ 


24 


11 




entering 
hospital 








8-15-98 


58191 


Dementia 


6yr8. 


MnlUple flbro- 


9-10-8 


Supra-vaginal hys- 




H.M. 








terminal 




myoma uteri 




terectomy; both 
adnexa removed 


9-8-08 


10698 
K. T. 


30 


8. 


II 


Paranoia 


6 mos. 


Multiple flbro. 
myoma uteri 


9-17-08 


Supra-vaginal hys- 
terectomy; ovarlei 
not removed 


12-2-08 


87116 


88 


8. 


i( 


Imbecility 


Life 


Retroversion, flbro- 


10-1-08 Supra- vaginal hys- 




R.M. 












myoma— lacerated 
cervix and peri- 
neum 




terectomy; ovariei 
removed 


4-18-08 


10297 


28 


W. 


ii 


Paranoia 


• • • • 


Ovarian cyst 


10-1-08 Cyst removed 




I.G. 
















through posterior 
vaginal incision 


4-29-08 


10888 


87 


W. 


Poor 


Dementia 


8 mos. 


Ovarian cyst, retro- 


9-15-08 Curettage, excision 




N.H. 








precox 




version, lacerated 
cervix and peri- 
neum 




cervix perineor- 
rhaphy, abdominal 
section, ovarian 
cyst removed 


8-12-08 


10620 
8. G. 


29 


8. 


Fair 


Epileptic 
pBychosis 


• ••• 


Adherent retrover- 
sion 


11-8-08 


Removal both 
adnexa, suspensio 
of uterus 


2-(M)8 


10099 

N.F. 


84 


8. 


cc 


Melancholia, 
acute 


8 mos. 


Chronic appendi- 
citis 


8-24-08 Appendectomy 


8-28-08 


10668 
L. S. 


46 


M. 


II 


Paranoia 


6 moB. 


Fibro-myoma 


12-8-08 Supra-vaginal hys- 
terectomy 


1-15-96 


41121 
L. L. 


K9 


W. 


Poor 


Melancholia, 
chronic 


2 days 


Multiple fibroids of 
uterus 


12-10-08 Vaginal hysterec- 
tomy 


9-6-08 


10692 


35 


M. 


Fair 


Melancholia, 


2 mos. 


Double adnexal 


12-24-08 Removal both 




M.M. 








acnte 




disease 




adnexa and hyster 
orrhaphy 


4-29-08 


10884 


45 


W. 


ti 


Dementia 


4 mos. 


Adherent retrover- 


1-5-04 Suspension of 




M.H. 








prsecoz 




sion 




uterus, left tube 
and ovary removes 


9-14-08 


10709 
L. P. 


81 


M. 


IC 


Mania, acute 


5 mos. 


Fibroid uterus 


1-14-04 Supra- vaginal hys- 
terectomy with re 
moval of ovaries 


10-18-01 


51871 


48 


, , 


It 


Melancholia, 


• • • • 


Uterine flbro- 


2-4-04 Supra- vaginal hys- 




M.G. 








chronic, 
alcoholic 




myoma 




terectomy with re 
moval of ovaries 


10-21-08 


10829 
A. R. 


28 


8. 


11 


Dementia 
Praecoz 


8 years 


Adherent retrover- 
sion 


1 terorrhaphy 


12-29-08 


11068 
M.H. 


46 


W. 


II 


Dementia 
paralytica 


1 mo. 


Fibro-myoma uteri 


4-21-04 Myomectomy, ap- 
1 pendectomy 


4-14-04 


11866 

M. 
McD. 


44 


8. 


II 


Mania 
depresslTe 


. • • • 


Fibro-myoma uteri 


7-11-04 Supra-vaginal hys- 
terectomy with 
ovaries removed 


10-1-08'10784 


23 


8. 


Poor 


Dementia 


10 yrs. 


Fibro-myoma uteri 


9-29-04 Myomectomy 


1 J.S. 




1 


secondary 






1 



LEROY BROUN. 
MAJOR OPERATIONS 



283 



Besolt of 
operation 


Physioal 

iinproyement 

fbllowlxig 

operation 


Mental im- 
proyement 

referable to 
operation 


Discharged 


Result 
mental 


Remain- 
ing in 
hospital 


Remarks 


Satisfactory 


Marked 


None 


.... 


.... 


2-1-1905 


Unchanged 


<t 


II 


CI 


12-20-04 


Improved 


.... 




t« 


II 


II 


.... 


.... 


a-1-1906 


Unchanged 


•1 


II 


II 


.... 


.... 


II 


Slight improvement be- 
fore operation 


*• 


Has 
Tubercolofis 


II 


Died 11-0-04 


Tuberculosis 


II 




cc 


Marked 


II 


.... 


.... 


II 


Unchanged 


<t 


Slight 


II 






II 


Visceral delusions still 


CI 


II 


Slight 


l»-Sl-04 


Improved 


.... 


exist unchanged 


It 


II 


None 








2-1-1006 


Unchanged 


41 


II 


II 


.... 


.... 


It 


II 


II 


II 


II 


.... 


.... 


II 


II 


tl 


Marked 


Slight 


.... 


.... 


II 


Slight improvement due 
to operation 


II 


Slight 


II 


.... 


.... 


II 


Unchanged 


CI 


II 


II 


.... 


.... 


II 


II 


C( 


Marked 


II 


.... 


.... 


11 


II 


cc 


SUght 


II 


Transferred 
to L. I. State 


Improved 


II 




cc 


It 


II 


Hospital 


.... 


II 


Unchanged 



284 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 



OPERATIONS FOR DISPLACED UTERI 



< 






J, 


e 




Duration of 








^ 


1 


li 


It 


Mental 
diagnosis 


mental 
disease 
prior to 
entering 
hospital 


Pelvic condition 


Date of 

To?^ 




6-a-oa 


9468 
M. G. 


27 


M. 


Fair 


MelanchoUa, 
chronic 


4yrs. 


Movable retrover- 
sion; lacerated 
cervix and peri- 
neum 


7-29-02 


Alexander's opera- 
tion; excision cervix 
and perineorrhaphy 


10-80-02 


9868 
C. 8. 


82 


8. 


Poor 


Melancholia, 
chronic 


2 yrs. 


Movable retrover- 
sion; lacerated 
cervix 


12-4-^2 


Alexander's open- 
tion; excision cervix 
and curettage 


10-1-03 


9785 
E. P. 


44 


M. 


Fair 


Melancholia, 
acnte 


1 mo. 


Movable retrover- 
sion; lacerated 
cervix and peri- 
neum 


12-4-02 


Alexander's opera- 
tion; excision cerdz 
and perineorrhaphy 


11-8-oa 


9887 
M. G. 


80 


M. 


t( 


Melancholia, 
acnte 


1 mo. 


Movable retrover- 
sion 


12-11-02 


Alexander's opersr 
tion; curettage 


8-25-08 


10254 
D. R. 


25 


8. 


iC 


Dementia, 
primary 


8 mos. 


Movable retrover- 
sion 


5-5-08 


Alexander's opera- 
tion; curettage 


2-14-08 


10128 
E. R. 


88 


M. 


tt 


Melancholia, 
acute 


lyr. 


Movable retrover- 
sion; lacerated 
cervix and peri- 
neum 


5-28-08 


Alexander's opera- 
tion; curettage, 
perineorrhaphy 


4-28-08 


10818 
8. J. 


24 


8. 


it 


Mania, 
depressiye 


8 wks. 


Movable retrover- 
sion ; endometritis 


8-25-08 


Alexander's opera- 
tion; curettage 


5-7-08 


10855 
N. Q. 


47 


8. 


Poor 


Alcoholic 
delirium 




Procidentia; 
chronic nephritis 


1-7-04 


LaForte's operaUon 


8-18-03 


10828 
E. C. 


38 


W. 


Fair 


Mania, 
chronic 


6 yrs. 


Movable retrover- 
sion; endometritis, 
lacerated peri- 
neum 


11-24-08 


Alexander's opera- 
tion; curettage, 
perineorrhaphy 


11-7-03 


10891 
A. M. 


36 


8. 


t{ 


Melancholia, 
acute 


11 days 


Movable retrover- 
sion 


1-22-04 


Alexander's opera- 
tion 


10-10-03 


10791 
T. H. 


26 


M. 


Ci 


Mania, acute 


6 wks. 


Movable retrover- 
sion ; lacerated 
cervix and peri- 
neum 


1-28-04 


Alexander's opera- 
tion; excision cer- 
vix and perine- 
orrhaphy 


8-21-08 


10648 
M. D. 


23 


8. 


tl 


Mania, acute 


2 mos. 


Movable retrover- 
sion 


2-2-04 


Alexander's opera- 
tion; curettage 


10-80-08 


10896 
L. M. 


27 


8. 


Poor 


Melancholia, 
chronic 


4 mos. 


Movable retrover- 
sion ; dysmenor- 
rhcea 


8-81-04 


Alexander's opera- 
tion; curettage 


12-24-08 


11060 
A. C. 


28 


M. 


Fair 


Dementia 
precox 


8 mos. 


Movable retrover- 
sion; lacerated 
perineum 


2-25-04 


Alexander's opera- 
tion; perineor- 
rhaphy, curettage 


8-9-04 


11269 
K. B. 


29 


8. 


it 


Mania, 
depressive 


1 wk. 


Movable retrover- 
sion 


6-26-04 


Alexander's opers- 
tion 


5-12-04 


11455 
A. H. 


89 


Sep. 


(t 


Paranoia 


5 yrs. 


Movable retrover- 
sion; lacerated 
perineum 


7-36-04 


Alexander's opera- 
tion; shortening 
utero-sacral liga- 
ments; perine- 


















orrhaphy 



LEROY BROUN. 
OPERATIONS FOR DISPLACED UTERI 



28s 



Satisfactory 



Physical 

Improvement 

following 

operation 



Marked 

Slight 
Marked 

Noticeable 
Marked 



None 



Slight 



Marked 
Slight 



Mental im- 
provement 
apparently 
referable to 
operation 



None 



Marked 

mo8. after 

operation 

Slight 



Marked 
Slight 

Marked 
SUght 



Dlaoharged 



Remit 
mental 



Transferred Improved 
4-08 



None 



»-14-08 
8-81-08 

1-so-oa 

9-14-08 
7-27-08 

11-20-08 



Died 4-26-04 
Nephritis 



2-12-04 

8-8-04 
5-9-04 

8-&-04 
7-0-06 

5-26-04 

9-20-04 
9-26-04 



Recovered 



Improved 



Recovered 



Remain- 
ing in 
hospital 



Died 



Improved 



Recovered 



Improved 
II 

Recovered 
Improved 



Remarks 



No mental improve- 
ment for 5 moB. after 
operation 

Some improvement be- 
fore operation 



Slight improvement be- 
fore operation. 

Considerable improve- 
ment before operation 

Re-admitted March 16- 
04 

Slight improvement 
before operation 

Slight improvement 
after operation, chronic 
nephritis, which was 
present on admission 

Some improvement be- 
fore operation 



Some improvement be- 
fore operation 

Some improvement be- 
fore operation 



Some improvement be- 
fore operation 

Some Improvement be- 
fore operation 

Slight improvement be- 
fore operation 

Some improvement be- 
fore operation 

Some improvement be 
fore operation 



286 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 



OPBRATIONS FOR DISPLACED UTERI 



g 






|l 


1. 




Duration of 








1 


1 




1 


Mental 
diagnoBls 


mental 
diseaee 
prior to 


Pelvlo condition 


Date of 
opera- 
tion 


Opeimtlon 


1 






entering 
hospital 








8-29-00 


7866 
A. C. 


30 


M. 


Poor 


Melancholia, 
chronic 


• • • • 


Movable retrover- 
sion; lacerated 
cerrix and peri- 
neum 


7-22-02 


Alexander's opera- 
tion; excision cer- 
vix, perineor- 
rhaphy 


8-38-02 


9449 
M. 8. 


29 


M. 


Fair 


Melancholia, 
chronic 


2yrt. 


Retroflexion; 
lacerated cervix 


9-16-02 


Alexander's opera- 
tion, excision of 
cervix 


5-11-02 


9667 
8. A. 


80 


M. 


CI 


Mania, 
chronic 


8 yn. 


Retroflexion; 
lacerated cervix 
and perineum 


10-80-02 


Alexander's opera- 
tion; excision of 
cervix, perineor- 
rhaphy and curet- 
tage 

Alexander's opera- 


9-11-02 


9780 


80 


W. 


tl 


Melancholia, 


16 moa. 


Movable retrover- 


11-20-02 




I. H. 








chronic 




sion; lacerated 




tion; exesion of 




K. 












cervix and peri- 
neum 




cervix, pierineor- 
rhaphy 


9-19-02 


9768 
J. A. 


88 


M. 


Poor 


Paranoia 


2 yrs. 


Movable retrover- 
sion; lacerated 
perineum 


12-19-02 


Alexander's opera- 
tion; perineor- 
rhaphy 


10-21-02 


9848 
L. H. 


88 


W. 


Fair 


Melancholia, 
acnte 





Retroversion, lacer- 
ated perineum 


81-4-08 


Gofle's opermtloD; 
perineorrhaphy 


8-7-08 


10198 
G. R. 


82 


8. 


Poor 


Dementia, 
primary 


4 mos. 


Movable retro- 
flexion 


4-80L.98 


Alexander's opera- 
tion 


8-21-08 


10247 
A. T. 


40 


W. 


Fair 


Paranoia 


8yni. 


Movable retrover- 
sion, lacerated 
cervix and peri- 
neum 


5-21-08 


Alexander's opera- 
tion, excision of 
cervix and pertne- 
orrhaphy. 


8-7-08 


10194 
M. D. 


81 


8. 


<{ 


Melancholia, 
chronic 


2 yrs. 


Movable retrover- 
sion, endometritis 


5-28-08 


Alexander's opera- 
tion, curettage 


(^-7-01 


8686 
M. 
D. C. 


26 


8. 


It 


Dementia 
terminal 


6 mos. 


Movable retrover- 
sion, right inguinal 
hernia 


8-25-08 


Alexander's opera- 
tion, herniotomy 


8-28-08 


10268 
L.8. 


86 


M. 


II 


Melancholia, 
chronic 


8 yrs. 


Retroflexion, lacer- 
ated cervix and 
perineum 




Alexander's opera- 
tion, excision of 
cervix and perine- 
orrhaphy 


11-17-02 


9918 
A. G. 


29 


W. 


Poor 


Melancholia, 
chronic 


2 yrs. 


Retroversion, lacer- 
ated cervix and 
perineum 


7-14-08 


Alexander's opera- 
tion, excision cer- 
vix, curettage and 
repair of perineum 


8-6-08 


10849 
J.G. 


35 


W. 


Fair 


Dementia 
paralytica 


7 yrs. 


Movable retrover- 
sion, lacerated 
cervix and peri- 
neum 


7-28-08 


Alexander's opeim- 
tlon, excision cer- 
vix, curettage aad 
repair of perinenm 


8-4M)8 


10181 


•• 


•• 


tl 


Dementia, 
primary 





Movable retrover- 
sion 


8-11-08 


Curettage, Alaxan- 
der's operation 


8-9-08 


10199 
C. B. 


48 


M. 


It 


Melancholia, 
acnte 


14 mos. 


Movable retrover- 
sion, lacerated 
cervix and perl- 
neum 


8-18-08 


Alexander's opera- 
tion, curettage and 
perineorrhaphy 


8-6-08 


10184 
B. C. 


80 


8. 


It 


Melancholia, 
acute 


2 mos. 


Movable retrover- 
sion 


8-29-08 


Curettage, Alexan- 
der's operation 



LEROY BROUN. 
OPERATIONS FOR DISPLACED UTERI 



287 



Result of 
opezation 


Physioal 

improYement 

following 

operation 


Mental Im- 
proYement 
apparently 
referable to 
operation 


Discharged 


Result 
mental 


Remain- 
ing in 
hospital 


Remarks 


lafclsfaetory 


Marked 


None 


9-.36-04 


.... 


2-1-05 


Slight ImproYement be- 
fore operation 


*i 


Ci 


cc 


CI 


.... 


CI 


Slight mental improYe- 
ment before operation 


C( 


Slight 


Ci 


.... 


.... 


CC 


Slight mental improYe- 
ment before operation 


C( 


None 


Ci 





.... 


II 


Some mental improYe- 
ment before operation 


nsatlsfaetory 


«i 


11 


.... 


.... 


11 


Slight mental ImproYe- 
ment before operation 


Satisfactory 
it 

cc 


Marked 

Slight 

It 


CI 

II 
II 


1-18-^5 


RecoYered 


2-1-06 
II 


Slight improYement be- 
fore operation 

Slight improYement be- 
fore operation 

Slight improYement be- 
fore operation 


cc 
c« 


t( 
(1 


l« 
II 


.... 





II 
It 


Slight improvement be- 
fore operation 

Slight improvement be- 
fore operation 


cc 


(i 


II 








II 


Slight improvement be- 
fore operation 


cc 


C( 


CI 


.... 


.... 


11 


Unchanged 


cc 


(1 


II 


.... 


.... 


II 


CI 


cc 


cc 


CI 


• . • • 


.... 


II 


Slight improvement 


cc 


Marked 


Slight 


.... 


.... 


II 


Slight improvement 
nnder general treat- 
ment 


Aistlsfactory 


None 


None 


.... 


.... 


II 


Slight improvement 
under general treat- 
ment 



288 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 



OPERATIONS FOR DISPLACED UTERI 









i 


1 




Duration of 








< 


s 




Is 


ll 


Mental 
diagnosis 


mental 
disease 
prior to 


Pelvic condition 


Date of 
To?' 




1 


1 




entering 
hospltel 






11-28- 


9861 
A. B. 


86 


8. 


Fair 


Mania 


— yrs. 


Lacerated cervix 
and perineum. 
Procidentia 


7-10-08 


Repair of cervix i 
perineum. Hyt- 
terorrhaphy 


4-29-08 


10880 
H. B. 


86 


M. 


II 


Melancholia, 
acnte 


8 wks. 


Movable retrover- 
sion, lacerated 
perineum 


10-6-03 


Curettaice, Alexai 
der*s operation, 
repair of perinei 


8-1-08 


10591 
H.M. 


81 


8. 


II 


Paranoia 


4 yrs. 


Endometritis; mov- 
able retroversion 


11-8-08 


Curettage, Alexia 
der's operation 


7-25-08 


10565 
M. B. 


48 


M. 


II 


Dementia 
precox 


lyr. 


Movable retrover- 
sion, lacerated 
cervix and peri- 
neum 


11-14-08 


Excision of cervix 
perineorrhaphy s 
Alexander's opcr 
tion 


(^-18-02 


9605 


28 M. 


Poor 


Me ancholiaf 


5 mos. 


Movable retrover- 


12-8-08 


Excision of cervix 




N. 








acate 




sion, lacerated 




perineorrhaphy n 




McS. 












cervix and peri- 
neum 




Alexander's opa 
tion 


8-9-08 


10200 
CD. 


26 


M. 


II 


Mania, acute 


4 wks. 


Movable retrover- 
sion, lacerated 
cervix and peri- 
neum 


12-1-03 


Vaginal shortenia( 
utero- sacral liga- 
ments, curettage 
and excision cen 


11-11-08 


10907 
M. N. 


81 


M. 


r*ir 


Paranoia 


6 mos. 


Movable retrover- 
sion, lacerated 
cervix and peri- 
neum 


1-7-04 


Alexander's opera 
tion, exciaioneer 
vix and perineor- 
rhaphy 


10-19-08 


10808 


27 M. 


II 


Dementia 


8 yrs. 


Movable retrover- 


2-11-04 


Curettage, Alexan 




E. L. 








pmcox 




sion 




der's operation 


12-17-08 


11025 

M. 
G. L. 


41 


M. 


II 


Paranoia 


5 yrs. 


Movable retrover- 
sion 


2-16-04 


Curettage, Alexaa 
der's operation 


2-8-04 


11188 
R. H. 


26 


M. 


Poor 


Melancholia, 
acnte 


8 days 


Saprsemia after 
labor 


2-16-04 


Curettage 


11-6-08 


10889 
N. P. 


88 


M. 


Fair 


Paranoia 


6 yrs. 


Movable retrover- 
sion, laceration of 
perineum 


8-24-04 


Curettage, Alex- 
ander's operaUoB 
and perineorrhap] 


9-18-08 


10722 

N. 8. 


86 


8. 


11 


Dementia 
pracox 


5 yrs. 


Movable retrover- 
sion 


8-24-04 


Curettage, Alex- 
ander 


11-11-08 


10908 
E. N. 


25 


M. 


II 


Melancholia, 
acute 


8 mos. 


Movable retrover- 
sion, laceration 
perineum 


4-7-04 


Alexander's opera- 
tion after vagini 
shortening of 
utero-aacral llgi- 
ments, perineor- 
rhaphy 


12-29-08 


11062 40 
8. G. 


II 


II 


Dementia 
precox 


4 yrs. 


Complete proci- 
dentia 


4-14-04 


LaForte's opera- 
tion 


12-16-92 


8480 85 
M. C. 


It 


11 


Melancholia, 
chronic 


.... 


Complete proci- 
dentia 


4-21-04 


LaForte'a opera- 
tion 


8-2-04 


11248 89 


It 


Poor 


Paranoia 


2 yrs. 


Movable retrover- 


6-2-04 


Alexander's opera- 




N.W. 












sion, lacerated 
cervix and peri- 
neum 




tion, excision ear 
vix, perineorrhap 



LEROY BROUN. 
0PSEATI0N8 FOE DI8PL1CBD UTSEI 



S^ 



BMuttof 
>peiatlon 


Physioal 

linprovement 

foUowinir 

operation 


Mental im- 
provement 

operation 


Diaoharged 


Eesolt 
mental 


Remain- 
ing In 
hospital 


Remarks 


^UMfMCtOTJ 


Marked 


BUght 


.... 


.... 


8-1-05 


Slight improTement 
nnder gfneral treat- 
ment 


«« 


Blight 


None 


.... 


.... 


II 


Unchanged mentally 


«« 


II 


II 




.... 


II 


Blight improTement 
mentally 


«« 


Marked 


II 


.... 


.... 


II 


Unchanged mentally 


ti 


BUght 


II 


.... 


.... 


41 


Blight Improvement 


Mtlsfkciory 


None 


41 




.... 


II 


Unchanged 


~ 
















BUght 


II 


.... 


.... 


II 


It 


41 


<( 


II 


.... 


.... 


41 


It 


MktUfaetory 


None 


II 


TrajQ^ferr^d 


1-11--04 


.... 


Blight improvement 


itisiAotory 


Marked 


BUght 


.... 


.... 


8-1-06 


Unchanged 


c« 


Bliglit 


None 


.... 


.... 


II 


Blight improvement 
under general treat- 
ment 


ftC 


II 


II 


.... 


.... 


II 


BUght improvement 
nnder general treat- 
ment 


c< 


11 


II 






II 


Blight Improvement 
under general treat- 
ment 


«< 


II 


II 


.... 


.... 


It 


Unchanged 


l( 


11 


II 


.... 


.... 


II 


II 


«c 


II 


II 


« • « . 


.... 


II 


It 



19 



290 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 



OPERATIONS FOR DISPLACED UTERI 



5 






^ 






Duration of 








1 


1 

28 


tt 


If 


Mental 
dla^osis 


mental 

distnrbanoe 

previous to 

entering 

hospital 


Pelvic conditions 


Date of 

opeiar 

tion 


OperatioD 


11-6-08 


10890 


Fair 


Dementia 


6 wks. 


Movable retrover- 


6-2-04 


Alexander's ope 




N. S. 








praecox 




sion, lacerated 
cervix and peri- 
neum 




tion, excision c 
vix, perineorrhi 


8-16-04 


11285 
8. P. 


20 


8. 


C( 


Melancholia, 
acate 


8 mos. 


Movable retrover- 
sion 


6-28-04 


Alexander, cnrct 


6-9-04 


11558 


50 


M. 


iC 


Inyolution 


2 yrs. 


Procidentia, com- 


7-26-04 


LaForte's oper» 




N. L. 








melancholia 




plete 




Uon 



MINOR OPERATIONS 



6-18-02 


9507 


28 


8. 


Fair 


Melancholia, 


3 previous 


Endometritis, sten- 


7-22-02 Divulsion and ei 




M. D. 








acute 


attacks 


osis of internal os 


1 Uge 


6-7-02 


9892 


21 


M. 


tt 


Puerperal 


1 mo. 


Endometritis 


8-1-02 Curettage 




M. D. 








mania 










4-29-02 


9378 
A. E. 


18 


S. 


It 


Circular 
insanity 


2 wks. 


Endometritis 


8-26-02 


Divnlsion andci 
tage 


10-11-01 


8963 
A. 0. 


29 


M. 


11 


Melancholia, 
acute 


Iwk. 


Amenorrhea, endo- 
metritis 


9-10-02 


Divulsion and ei 
tage 


9-8-02 


9721 

N. B. 


82 


cc 


t( 


Melancholia, 
acute 


6 mos. 


Lacerated cervix 
and perineum 


10-7-02 


Excision cervix, 
perineorrhaphy 
curettage 


8-1-02 


9644 

N. B. 


85 


tl 


II 


Melancholia, 
acute 


8 days 


Lacerated cervix 
and perineum 


11-6-08 


Excision cervix, 
curettage, peri- 
neorrhaphy 


8-28-02 


9800 
A. G. 


42 


(t 


It 


Melancholia, 
chronic 


2 yrs. 


Retroposited uterus 


11-18-08 


Excision eervix 


10-16-02 


9884 
B. X. 


84 


it 


Poor 


Melancholia, 
chronic 


11 mos. 


Lacerated cervix 
and perineum 


11-18-08 


Excision cervix, 
perineorrhaphy 


12-12-01 


9076 
H. H. 


30 


li 


Fair 


Melancholia, 
acute 


8 days 


Lacerated cervix < 
and perineum 


12-19-02 


Excision cervix, 
perineorrhaphy 


10-81-02 


9875 
M. Z. 


35 


It 


It 


Melancholia, 
chronic 


2 yrs. 


Lacerated cervix 
and perineum 


1-29-08 


Excision cervix, 
perineorrhaphy 


7-11-02 


9564 
T. 8. 


22 


8. 


II 


Melancholia, 
acute (hys- 
terical) 

Melancholia, 


2 mos. 


Thickened nymphs 
and clitoris 


9-26-02 


Excision clitoris 
nymplus 


11-16-02 


9917 


37 


M. 


II 


4 mos. 


Lacerated cervix 


2-12-08 


Excision cervix, 




C. S. 








acute 




and perineum 




perineorrhsphy, 
curettage 
Excision cerrix i 


2-28-03 


10189 


28 


II 


tl 


Paranoia 


8 yrs. 


Lacerated cervix 


5-14-08 




F. C. 












and perineum 




perineorrhaphy 


10l4M)2 


9796 
M. F. 


37 


II 


II 


Melancholia, 
acute 


9 days 


Lacerated perineum 


8-14-08 


Curettage, repaU 
perineum 


8-6-01 


8880 
A. M. 


25 


II 


It 


Melancholia, 
chronic 


1 mo. 


Lacerated cervix 
and perineum 


8-12-02 


Excision cervix, 
repair of perlac 



LEROY BROUN. 
OPERATIONS FOR DISPLACED UTERI 



291 



Result of 
operation 


Physical 

improvement 

followingr 

operation 


Mental im- 
provement 
apparently 
referable to 
operation 


Discharged 


Result 
mental 


Remain- 
ing in 
hospital 


Remarks 


laUsfActory 
SaUfactory 


Slight 
Marked 

4t 


None 

14 

Slight 


11-12-04 


Improved 


2-1-06 

tc 
it 


Unchanged 

Slight 

Marked mental improve- 
ment not referable to 
operation 



MINOR OPERATIONS 



Aafactory 


Marked 


Marked 


5-28-08 


Improved 


, , 


(t 


Noticeable 


Slight 


1^28-08 


Recovered 


. . 


«t 


ii 


tt 


11-7-02 


Improved 


.. 


nstmation re- 
imed 3 mos. 
rter operation 


Marked 


None 


4-8-08 


tt 


... 


tisfactory 


Noticeable 


tt 


11-16-02 


Recovered 


... 


(1 


t< 


tt 


Transferred 


Improved 


... 


(C 


Marked; 

menstruation 

regular and 

painless 

Slight 


Slight 
tt 


6-27-08 
6-4-08 


tt 
tt 


. • • 


Ift 


Noticeable 


None 


6-2-08 


tt 






Marked 

None 
Marked 


Marked 4 
mos. after 
operation 
None 

Marked 
especially 


6-8-08 

Transferred 
5-28-08 


Recovered 

Not 
Improved 
Recovered 


... 


C( 


tt 


Slight 


9-19-08 


Improved 


... 


(C 


Noticeable 


Marked 


6-16-08 


Recovered 




(C 


tt 


tt 


2-26-04 


tt 


... 



•• 


Some improvement be- 
fore operation 

Operation no effect in 
cure 

Operation no effect in 
improvement 



Operation no effect in 
cure 



Slight improvement be- 
fore operation 
Re-admitted Oct. 10-08 

Some improvement be- 
fore operation 



Improved more rapidly 
after operation 

Re-admitted Jan. 18-04 

Slight improvement be- 
fore operation 

Had begun to improve 
before operation 



2^2 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 
MINOR OPERATIONS 



11-7-Oa 

11-19-03 
11-8-03 

8-14-08 

8-38-08 
4-26-95 

8-5-08 

8-6-08 
6-8-08 

7-1-04 
8-31-08 

11-18-03 

3-35-08 
8-8-08 



I 



9884 
M. 8. 

9185 
V. 8. 

9934 
T. M. 



9891 
N. K 



10338 
M. S. 

10361 
E. K. 
43147 
K. K. 



10179 
H. 8. 



10191 
B. L. 

10419 
B. 8, 



10941 
B. D. 
10346 
O. 8. 

9906 
P. H 

10147 
B. 8. 
10183 
E.M. 
C. 



Ii 



w. 



If 

O 



Fair 



Poor 



Poor 



Fair 



Poor 



Fair 



Ane- 
mic 

Fair 



Mental 
diafirnoais 



Duration of 

mental 

dlaturbanee 

previoua to 

enterinar 

hospital 



Chronic 

delnsional 

inBanity 
Epilepsy, 

dementia 

Mania, acute 



Melancholia, 
acnte 



Melancholia, 
acnte 

Mania, 

depressiTS 
Dementia, 

terminal 



Melancholia, 
acnte 



Melancholia, 
acnte 

Exhanetiye 
psychosis 



Melancholia, 

chronic 
Dementia, 

terminal 

Melancholia, 
chronic 

Melancholia, 

acnte 
Melancholia, 

chronic 



5 mos. 
4yrs. 

6 wks. 



9 mos. 3 
previons 
attacks 



3 mos. 

4 days 
4 wks. 



lyr. 

3 mos. 
iwk. 

3 or 8 yrs. 
8 mos. 

5 mos. 

8 mos. 
3 mos. 



Pelvic condition 



Lacerated perineum 



Laceration peri- 
neum, endometritis 

Laceration cerrix 
and perineum 



Laceration cerriz 
and perineum 



Endometritis 



Sapramia following 
confinement 
Carcinoma uterus 



Laceration of eeryix 
and perineum 

Laceration of cervix 
and perineum 

Puerperal septicie- 
mia 



Endometritis 

Laceration of cervix 
and perineum 

Laceration of peri- 
neum endometri- 
tis; retroversion 

Laceration cervix 
and perineum 

Laceration cervix 
and perineum 



Date of 

opeiar 

tton 



1-99-48 

3-13-03 

8-5-08 

8-14-08 

8-3e-08 

4-1-08 
4-80-08 

5-36-08 

6-0-08 
6-9-08 

1-11-08 
6-11-08 

6-3-08 

6^3-08 
6-37-1 



Openrtkm 



Curettage, pefint- 
orrhaphy 

Curettage, perine- 
orrhaphy 

Excision cervix, 
perineorrhaphy 



Excision cervix, 
repair of peilneu 



Curettage 



Excision of cervii 
and repalt of pt 
neum 

Curettage, exdsia 
of cervix and re- 
pair of periDeui 

Exploration of ei 
Ity of the uterai 



Curettage 

Excision cervix a 
repair of perinei 

Curettage, repair 
perineum 

Excision cervix, j 
pair of perineun 

Excision cervix a 
repair of perlnev 
curettage 



LEROY BROUN. 
laNOR 0PK&ATI0N8 



293 



Result of 
operation 


Physieal 

Improvement 

following 

operation 


Mental im- 
provement 

wSeSblefo 
operation 


DlM)hAiged 


Remit 
mental 


Remain- 
ing in 
hoepltal 


Remarks 


teUsfmctory 


Noticeable 


None 


4-9-04 


Improved 


• • • • 


Re-admltted 


ti 


None 


(( 


Died, tnher- 
cnlosis 1 yr. 
after 


.... 


• • • • 




ct 


Marked 


Marked 


6-80-08 


Recovered 


• . • . 


Four mos. prior to 
operation no improve- 
ment; after operation 
improvement rapid to 
time of discharge 


<c 


t< 


It 


4-17-08 


II 


Re-ad- 
mitted 
5-3-04 


No improvement before 
operation ; 1 mo. after 
operation bright and 
cheerful having no de- 
lusion or trace of 
former depression 


cc 


Slight 


IC 


5-11-08 


II 




Mental depression in 
part relieved bj opera- 
tion 


«• 


Marked 


li 


7-4-08 


11 


.... 


No improvement before 
operation 


None 


None 


None 




Died June 33, 
exhaustion 
from pro- 
gress of car- 
cinoma 


• • . • 




latiafActoij 


Marked 


Marked 


7-38-08 


Recovered 




Considerable improve- 
ment prior to opera- 
tion. Remained in 
hospital 4 mos. 


iC 


«( 


(1 


0-19-08 


II 


• . • • 


Re-admitted. Consider- 
able improvement 
prior to operation 


tc 


None 


None 


Died 0-17-08 
Acute lobar 
pneumonia 






Exploration of the 
uterus was to deter- 
mine presence of pla- 
cental or decidual 
tissue 


(• 


Marked 


Slight 


0-33-08 


Improved 





Some improvement 
prior to operation 


IC 


SUght 


u 


11-19-08 


II 


.... 


Slight mental improve- 
ment prior to opera- 
tion 


«» 


Marked 


li 


10-38-08 


II 


. • . • 


Slight improvement be- 
fore operation 


c« 


Slight 


II 


Died 8-14-04 
Exhaustion 


.... 


. • . • 


Slight improvement be- 
fore operation 


«• 


(( 


None 


.... 


• . . . 


8-05 


Slight improvement be- 


* 












fore operation 



294 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 



MINOR OPERATIONS 



; 






i 






Duration of 








5 


1 


< 


P 


p 


Mental 
diagnosis 


mental 

dlsturhanoe 

previous to 

enterlnflT 

hospital 


Pelvic condition 


Date of 
opera- 
tion 


Operation 


8-17-08 


10314 
P. V. 


41 


M. 


Fair 


Paranoia 


3yrs. 


Laceration cervix 
and perineum 


7-19-08 


Excision cervix a 
repair of perineu 
curettage 


4-33-08 


10815 
R. G. 


28 


4( 


Poor 


Mania, 
chronic 


4 mos. 


Endometritis; 
laceration of peri- 
neum 


7-35-08 


Curettage, excislo 
cervix and repalr 
perlneam 


(J-8-08 


10487 

E. 
0' L. 


44 


«( 


Fair 


Melancholia, 
chronic 


8yrs. 


Endometritis; 
laceration of peri- 
neum 


8-1-08 


Curettage and repi 
of perineum 


8-35-08 


10355 
H. R. 


26 


{{ 


(( 


Dementia, 
terminal 


4 mos. 


Laceration cervix 
and perineum 


8-11-08 


Curettage, excisioi 
of cervix and re- 
pair of perineals 


6-17-01 


8710 
M. P. 


25 


l< 


«i 


Melancholia, 
chronic 


5 yrs. 


Endometritis; 
laceration of cer- 
vix and perineum 


8-1-08 


Curettage, exciaioi 
of cervix and pci 
neorrhaphy 


8-30-08 


10341 
D. T. 


33 


(1 


it 


Melancholia, 
acute puer- 
peral 


11 days 


Endometritis; 
laceration of cer- 
vix and perineum 


8-4-08 


Curettage, repair 
cervix and peri- 
neum 


8-19-08 


10388 
L. L. 


28 


l( 


ti 


Dementia, 
secondary 


10 yrs. 


Complete laceration 
of perineum 


8-11-03 


Repair of perinea 


8-15-08 


10800 
M.N. 


86 


iC 


Poor 


Melancholia, 
acute 


3wks. 


Fistula in ano 


8-15-08 


Repair 


8-18-08 


10380 
8. L. 


84 


it 


Fair 


Mania, acute 


3wks. 


Laceration cervix 
and perineum 


8-15-08 


Curettage and repi 
of perineum 


8-19-08 


10340 
C. S. 


46 


«i 


(C 


Paranoia 


3 wks. 


Lacerated cervix 
and perineum 


8-8-08 


Curettage, exciaio 
of cervix, perinec 
rhaphy 


8-88-08 


10365 
A. B. 


86 


t( 


u 


Paranoia 


lyr. 


Lacerated cervix 
and perineum 


8-8-08 


Curettage, exeiaio 
of cervix, perinei 
rhaphy 


6-1-08 


10840 
M. K. 


27 


11 


(t 


Dementia 
precox 


1 mo. 


Endometritis 


8-18-08 


Curettage 


6-10-08 


10882 
M. D. 


30 


s. 


t( 


Melancholia, 
acute 


18 mos. 


Endometritis 


9-10-08 


Curettage 


5-33-02 


9424 

R. 

McG. 

B. 


85 


M. 


cc 


Dementia 
precox 


7 or 8 wks. 


Lacerated cervix 
and perineum 


8-5-03 


Excision of cervix 
perineorrhaphy 


10-10-02 


9827 
L. C. 


24 


•• 


Fair 


Dementia 
terminal 


9 yrs. 


Endometritis 


4-3-08 


Curettage 


6-6-08 


10429 
E. T. 


32 


M. 


iC 


Maniacal 
delusional 
insanity 


3 mos. 


Lacerated cervix 
and perineum 


11-10-08 


Curettai^ exciaioi 
of cervix and 
perineorrhaphy 


8-31-08 


10249 
M.S. 


80 


u 


IC 


Mania, acute 


3 wks. 


Endometritis, 
lacerated cervix 
and perineum 


13-8-08 


Curettage, tracbel* 
orrhaphy and 
perineorrhaphy 


3-4-08 


10093 
C. R. 


34 


(t 


4< 


Cl <i 


8 mos. 


Endometritis, 
lacerated cervix 
and perineum 


18-15-08 


Curettage, excisioi 
of cervix, perine- 
orrhaphy 


7-1-08 


10490 
A. 0. 


35 


tc 


C4 


Melancholia, 
acute 


8 wks. 


Lacerated cervix 
and perineum 


9-15-08 


Curettage, excisioi 
of cervix, perine- 
orrhaphy 



LEROY BROUN. 
MINOR OPERATIONS 



295 



Reeolt of 
opozmtion 


Phivical 

ImpzoTement 

following 

operation 


Mental Im- 
provement 
apparently 
referable to 
operation 


Blflcharged 


Result 
mental 


Remain- 
ing In 
hospital 


Remarks 


btlflfaciory 


Marked 


None 


• ... 


.... 


2-05 


Condition unchanged 




<t 


it 


.... 


.... 


ii 


Slight Improvement be- 
fore operation 




it 


it 


.... 


.... 


it 


Slight Improvement be- 
fore operation 




(( 


it 


.... 


.... 


it 


Slight Improvement be- 
fore operation 




CI 


ii 


.... 


.... 


it 


Slight improvement be- 
fore operation 




it 


ii 


.... 


.... 


ii 


Unchanged 




C( 


it 


.... 


.... 


it 


Slight improvement 




tc 


ii 


.... 


.... 


ii 


Unchanged 




ii 


ii 


.... 


.... 


It 


ii 




ii 


Slight 


10-28-08 

Re-admltted 

6-2-04 


Improved 


.... 


Slight mental Improve- 
ment before operation 




Slight 


ii 


2-5-04 


ii 





Slight mental Improve- 
ment before operation 




Marked 

SUght 

None 


Marked 

Slight 

None 


1-4-04 

10-16-08 

Died 10-28-04 
Exhaustion 


Recovered 

Improved 

None 




Slight mental Improve- 
ment before operation 

Slight mental improve- 
ment before operation 


«i 


Marked 


None 


Transferred 


Improved 




Transferred to East 


€1 


ii 


Slight 


8-4-04 
10-12-04 


Recovered 


.... 


Hospital Aug. 4-04 
Great improvement be- 
fore operation 


«t 


Slight 


ii 


4r-18-04 


it 


• * • . 


Slight mental Improve- 
ment before operation 


«( 


«i 


ii 


1-11-04 


ii 


.... 


Slight mental improve- 
ment before operation 


<l 


Marked 


It 


11-6-08 


«i 


.... 


Considerable mental Im- 
provement before 
operation 



296 SURGERY IN THE MANaAtTAif STATE HOSPITAL WEST. 
miCOR OPERATIONS 



a 






J, 






Duration of 








•0 
< 


^ 


£ 

< 


M. 


Fair 


ifental 
dlairnosif 


mental 

disturbance 

prevlouB to 

entering 

hospital 


PelYlo eondition 


Date of 
opera- 
tion 


Opention 


8^iM)8 


10800 


80 


Melancholia, 


1 mo. 


Lacerated cerriz 


1-13-04 


Excision of oertli 




M.R. 








acute 










10-83-08 


10888 
B. Q. 


35 


<i 


i< 


Melancholia, 
acute 


5 mos. 


Endometritis 


1-82-04 


Curettage 


12-15-08 


11058 
I. T. 


37 


8. 


Ci 


Mania, acute 


1 mo. 


Constriction of 
urethra 


3-4-04 


Urethra dilmted, 
curettage 


13-14-08 


11017 
8. 8. 


31 


« 


C( 


Melancholia, 
chronic 


17 mos. 


Endometritis 


8-10-04 


Curettage 


13-38^8 


11057 
8. R. 


35 


M. 


11 


Mania, acute 


8 mos. 


Lacerated ceryix 
and perineum 


4r-7-04 


Excision of cerriz 
and peiineorrtiapl 


7-8-08 


10496 
E. T. 
1138U 


50 


i( 


CI 


U It 


3 mos. 


Lacerated perineum 


4^14-04 


Peilneorrhmpby ' 


8-17-04 


36 


8. 


Poor 


Dementia 


1 mo. 


Anteflexion 


6-36-04 


Curettage 




M.G. 








precox 










5-13-04 


11457 
B. M. 


83 


M. 


Pair 


Dementia 
precox 


18 mos. 


Endometritis, 
lacerated peri- 
neum 


7-19-04 


Curettage, perine- 
orrhaphy 


11-5-08 


10887 
B. L. 


85 


(( 


11 


Maniacal 
delusional 
insanity 


10 days 


Endometritis, 
lacerated ceryix 
and perineum 


7-80-04 


CuretUge, excisloi 
of cervix and 
perineorrbapby 


5-37-01 


8668 
M.M. 


85 


8. 


11 


Melancholia, 
chronic 


lyr. 


Endometritis 


7-39-08 


Curettage 


7-81-01 


8818 
E. P. 


33 


t( 


t< 


Melancholia, 
chronic 


8 yra. 


Anteflexed uterus, 
dysmenorrhcea. 


8-5-08 


Curettage 


f-17-01 


8918 
C. E. 


37 


M. 


Poor 


Melancholia, 
chronic 


iKy«. 


Lacerated cervix 
and perineum 


8-86-08 


Excision of eervt^ 
perin eorrbaphy , 
curettage 


1-8-03 


9139 
B.S. 


89 


W. 


Fair 


Dementia 
precox 


2K y". 


Lacerated cerTix 
and perineum 


9-80-08 


Excision of eervt^ 
perineorrhaphy, 
curettage 


13-34-01 


9098 
A. L. 


82 


M. 


IC 


Melancholia, 
chronic 


6 mos. 


Lacerated cervix 
and perineum 


9-9-08 


Excision of cervix, 
perineorrhaphy, 
curettage 


1-16-03 


9144 
G. H. 
L. L. 


20 


8. 


u 


Mania, 
chronic 


6wks. 


Endometritis 


9-88-4)3 


Curettage 


8-9-02 


9634 
L. Q. 


25 


(1 


11 


Dementia, 
primary 


•• 


Lacerated ceryix 
and perineum 


10-10-03 


Excision cervix an 
perineorrhaphy 


9-19-08 


9761 
E. H. 


•• 


M. 


11 


Parabola 


5yr8. 


Ceryical polyp 


11-18-08 


Excision of polyp 


10-21-02 


9849 
M.K. 


84 


(C 


11 


Melancholia, 
chronic 


8 mos. 


Lacerated cervix, 
perineum 


12-11-08 


Excision of cervix 
and perineorrhapi 


9-8-02 


9713 
A. D. 


261 «» 


It 


Melancholia, 
chronic 


3 mos. 


Endometritis 


1-1-08 


Curettage 


10-81-02 


9872 


22; 8. 


u 


Melancholia, 


SKyrs. 


It 


8-86-08 


tc 




T. H. 








acute hye- 
terlcal 










8-18-03 


9653 
T. L. 


44 


W. 


It 


Melancholia, 
acute 


9 mos. 


Endometritis; 
lacerated cervix 
and perineum 


8-5-08 


Excision of cervix 
and perineorrhapi 



LBROY BROUN. 
MINOR OPERATIONS 



^7 



Result of 
opexatton 


Phivioal 

improvement 

following 

opermtlon 


Mental im- 
provement 
apparently 
referable to 
operation 


DiBoliarged 


Result 
mental 


ingin 
hospital 


Remarks. 


&ft«i>fm<!iory 


UtTktd 


Slight 


8-82-04 


Recovered 


.... 


Improvement before 
operation 


<t 


Slight 


It 


8-4-04 


II 


.... 


Improvement before 
operation 
Slight improvement 


cc 


tc 


II 


8-89-04 


Improved 


.... 














before operation 


C( 


l( 


II 


4-14-04 


Recovered 





Improvement before 
operation 
Slight improvement 


(C 


(< 


None 


6-10-04 


Improved 


.... 














before operation 


(i 


<( 


Slight 


6-25-04 


Recovered 


.... 


Improvement before 
operation 
Some improvement be- 


• c 


Marked 


Marked 


6-88-04 


II 
















fore operation 


IC 


Slight 


None 


10-11-04 


Improved 


.... 


Slight Improvement be- 
fore operation 


41 


ti 


SUght 


0-l»-04 


Recovered 


.... 


Marked improvement 
before bperation 


• 1 


Marked 


II 




Improved 


8-1-05 


Slight improvement be- 
fore operation ; been in 
hospital four years 


11 


None 


i^one 







II 


No improvement before 
or after operation 


t( 


Some 


cc 




.... 


li 


No mentsl improvement 
before olr after opera- 
tion 


• ( 


Marked 


II 




.... 


II 


No mental improvement 
before or after opera- 
tion 


c« 


Slight 


II 




.... 


II 


Slight iliental improve- 
ment before operation 


l» 


((. 


Slight 




.... 


li 


Some mental improve- 
ment before operation 


t< 


t( 


None 




.... 


II 


Slight mental improve- 
ment before operation 


Ift 


None 


II 




• . . • 


u 


No mental improvement 
before or after opera- 
tion 


ift 


Marked 


II 







II 


Some mental improve- 
ment before operation 


l« 


t< 


II 




.... 


i< 


Some mental improve- 
ment before operation 


«l 


(1 


11 




.... 


II 


Slight mental improve- 
ment before operation 


cc 


(i 


Slight 


12-80-04 


Recovered 


.... 


Mental improvement 
before operation 



298 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 



MINOR OPERATIONS 



a 






h 






Duration of 








a 
3 


1 


s 


8d 


11 




Mental 
diagnoala 


mental 

disturbance 

previous to 

entering 

hospital 


Pelvic oondltion 


Date of 
opera- 
tion 


Operation 


12-6-01 


9066 
R. 8. 


41 


M. 


Pair 


Melancholia, 
chronic 


12 yrs. 


Fistula in ano, 
lacerated perineum 


6-28^8 


Excision of fistula 
in ano, perineor- 
rhaphy 


9-14^1 


8901 
M. P. 


89 


<i 


i( 


Melancholia, 
chronic 


2yr8. 


Endometritis; 
lacerated spliincter 
ani 


8-26-08 


Perineorrhaphy and 
curettage 


10-9-02 


9816 
P. N. 


25 


8. 


iC 


Mania, 
chronic 


2 mos. 


Endometritis; 
lacerated cervix 
and perineum 


4-2-08 


Curettage, trachel- 
orrhaphy, perine- 
orrhaphy 


9-6-02 


9720 
R. S. 


22 


M. 


(i 


Dementia, 
secondary 
to epilepiy 


lyr. 


Lacerated cervix 
and perineum 


4-9^8 


Excision of cervix 
and perlneorrhaph] 


12-9-84 


1792 
R. P. 


42 


•• 


" 


Mania, 
chronic 


2 yrs. 


Cervical polyp, 
lacerated sphincter 
ani 

Cyst of right breast 


4-28-08 


Excision of polyp, 
perineorrhaphy 


2-6-92 


81- 


88 




Poor 


Dementia, 


8 yrs. 


5-7-08 


Excision of cyst 




220 
J. N. 
10278 








secondary 










4-2-08 


61 


8. 


Pair 


Paranoia 


.... 


Geryical polyp 


6-27-08 


Excision of polyp 


7-4-92 


V. JEd, 

8878 86 
M. F. 


? 


K 


Dementia, 
terminal 


1 mo. 


Lacerated cervix, 
perineum, endo- 
metritis 


8-25-08 


Curettage, repair 01 
cervix and peri- 
neum 


11-15-02 


8915 88 
N. T. 


M. 


C( 


Melancholia, 
chronic 


8 wks. 


Laceration cervix 
and perineum 


8-25-08 


Curettage, exclaion 
of cervix and 
perineorrhaphy 


8-8-08 


10174 27 

N. T. 


i4 


ii 


Melancholia, 
acnte 


.... 


Laceration of cervix 
and perineum 


9-1-08 


Curettage, excision 
cervix and perine- 




















orrhaphy 


4-16-08 


10808 
M.H. 


86 


8. 


iC 


Paranoia 


2 yrs. 


Specific endo- 
metritis 


9-5-08 


Curettage 


8-7-08 


10610 
P. V. 


41 


M. 


(( 


Dementia, 
terminal 


18 yrs. 


Laceration of cervix 
and perineum 


9-5-08 


Curettage, excision 
of cervix and 
perineorrhaphy 


5-15-08 


10880 

N. G. 


41 


8. 


Poor 


Melancholia, 
acnte 


2 yrs. 


Laceration of 
perineum 


9-17-08 


Curettage and 
perineorrhaphy 


6-26^8 


10478 
A. P. 


86 


(1 


Ci 


Melancholia, 
chronic 


8 yrs. 


Endometritis and 
retroversion 


9-17-08 


Curettage 


7-25-08 


10561 
C. D. 


47 


W. 


Fair 


Melancholia, 
chronic 


8 yrs. 


Endometritis 


9-29-08 


Curettage 


8-1-08 


10598 
E. S. 


47 


? 


(C 


Dementia, 
terminal 


.... 


Laceration of cervix 
and perineum 


9-29-08 


Curettage, excision 
cervix and perine- 
orrhaphy 


7-4-08 


10504 
E. M. 


88 


8. 


l( 


Dementia 
pracox 





Laceration of cervix 
and perineum 


10-6-08 


Curettage, excision 
cervix 


8-1-08 


10958 
E. 8. 


47 


M. 


<( 


Dementia 
precox 


.... 


Laceration cervix 
and perineum 


10-8-08 


Curettage, excision 
cervix and perine- 
orrhaphy 


9-10^2 


9727 

N. D. 


45 


tt 


l( 


Melancholia, 
chronic 


20 mos. 


Complete laceration 
through perineum 


10-15-08 


Repair of laceratlo 


7-17-08 


10540 


80 


« 


Poor 


Dementia 


8 yrs. 


Laceration cervix 


10-5-08 


Excision of cervix 


E. P. 








precox 




and perineum 




and repair of 
perineum 



LEROY BROUN. 
MINOR OPERATIONS 



299 



Result of 
operation 


Physical 

improvement 

following 

operation 


Mental im- 
provement 
apparently 
referable to 
operation 


DiBohazged 


Reenlt 

mental 


Remain- 
ing In 
hospital 


Remarks 


Satisfmctory 


Marked 


Marked 






2-1-06 


Some mental improve- 
ment before operation 


<« 


ct 


None 








Some mental improve- 
ment before operation 


«( 


tt 


tt 








Some mental improve- 
ment before operation 


11 


Slight 


if 








No mental improvement 
before or after opera- 
tion 


c« 


Marked 


tt 








Mental improvement 
before operation 


«• 


ti 


tt 








Slight improvement 
before operation 




Slight 
Marked 


tt 
tt 








Slight improvement 
before operation 
No change 


«( 


it 


it 








tc tc 


tc 


tt 


ii 








Slight mental improve 
ment 


Jnsstisfactory 


None 


tt 




• 




No change 


Smtiflfactory 


SUght 


tt 








tt tt 


ct 


Has tubercQ- 
losii 


tc 








Slight mental improve 
ment 


it 


Marked 


tt 








Slight mental improve 
ment 


(t 


it 


ft 








Slight mental improve- 
ment 


(i 


Slight 


tt 








No change 


i( 


Marked 


tt 








tc ct 


t« 


Slight 


tt 








tt cc 


i( 


(t 


it 








cc cc 


it 


Marked 


tt 








cc tc 



300 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 
MINOR OPBRATION8 



g 






i 






Duration of 








a 
5 


s 


1 


|i 


P 


Mental 
diagnosis 


mental 

disturbance 

prevloua to 

entering 

hospital 


Pelvic oondition 


Date of 


Operation 


7-29-08 


10557 
D. S. 


80 


M. 


Pair 


Dementia 
priBcox 


... 


Endometritis 


11-10-08 


Curettage 


2-5-08 


10097 
E. D. 


88 


CI 


cc 


Melancholia, 
chronic 


8 yra. 


Endometritis, 
laceration of 
perineum 


11-17^8 


Curettage and 


2-10-08 


10118 
D. H. 


85 


ii 


ti 


Melancholia, 
acute 


8 mo8. 


Endometritis, lacer- 
ation of cerrix 
and perineum 


11-17-08 


Curettage, repair i 
cervix and peri- 
neum 


1-7-08 


10025 
C. K. 


22 


ii 


u 


Dementia 
paralytica 


lyr. 


Endometritis, lacer- 
ation of cerrix 
and perineum 


11-24-4)8 


Curettage, exdsioa 
of cervix and re- 
pair of perineum 


6-19-08 


10467 
E. G. 


50 


<i 


cc 


Paranoia 


8 yrs. 


Laceration of peri- 
neum 


11-24-03 


Perineorrhaphy 


2-6-08 


10127 
P. S. 


84 


it 


iC 


Melancholia, 
chronic 


4 moB. 


Endometritis, lacer- 
ation of perineum 


12-1-08 


Perineorrhaphy and 
curettage 


7-7-90 


22245 
L.W. 


24 


W. 


cc 


Melancholia, 
chronic 


• • 


Endometritis, lacer- 
ation of perineum 


12-8-<)8 


Curettage and 
perineorrhaphy 


6-6-08 


10481 
M. E. 


80 


iC 


cc 


Dementia 
praecoz 


2 mo8. 


Endometritis, lacer- 
ation of perineum 


12-15-08 


Curettage, exeisleB 
of cervix and 
perineorrhaphy 


9-7-08 


10720 
T. G. 


88 


(i 


Poor 


Melancholia, 
acnte 


2 mos. 


Endometritis 


12-82-08 


Curettage 


&-15-08 


10879 
M. D. 


84 


(( 


Fair 


Dementia 
prsecox 


8 wks. 


Laceration of peri- 
neum 


12-24^8 


Perineorrhaphy 


8-21-08 


10658 
N. G. 


86 


s. 


cc 


Dementia 
paralytica 


1 mo. 


Endometritis 


l».484-08 


Curettage 


8-4-08 


10175 
M. C. 

10618 


46 


M. 


cc 


Paranoia 


8 mot. 


cc 


12-29-08 


cc 


8-12-08 


27 


(( 


cc 


Mania, 


lyr. 


Laceration cerrix 


1-19-04 


Curettage, trachel- 




0. D. 








chronic 




and perineum 




orrhaphy 


8-17-08 


10622 
J. M. 


21 


a 


»c 


Mania, acute 


11 days 


Laceration peri- 
neum, endometri- 
tis 

Endometritis, lacer- 


1-18-04 


Curettage, perine- 
orrhaphy 


5-14-08 


10876 


26 


t( 


cc 


Dementia 


12 days 


1-26-04 


Curettage, perine- 




K. K. 








praecox 




ation perineum 




orrhaphy 


10-28-08 


10888 


29 


8. 


cc 


Melancholia, 


6 yrs. 


Endometritis 


2-9-04 


Curettage 




M. F. 








chronic 










8-6-08 


10188 
G. B. 


32 


M. 


cc 


Paranoia 


8yrs, 


Endometritis, lacer- 
ation perineum 


12-17^8 


Curettage, perine- 
orrhaphy 


12-5-03 


10985 

M. 
McC. 


48 


it 


cc 


Melancholia, 
chronic 


7 yrs. 


Laceration cervix 
and perineum 


4-19-04 


Curettage, excisioa 
cervix, perineor- 
rhaphy 


9-19-08 


10728 
M. C. 


85 


8. 


Good 


Paranoia 


5 yrs. 


Laceration cervix 


2-20-04 


Trachelorrhaphy 
and curettage 


11-25-08 


10940 
C. D. 


80 


M. 


Pair 


Mania, acute 


4 mos. 


Endometritis, lacer- 
ation perineum 


8-1-04 


Curettage, perine- 
orrhaphy 


10-10-08 


10798 
F. 8. 


80 


i( 


cc 


Mania, 
chronic 


5 yrs. 


Laceration peri- 
neum 


8-8-04 


Perineorrhaphy 


10-19-08 


10806 
M. D. 


28 


S. 


cc 


Dementia 
priecoz 


2 yrs. 


Movable retrover- 
sion 


8-10-04 


Curettage 



LEROY BROUN. 
MINOR OPERATIONS 



301 



&eralt of 
operation 


PhTBlOAl 

improvement 
foUowliw 
opention 


Mental im- 
provement 
apparently 
referable to 
operation 


Discharged 


Result 
mental 


Remain- 

Inirln 

hospital 


Remarks 


SatUfACtory 


Slight 


None 


.... 


.... 


•-1-05 


No change 


«• 


Marked 


<c 


.... 


.... 


.... 


Slight Improvement 


c< 


«( 


u 


.... 


.... 


2-1906 


SUght Improvement 


cc 


Slight 


it 


.... 


.... 


<< 


No Improvement 


«« 


<( 


<i 


.... 


«... 


i« 


ii it 


4C 


<i 


Slight 





.... 


«i 


Slight Improvement 


<t 


« 


None 


.... 





(( 


ii ii 


AC 


<( 


<c 


.... 


.... 


li 


Unchanged 


•« 


(( 


i4 


11-1-04 


Recovered 


.... 




tt 


i< 


li 


- 


.... 


2-1906 


Unchanged 


<< 


K 


(i 


.... 


.... 


i< 


it 


tc 


Marked 


it 


.... 


.... 


t( 


ii 


c< 


Slight 


(i 







ii 


4t 


<( 


it 


<« 




.... 


(« 


Slight Improvement 


(t 


<i 


(( 





.... 


<t 


Unchanged 


ct 


i< 


(i 


.... 





n 


Slight Improvement 


i< 


« 


.... 





.... 


« 


ti ii 


« 


Marked 


None 


.... 


.... 


i< 


«« it 


<c 


Slight 


it 


.... 


.... 


<l 


ii ii 


iC 


Marked 


Slight 


.... 


... 


<i 


ti tt 


it 


it 


None 








« 


it tt 


(< 


Slight 


Slight 


.... 


.... 


ti 


ii ti 



302 SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 
MINOR OPERATIONS 



g 






, 






Duration of 








< 


1 


1 


jl 


ll 


Mental 
diaffnoaU 


mental 

dieturbanoe 

prevloua to 

enterlDflr 

hospital 


Pelvic condition 


Date of 
opera- 
tion 


Operation 


8-24-08 


10656 
M. D. 


88 


M. 


Fair 


Dementia 
pnecoz 


•• 


Laceration cervix 
and perineum; 
hemorrhoid! 


8-81-04 


Excision cervix an 
repair of perlneuj 
removal hemor- 
rhoids 


1-28-04 


11189 
C. D. 


21 


W. 


« 


Mania, acnte 


1 mo. 


Endometritis, lace- 
ration of cervix 
and perineum 


4-19-04 


Curettage, excisioi 
cervix and peri- 
neum 


12-10-08 


11000 
M. G. 


28 


8. 


C( 


Melancholia, 
chronic, 
alcoholic 


5yrs. 


Anteflexion 


4-20-04 


Curettage, uterioe 
stem 


12-80-08 


11074 
R. H. 


26 


M. 


Poor 


Melancholia, 
acute 


4 moB. 


EndometritiB, 
laceration peri- 
neum 


4-26-04 


Curettage, perine- 
orrhaphy 


8-9-04 


11270 
A. 8. 


87 


i( 


Fair 


Paranoia 


4 yrs. 


Endometritis, 
laceration of cer- 
vix and perineum 


5-5-04 


Curettage, perine- 
orrhaphy 


10-26-08 


10851 
C. 8. 


86 


(( 


Good 


Dementia 
precox 


8 moB. 


EndometritiB, 
laceration of cer- 
vix and perineum 


6-21-04 


Curettage, excisioi 
cervix and repair 
perineum 


4-16-04 


11868 
R. R. 


89 


a 


Fair 


Paranoia 


17yrB. 


Movable retrover- 
sion, lacerated 
cervix and 
perineum 


6-22-04 


Curettage, excisioi 
cervix, repair of 
perineum 


4-18-04 


11858 
F. N. 


24 


8. 


K 


Dementia 
precox 


lyr. 


Anteflexion 


6-9-04 


Curettage 


4-5-04 


11884 
8. M. 


88 


M. 


ii 


Dementia 
precox 


Imo. 


Rectocele laceration 
cervix and peri- 
neum 


6-28-04 Excision of cervix 
and perineorrhapl 


8-17-04 


11291 
0. K. 


22 


8. 


(C 


Dementia 
precox 


4 days 


Movable retrover- 
sion 


6-9-04 Curettage 


1-18-02 


11110 


42 


W. 


ii 


Dementia 


lyr. 


Complete laceration 


7-19-04 Repair of laceratic 




M. B. 








paralytica 




of perineum 






4-22-04 


11800 
T. M. 


81 


8. 


ii 


Mania, acnte, 
recurrent 


2wkB. 


Endometritis 


7-28-04 


Curettage 


10-28-04 


10846 
L. R. 


81 


M. 


(I 


Dementia 
precox 


2wk8. 


Laceration cervix 
and perineum 


7-23-04 


Curettage, excisioi 
cervix and peri- 
neum 


6-29-04 


11604 
N. F. 


82 


t( 


ii 


Dementia 
precox 


5yrB. 


EndometritiB, 
laceration of 
perineum 


7-80-04 


Curettage, perine- 
orrhaphy 


4-21-04 


11882 
C. K. 


88 


« 


ii 


Dementia 
precox 


2 moB. 


Endometritis, 
laceration of cer- 
vix and perineum 


8-29-04 


Curettage, excisioi 
cervix and peri- 
neum 


8-80-04 


11828 
L. L. 


28 


i( 


it 


Melancholia, 
acute 


6 yrs. 


Anteflexion 


8-29-04 


Curettage 



LEROY BROUN. 
MINOR OPERATIONS 



303 



Besultof 
operation 


Physical 

improvement 

foilowinflr 

operation 


Mental im- 
provement 
referable to 
operation 


Disohazved 


Result 
Mental 


Remain- 
ing in 
hospital 


Remarks 


Satisfactory 


Slight 


Slight 






2-1905 


Slight improvement 


t« 


tt 


None 






tt 


tt tt 


it 


Mariced 


tt 






(t 


(t ii 


t« 


tt 


Slight 






tt 


(( tt 


i« 


Slight 


None 






ft 


(t tt 


it 


tt 


Slight 






tt 


i< tt 


it 


Marked 


None 






tt 


Ii it 


ti 


Slight 


tt 






tt 


Unchanged 


it 


tt 


tt 






tt 


(t 


<t 


None 


tt 






tt 


Slight improvement 


It 


Slight 


tt 






tt 


it tt 


(t 


tt 


tt 






tt 


ti it 


tt 


Marked 


tt 






tt 


ii tt 


(4 


Slight 


tt 






tt 


Unchanged 


tt 


it 


Slight 


.... 




tt 


Slight improvement 


(t 


tt 


None 


.... 




tt 


ii tt 



304 SURGERY IN THE MAIf HATTAN STATE HOSPITAL WEST. 

DISCUSSION. 

Dr. Henry M. Kurd. — I do not think these papers should pass without a 
word. The submission of such papers indicates in a gratifying way the 
great improvement which has occurred in the method of caring for patients 
during the last twenty-five years. The feeling then was that an operation 
should not be done upon a patient unless a very clear indication existed 
for it In other words, no operation should be done if it possibly could be 
avoided. Nowadays we feel that it is the duty of every man interested in 
the welfare of the insane to do all he can to foster their general health. 
We may not find in this course of treatment a panacea for insanity, but 
we do find that many patients are much benefited by the surgical operation. 
Their condition is more comfortable. We find many instances where the 
services of the dentist in caring for the teeth, or of the oculist in providing 
proper spectacles for the eyes, add much to the comfort and general health 
of the patient I believe in addition that these patients have a right to be 
operated upon with the idea of curing them. If they are not cured a 
certain percentage at least are made more comfortable by operatioa 

Under these circumstances, it seems to me that I have a right to con- 
gratulate the Association upon the much more liberal view taken of the 
relations of surgery to the treatment of insanity than formerly existed. 

Dr. Hutchings. — I am glad to sec papers of this character coming be- 
fore the Association, for it is evidence that careful attention is being given 
to the surgical needs of those who are unable, from the nature of their 
affliction, to demand such for themselves. As an association calculated to 
mould public opinion, we should employ extreme care in the preparation of 
papers of this character, to be sure that we do not claim more in the way 
of improvement and cure with reference to the mental state than the facts 
justify. Where a mental recovery follows a surgical operation, before the 
surgeon can claim the credit of the cure he must present the history of 
the case with such detail that it may be fully understood by all who read it, 
and show how the unfavorable S3rmptoms were modified by the operation. 
Under such a searching method of inquiry there will probably be found 
fewer cases that will meet the requirements than is believed by many. 

I am glad to notice that Dr. Broun has made no extravagant claims, and 
has taken the safe ground that the operation is intended to benefit the 
general health by relieving pain or other symptoms, and discredits the 
theory of affecting the mental operations by refiex action through remote 
organs. 

Dr. G. H. Hill. — There have always been two objections advanced 
against operating upon the insane. One is that in surgery the operator 
should have the consent of the patient There is a legal doubt about the 
right to operate upon a patient without this consent 

Another excuse for not operating is that the patients are not interested 
in the operation, do not co-operate with the operator, and worse than all. 



LEROY BROUN. 305 

that they may antagonize the efforts of the surgeon and nurse hy remov- 
ing bandages, etc, so that the results of operating upon disorderly, un- 
reasonable patients are not nearly as favorable as the same operations 
performed upon sane patients. 

Db. Woodson. — I believe that where there is a pathological condition 
existing in the insane that can be benefited by the surgeon, they should 
have the benefit of the surgeon's skilL It has not been my experience that 
those who have been under my care have hesitated to be operated upon ; the 
fact is they are eager for operations and their friends are also anxious. 
They insist upon operations when there is absolutely nothing to indicate 
that an operation should be performed. I believe that it is necessary to 
have dentists, oculists, and aurists, and I believe that every well-regulated 
institution should have a consulting gynecologist. I do not believe the 
conservative man feels that he has cured insanity because he has oper- 
ated, but operates to relieve a pathological condition. I have followed and 
advocated this for a long time and have antagonized some of our members 
who were enthusiasts along these lines. I am still in favor of the same 
conservatism. 

Dr. Dent. — ^I rise to take up Dr. Broun's paper and to deny, if that is 
the opinion, that he operates to relieve mental symptoms. Dr. Broun 
specifically states that this is not the case. It is claimed in the institution 
that modem psychiatry does not exclude physical treatment upon the same 
principles as applies to general practice among sane people. 

These patients are women carefully selected by my assistants and referred 
to me for my advice and consent The consent of the friends or relatives* 
is secured in every instance. Moreover, Dr. Broun is an exceedingly con- 
scientious man and in no case would he operate for self-gratification. 

I requested Dr. Broun to tabulate these cases and make this report for 
the benefit of the Association, and realizing that everyone is inclined to 
'' toot his own horn " I told him to be very careful and confine himself to 
a statement of the work done with the results pertinent to the operations. 
I have seen a few recover that doubtless would have recovered anyway. 
In manic depressive insanity we all know that recovery is probable and 
also that it is very likely to recur again. We have operated for fibroid 
tumors as large as twelve pounds in weight, and the relief thus given has 
tended to mental improvement following the improvement to general 
health. 

Dr. Puntdn. — ^I think the danger lies in the promise of the gynecologist 
to accomplish too much for the patient They are also too apt to promise 
the friends that the operation will relieve the mental condition. The result 
of my experience is that the mental condition is usually greatly empha- 
sized by such operations. The vast majority of them are therefore not 
benefited by the operation. My judgment is that the average gynecologist 

20 



306. SURGERY IN THE MANHATTAN STATE HOSPITAL WEST. 

is not familiar with the insane condition and promises too much for his 
operation, and as a result, friends and patient are disappointed and the 
gynecologist finally suffers in repute, 

I think operations are sometimes indicated, but we should be very care- 
ful as to the extent of our claims for their benefit 

The President. — If there is any condition existing in the insane woman 
that would call for operative interference in the sane woman, the operation 
should be performed. I hold out no hope for recovery and tell the friends 
so. If the mental condition should improve, it would be a happy 
termination. 



SOME OBSERVATIONS ON THE RELATIONS OF THE 

GASTROINTESTINAL TRACT TO NERVOUS 

AND MENTAL DISEASES. 

By ROBERT COLEMAN KEMP, M. D., New York City, 

Consulting Physician, Gastrointestinal Diseases, to the Manhattan State 
Hospital, Ward's Island, etc, 

Mr. President and Gentlemen. — ^As I have not the honor of 
being a member of the American Medico-Psychological Associa- 
tion, or even a neurologist, I assure you that I appreciate all the 
more the invitation of your Secretary, my friend, Dr. Dent, to read 
a paper before you. I have selected as my title " Some Observa- 
tions on the Relations of the Gastrointestinal Tract to Nervous and 
Mental Diseases." You are all doubtless familiar with the investi- 
gations of Bouchard, Vaughan, Herter, and many others, into the 
subject " auto-intoxication," and it must be evident to you that my 
remarks will be entirely based upon this theory. This field opens 
up enormous possibilities, and although much good work has 
already been carried on, I believe the subject to be really in its 
infancy. For your complete understanding, it would seem to me 
to be advisable to first refer to the physiology of digestion. 

There are certain inorganic ferments contained in the saliva, 
bile, gastric juice, pancreatic juice, and intestinal juice which are a 
part of the human organism at birth. 

There are, furthermore, many organic ferments which are 
immediately acquired after birth, and which play an important 
part both in the physiology and in the pathology of the gastro- 
intestinal tract. At birth, this tract is sterile, as is confirmed by 
examination of the meconium. It is first infected in the new-bom 
infant by the swallowing of air, and then with the bacteria of the 
food and the saliva. The feces of the adult and nursling contain 
bacteria to the extent of approximately one-fourth to one-third of 
the dried weight of the excretion — which would sum total many 
millions. 



308 GASTROINTESTINAL TRACT. 

With normal digestion, fermentation of the carbohydrates in the 
small intestines is produced by the micro-organisms therein, to a 
physiological degree; the organic acids, the derivatives of such 
fermentation, acting as a stimulus to normal peristalsis. These 
acids prevent the putrefaction of albuminates within the small 
intestines, and partly check the decomposition of the carbohy- 
drates. The putrefaction of the albuminates physiologically takes 
place in the large intestine, the contents having an alkaline re- 
action. Here are developed skatol, which gives the odor to the 
feces, indol, phenol, and various gases, and the other products of 
putrefaction. The bacillus coli communis is believed to be an 
important factor in these putrefactive processes in the large intes- 
tine, and the production of indol depends largely on this activity. 
It is not a product of pancreatic fermentation as was formerly 
supposed. In this viscus also, a small proportion of fat is decom- 
posed into glycerin and fatty acids by tihe bacteria. When carbo- 
hydrates are present, as well as proteids, the colon bacilli ferment 
the carbohydrates first, and no indol is manufactured until this is 
nearly completed. Undoubtedly, putrefactive bacteria of various 
types are at all times present in the stomach and small intestines, 
but their activity is inhibited, until conditions favorable to their 
development arise. Thus normal fermentation of carbohydrates 
in the small intestine has this effect. 

The first inorganic ferment which we find is in the saliva, and 
this acts for the transformation of the carbohydrates. We must 
remember that proper mastication of the food, and care of the 
teeth, all have an important bearing on digestion. Acid fermenta- 
tion in the mouth interferes with the action of the saliva, and, 
moreover, it has been demonstrated that cleansing the mouths of 
nursing infants alone will diminish fermentative processes in the 
gastrointestinal tract. 

In the stomach, we have the combined action of hydrochloric 
acid and the ferment pepsin on the proteids ; the rennet ferment 
curdles milk and unless excessive hyperacidity be present, further 
fermentation changes occur in the sugars. Besides this, a small 
percentage of the fats is split into fatty acids. Meltzer has 
demonstrated that only a small quantity of water is absorbed from 
the stomach. Excessive hydrochloric acid, moreover, checks 
further changes in the sugars. 



ROBERT COLEMAN KEMP. 3O9 

The motor functions of the stomach and intestines are of great 
importance. A small meal, such as a soft boiled egg, a slice of 
toast and a glass of water, will pass through the stomach in about 
two hours ; and at the end of this time, under normal conditions, 
only a small amount of gastric juice can be aspirated. About the 
same period of time, two hours, is consumed in the passage through 
the small intestines ; while for about twenty hours the final pro- 
ducts remain in the large intestine before expulsion from the anus. 

Normal peristaltic action of the stomach and intestines is, 
therefore, a most important factor in the prevention of abnormal 
fermentation, or putrefaction. 

With atony of the stomach, we have as a result motor insuM- 
ciency and stasis. It has been demonstrated that the presence of 
free hydrochloric acid, even in considerable quantities, does not 
prevent gaseous fermentation, or putrefaction, if stasis be present. 

Furthermore, simple atony of the stomach will often progress to 
chronic dilatation ; and, in fact, I believe it to be a frequent course, 
if left untreated. With this dilatation there may be increased 
fermentation, or putrefaction. Butyric acid may be produced. 
This acid has a distinctly depressive effect on the central nervous 
system. Together with lactic and acetic acids, its presence indi- 
cates gastric stagnation, destruction of glandular elements by 
malignant, or other disease, putrefaction, or fermentation. Bu- 
tyric acid is classified among substances acting as auto-toxins. 
Hydrogen sulphide (H2S) at times is found in dilated stomachs, 
together with other gases, the absorption of which cause toxemic 
symptoms. 

In a recent work by Dr. Wm. H. Thomson, entitled " Graves' 
Disease, With and Without Exophthalmic Goitre," the author 
holds that gastrointestinal toxemia is the cause of this disease, 
and describes some twenty-eight symptoms occurring both with 
and without goitre. Curiously enough, ethylidenediamin, a 
ptomaine found at times by KulneflF in the liquids of the stomach 
in dilatation of that organ, when injected into mice and guinea 
pigs, will produce exophthalmos and some symptoms found in 
Graves' Disease. This is of interest, and certainly suggestive. 
Mold in the stomach, chronic gastritis, and achylia gastrica, may be 
found in dilatation of the stomach. It can thus be readily under- 
stood how perversions of the gastric digestion may be a marked 



3IO GASTROINTESTINAL TRACT. 

causative factor in the production of additional disturbances in the 
intestinal tract below, and be productive of excessiye fermentation 
or of putrefaction. A careful examination of the secretions and 
motor functions of the stomach is, therefore, one of the first requi- 
sites for scientific research into auto-infection from the gastro* 
intestinal tract. 

Under normal conditions, when the chyme enters the small 
intestine, its reaction is acid, due to the hydrochloric acid con- 
tained therein. 

The bile is one of the chief factors in gradually altering the 
reaction to neutral or alkaline. It strongly supplements the action 
of the pancreatic juice in emulsifying fats and its absence or dimi- 
nution lessens this function. It, furthermore, precipitates the 
pepsin from the chyme, and allows it to be the more readily 
absorbed. Some consider that it has antifermentative and anti- 
putrefactive powers, and that it helps maintain the nutrition of 
the epithelial cells. The bile exercises a distinct effect on the 
peristalsis of the intestines, and certain noxious products are by it 
eliminated from the body. 

The pancreatic juice contains an amylolytic ferment, a lipolytic 
ferment, and a proteolytic ferment, with which you are all familiar. 
They act in a neutral or alkaline medium, though small quantities 
of acetic, or lactic acid, seem to favor their activity. The organic 
ferments, existing in the small intestine, aid in the production of 
these acids. According to Ewald, prolonged action of the pan- 
creatic juice may produce hypoxanthin. It is now believed to be 
a product of putrefaction. This is a leucomaine, which causes 
nervous irritability and tetanic convulsions, a fact of interest. 
During the process of normal amylolytic fermentation, organic 
acids are given off which are an aid to stimulating intestinal peri- 
stalsis, and these acids are of service in checking putrefaction. 
Peristalsis of the intestine also renders putrefactive changes less 
likely. Stasis of the intestines is an aid to putrefaction, just as is 
motor insufficiency in the stomach. Butyric acid and hydrogen 
sulphide are auto-toxins, which may also be produced in the small 
intestines. The intestinal juice is claimed to augment the activity 
of the pancreatic ferments, according to Pawlow, and to help 
neutralize some of the acids formed by the fermentation of the 
carbohydrates. The reaction in the lower jejunum and ileum is 



ROBERT COLEMAN KEMP. 3II 

acid. When the intestinal contents pass into the colon, the re^ 
action becomes alkaline, fermentation stops, and putrefaction 
begins, and the fecal odor appears. In the large intestine great 
absorption of water occurs, the albuminates are absorbed, as are 
also sugars and fats to a degree. 

Marked auto-infection can occur from this viscus. Among the 
ptomaines found after prolonged stasis are cadaverin and putres- 
cin, which give the sjrmptCMns of muscarin poisoning. Moreover, 
indol is here developed. Herter has administered it to animals, 
and observed cardiac and respiratory depression, marked contrac- 
tion of the pupils, clonic spasms', and increased reflex irritability. 
Small quantities taken daily, for several weeks, produced nutritive 
changes, frontal and occipital headaches, colic, diarrhea, unnatural 
mental activity, and a tendency to the neurasthenic state. Indol 
is absorbed from the intestines, and forms indoxyl-potassium 
sulphate, or indican, and is so eliminated in the urine. The causes 
of indicanuria are excessive proteid diet, catarrh of the small 
intestines, causing alterations in the mucosa and increased intes- 
tinal putrefaction therefrom, typhoid, cholera, etc., constipation, 
alimentary putrefaction, decrease of normal digestive fluids, 
intestinal obstruction and peritonitis. Certain drugs, such as 
salol, salophen and creosote, will cause its appearance, while 
urotropin will diminish it. 

Regarding the urinary test for this condition, Jaffe's is the one 
frequently employed. Rosenbach's test, which consists in boiling 
the urine with nitric acid, gives a Burgundy red. This also 
demonstrates putrefactive changes, but not invariably that indican 
is one of the elements. This sometimes occurs when no indican 
is found by Jaflfe's test The result is due to substances of a like 
class. Other conditions of the urine occur as a result of these 
toxemias from the gastrointestinal tract, — ^the appearance of 
albumen and casts, or diminished urea excretion. The kidneys 
may become damaged from these toxins, and in turn, toxemia 
from the kidneys may result. We must remember that absence 
of indican in the urine does not invariably indicate absence of 
putrefaction, as in diarrhea, the indol may be to a great extent 
eliminated. 

Finally, the functions of the liver and its relations tp toxemia 
must be briefly considered. We have already described the action. 



312 GASTROINTESTINAL TRACT. 

of the bile in the intestines. The liver acts as a store-room of the 
organism, — as for peptones, and sugars in the form of glycogen, 
these substances being kept there until their final use in the system. 
It excludes poisonous matters from the general circulation, by 
removing them from the portal vein and excreting them by the 
bile. Thus, Herter demonstrates that the liver is the chief organ 
for the removal of indol. Various poisons and other auto-toxins, 
as of typhoid, etc., are similarly destroyed, or chemically changed. 
Therefore, any diminution of the functional mass of the liver, or 
interference with its functions, impairs this property, and toxemia 
results. 

The bile itself, when absorbed into the system, acts as a poison, 
and produces a definite toxemia. Moreover, catarrhal conditions 
of the intestines will often cause obstructive jaundice ; or the colon 
bacillus may become a source of infection of the ducts and gall- 
bladder. Insufficiency of the biliary secretion, or the absence of 
bile from the intestinal tract, favors in turn those conditions which 
result in auto-intoxication — due to the induced obstinate constipa- 
tion, from the absence of its antiseptic and peristaltic stimulant 
effect, and we have the well-known S3ntnptoms of bilious indiges- 
tion. You are all familiar with the slow pulse, and other symptoms 
of jaundice, unquestionably due to auto-intoxication. 

It is interesting to note that hepatic disease may be produced 
experimentally by substances allied to the auto-toxins, thus, in the 
production of hemoglobinemia by the injection of free hemoglobin, 
or distilled water, jaundice is produced. Furthermore, poisons 
circulating in the blood cause a change in normal bile, in which it 
increases in viscidity, causing agglutination of the walls of the bile 
ducts, obstruction of their lumen, and consequent retention of bile 
within the sac. Stadelman was able to produce jaundice experi- 
mentally in animals by poisoning them with arseniureted hydro- 
gen and toluylendiamin, and found that there was an enormous 
increase in the biliary secretion, and that it was very thick and 
tenacious. Autopsies showed no catarrh of the duodenum, or 
obstruction of the common duct Moreover, the bile acids, if 
injected, cause disintegration of the red blood corpuscles, with 
liberation of hemoglobin. They delay the coagulation period of 
the blood, and reduce motor and sensory irritability, and may 
cause coma, insensibility, and death. 



ROBERT COLEMAN KEMP. 313 

It is evident, therefore, that the liver cannot produce normal 
bile from abnormal blood ; and the fact that jaundice is caused by 
exposure to cold, syphilis, typhoid, phosphorous, and other poisons, 
shows how easily the secretion of the bile is altered, and suggests 
that intrinsic poisons, which are often hemolytic in their action, 
may act as causes. Toxic materials absorbed from the intestinal 
tract, or from the urinary tract, in addition, may cause altered 
secretions, and the retention of bile from its own viscosity may 
ensue. The absorption of bile is, therefore, a serious complication, 
when surgical operations are necessary, owing to the increased 
danger of hemorrhage on account of the lengthened coagulation 
period. In fact, hemorrhages from the various organs at times 
ensue — even subcutaneous in character, — sl condition like purpura 
hemorrhagica. For this condition, large and frequent doses of 
calcium chloride have been recommended. Moreover, the toxemia 
causes them to take anesthetics badly, and renders them liable to 
shock and collapse, and these patients have little resistant powers 
against sepsis and disease. 

Having thus described the relations of the gastrointestinal 
functions to toxemia, at this point I wish to call to your attention 
several important propositions. 

First: That epileptiform seizures, or even true epilepsy, may 
in some cases result from auto-infection. 

Second: That in many cases of nervous, or mental, diseases, 
derangements of the gastrointestinal functions with resulting auto- 
infection, may aggravate the original condition from which the 
patient may be a sufferer, and thus create a vicious circle. 

Third : That it is our duty as physicians, as much to our poor 
asylum as to our private patients, to place them in the best possible 
physical condition. 

And, finally, that on the patient's admission to such institutions, 
a thorough investigation should be made in each individual case 
into the existing conditions of the gastrointestinal tract, and appro- 
priate treatment be instituted in each ; for by this means alone can 
a scientific study of the relaticxis of toxemia to nervous and 
mental diseases, and the results of treatment, be obtained. My 
friend. Dr. Dent, is the first one to appreciate the value of this 
method ; and, as I shall describe to you later, it has already been 
instituted at the Manhattan State Hospital, West, Ward's Island. 



314 GAStROINTESTINAL TRACT. 

I shall first consider epileptiform convulsions and epilepsy 
resulting from toxemia from the gastrointestinal tract I judge 
that you are all familiar with the fact that the camivora are sus- 
ceptible to convulsive seizures from dietetic disturbances, while 
the herbivora are exempt. It is, furthermore, interesting to note 
that the administration of meat to young dogs will often be pro- 
ductive of convulsions. The intestinal walls of infants permit the 
passage of proteids, while those of adults do not, which may 
account for the greater frequency of nervous manifestations in 
children. Moreover, red meats in every event tend to aggravate 
nervous conditions, and it is customary in the modem treatment of 
epilepsy to largely eliminate them from the dietary. I have, 
furthermore, noted, in my own cases of epilepsy that were the 
result of toxemia, that the patients were large eaters, especially 
of the red meats. I shall first consider epileptiform seizures in 
the young. 

In our study of convulsive seizures in infants and young 
children, resulting from the administration of improper food, or 
from overloading the stomach, it was possible to distinguish two 
classes of cases, gastric and enteric. In the gastric cases, the 
convulsive seizures come on a short time after the administration 
of food, half an hour to an hour, or even less, and emesis often 
produces immediate relief. I have noted acute dilatation of the 
stomach in these cases. Just as in adult cases, to which I shall 
shortly refer, this acute dilatation, I believe to be caused by auto- 
infection, resulting from fermentative or putrefactive processes 
in the stomach. Such attacks, continuously repeated, may pre- 
dispose to the convulsive habit, and become a factor in the produc- 
tion of epilepsy. Furthermore, repeated attacks may tend to 
render the stomach atonic, and may result in chronic dilatation, 
with chronic toxemia as a result. I have referred to this class of 
cases in my article, entitled " Observations on Dilatation of the 
Stomach and on Gastroptosis," Medical News, August 6, 1904. 
In the enteric type the convulsions occur several hours after the 
administration of food, and are relieved by the use of an enema. 
These result from toxemia from the intestinal canal. Castor oil 
or calomel should then be used as adjuvants. 

We may have, instead of these well-defined types, a combination 
of the two. Holt and many others believe that intestinal putrcfac- 



ROBERT COLEMAN KEMP. 3I5 

tion, exciting convulsions in young children, is an important factor 
in the production of epilepsy. Repeated oonvulsiOtts certainly 
predispose to flie convulsive habit. On the other hand, chronic 
dilatation of the stomach, in the young, may result from improper 
feeding and the products resulting, may be a cause of toxemia 
from the stomach direct, or after entrance into the intestines. As 
a matter of interest, we would note that rickets, which is con- 
sidered one of the factors in the production of epilepsy, has often 
associated with it chronic dilatation of the stomach. Furthermore, 
Bouchard, in his well-known work on "Auto-infection," lays great 
stress on the chronic toxemia resulting from chronic dilatation of 
the stomach. I am thoroughly convinced that many cases of 
disturbances of the nervous system, chorea, so-called idiopathic 
epilepsy, and other nervous conditions commencing in early 
childhood, can often be justly imputed to this type of chronic 
toxemia. Derangements of the liver and renal functions are 
often associated, or result from gastrointestinal disturbances, and 
take an active part in the toxemic process. Fortunately, bene- 
ficent Nature steps in, in many cases, and the toxins are eliminated, 
with no permanent harm to the patient; while other cases may 
suffer from continual absorption, from prolonged constipation, for 
example, without any symptoms whatsoever. There is a great 
difference in the individual. 

I should now like to call to your attention some interesting data 
regarding epileptiform attacks in adults. Mangelsdorf of Bad 
Kissengen has examined over 400 cases of epilepsy, and several 
hundred cases of migraine, and has found acute dilatation of the 
stomach, just preceding or during the attacks. He made accurate 
drawings, in many cases, of the extent of the dilatation. Another 
interesting type is gastric tetany, in which gastric dilatation is a 
factor. Smith reports a case in which a patient with dyspepsia 
and gastrointestinal flatus failed rapidly in strength, and became 
troubled with insomnia. Tetanic attacks occasionally occurred, 
in which the fingers were forced into the palms. There was 
trismus, and the wrists were extended and rotated outwards. The 
patient suffered mentally, and sleep was disturbed by spectral 
delusions. The stomach was found to be dilated, and in a condi- 
tion of ptosis, and the patient became eventually extremely 
asthenic. These recurring attacks were entirely relieved by lavage 



3l6 GASTROINTESTINAL TRACT, 

and non-nitrogenous diet, but when these measures were n^lected, 
symptoms at once showed themselves. Dujardin-Beaumetz re- 
ports a case of gastric dilatation with very similar S3rmptoms; 
and Strong describes seven cases, characterized by spontaneous 
intermittent muscular contractions, and remarks their similarity 
to epilepsy. Simpson and Kussmaul find tetany a fairly common 
accompaniment of dilatation of the stomach. Moynihan believes 
it to be not very rare, and what is of extreme interest, reports Hve 
cases in which gastroenterostomy was performed, with a residting 
cure in each case. This is most sigtiihcant, as thorough drainage 
of the dilated stomach, the source of auto-infection, was removed 
and the patients were cured. Mayos work is also suggestive. 

I believe that, in certain cases of marked dilatation, or ptosis of 
the stomach with resulting auto-infection, the field of surgery will 
play an important part for the relief of nervous and mental 
diseases. Bouveret, Ewald, Fleiner, Einhom, and many others 
have reported cases of gastric tetany. Amato reports a case of 
gastric dilatation with tetany, resulting in death. He has intro- 
duced fermenting materials into the stomachs of animals, and 
produced dyspnea, myosis, muscular contractions and trismus. 
The liver and pancreas (post-mortem) showed lesions such as are 
usually found in poisonings and intoxications. 

An interesting case of catalepsy, associated with tetanic spasms, 
has been reported to me by Dr. John C. Minor. The patient 
suffered from chronic dilatation of the stomach with ptosis of the 
organ. Following an attack of constipation, or marked indis- 
cretions of diet, she would suddenly become absolutely stiff with 
flexion of the limbs, the eyes tightly closed, and would remain 
unconscious for a number of hours. From this condition, as she 
emerged into consciousness, the feet would extend, the knees 
increase in flexion, and there would be spasmodic twitchings of all 
the limbs. Between attacks the bowels would remain extremely 
loose, there being many watery movements during the day. As 
the attack was wearing off, many watery movements would occur 
— as many as twenty. While the patient's bowels remained loose, 
no attacks would occur. A contributing factor to the gastrointes- 
tinal disturbance was believed to be morphine, of which the patient 
at times took considerable quantities. 



ROBERT COLEMAN KEMP. 317 

Epilepsy, without question, may be in some cases directly attri- 
buted to auto-intoxication from the digestive tract In the Medical 
Record, January 28, 1905, appears an interesting article by Dr. 
Wm. Spratling, Medical Superintendent of the Craig Colony for 
Epileptics, entitled " Gluttony, or Food Poisoning, as a Cause of 
S3rmptomatic Epileptic Convulsions." I quote as follows : 

" The first few cases of symptomatic epileptic convulsions that 
I saw in middle-aged men, in which convulsive attacks invariably 
followed gross over-indulgence in eating and drinking, did not 
impress me as constituting a class of sufficient importance to 
warrant their being placed in a group alone. But having seen 
18 or 20 such cases during the past two years, I have come to 
believe that they represent a distinct phase of the subject that is 
well worth calling special attention to, particularly since they are 
usually so amenable to treatment ; substantially all of them making 
satisfactory recoveries when treatment is promptly instituted and 
observed as long as the nature of the case requires. 

" The cases of this kind that do not turn out well under treat- 
ment are those in which the patient is unwilling to deny himself 
the pleasures of the palate, except spasmodically and immediately 
after he has had a convulsion. But fortunately the lesson learned 
at such times is soon forgotten, and all such individuals stand in 
danger of ultimately becoming confirmed epileptics of the so-called 
' habit ' type, and to suffer all the mental and physical accompani- 
ments of that affliction. 

" Usually those who suffer in the way I am about to describe are 
between 35 and 45 years of age. Most of them are men of robust, 
frequently plethoric physique ; all are hearty eaters ; all lead more 
or less inactive, indoor lives, and some are heavy drinkers. When 
the latter factor complicates the case, the prognosis is less hopeful 
than when there is excessive food consumption only ; not because 
the type of convulsions induced by alcoholic indulgence yields less 
easily to treatment, but because the drink habit is not so readily 
broken. 

" While it is true, as a general rule, that heredity plays but little 
part in the causation of epilepsy, when it originates anew after the 
twentieth year, I have found that it is quite frequently a factor of 
some degree in the cases in question. It seems that there need 
not be insanity, or alcoholism, or epilepsy, or some other nervous 



3l8 GASTROINTESTINAL TRACT. 

affection in the ancestors of such cases as these, but a stomach 
disorder of pronounced type, like an aggravated dyspepsia, may 
make its influence felt in some obscure way in the offspring. 

" A very intelligent professional man, 40 years of age, came 
under my care eight years ago. He was subject to symptomatic 
grand mal attacks that invariably appeared the day following 
gross dietetic indiscretions, such indiscretions usually occurring 
between midnight and 2 a. m. He had a weak stomach and could 
digest certain foods only. On investigation I found that his father 
suffered the better part of life in the same way. The father re- 
spected his nutritional peculiarity, but the son did not; so the 
father escaped anything more serious than a severe, periodic 
dyspepsia; while the son was threatened with becoming a con- 
firmed epileptic. After having an attack while speaking in a 
public hall once, he realized his danger, changed his manner of 
living, and had been free from attacks for five years when I saw 
him last on November 24, 1904. 

" The primary cause of convulsive attacks in cases of over- 
eating and over-drinking in certain individuals seems to lie, first, 
in a weak stomach, and, second, in some obscure disorder of 
metabolism. Not only is the amount of food habitually taken by 
such persons beyond all reasonable requirements, but it is usually 
of an improper kind, and is taken to gratify what seems to be an 
abnormal appetite. 

" The type of convulsion usually induced is of the grand nud 
variety, though it is not definitely fixed. So long as the attacks 
remain grand mal only, the case is less likely to pass into * habit ' 
epilepsy than when the type changes. The last case of the kind 
I saw was that of a newspaper man, 38 years of age, who suffered 
grand mal attacks for some years, but whose dietetic habits were 
so atrocious that the seizures at the end of that time changed to 
infrequent grand and very frequent petit mal, with the result that 
some mental enfeeblement is becoming apparent, his memory in 
particular failing. This annoys him painfully, for in his work a 
good memory is a necessity. Along with the change in the type 
of his convulsions have come periods of marked automatism. 

" The day before I saw him he had a breakfast of cereals, eggs, 
fried potatoes, pancakes and coffee ; a hearty dinner at noon of a 
rich soup, chicken pie, several vegetables and pudding, with wine 



ROBERT COLEMAN KEMP. 319 

sauce for desert ; for supper he had a heavy meat pie, of which he 
ate heartily, three large, baked potatoes, three pieces of apple pie, 
and three cups of tea ; and yet he wondered why he suffered so 
much from headaches, from his stomach, from eructations of gas 
and flatulence, and attacks of momentary unconsciousness that 
were increasing in frequency, and that, worst of all, were fast 
undermining his mental faculties. He had written me two letters 
within a week, one on the day before I saw him, and yet he could 
not recall my name when I met him. 

"While the indications for treatment in such cases are plain 
enough, they are not so easily carried out. The cause of the con- 
vulsions must be sought in toxic states due to faulty metabolism. 
We must first eliminate waste and toxic products, and then plan 
a course of treatment which will prevent a recurrence of such 
products." 

In a number of cases of epilepsy, during the past few years. 
Dr. Wm. H. Thomson has secured brilliant results with the cure 
of patients from treatment of the gastrointestinal tract. In a few 
instances, gastric analysis showed hyperchlorhydria, while in a 
number of cases there was hypochlorhydria, with or without gas- 
tric dilatation. The treatment consisted in avoidance of red meats, 
intestinal disinfectants, regulation of the bowels, diet and medi- 
cation suitable to the individual condition of the stomach, and 
temporarily sodium bromide, combined with antipyrin, to lessen 
reflex irritability and break the convulsive habit. I have treated 
recently several interesting cases of epilepsy, which were unques- 
tionably due to auto-infection from the digestive tract. Time, 
however, will only allow me to briefly refer to one case. 

A young man, aged 25, with a negative family history, came to 
me for treatment, having had epileptic attacks for about six 
months. About a year previous to this, he had been in the 
Philippines, where he had a severe attack of dysentery. Since 
that time he has been troubled with occasional mucous discharge 
from the bowels. For some months past, however, he has been 
constipated, belches gas from the stomach, and has water brash 
and a sour ta$te in his mouth; tongue is coated. The gastric 
symptoms are more marked before his attacks. He has averaged 
one attack a month for four months, and during the last two 
months has had seven attacks. The early attacks are between 



320 GASTROINTESTINAL TRACT. 

7 and lo p. m., but more recently have been from 4 to 7 a. m. 
They clearly followed extreme indiscretions in diet, and the moither 
of the patient (who is a trained nurse) sent him to me for treat- 
ment, believing that gastrointestinal disturbances were the factors 
in the case. In the early morning attacks, he would be awakened 
by abdominal discomfort, then the hands would begin to twitch, 
the wrists and arms would flex, then these would be raised auto- 
matically to the level of the head, and he would then become 
unconscious. The tongue was bitten during a number of the 
attacks. Examination of the stomach contents showed: Total 
acidity 120 -|-, Free HCl. 90 -(-, a condition of hyperchlorhydria. 
There were intestinal tympanites, and some odor to the stool. 
Constipation was marked. The patient was shut off from red 
meats, smoking and drinking, and placed on a simple diet, 
especially a light supper. The bowels were freely opened with 
calomel, and thereafter kept carefully regelated. He was given 
benzoate soda gr. X t. i. d. for the intestinal putrefaction ; and 
soda bicarb, grs. X to XX t. i. d. an hour after meals for hyper- 
acidity. Sod. bromide gr. X four times a day (one of the doses 
at bed time) was given to break the convulsive habit This treat- 
ment was continued, but the bromide was gradually diminished, 
and then finally stopped entirely. For four months he had na 
attacks. He then ate a large amount of candy during the afternoon 
and evening, and promptly had an attack early the next morning. 
Calomel was given, and bromides were begun again, and in a few 
days dropped. During the next three months, he had three 
attacks — all following indiscretions in diet, and since then has been 
perfectly well — sl period of ten months so far, by merely taking 
gastrointestinal treatment and exercising care in diet. This case 
would seem to be of interest. 

I have noted several other cases where hyperchlorhydria with 
atony of the stomach, and a number with hypochlorhydria and 
dilatation. 

The question of etiology of epilepsy is of so great interest, that 
Dr. Wm. H. Thomson has instituted a general research on the 
subject at the Manhattan State Hospital, West, Ward's Island, in 
which in each epileptic patient the organs of the body are 
examined by the various specialists who visit this institution, and 
abnormalities, if present, are corrected. The scientific work in 



ROBERT COLEMAN KEMP. 



321 



gynecology, by Dr. Leroy Broun, speaks for itself. By this 
means we hope in time to secure some very valuable data. In 
Book I (which I pass around for your observation) you will see 
our gastrointestinal history sheets for these cases. These are very 
complete. Appropriate medication is given, such as may be indi- 



cate! 



case or 




Fig. I. 
A Few Cases Among Epoeptics and Pasehcs. 

cated in each case, antacid, or hydrochloric acid mixtures. The 
bowels are carefully regulated, and lavage is employed, if required. 
Intestinal antiseptics, such as benzoate of soda, resorcin, soda 
salicylate, and sulpho-carbolate of soda, are given. The red meats 
are omitted. Bromide of soda, with antipyrin, is administered, 

21 



322 



GASTROINTESTINAL TRACT. 



to lessen reflex irritability and break the convulsive habit. Mat- 
zoon is made in the hospital especially for these cases. These 
patients live as much as possible in the open air, a method which 
Dr. Dent carries out in fact with all his cases in the hospital. 

You will kindly observe the photograph which I now pass 
around for inspection (Fig. i). It demonstrates the position of 
the stomach in epileptics recently examined. The anatomical re- 
gions were marked out in blue pencil on the abdomen of each case 
and during transillumination of the stomach, the outlines were 
drawn in colored pencil. These markings were redrawn directly 




Fig. 2. — Circumscribing Gastrodiaphane. 
Devised at the Ward's Island Oastrolntestlnal Clinic. 



from each subject on paper stamped with a special instrument, 
giving the anatomical regions. The results secured were as fol- 
lows : Females, total number, 34 cases ; gastroptosis, 16 ; dilated 
stomachs, 16; stomach in normal position, 2. Males, total num- 
ber, 6 cases ; dilatation of the stomach, 5 ; stomach in normal posi- 
tion, I. 

The motor functions of the stomach and the analysis of the 
gastric contents were made with all these patients. These factors 
were considered in making the diagnosis. There was abnormal 
secretion in the stomachs occupying the normal position. These 
data are certainly suggestive. There has been improvement in 
some of these cases, but it is too soon to report definite results. 



ROBERT COLEMAN KEMP. 323 

Of course, many of these asylum patients are of the worst type, 
and in some degenerative changes have occurred in the brain. 
Nevertheless, even under such conditions, auto-intoxication can be 
minimized and susceptibility to convulsions can be diminished by 
proper treatment. 

These stomachs were transilluminated with the gastrodiaphane 
and fluorescein solution. On Card "A" you will see a picture of 
the new "Circumscribing gastrodiaphane" (Fig. 2), which was 
especially devised for work in this hospital. On Card " B " is a 
description of the various fluorescent media employed, also a new 
method, and devised by the author at this institution.* 

There seems to be an unfortunate disposition on the part of 
neurologists to consider various gastrointestinal disorders, dilata- 
tion of the stomach, inordinate appetite, stuffing, bolting the food, 
etc., as the result of nervous or mental disease. They forget that 
bulimia (inordinate hunger soon after a meal), acoria (absence of 
satiety), polyphagia, etc., are often found in addition in stomach 
disease. I think that we have, even at this point, fully demon- 
strated that the gastrointestinal disturbances may be primary. 

Many nervous conditions, neurasthenia, mental depression, and 
melancholia, can be imputed to auto-intoxication. Brokers, and 
professional men, with irregular habits of life, constitute almost a 
class in themselves. Bolting the food, or excessive eating or 
drinking, rich food, etc., are factors in the production of hyper- 
acidity, motor insufficiency, dilatation of the stomach, constipation, 
and auto-intoxication, with resulting disturbances of the nervous 
system, and the treatment of the gastrointestinal conditions will 
rapidly restore the patient's nervous tone in many cases. Mental 
depression often accompanies, or is a symptom of toxemia, and 
this condition may even progress to depressive insanity. Among 
other symptoms of auto-infection from the digestive tract, are 

*8 oz. of water containing sod. bicarb, gr. XV and 3i glycerine is first 
administered. A second 8 oz. of water containing gr. XV sod. bicarb, and 
% to % gr. of fluorescein (Merck) should be administered and then 
a half glass of plain water. The patient should have no food in the stom- 
ach and the electric bulb should be passed with the patient sitting erect 
The patient should then stand and the room be darkened. Quinine bisulph. 
gr. X in a weak acid solution or aesculin gr. ^ to i gr. in an alkaline 
solution may be substituted for fluorescein. 



324 GASTROINTESTINAL TRACT. 

apathy, insomnia, somnolence, and inability to concentrate the 
attention. Resulting from the auto-intoxication of jaundice, we 
may have all grades from mental depression to melancholia and 
insanity. It may cause coma, muscular twitchings, convulsions 
and death. Stem reports a case of narcolepsy in which, having 
excluded syphilitic endarteritis, he imputes the condition to auto- 
infection, resulting from dilatation of the stomach and hyper- 
chlorhydria. 

Hamilton offers the following conclusions, having made a 
special study of the digestion and urine in the insane : 

Varying and fugaceous illusions and hallucinations, pallor, in- 
creasing exhaustion, verbigeration, confusion and unsystematized 
delirium, are due to auto-intoxication. Auto-intoxication is 
common in alcoholism and the drug habits. Epileptiform attacks 
are directly connected with putrefactive conditions in the intes- 
tines. An interesting condition, resulting from auto-intoxication, 
is Graves' Disease. I have already referred to the work of Dr. 
Wm. H. Thomson, " Graves' Disease, With and Without Exoph- 
thalmic Goitre." He holds that the toxin is formed Arst in the 
alimentary canal, and then remains in the circulation on account 
of disturbance of the thyroid. He describes twenty-eight char- 
acteristic symptoms. Many cases of true Graves' disease exist 
without thyroid enlargement. He believes that implication of the 
thyroid is secondary, just as is the enlarged spleen in some cases 
of chronic ague. He has secured some brilliant results by treat- 
ment of the gastrointestinal tract. I have already referred to the 
suggestive fact that ethylidenediamin, a ptomaine found in some 
cases of dilated stomach, will produce exophthalmos on injection 
into animals. 

Another interesting class of nervous cases, resulting from auto- 
infection, are those in which ptosis of the gastrointestinal tract 
is the primary factor. There are various types of this condition, 
from those of a mild degree to the extreme cases described by 
Glenard. With the descent of the stomach and intestines, there is 
a nephroptosis of the right kidney, sometimes of both, and there 
may be in addition ptosis of the liver and spleen. A brief descrip- 
tion of the etiology is necessary. 

In the first place, the vertical stomach is the fetal position of the 
organ. Examination of infants and of young children will demon- 



ROBERT COLEMAN KEMP. 325 

strate occasionally a congenital gastroptosis to exist, and in some 
cases gastroptosis with its associated enteroptosis have been 
accidentally discovered and have undoubtedly existed for many 
years, with no symptoms resulting, and the patient be in perfect 
health; but some contributory factor, local irritation, anemia or 
intercurrent disease may destroy the equilibrium, and gastro- 
intestinal disturbances, constipation, etc., occur, causing auto- 
infection, and as a result neurasthenia. The maintenance of a 
certain degree of intraabdominal tension is a factor in preserving 
the position of the viscera ; thus a loss of tone in the abdominal 
muscles, or absorption of omental, or intraabdominal fat, may be 
factors in the production of ptosis. So also may an abnormal 
elongation of the mesentery, or an atonic conditicm of the suspen- 
sory ligaments of the stomach and colon. The loss of tone in the 
stomach and intestines — atony — ^is another factor in the production 
of ptosis. I have always believed dilatation of the stomach and 
gastroptosis to be progressive degrees of atony ; that in ptosis of 
the stomach, the organ was dilated and that gastroptosis might 
be primary, with enteroptosis a secondary condition ; this agrees 
with Riegers views. I cited a case in which I was convinced 
dilatation first occurred, then gastroptosis, and later enteroptosis. 
G16nard, on the other hand, claims tiiat enteroptosis is invariably 
the primary condition. The conditions are undoubtedly associated, 
but I believe that either may precede. 

It is not the degree of the descent of the lower border of the 
stomach which constitutes a ptosis. With gastroptosis, the lesser 
curvature of the stomach descends with the greater and loses its 
relations to the diaphragm; while in dilatation, the muscular 
fibers elongate in the vertical direction, — ^the greater curvature 
alone sinks, and the lesser curvature maintains its relations and 
does not sink. 

The gastric condition may be one of hyperchlorhydria, or of 
hypochlorhydria, or even of achylia gastrica. If the splashing 
sound be confined to below the umbilicus, and to the left of the 
median line, and one can determine a floating kidney, we can be 
sure that gastroptosis is present In the milder degrees of ptosis, 
it is not so easy to diflferentiate between ptosis and simple dilata- 
tion ; and in this event it may be necessary to employ inflation with 
air, or transillumination of the stomach. 



326 



GASTROINTESTINAL TRACT. 



Undoubtedly many cases of neurasthenia, treated with brilliant 
results by the Weir-Mitchell rest cure, are the result of gastrop- 
tosis. Rest and the putting-on of fat to increase intraabdominal 
tension are of value in ptosis. Rose's adhesive plaster belt is of 
service in the treatment of these cases, as it supports the organs 





Fia 3. 



Without Belt. 

Dilatation of the Stomach. 

TranslllamlDatlon with Fluoresoein 
before application of Rose's Belt. 

(Case I.) 



With Rose's Belt. 

Dilatation of the Stomach. 

Same patient (Case I). TransiUu- 
mination with Fluorescein after ap- 
plication of Rose's Belt. 

By accurate measurement the stom- 
ach has been elevated and the lower 
border is 4 Inches higher than It waa 
before the belt was applied. The 
lo^er border now lies above the um- 
bilicus. 



and increases intraabdominal tension. I show you a malnikin with 
the belt applied, and also the plaster-strapping ready cut for use. 
At the Ward's Island clinics, we were the first to employ the 
moleskin plaster for the belt. The zinc oxide on moleskin, 7 
inches wide, and manufactured by Johnson & Johnson, is the best 
for this purpose. In a new work, entitled " Atonia Gastrica," by 



ROBERT COLEMAN KEMP. 327 

Dr. Rose and myself, and published by Funk & Wagnalls, you will 
find a full description of the method. 

I consider mucous colic to be one of the manifestations of 
Glenard's disease, and the neurasthenic condition present in this 
disease to be the result of auto-infectiofk These views are given 
in a paper, entitled " Mucous Colic," American Medicine, March 4, 

1905. 

In conclusion, let me say that many cases of neurasthenia occur- 
ring in women are due to auto-infection, associated with ptosis 
of the viscera ; and I have seen excellent results secured from the 
treatment of the latter condition. In extreme cases, surgical 
measures, such as revision of the abdominal muscles, with shorten- 
ing of the suspensory ligaments of the stomach, or gastroplication, 
as suggested by Dr. Robert T. Morris, would be of value. I have 
already called to your attention that auto-infection from the gas- 
trointestinal tract may, in many cases, even when there are organic 
changes in the brain, create a vicious circle and aggrazfote the 
symptoms. 

Such derangements of the digestive functions occur in syphilis, 
from alcohol and from drug habits, as well as in other conditions,, 
as for example, I present the following data to you of 13 cases of 
dementia paralytica, investigated by Dr. Dent. You will note a. 
diminution in the frequency of the convulsions, and a lowering 
of the temperature in these cases, resulting from regulation of the 
bowels and treatment of the gastrointestinal tract appropriate to» 
each case. 

Dementia Paralytica. 13 Cases. Analysis. 

Tabetic type : 4 cases. 

Cerebral type : 9 cases. 

Hyperacidity: i case, with dilatation of stomach slight and 
commencing. 

Achylia gastrica (functional) : i case. 

Hypoacidity: 11 cases, with two severe types of chronic gas- 
tritis. 

Dilatation of stomach: 11 cases. 

Gastroptosis : 2 cases. 

Chronic constipation, marked and of varying degrees of 
severity : 13 cases. 



328 GASTROINTESTINAL TRACT. 

Odor to breath : 13 cases. 

Evidences of putrefactive changes in the gastrointestinal tract : 
13 cases. 

Temperature — ^no result from treatment: 2 cases. (In one of 
these the temperature was due to foul bed sores.) 

Temperature lowered in 11 cases, and in some very decidedly 
as a result of treatment, and remained lowered. (Note: — ^Rectal 
irrigation was an aid in lowering the temperature in three cases.) 

Convulsions : none occurred at any time in 7 patients. 

G)nvulsions: diminished in frequency in 5 patients by treat- 
ment 

Attack of s)mcope: (equivalent to convulsive seizures) abso- 
lutely stepped by treatment, i case. 




Fia 4.— Rbcubrbnt Rectal Ibrigator (Kemp). 

Died: i case. 

In Book II, you will find abstracts of each case, with a photo- 
graph of the stomach. The data are tabulated on the cover. 
As intestinal irrigation proved of value in 3 cases, I show you 
the Kemp irrigating tube (recurrent), which is of service for the 
purpose. The outflow is curved and larger than the central 
inflow. It is employed in all of our large hospitals. 
» Surgery. — ^I have already called to your attention the brilliant 
result^ secured by Moynihan in gastric tetany, through drainage 
of the dilated stomach by gastroenterostomy, and hence the pre- 
vention of auto-infection, and the cure of his patients. I have also 
referred to the value of surgical procedure in mucous colic, with 
its associated neurasthenia. In some of our patients suffering 
from nervous or mental diseases, with marked dilatation of the 
stomach and auto-infection, I believe that we should resort to 
gastroenterostomy, or gastroplication, after failure of the simpler 



ROBERT COLBHAK KEMP. 329 

measures. It will relieve the toxemia and break the vicious circle, 
thereby ameliorating symptoms, even in the worst type of cases. 
A case of gastroptosis and dilatation, with nephroptosis of the 
right kidney, the patient being melancholic, was recently operated 
on at the Manhattan State Hospital, West, Ward's Island, by Dr. 
Bickham. There was albuminuria, and congestion of the kidney, 
and the patient's attention was directed to that organ. I advocated 
that a nephropexy should be first done, to relieve the existing 
congestion and for the mental effect' 

If mechanical support by Rose's belt and medical treatment of 
the auto-infection do not relieve the nervous symptoms, gastropli- 
cation and shortening of the suspensory ligaments of the stomach 
will be performed. I believe in some cases that in surgery, we 
have a brilliant future for the relief of nervous and mental disease, 
especially in the types mentioned. Finally, since auto-infection 
from the gastrointestinal tract would seem to have such an import- 
ant relation to nervous and mental diseases, a new method has been 
instituted at the Manhattan State Hospital, West, Ward's Island. 

In Book I, on the last page, you will observe a gastrointestinal 
chart for new cases (Fig. 5). On this is placed the mental diag- 
nosis, and also the gastrointestinal condition found by examination. 
At the bottom of each chart, a memorandum is made of the treat- 
ment. This chart is bound in with the history of the patient. A 
duplicate is filed separately, so that at any time under the various 
types of nervous or mental disease, we can find the conditions ex- 
isting in the gastrointestinal tract, and the treatment employed — 
with results secured— without reading through the histories of the 
cases. A special physician is appointed to examine each case on 
admission, and appropriate treatment is at once instituted. We 
have certain standard mixtures at hand, an acid hydrochloric mix- 
ture with pepsin, and antacid mixture (magnesia usta 3 parts, soda 
bicarb, i part), and an antifermentative mixture (resordn gr. V, 
benzoate soda grs. X, sulpho-carbolate of soda grs. 3). Special 
cases, such as ulcer of the stomach, etc., are referred to the 
visiting gastrologist The bowels are regulated, and hydrotherapy 

^ This patient was ultimately discharged markedly improved, with a gain 
of 38 pounds in weight The stomach lay 2 inches higher, due to accu« 
mulation of fat and general improvement, on the date of her discharge. 



330 



GASTROINTESTINAL TRACT. 



MANHATTAN STATE HOSPITAL, WEST, WARD'S Island 



Name, 




Age. 


Ward, 


Date, 




Diagnosis 






GABTB0INTB8TINAL CHART 








Diagnosis 






V 


Btomaoh 




Perca salon 


V 




^-^ 

\ 


7- 


Normal Position 


Splashing Sound 


/ 






Atony 


Palpation 


/ 






\ 






\ 


y 


^\ 


Dilatation 


Nephroptosis 


/ 




Gastroptosls 


Vomiting 


Cast 


J 


\ 1 




Ewald*8 Test Breakl 


Residuum Aspirated c. c. 


Reaction 


Total A 


cldity Free 


Hcl. 


Uffelman*s Test 


Pepsin 


Rennet 


Starch Digestion 


Mucus 


Blood 


Hyperacid 


Normal 


Hypoacld 


Achylla 


GastrlUs 


Fermentation 


Anacld 








Liver 








JnteBtines 




Spleen 




Percussion 








Palpation 








MovemenU 








Normal 


Irregular 


Constipation 


Diarrhoea 


Mucus 


Blood 


Odor 




Enteroptosls 








Treatment 






Results 





Fia 5.— Gastsoiktestinal Chart. 



ROBERT COLEMAN KEMP. 331 

(for which there are all the modern facilities) is applied when 
indicated. The history of Grace W., which I pass around, demon- 
strates its value. It is appended in Book I. By such means the 
influence of auto-infection from the gastrointestinal tract on each 
patient is carefully observed. Complete urinalysis — estimation of 
urea — ^the presence of indican, etc., are carried out in every case. 
To my knowledge, this is the first institution in the country which 
has placed the study of the relations of auto-infection to nervous 
and mental diseases on a practical, clinical basis ; and it is from 
such investigations that we secure results from the science of 
medicine, and the greatest benefit to suflfering humanity. 
107 East S7th St, New York City. 

DISCUSSION. 

Dk. C. G. Hill. — Mr. President: I would like to say a few words in 
commendation of Dr. Kemp's excellent paper. I have held for a long time 
that the presentation and discussion of such papers as this would be pro- 
ductive of more practical good in the treatment of insanity than all the 
abstract theories of the classification of mental diseases, etc., that we are so 
prone to enter upon. I think Dr. Kemp deserves a great deal of credit for 
his careful and painstaking work and especially for his excellent diagrams 
of stomach dilatation. There is no question in my mind about the influence 
of autointoxication, not only in epilepsy but in all forms of mental disturb- 
ance, not excepting paranoia. I would take issue with Dr. Kemp, however, 
in regard to some of his conclusions. I believe that an accurate quantitative 
analysis of the twenty-four hours' urine when properly interpreted affords 
a better index to the condition of the stomach than the contents drawn 
by the stomach tube. The nervous irritation caused by the introduction of 
the tube, surely affects the secretions of that organ so that the accuracy 
of our test is in proportion to the susceptibility of the patient, and it is 
impossible to adjust this personal equation in estimating the result; but 
the collection of the twenty-four hours' urine causes no dread or shock and 
may even be done without the patient's knowledge. I have in my posses- 
sion tabulated analyses of the twenty-four hours urine of epileptics run- 
ning through many consecutive days and it is easy to trace by the changes, 
in the urine the approach of an epileptic attack, the day of the attack and 
the subsidence of the chemical conditions Associated with an epileptic seiz- 
ure. I might say in this connection that almost precisely the same condi- 
tion prevails in migraine, suggesting a striking similarity in these diseases. 
I have also observed that both the stomach and urinalysis reveal a 
typical epileptic stomach. This is characterized generally by a decided 
hyperchlorhydria, and whether this is or is not very marked there is gen- 
erally a complete absence of the starch digestion. The observation of 



332 GASTROINTESTINAL TRACT. 

this condition has changed my views on the dietary of epileptics. I pre- 
scribe fresh meats, eggs, fowl, and fish because they are the most easily 
digested by such a stomach, while white bread, potatoes, and other starchy 
foods are not digested and hence become toxic and increase the tendency 
to epilepsy. 

I have on more than one occasion stopped the epileptic seizure by 
inhibiting all starchy food and limiting the diet to a reasonable amount 
of well-prepared nitrogenous food. In these cases a liberal indulgence 
in starchy food, even for a single meal, will promptiy precipitate an attack 
of epilepsy. 

But this paper is so full of suggestions that it would lead us into all 
kinds of fields. I did not intend to say so much but arose to offer a vote 
of thanks to Dr. Kemp for giving us such an interesting and thoroughly 
worked-out paper on a subject of so much importance to this association 
of specialists. Seconded by Dr. Pilgrim and carried unanimously. 



OBSERVATIONS ON SOME RECENT SURGICAL CASES 
IN THE MANHATTAN STATE HOSPITAL EAST. 

By JOHN RUDOLPH KNAPP, M.D. 

Assistant Physician, ManhcUtan State Hospital, East, WanTs Island, 

New York City. 

The question of surgical interference upon persons of unsound 
mind has always been an interesting and much disputed one, and 
as the older surgeons taught that an insane person was a very 
doubtful subject for operation, comparatively few were performed 
upon persons of this class. 

That insanity is a serious and important complication with 
which the surgeon has to deal cannot be doubted, still the im- 
proved facilities and technique of recent years have lessened the 
dangers to a marked degree, so that even extensive major opera- 
tions are now performed with very gratifying results, both physi- 
cal and mental. 

Recently in our hospital, under the superintendency of Dr. 
A. E. Macdonald, several major operations have been performed 
by Dr. Wm. C. Lusk and Dr. Ramon Guiteras, of the Board of 
Consultants, with a large percentage of permanent cures and 
palliative results in most instances. 

A preliminary report of a successful operation for the radical 
cure of prolapse of the rectum of sixteen years' duration in a 
case of primary dementia was published in the Medical Record 
of June 6, 1903. This operation consisted in anchoring the sig- 
moid flexure to the anterior abdominal wall (sigmoideopexy). 
At the time of writing the report only ten weeks had elapsed 
since the date of operation, and the patient was up and about 
without any return of the prolapse. The patient now, two years 
and three months since the operation, is still up and about and 
there has been no evidence of a recurrence. His physical com- 
fort has been greatly enhanced, and his mental condition is much 
more cheerful. 



334 RECENT SURGICAL CASES. 

Since the above operation, several others have been performed 
of a similar character with uniformly good results. Reports of 
the same will probably follow in due course. 

The question of hernia is an important one in hospitals for the 
insane. About one male patient in every eighteen admitted to 
our hospital suffers from hernia in one form or other and of 
varying sizes. These cases always tend to become irreducible 
with consequent danger of strangulation. Treatment by the 
application of a truss is often unsatisfactory, and in many cases 
the physical annoyance to the patient from a hernia of long stand- 
ing, with its tendency to increase in size, is an important feature ; 
and it has been noticed that its presence often aggravates the 
morbid mental condition. 

Several operations have been recently performed at this hospi- 
tal for the radical cure of inguinal hernia of long standing, some 
of them of large size. A complete cure resulted in every case; 
and the marked physical comfort following has been very gratify- 
ing ; and now, after the lapse of fourteen months, in no instance 
has there been a recurrence. 

The uniform good results obtained in all the cases were, no 
doubt, largely owing to the special attention paid to the points of 
technique employed. The operation selected was that practiced 
and recommended by Bassini. 

The average time that the patients were under the anaesthetic 
was one hour and ten minutes, the operation proper lasting one 
hour. Following the operation, if the temperature did not rise 
above loo** F., the wound was not dressed for a week, but in 
case of a rise of temperature, with continuance above this point, 
the dressing was removed, the wound opened up and irrigated, 
and dressed daily until union was complete. 
. This precaution was observed because the insane frequently 
have a subnormal temperature when apparently in very fair physi- 
cal condition, and the febrile reaction after operation is often not 
attended by such a marked rise of temperature, even when sup- 
puration is present, as is usually observed in cases not the subject 
of mental derangement. 

In one case a hernia into the bladder walls, which is a rare 
congenital condition, was encountered, but required no special 
consideration other than a careful dissection of the sac. In every 



JOHN RUDOLPH KNAPP. 335 

instance the patient reacted well from the primary effects of the 
operation, and passed on to recovery without any special incident. 
Primary union occurred in most of the cases ; in the others there 
was some sloughing of the cellular tissue adjacent. The re- 
sultant firm cicatrix following this condition seemed to render 
the operation more successful, although avoidance of infection 
and healing by primary union are considered important essen- 
tials in the prevention of recurrence. 

The shortest time from the date of the operation imtil the 
woimd was entirely healed was thirteen days, and the longest, 
thirty-one days, although it was our practice to allow the patient to 
remain in bed about a week longer in order to secure a firm 
cicatrix, and facilitate the strengthening of the relaxed abdomi- 
nal muscles. 

The special points of technique employed and which should 
never be omitted, consisted in anchoring the sac by firm suture 
to the abdominal wall at the internal abdominal ring, accurate 
approximation in suturing and thereby lessening tension, careful 
dissection of the sac, and the avoidance of bruising the tissues 
during the manipulations. 

Authorities on the subject of hernia have stated, that opera- 
tions may be performed between the ages of four and sixty. 
Instances have been recorded where the operation has been per- 
formed two days after birth, and recently a case has been re- 
ported where a successful operation for strangulated hernia was 
performed under local anaesthesia upon a patient aged ninety- 
seven. 

Among the cases referred to, the youngest was twenty-three 
and the oldest sixty-three. It is worthy of note that primary 
union occurred in all the younger cases, and more or less suppur- 
ation in those over sixty years of age. This would seem to indi- 
cate that advancing age predisposes to suppuration by rendering 
the tissues more vulnerable to attacks of micro-organisms of sup- 
puration, and as evidences of senility frequently present them- 
selves much earlier in the insane, it is important that this should 
be borne in mind when recommending insane cases for operation. 

That there is always danger of a hernia becoming strangulated 
was exemplified in a case of chronic mania. A woman, aged 
thirty-six, who suffered from an umbilical hernia of long stand- 



336 RECENT SURGICAL CASES. 

ing. Following a period of excitement the hernia protruded and 
could not be reduced. Symptoms of strangulation suddenly de- 
veloped, the prolapse became tense and tender on pressure, pain 
was constant, and vomiting supervened. Hot compresses applied 
to the hernia and several enemata of warm water, with a full 
dose of morphia, relieved the more distressing symptoms, but the 
patient passed rapidly into a condition of collapse. After a care- 
ful examination it was decided to operate at once. The hernia 
was exposed; the gut, together with a mass of omentum, was 
found to be strangulated at the edge of the ring. The former 
was deeply congested and oedematous. This condition was 
treated by hot compresses about the gut, until the circulation 
became partially re-established. The mass of oedematous omen- 
tum was tied oflf, the intestine returned to the abdominal cavity, 
and the operation for radical cure completed. 

The operation was long and tedious, lasting two hours and 
fifteen minutes, but the patient reacted well, and recovered with- 
out any special incident. She is now in excellent physical condi- 
tion, but being a chronic case, there is little change in her mental 
state. A few hours' delay would have resulted in the death of 
the patient. 

Malignant disease of the testicle presents many points of inter- 
est to the surgeon, especially from the standpoint of diagnosis ; 
and as regards the operation of castration, either as a permanent 
cure or palliative measure. The lack of definite information on 
the subject tends to increase the interest. Statistics show that 
the results do not diflfer materially from those obtained by opera- 
tion on sane patients; some cases are followed by a permanent 
cure, in many there is sooner or later a recurrence of the dis- 
ease ; while in others, a very temporary relief is the result. The 
cases that are likely to recur are those in which there is involve- 
ment of the epididymis, with thickening and infiltration of the 
cord, and those in which the scrotum is adherent 

A case of sarcoma of the testicle, following an attack of ure- 
thritis and epididymitis, occurring in a patient, aged twenty-two, 
convalescing from acute melancholia, presented such striking 
diagnostic and prognostic features that his history will be briefly 
cited. 

Following the attack of epididymitis the right testicle gradually 



JOHN RUDOLPH KNAPP, 337 

increased in size until about three weeks prior to operation, when 
it somewhat suddenly showed evidences of greater enlargement. 
It became firmer and heavier ; there was some thickening of the 
cord, attended with increased vascularity of the scrotum and 
adjacent tissues. There was little pain except when the patient 
stood for any length of time, and this was always relieved by 
l3dng down. The growth was uniform in size and heavy, and 
there was some enlargement of the lumbar l3rmphatic glands. 
The patient showed little evidence of cachexia. About thirty 
weeks after the testicle first began to enlarge it was decided to 
operate. The organ was found to be completely infiltrated with 
the sarcomatous growth and was removed; the cord was much 
thickened and the scrotum adherent 

The wound healed gradually and the patient returned to his 
work in the tailors' shop, but about fifteen weeks following the 
operation it was noticed that at a point about half an inch above 
where the cord was lighted there was some swelling and ttmie- 
faction of the tissues. This gradually increased until the mass 
became larger and the skin ulcerated. Twenty weeks after the 
primary operation, a second was performed, which consisted in 
making an incision to the bottom of the mass and curetting it 
away, but following this the growth infiltrated rapidly, the pa- 
tient became emaciated, and died of lobular pneumonia and 
sapraemia twenty-five weeks after the primary operation. 

The second operation was performed simply as a palliative 
measure, as there could be but little hope of permanent relief 
unless the secondary growth were located in the scrotum. 

In this case the principal diagnostic considerations pointing to 
its malignancy were : the gradual and uniform enlargement up to 
a certain point, when there occurred a somewhat sudden increase 
in size ; the firmness and heaviness of the testicle, and the enlarge- 
ment of the lumbar lymphatic glands. The lack of constant pain, 
the vascularity of the scrotum, and the late development of 
cachexia differentiating it from carcinoma. 

From the standpoint of prognosis : the history, the involvement 
of the epididymis with thickening of the cord, and the adhesions 
to the scrotum were the important features that pointed to a 
recurrence. 

The results in this case did not differ materially from those 

22 



338 RECENT SURGICAL CASES. 

often experienced. As a palliative measure the operation would 
seem to be justified as a period of fifteen weeks passed, during 
which the patient was comparatively comfortable, and without 
operation it is probable he would not have lived so long, although 
from studying such a case the malignancy of certain neoplasms 
of the testicle is forcibly demonstrated and better appreciation 
had of the axiom handed down by the older surgeons to the eflEect 
that the patient who refused operation survived the castrated one. 

The boundary line between operable and inoperable cases is 
from time to time the subject of discussion, and it still remains 
an open question whether some of the operations performed for 
the prolongation of life in cases of malignant disease were justi- 
fied; on the other hand, it is quite probable that palliative pro- 
cedures might oftener be resorted to. 

Reports have been made of inoperable cases of malignant dis- 
ease of the uterus where the internal iliac arteries have been 
ligated with prolongation of the patient's life. The external 
carotids have been bilaterally tied in cases where the neoplasm 
was nourished by these vessels. The common carotid has also 
been ligated, but the effect of such a procedure upon the cerebral 
circulation renders it a serious undertaking. 

In one instance in our hospital the latter operation was per- 
formed for an inoperable sarcoma of the face of enormous size, 
originating from the infraorbital region. The patient was a case 
of dementia secondary to chronic melancholia; aged sixty years. 
He had been insane twenty-seven years. The growth had existed 
for about nine months but grew very rapidly, and at the time of 
operation was undergoing extensive ulceration. The operation 
consisted in ligating the artery just below the bifurcation in the 
triangle of election. The occurrence of troublesome haemorrhage 
from some of the smaller vessels beneath the angle of the jaw 
caused some delay, so that the operation lasted two hours. 

The patient, however, reacted well from the anaesthetic, par- 
took freely of nourishment, and for a time seemed brighter men- 
tally than for some months previous; but died of lobular pneu- 
monia on the third day following operation. The patient lived 
too short a time for any definite opinion as to the general advan- 
tages of the procedure to be determined. The effects, however, 
upon the growth for the time were marked ; the ulceration dimin- 



JOHN RUDOLPH KNAPP. 339 

ished, and the neoplasm lost to a pronounced degree its turgid 
and angry appearance. The operation in similar, but more favor- 
able cases, would seem to be a valuable palliative measure. 

The operation of trephining is an ancient one and has been 
handed down by the Fathers of Medicine. Skulls have been 
found in excavations which show that savage tribes performed 
the operation with considerable skill. 

At one time the operation was done by enthusiastic operators 
who paid but little attention to indications or focal symptoms, but 
at the present time a more, conservative view is taken and the 
operation is not performed imless either evidences of compres- 
sion exist, or the focal symptoms localize the lesion. Surgical 
operations upon the cranial cavity of the insane have always 
been absorbing in their interest ; and some authors quote figures 
which attribute alleviation of the mental condition, in a large 
percentage of cases, entirely to the operation ; such figures are 
misleading, as in the acute or recoverable forms of insanity a 
large percentage of cases pass on to recovery during the first 
year who have not been operative subjects. However, when an 
operation, and particularly one on the cranial cavity, has been 
performed upon a patient who has been insane over three years 
(the limit aftef which alienists agree that recovery rarely occurs), 
and the operation is a success from the surgical standpoint, and 
is also followed by an improvement in the mental condition, the 
subject is approached with more than usual interest. The follow- 
ing case is illustrative : 

A male patient, aged forty-two, who suffered from melancholia 
of four years' duration, which developed after operation for ap- 
pendicitis and appendicular abscess followed by post operative 
peritonitis. His insanity was of the suicidal type, with impulsive 
tendencies, and hallucinations of sight and hearing, followed by 
suspicion and hypochondriasis. 

About December i, 1903, he was noticed to be gradually fail- 
ing mentally, was dull and confused, complained that he could 
not read the paper as well as formerly, that the letters seemed 
blurred; was unable to swallow properly, owing to the loss of 
power in the muscles of the throat, saliva dribbled from his 
mouth, and his speech became inarticulate. 

January 7, 1904, he suddenly became excited, rushed about the 



340 RECENT SURGICAL CASES. 

ward, talked in a rambling and exalted strain, said that he was 
the strongest man in the world, and claimed to have an inspira- 
tion from God. Was placed in bed, but turned the bedding up- 
side down, and threw the bed clothes on the floor. 

This excitement continued until January lo, 1904, when at 
10.15 a. m., he was seized with an epileptiform convulsion, con- 
fined to the left side of the body. At 3.45 p. m., he got out of 
bed and stood up, when he was again suddenly seized with a 
convulsion, and falling forward to the floor, struck the frontal 
region of his head on the left side above the eye. When replaced 
in bed his pulse was slow and full, rate 70, and he was uncon- 
scious. 

January 10, 7.00 p. m., still unconscious, eyes drawn to the 
right ,pupils widely dilated, temperature 98,6*, pulse 70, respi- 
ration 22. 

January 11, 9.00 a. m., temperature 98.6**, pulse 92, respiration 
23; still unconscious; very restless, especially so when the seat 
of injury is pressed upon. Pupils dilated and do not react to 
ordinary light, eye balls drawn to right, shows marked muscular 
resistance, cannot be induced to protrude his tongue, no embar- 
rassment of respiration, bowels moved involuntarily four times 
during the night, passed an enormous quantity of urine involun- 
tarily. 

January 11, 11.00 a. m., patient winces and partly rouses up 
when seat of injury is pressed upon, occasionally draws up his 
legs, rubs his head with his hands, at times groans, champs his 
teeth, answers yes or no only when roused by shouting in his ear. 
Passes urine and faeces involuntarily, sleeps heavily, pupils dilated 
and only react upon strongly transmitted light, is apparently deaf, 
and is unable to extend his limbs without pain, reflexes markedly 
exaggerated, suffers from choked disc. 

January 12, patient remains in much the same condition, except 
that he cannot be roused by shouting in his ear ; his breathing is 
stertorous. 

It was recommended to operate at once by trephining over the 
area of injury, as it was possible that a depressed fracture ex- 
isted, although the gradual development of the symptoms pointed 
to a condition of cerebral pressure from increased intracranial 




Cerebkal Pressure 
(prior to operation). 



Cerebral Pressure 
(following operation). 




Sarcoma of the Face. 



■ I 

DC 

> 

i 

It 



JOHN RUDOLPH KNAPP. 34I 

tension, rather than to cerebral compression from a depressed 
fracture. 

Patient was anaesthetized ; the trephine was applit i just above 
the seat of injury, and a button of bone removed. The tissues 
were found to be the seat of a hematoma, but no fracture ex- 
isted. Immediately upon removing the button of bone it was 
noticed that the dura bulged into the opening from the intracranial 
pressure. The dura was then incised, which was followed by the 
escape of about six drachms of clear fluid. 

Several layers of gauze were then introduced beneath the dura, 
and allowed to remain in as drainage, the periosteum being 
brought together over the drain by means of a continuous cat-gut 
suture. The wound was dressed, and the gauze drain allowed 
to remain for twenty-four hours. 

Following the operation the temperature rose to 99.|-®, pulse 
72, respiration 20; after this the temperature approached the 
normal, and continued in this way until recovery was complete. 

After reacting from the anaesthetic, the patient spoke a few 
words, but was restless and confused for three or four days, when 
he began to realize his surroundings, and recognize those about 
him. He gradually improved until January 24, when he had a 
general convulsive seizure, which was attributable to reflex 
causes, being constipated and having eaten too heartily, with a 
brain in a hyper-sensitive condition. 

Following this, upon one occasion, he complained of pain in 
the forehead, radiating down the left arm, which was relieved by 
a dose of anti-pyrin and sodium bromide. For some weeks fol- 
lowing the operation he continued in a hyper-sensitive and hypo- 
chondriacal condition, but gradually and progressively improved ; 
took notice of everything going on about him, kept himself well 
posted on current events, became cheerful, good natured, would 
recall his feelings prior to the operation, and described them 
accurately. Had no more depressed periods, suicidal impulses, 
or convulsions ; gained in weight, anaemia disappeared, conversed 
readily, spoke distinctly, eye sight good, no blurring of the letters, 
swallowed readily, suffered no pain in the head, and made a 
complete recovery both mentally and physically. 

It is interesting to note that the embarrassed breathing con- 
tinued during the operation until the dura was incised and the 



342 RECENT SURGICAL CASES. 

effusion allowed to ^cape, almost immediately the stertor ceased, 
the respiration assumed a rc;gular rhythm, and the pulse became 
steadier. This was in accordance with observations and experi- 
ments, for it has been shown by recent observers, that as long as 
the vasomotor system maintains the blood pressure at a higher 
level than the intracranial pressure, the respiratory center will 
be nourished and perform its function. If the blood pressure 
falls below the intracranial pressure the function of the respira- 
tory center will be interfered with, and rapid cardiac action and 
low blood pressure ensue. 

The development of the period of excitement with exaltation, 
attended by cerebral symptoms and followed by convulsions, 
brought up the question of diagnosis of the mental state. Had 
we to do with a case of paresis ? The previous history of absence 
of somatic symptoms and the rapid development of pressure 
sjrmptoms, as compared with those of paresis, were the determin- 
ing factors in the diagnosis. 

The occurrence of the epileptiform seizure following the opera- 
tion suggested the possibility of the existence of epilepsy, but this 
was rendered extremely improbable by a careful inquiry which 
demonstrated the absence of previous seizures. The development 
and final outcome of the case warranted the diagnosis of increased 
intracranial pressure due to causes operating from within the 
cranial cavity. 

It is not the object of this paper to discuss the pathogenesis 
of intracranial effusions, but when we bear in mind that the pia- 
arachnoid membrane is serous in character, being covered on its 
outer surface by endothelium ; that it is the disposition of morbid 
processes, as shown by numerous autopsy findings, to affect simi- 
lar structures throughout the body, and that the patient for a 
considerable period suffered from post-operative peritonitis, it is 
not improbable that the same infection which involved the peri- 
toneum also attacked the pia-arachnoid, inducing hyperemia in 
that structure, which was subsequently followed by the accumu- 
lation of serous fluid. The involvement of serous structures fol- 
lowing general systemic infections is a line of investigation from 
which much has yet to be heard. 

Although in operations upon the insane many difficulties are 
encountered not experienced in dealing with cases of sound mind. 



JOHN RUDOLPH KNAPP. 343 

particularly in the line of profound exhaustive states, early senile 
changes, and more requisite watchful care in the after-dressing 
and treatment, yet the results obtained fully demonstrate that 
surgery, in carefully selected cases, is one of the valuable means 
at our command for the alleviation of physical suffering, and, in 
many instances, if judiciously employed, will also be attended by 
an amelioration of the mental state. 



THE LIVER AND ITS RELATION TO MENTAL AND 
NERVOUS DISEASES. 

By CHARLES G. HILL, AM., M.D. 

The liver and its functions have been associated with mind and 
its disorders from time immemorial. Homer speaks of the 
Cholos of Achilles in the Iliad, and frequent reference is made to 
this connection in Juvenal and other Latin poets. When and by 
whom the name of melancholia was first applied to the now well- 
tcnown disease I have never been able to ascertain, but bile and 
bad temper are more closely linked together in the popular mind 
than any other psychical and physical conditions. The inter- 
changeableness of these conditions has also long been recognized 
and it is deemed as fitting in literature to speak of the gall of 
bitterness as the bitterness of gall. The liver was generally sup- 
posed to be chiefly the seat of anger, but not of anger alone, as 
the " Jecur ulcerosum " of Horace was induced by love. Plautus 
terms this tender feeling " Morbus hepaturius." Solomon speaks 
of the misguided youth in whom the "dart of passion strikes 
through his liver," but it is to grief that Jeremiah alludes when 
he complains, " My liver is poured upon the earth." That mental 
emotions may produce disease of the liver and disease of the liver 
cause mental disturbance is too well established to be questioned, 
especially since we have it on the authority of that great alienist, 
William Shakespeare, who, in the " Merchant of Venice," says : 

" Why should a man whose blood is warm within, 
Sit like his grandsire cut in alabaster. 
Sleep when he wakes, and creep into the Jaundice by being peevish?" 

Not only jaundice but many other diseases of the liver either 
of a functional or organic character, such as acute atrophy, cirr- 
hosis, gall-stones, have been traced to the emotions, and even 
cancer is claimed by good authorities to have been caused by grief, 
worry, anxiety, or shock. 

To appreciate the importance of the liver and its relations to 
the healthy functionation of the nerve cells we must remember 



346 THE LIVER. 

that it IS the largest organ of the body, and that it stands like a 
faithful sentinel on guard to preserve the purity and integrity of 
the blood by which the cells are nourished and from which they 
extract those subtle chemical elements that enable them to per- 
form their complex functions. We heap censure and abuse on 
this poor unromantic and overworked organ when its deficiency, 
or rather insufficiency, make it self-felt in our mental or physical 
discomfort, rarely stopping to realize that the stomach, that vile 
old sinner, should be held accountable. From the errors, ex- 
cesses, and abuses of this member so many poisons have been 
caught and tagged by the organic chemist, any one of which, if 
not arrested, modified, or subdued by the ever-faithful liver, 
would produce serious results, the wonder is that still we live 
and that civilized races have not been annihilated. The liver, 
standing as it does like a gladiator in the breach gallantly defend- 
ing the citadel, is frequently being wounded by the arrows of its 
enemies, the gastro-intestinal toxins that constantly assail it. Its 
duties expose it to great danger. Not only attacked by these 
agencies in the front, but alcohol, lead, arsenic, and other ex- 
traneous poisons assail it on its flanks and grief, worry, love, and 
anger fall upon its rear. Since I have referred to alcohol, allow 
me to correct a wide-spread error in regard to its action on the 
liver. According to the popular belief alcohol and cirrhosis are 
very closely linked together. A bibulous friend of mine when 
he consents to take another drink always says that he will close 
up one more cell of his liver and then stop, and yet it is often a 
matter of surprise in post-mortem examination that many heavy 
drinkers escape the supposed inevitable hob-nailed liver, while this 
condition is often found in temperate or abstemious people. Boix 
in his interesting work on " The Liver of Dyspeptics " has ex- 
plained this very clearly. He has shown by numerous experiments 
on rabbits that the various toxic acids resulting from disturbances 
of the stomach quite readily produce the cirrhosis that we are 
prone to attribute to alcohol. In his experiments he caused rab- 
bits to swallow butyric, lactic, valerianic, acetic, oleic, palmetic, 
stearic, margaric, and oxalic acids, aldehyde, acetone, pepper, and 
living cultures of Bacterium coli communis, and these were all 
found to produce a typical cirrhosis. In some instances he added 
alcohol to these various substances and found that the liver de- 



CHARLES G. HILL. 347 

generation was delayed, the life of the animal prolonged, and 
cirrhotic lesions less pronounced in post mortem inspection. It is 
quite worthy of remark that previous to this La Fitte had con- 
scientiously experimented on thirty-four rabbits to whom for a 
period of time varying from four days to fifteen months, wine, 
alcohol, and absinthe were administered, and while these animals 
presented some lesions of the liver they bore no resemblance to 
the so-called alcoholic atrophic cirrhosis. Hence it seems safe to 
infer that it is not the alcohol per se that causes the degenerative 
changes in the liver that we are prone to attribute to it, but the 
irritating and caustic action of whiskey and other concentrated 
alcoholic beverages causing first a mucous gastritis with the 
formation of the various acid toxins, and secondarily the well- 
known diseases of the liver. It is plainly shown that other 
digestive disturbances than those caused by alcohol will produce 
exactly the same results. Practically this is a matter of great 
importance in the treatment of the insane and neurotic. In in- 
sanity a pathologic condition of the stomach almost invariably 
exists. If you will look carefully into the personal history of 
your patients and not bother so much about what the grand- 
mother or grandfather's sister died of, you will find that indi- 
gestion had been a marked symptom prior to the development of 
the psychical disturbance. As a result of this you will find a 
defective liver incapable of arresting the toxic products of the 
digestive errors, and then if you will overlook the complex classi- 
fication of his mental derangement you will find that you are deal- 
ing with an auto-intoxication primarily which has incidentally 
developed the mental symptoms that brought him to your insti- 
tution. And if you think these plebeian dyspeptic troubles too 
common-place for the psycho-pathologist, you can go a little 
deeper into the cause of the dyspepsia and you will find social 
and psychical causes often lying at the root of the gastro-hepatic 
disease. While Dr. Beaumont in his remarkable observations on 
the stomach of St. Martin describes very vividly the mucous 
gastritic congestion and ulceration that he always found after 
the old Canadian had been on a debauch, he also observed that 
" anger or other severe mental emotions would sometimes cause 
the inner or mucous coat to become morbidly red, dry, and irri-* 



348 THE LIVES. 

table, occasioning at the same time a temporary fit of indiges- 
tion." 

Dr. Tuke in his " Influence of Mind on the Body " says : " Pleas- 
urable emotions increase the amount of gastric secretion, the oppo- 
site effect being produced by depressing passions." That there 
is an inherent difference in individuals, in the resistance of the 
liver to these toxic poisons as well as in its capacity for doing 
extra work when called upon, is very evident. This applies also 
to the stomach and the same might be said on the other hand 
of the susceptibility of these organs to functional disturbances 
from emotional or psychical causes. Now when we take into con- 
sideration the fact that these conditions are often hereditary it 
becomes a matter of as much importance to look for inherited 
stomach and liver shortcomings as to investigate the mental de- 
fects of the antecedents of a patient 

The modus operandi of the liver degeneration and subsequent 
auto-intoxication is as follows: A function of the liver is to 
reduce or oxidize these substances and either permit them to 
enter the circulation in a non-toxic form or to be eliminated by 
the kidneys or excreted into the intestines with the bile. The for- 
mation of a larger amount of toxin than the liver is capable of 
acting upon or any deficiency in the chemic activity of the liver 
cells or imperfect elimination of bile will permit an auto-intoxi- 
cation of the system. If toxins are formed in excess in the 
digestive tract over a considerable period of time there is pro- 
duced a cell fatigue and ultimate cirrhosis of the liver causing 
insufficiency of that organ. Thus all the toxins produced in the 
intestines, whether from the action of bacteria, perverted meta- 
bolism, or constipation, as well as exogenous toxins, have the 
effect of producing a cirrhosis and consequently insufficient hepatic 
functionation. The principal constituents of the bile are the 
bile salts, taurocholate and glycocholate of soda, the bile pigment 
bilirubin, and cholesterin. The principal function of the bile 
salts is to hold in solution the cholesterin and bilirubin, preventing 
the formation of gall-stones and to increase the eliminative power 
of the bile. In the intestine the bile acids aid materially in the 
saponification and absorption of fats. 

The toxic effect of the bile salts when injected into the blood 
has been carefully studied and may be summarized as follows : 



CHARLES a HILL. 349 

1. Injected even in small doses into the blood stream they pro- 
duce a widespread disintegration of the red blood corpuscles with 
liberation of haemoglobin ; brought into contact with cells of the 
body they cause disintegration. 

2. In small doses they increase coagulation. 

3. In large doses they arrest coagulation. 

4. In very small doses they act as vaso-dilators. 

5. In large doses as vaso-constrictors. 

6. They reduce motor and sensory irritability. 

7. They slow the heart-beat by direct action on the heart- 
muscle and cardiac ganglia. 

8. They act on the higher cerebral centers, causing coma, 
stupor, and death. The physiologic action of the bile salts when 
administered by the mouth is as follows : 

9. They are trjie chologogues, probably the only ones at our 
command, increasing both the solid and liquid constituents of the 
bile. 

10. Their presence in the blood serum (Croft claims that they 
exist in the normal blood) stimulates the liver cells. 

11. They act as solvents for cholesterin and bilirubin and other 
substances eliminated by the bile, preventing the formation of 
gall-stones. 

The importance of a sufficiency of bile salts to the proper 
functionating of the liver cannot be overestimated. Without 
them the liver cells do not receive their normal stimulus, the 
toxic products of hepatic metabolism are not eliminated, choles- 
terin and bilirubinate of calcium are precipitated, forming gall- 
stones. Hecter and Wakerman have shown that the secretion 
of bile salts is reduced by any inflammation of the gall bladder 
whether from infection or not. 

Bilirubin is also toxic; formed in all probability from haemo- 
globin in the liver, it is eliminated with the bile into the intes- 
tines, there converted into hydrobilirubin and stercobilin, the 
former being partially absorbed and eliminated by the kidneys, 
the latter eliminated with the faeces. The hydrobilirubin is further 
changed to urobilin in the urine. Considerable controversy exists 
as to whether bilirubin is only formed in the liver or m other 
organs as well. As bilirubin occurs in the skin pigment and in 
old blood clots, it is probable that under certain conditions it may 



3SO THE LIVER. 

be formed in other organs than the liver, but it is supposed that 
these conditions are rare; the occasional bilirubin found in the 
blood may be considered as the result of defective elimination by 
the bile ; the pigment circulating in the blood is deposited in the 
tissues, producing icteroid discolorations ; therefore the liver when 
stimulated to proper action removes the pigment from the blood, 
gradually cleaning up the complexion. 

The toxicity of bilirubin is undoubted. Bouchard found that 
4 to 6 cc. of bile per kilogram of animal caused death in con- 
vulsions, but that if the bile was decolorized by passing it through 
animal charcoal the toxicity was reduced two-thirds and that the 
animal died in coma and not in convulsions. This result of the 
French scientist has not been confirmed. Bilirubin has been 
shown to reduce the electrical activity of muscles to a very marked 
degree, especially the heart muscles, but intravenous injections 
of bilirubin do not cause more than transient symptoms. The 
explanation of this is that the tissues rapidly fix the bilirubin in, 
thus withdrawing it from the circulation. In certain cases of 
neurasthenia there is an excess of bilirubin in the plasma, the 
quantity being sufficient to give Gmellin's reaction. Normal 
plasma contains a trace of bilirubin ; Gmellin's reaction is positive 
to one in forty thousand, so that a very faint trace will produce 
the blue ring. If the serum be diluted with twice its volume of 
water the reaction is still evident The symptoms produced by 
cholcemia are described by the patient as nervousness ; there is a 
feeling of fatigue, inability to work, a nervous irritability accom- 
panied with a despondency which may be so great as to become 
a true melancholia. The patient complains of bad digestion char- 
acterized by a feeling of heaviness in the region of the stomach 
after eating, followed in an hour or two by thirst with acid eruc- 
tation. There may be pains in the region of the stomach imme- 
diately after eating which cease in a few minutes, reappearing in 
three or four hours, patient feeling as though they were moving 
towards the oesophagus. There may also be a sick stomach, but 
rarely any vomiting. The appetite remains normal or may be 
capricious and exaggerated, rarely decreased, occasionally a true 
anorexia occurs. It must be borne in mind that a patient's ac- 
count of what he eats is not reliable, the only way of finding out 
the condition of his appetite is to test his twenty-four hours' urine 



CHARLES G. HILL. 35 1 

for total nitrogen. Constipation is a marked symptom, often with 
occasional attacks of diarrhoea without apparent cause, the stool 
being acid and burning, containing much bile and perhaps blood 
and mucus ; the diarrhoea may commence with vomiting of bile. 
The stomach examination shows hyperchlorhydria with excess 
of organic acids, occasionally hypochlorhydria, the stomach con- 
tents are thick and viscid, containing very much acid mucus, there 
is also excessive gas formation. Digestion appears to be rapid 
and complete. The pulse is normal or slow, is irregular and 
irritable. The mean blood pressure is high in proportion to the 
maximum. There is a hyperacidity of the saliva with a bitter 
taste in the mouth and a foetid breath. A common symptom is a 
reversal of temperature, the maximum being at 7 a. m. and the 
minimimi, which may be below normal, at 7. p. m. Subjective 
temperature may occur and rarely slight intermittent fever. 
Epistaxis is common, h^matemesis rare, retinal haemorrhage is 
not common, and in old patients purpura on the back of the hands 
is ccmimon, as well as cerebral haemorrhage and menorrhagia. 
The skin has a dirty yellowish hue, generally termed a bilious com- 
plexion; the discoloration is most marked on the back of the 
hands and dorsum of the foot; the skin over the knuckles may 
be a normal shade or nearly so, while the skin between the joints 
is pigmented, varying from a dirty yellow to a dark brown. Spots 
may occur on the palms of the hands, soles of the feet, the labia, 
on the face and various parts of the body. The whole skin is 
discolorized with deeper colorations in patches. 

The mental symptoms differ in each case; the prevailing con- 
dition is that of melancholia, a deep despondency looking on the 
gloomy side of everything, exaggerating eyery trifle, a fear of 
some imdefined danger with a desire for death which may cause 
suicide. Hearing voices is also common ; the patient may jump 
from the window to get -away from the persecutor but without 
suicidal intent. From the worry and depression there is loss of 
weight, insomnia, and headache, the latter being usually at the 
vertex or occiput; the mental symptoms develop slowly and in- 
sidiously, progressing to insanity. The nervous and mental symp- 
toms of this form of neurasthaenia, which may become a true 
melancholia, are undoubtedly due to bilirubin intoxication, bili- 
rubin anaemia, from defective metabolism, or the plugging of the 



35^ THE LIVER. 

capillaries with mucus, or obstruction of the gall ducts. Disease 
of the gall bladder is common in mental diseases ; gall-stones oc- 
curred in 26 per cent of the women at E. Michigan asylum. 
Almost all melancholies suffer from disease of the gall bladder 
and a very large percentage have gall-stones, while they are rarely, 
if ever, present in mania. The primary condition necessary for 
the formation of a gall-stone is the absence of a sufficient quantity 
of bile salts to hold the cholesterin and bilirubinate of calcium in 
solution; the absence of the bile salts produces an hepatic staSis 
which is followed by chronic insufficiency, causing a number of 
substances to be thrown back into the circulation. Cholesterin is 
probably non-toxic, though Flint speaks of cholesteraemia as a 
special dyscrasia. At Mount Hope there was found excess of 
cholesterin in the blood in the only two cases of melancholia which 
were examined thoroughly for this product. 

Glycosuria from hepatic insufficiency is found occasionally in 
asylums. I have had some half-dozen cases at Mount Hope, all 
melancholies except one, who was not committed as insane but was 
suffering from slight mania. Two of the melancholies recovered ; 
they ceased to eliminate sugar even on ordinary diet, and their 
psychic symptoms disappeared with the sugar in the urine. In 
another case the sugar disappeared from the urine but the patient's 
physical condition was unimproved. In the other cases neither 
the glycosuria nor the mental symptoms were effected by the treat- 
ment. From the multiplicity of the functions of the liver it is 
impossible to specify any particular form of toxaemia that may re- 
sult from hepatic insufficiency, but it is evident that when the or- 
gan which is the safeguard of the system against the toxins taken 
into the body with the food (exogenous toxins), the toxins formed 
in the alimentary canal (indogenous toxins) becomes diseased, 
reducing its chemic activity, a toxsemia must result, and as toxins 
as a rule produce their most apparent symptoms on the nervous 
system it follows that hepatic insufficiency is a condition demand- 
ing treatment in all cases of insanity. 

Toxins exist in the blood stream under normal conditions in 
small quantities, which the kidneys are able to eliminate without 
detriment, but if there is an excess the strain put upon the kidney 
causes a renal insufficiency which increases the toxaemia and im- 
pairs the kidneys. It has been observed that in cases of bilirubin- 



CHARLES G. HILL. 353 

aemia nephritis is nearly always present with or without albumen. 
In the former condition the kidney insufficiency can be detected by 
a careful quantitative analysis of the urine and by taking the freez- 
ing point. Marked kidney insufficiency in the insane producing 
acute uraemia is less common than would be expected. This may 
be explained by the nature of the toxins. The kidney may be able 
to eliminate the purin bodies and the organic in normal or almost 
normal quantities, failing to eliminate the organic toxins. The 
pathologic conditions produced in the liver are usually fatty de- 
generation occurring mostly in those cases which run a rapid 
course, diseases of the gall bladder, the so-called atrophic cirrhosis, 
and occasionally hypertrophic cirrhosis. In the latter conditions 
there is a dilatation of the portal veins which communicate with 
the general circulation increasing the toxaemia, a great amount of 
portal blood passing directly into the general circulation without 
passing through the liver. 

The treatment of these conditions presents great difficulties. 
Every effort should be made to trace out the source of the intoxi- 
cation. G>nstipation should be especially combatted, and particu- 
lar attention must be paid to the stomach. As most of the toxins 
are acid and will combine with alkalies rendering them less active, 
alkaline treatment is indicated, care being taken to administer a 
sufficient amount of sodium chloride to keep up the normal pro- 
portion of inorganic salts in the plasma. The administration of 
calcium in order that the organic acids may form calcium salts 
which are less soluble than the alkali salts and are therefore elim- 
inated in the faeces is also of service. The administration of large 
quantities of water containing the inorganic salts of the plasma in 
proper proportion is also important, it having a tendency to dis- 
solve the calcium salts precipitated in the arteries in arterial 
sclerosis and also to reduce die peripheral blood tension. The 
stimulation of the liver is best obtained by the administration of 
the bichloride of mercury in small doses combined with soditmi 
glycocholate mass. The latter when administered per os is ab- 
sorbed from the intestine, passing into the liver it stimulates the 
ceUs, at the same time dissolving the accumulated metabolic pro- 
ducts, producing a free flow of bile into the intestine. Under its 
use the icteroid discoloration of the skin disappears and in many 
cases the constipation is relieved. 

2Z 



354 THE UVER. 

Hepatic insuf&ciency, combined as it often is with renal insuffi- 
ciency, causes a retention of substances which are normally trans- 
ferred and eliminated ; the action of these substances upon the cells 
of the nervous system is to modify the metabolism. Where the in- 
toxication is slight and transitory the symptoms produced do not 
permanently affect the cellular functions, but if the action is inten- 
sified and prolonged, the functional disturbance becomes accentu- 
ated, definite, and permanent, as shown by the changed form and 
chemical reaction of the cells. The genesis of auto-intoxication of 
the cells of the nervous system is complicated, but may be illus- 
trated by the simple toxaemias, such as those of alcohol, morphine, 
cocain, and cannabis indica, which produce delusions, hallucina- 
tions, and illusions closely resembling in some cases those of 
chronic insane. A more perfect simulation of mania can hardly be 
imagined than that of a person thoroughly under the influence of 
' alcohol or cocain. The insensibility to pain, volubility, the dis- 
connected conversation, the rapidity of thought, the indifference to 
environment and the psychic well-being form a complete picture 
of mania. This transient mental derangement differs from the 
insanities, as a rule, only in the character and source of the toxin 
or intoxicant. It one case it is introduced as a finished product 
into the tissues of the individual, produces its effect, and is elim- 
inated, and when not repeated leaves the nervous system in its 
normal condition. In the other case, when the result of some 
gastro-intestinal or hepatic defect, it is continuously formed, flow- 
ing into the blood as rapidly as it is eliminated and the organic 
cells and the nerve cells are slowly and insidiously poisoned until 
they are beyond the possibility of restoration. 

And, in conclusion, I would like to repeat what I have said on 
several occasions, that when psychiatry turns aside from psychol- 
ogy, leaving it as an abstract study to those to whom it belongs, 
only considering its effect upon bodily functions, and devotes itself 
to the chemistry of the secretions and toxins of the body, it will 
make the greatest advancement ever known in its history. 



TUBERCULOSIS AMONG THE INSANE. 

By C. FLOYD HAVILAND, M. D., 

Assistant Physician Manhattan State Hospital, East, Ward's Island, New 

York City. 

The voluminous literature existing upon the subject of 
pulmonary tuberculosis precludes the possibility of the advance- 
ment of any novel ideas. However, certain familiar features of 
the disease among the insane should be emphasized, as they appear 
to have a special significance. 

The past year has witnessed the greatest advance in the spread 
of general knowledge of tuberculosis, in measures adopted for 
prophylaxis and in phthisiotherapy. It is, therefore, important 
that it should be considered how far this advance can be made ap- 
plicable in hospitals for the insane, where none will dispute the 
disease is yet the strongest factor in augmenting the death rate. 

In two per cent of the population of the state hospitals of New 
York the disease has been diagnosed and this percentage varies but 
little from that obtained by Mott of London and other investigators 
among the consumptive insane, but common as pulmonary tuber- 
culosis is among the insane, the impression is gaining ground 
that the number of diagnosed cases does not even closely represent 
the total number of insane tubercular patients. 

In fact some authors deem tuberculosis to be well nigh universal 
even among the general population. Autopsy records of both 
general hospitals and hospitals for the insane show post-mortem 
findings of tubercular foci, greatly in excess of reported cases. 
According to some statistics fiftyto seventy-five per cent of autop- 
sies show cicatrices in the lungs of old tubercular lesions, while 
Naegeli concludes as the result of extensive observation that prac- 
tically all persons dying beyond the age of thirty years present at 
autopsy evidence of having at some time suffered from pulmonary 
tuberculosis. While this view may be extreme, the evidence is 
conclusive that even yet the widespread character of the disease 
is not fully appreciated. 



356 TUBERCULOSIS A^ONG THE INSANE. 

Many such cases, though recovering, without recognition, prove 
the means of infecting others, in whom a fatal result ensues, hence 
the necessity for unceasing and vigilant effort in making early 
diagnoses, particularly among the insane in hospitals. 

The frequent discovery of healed tubercular lesions at necrospy 
is encouraging, however, proving as it does, the curability of the 
disease, while it demonstrates that Knopf is correct when he 
affirms that the majority of cases recover. What further stimu- 
lus then is needed to induce constant therapeutic effort? 

In seeking the cause of the greater prevalence of tuberculosis 
among the insane, it is, however, necessary to seek further than to 
assume it to be due to lack of isolation and to undiagnosed cases 
spreading infection, for there are now few or none of our hospitals 
which do not in some measure provide isolation, while with ad- 
vance in knowledge upon the subject, hospital physicians as never 
before, are diagnosing the incipient cases. 

It appears probable that pulmonary tuberculosis frequently ap- 
pears among the insane, as the result of a reawakening of on 
arrested process, brought about by the physical disturbance at- 
tendant upon or produced by the psychosis. The tubercle bacilli 
may lie inactive for years, in a condition, which if it be not a 
spore state is closely allied to it, only to again become active, under 
the excitation of some condition — ^acute psychoses being attended 
by conditions most favorable. 

While the reduced physical resistance of the acute insane ren- 
der them particularly susceptible to new infection, yet the marked 
advance made in recent years in hospital treatment render them 
less frequently exposed to tubercular infection and the number of 
new cases developing within our hospitals is steadily decreasing. 

It was formerly supposed that the increased proportion of con- 
sumptives among the insane was due to the fact that the physical 
disease often produced the mental alienation. There appears, 
however, no evidence that there is a specific psychopathology of 
tuberculosis, it playing no part in the production of a psychosis, 
except in a small number of cases as a contributory etiological 
factor. While it be true that the central nervous system is no 
more exempt from a tubercular toxaemia than would it be from 
one produced by any infectious disease, yet such toxaemia is never 
the cause of insanity, except in a small number of toxic and ex- 



C FLOYD HAVILAND. 357 

haustion psychoses, playing no greater part in the production of 
such psychoses than any similar infectious disease. 

In considering the various modes of infection it may be said 
that infection through the abraded surface of ihe skin is of com- 
paratively small importance, either among the sane or the insane. 
However, it should be remembered that pulmonary tuberculosis 
may be secondary to a superficial tuberculosis, the infection being 
carried through the lymph channels to the constricted pulmonary 
apices, so that a patient with superficial tuberculosis should be 
treated as one with the pulmonary form, especially in a hospital 
for the insane where prophylaxis is of such paramount importance. 

Infection through the respiratory iract has long been considered 
the principal means of infection among all classes of consump- 
tives. However, although infection by this means is all too fre- 
quent, yet it is losing its comparative importance as a mode of 
infection among the insane. It is, of course, to be guarded against 
by every means within our power, but since we have learned that 
the expired air of tubercular patients does not contain tubercle 
bacilli and direct infection of the lungs only occurs through the 
medium of dried tubercular sputum, energetic efforts have been 
made in our institutions for the proper disposal of tubercle 
sputum and this means of infection is becoming less frequent, 
although the difficulties attending the disposal of the sputum 
among insane patients still renders infection through the res- 
ph^tory tract one of the two great modes of infection. 

Infection through the digestive tract is rapidly assuming an 
importance formerly denied it, not only among the insane, but 
among the sane. Knopf states that infection by this means is 
equally frequent, as infection through the respiratory tract. And 
there can be no doubt that this is true amon^ the insane, where 
such a large proportion are careless and untidy in their eating 
habits, and where with many the mouth appears to be the natural 
receptacle for all objects. Although primary intestinal tuberculo- 
sis is rare among both insane and sane adults, owing to the ability 
of the intestinal epithelium to successfully resist the tubercle bacilli, 
yet the fact remains that the bacilli may be taken up by the lymph 
channels of the stomach and intestines, only to be deposited in 
Ae pulmonary apices, with subsequent development of the pul- 
monary form of the disease. And that this may occur far more 



358 TUBERCULOSIS AMONG THE INSANE. 

frequently among the insane than is commonly supposed is evinced 
by a consideration of their personal habits. The great frequency 
of this mode of infection demonstrates the necessity of carefully 
guarding the source of the milk supply in institutions. While 
difference of opinion still exists as to the identity of bovine and 
human tuberculosis, it is better to err upon the side of safety and 
rigidly exclude the possibility of the milk of tubercular cows being 
used. Despite Koch's position upon the subject it has been proven 
that the injection of tubercle bacilli obtained from a himian being 
may produce tuberculosis in a cow, while with cultures of bacilli 
obtained from man and from cows no difference has been observed 
to determine their origin, unless it be the greater virulence ex- 
hibited by the latter when used upon test animals. Infection 
through the digestive tract must then be guarded against with 
the same care we exercise to prevent direct pulmonary infection. 

The common selection of the pulmonary apices, as the seat of 
the primary infiltration in any form of the pulmonary disease de- 
mands especial comment. While it is undoubtedly true that de- 
ficient aeration is a factor in rendering these areas fertile fields for 
tubercular activity, yet their proximity to the upper air passages 
must largely account for their becoming so frequently diseased. 
This, however, fails to account for the fact that the apices are also 
the most common seat of infiltration, in infection through the 
digestive tract, and J. O. Cobb of Philadelphia advances the in- 
genious theory that the anatomical arrangement of the great veins 
and lymph channels in the angle of the neck is such that a vis-a- 
fronte is produced, causing, by means of suction, a counter lymph 
current, so that there is an area of lymph stasis at the pulmonary 
apex, with consequent deposit of bacilli. 

The different psychoses present various specific physical condi- 
tions which render the insane easy victims to tubercular infec- 
tion. The afuemia so common among the acute insane is un- 
doubtedly a factor, being associated as it is with catarrhal condi- 
tions, the respiratory tract being most frequently so affected. 
With the descent of such a process the way is prepared for the 
pernicious activity of the tubercle bacilli. 

In depressed states the appetite is impaired, there is defective 
metabolism, especially in the power to assimilate fats, while mus- 
cular weakness is common. There is disordered circulation, the 



C. FLOYD HAVILAND. 359 

depressed nervous state rendering respiration imperfect, thus com- 
pelling increased cardiac action with resulting circulatory disturb- 
ances in the lungs and consequent impairment of their nutrition, 
thus furnishing a field most favorable for tubercular infiltration. 

In maniacal states there is also impaired metabolism, with poor 
nutrition and disordered circulation, which combined with the 
diminished phagoc3rtic power common to all persons in a debili- 
tated physical state render conditions favorable for tubercular 
activity. In such cases there is often a disordered vasomotor 
system, with attending peripheral congestion and a consequent 
retention of toxines, which is one cause of the disease running a 
rapid course among these patients. 

But the greater number of tubercular insane is found among 
the mentally deteriorated, particularly such as develop the disease 
subsequent to a period of hospital residence. These are the 
patients who so frequently become infected through the digestive 
tract as a result of their careless personal habits. 

The dement has little power of resistance, at the best being 
prone to acute inflammations from trivial causes. The good 
physical condition of the majority of dements in hospitals is to 
be attributed to hygienic environment and their habits of life 
rather than to the cessation of mental activity. In addition these 
patients usually present a slow and sluggish circulation, with 
defective respiration which factors operate as in the acute psy- 
choses. Moreover, cardio-vascular changes are of frequent oc- 
currence among them, particularly the senile cases and when 
these changes manifest a pulmonary localization with impover- 
ished nutrition of lung tissue resulting, then is the soil thus pre- 
pared for infection. 

In general it may be stated that the various psychoses present 
as concomitant features conditions which cause direct impair- 
ment of pulmonary nutrition with frequent inability of the lungs 
to withstand invasion when exposed to infection. 

But the two great etiological factors of tuberculosis among 
the insane remain to be mentioned. More and more it is becom- 
ing known that alcoholism and syphilis are predisposing causes 
in its production. It is unnecessary to dwell upon the prevalence 
of these diseases among the insane, for we all know that without 
them our institutions for the mentally alienated would have small 



360 TUBERCULOSIS AMONG THE INSANE. 

need to exist. As is known, these conditions produce the dimin- 
ished resistance, the disordered metabolism and the diminished 
phagocytic power so favorable to the tubercle bacilli and when 
thus considered the role assumed by alcoholism and syphilis in 
the production of tuberculosis assumes vast proportions. Various 
European sanatoria for consumptives state that from thirty to fifty 
per cent of their patients are syphilitic, while Douty goes so 
far as to affirm that syphilis must first be dealt with before any 
effectual means can be found to stamp out tuberculosis. At all 
events the insane, as being in a large proportion either alcoholic 
and syphilitic, require especial protection from infection, because 
of this fact alone. 

The diagnosis is now made with the assistance of the serum 
test. X-ray examination, tuberculin reaction, and sputum examina- 
tion. 

The serum reaction is, however, unreliable. First presented 
by Arloing in 1898, it was claimed by him and other Italian 
scientists to be a valuable aid in diagnosis. This assertion has 
since been denied by Koch, while after a long series of experi- 
ments, Schwarzkopf gives his conclusions in the Munchener 
Medizinische Wochenschrift for April 12, 1904, that the blood 
of both healthy and tubercular rabbits at times have shown the 
agglutinating power for tubercle bacilli, but in neither was the 
reaction constant. Experiments by various American investiga- 
tors have since confirmed the unreliable character of this method 
and at best it can only be regarded as confirmatory evidence in 
making a diagnosis. 

The use of the X-rays has been highly lauded and is of un- 
doubted value. But pleuritic thickenings will cast a shadow so 
similar to pulmonary infiltration that there is considerable possi- 
bility of error and this procedure is also to be only employed to 
obtain confirmatory evidence. 

The use of tuberculin as a therapeutic agent is still of ques- 
tionable value, but few deny that it is of definite worth in diagno- 
sis. The evil effects formerly sometimes found to follow its 
administration were due to its indiscriminate use and are not 
known if it be intelligently employed. For it is true that only 
selected cases should be diagnosed by this means, but fortunately 
the cases to be excluded are the ones most easily diagnosed by 



C. FLOYD HAVILAND. 361 

Other methods, while suitable cases for diagnosis with tuberculin 
are cases in which the dia^osis is obscure, when other means 
alone are used. Tuberculin should not be employed in any febrile 
case nor in a case of advanced disease, but used in a case with 
incipient tuberculosis, with no elevation of temperature, and with 
obscure physical signs, a positive reaction establishes a diagnosis, 
at the time when treatment is of the most avail. With properly 
selected cases care must also be exercised in technique. No more 
than one milligram of a i% solution of Koch's tuberculin diluted 
with .5% aqueous solution of carbolic acid should be employed for 
the initial injection, successive injections being increased by two to 
three milligrams until ten milligrams have been given in a single 
dose, when if no reaction occurs the patient may be declared free 
from tuberculosis, any elevation of temperature less than i** F. 
being deemed negative. The frequency of delayed reaction must 
be considered, but with an interval between injections of from 
forty-eight to seventy-two hours no danger need be apprehended 
and tuberculin will be found to be a valuable means of diagnosis. 

There are now none to dispute the conclusive character of a 
diagnosis resting upon a microscopical examination of the sputum, 
and such examination is, of course, a routine practice. However, 
positive as the diagnosis is rendered by the presence of tuber- 
cle bacilli in the sputum, their absence means nothing. Especially 
is this true among the insane where with inactive reflexes there 
is often little or no cough and where there is often little or no 
expectoration. But even with the classical symptoms present 
microscopical findings are negative until the disease has so far 
advanced that there is breaking down of a tubercle with discharge 
of bacilli into a bronchiole, which means that it has progressed 
beyond that early stage in which it is our aim to diagnose. Mic- 
roscopical examination, valuable as it is with positive results, is 
valueless with negative results. 

While it would thus be unjustified to belittle laboratory methods 
of diagnosis, yet physical examination must continue to be as 
it ever has been, the basis upon which the majority of diagnoses 
must rest. But important as it is among sane patients, it is even 
more important among the insane where the disease is so fre- 
quently masked by negative and at3rpical characteristics, but where 
physical examination ever furnishes a ready means of ascertaining 



362 TUBERCULOSIS AMONG THE INSANE. 

pulmonary conditions. Physical examination is not an easy art 
to acquire and only long continued effort makes proficiency. 
Even with proficiency numerous obscure cases are found in which 
the diagnosis can only be determined by oft repeated examina- 
tion and by a careful consideration of the clinical history. Should 
attention be called to a patient showing a gradual loss in vigor, 
strength, and weight, with accompanying digestive disturbances, 
particularly if this be associated with a quick, rapid pulse, be- 
coming more hastened in the afternoon, examination of the lungs 
should follow as a matter of routine, even if at this early stage no 
other symptoms present themselves. Even in the very beginning 
of pulmonary infiltration, however, there is more or less pressure 
exerted upon the finer bronchi, with interference with the normal 
elasticity of the lungs, so that respiration is interrupted, being 
manifested by changes in the normal respiratory murmur. In 
the very incipiency of the disease careful examination will reveal 
a circumscribed area, over which there is impaired resonance, 
even if pronounced dulness be absent, there is increased vocal 
resonance while the normal respiratory murmur becomes feeble 
and irregular. This is accompanied by a roughening of inspira- 
tory and a prolongation of expiratory effort, while an occasional 
crepitant rale may be heard at the end of inspiration. With such 
physical signs associated with a continuous elevation of tempera- 
ture even if only a continuous temperature of 99® F. together with 
the hastened pulse and digestive disturbance the diagnosis may be 
safely made. 

The possibility of early diagnosis by physical examination is 
thus emphasized as there are now none who fail to recognize that 
this is the stage for successful treatment. As the disease pro- 
gresses its character changes, mixed infection occurs and the sim- 
ple tuberculosis becomes phthisis with a less favorable prognosis. 

In no direction have hospitals for the insane shown greater 
advance than in the provisions made for the isolation of tubercular 
patients. In some states separate buildings have been erected for 
the care of such patients. The State of New York has buildings 
about completed at the Binghamton State Hospital, which are built 
according to the most modem ideas upon sanatoria construction, 
while provision has been made for the erection of similar buildings 
in connection with the St. Lawrence State Hospital at Ogdens- 



C. FLOYD HAVILAND. 363 

burg and the Middletown State Hospital, a full account of which 
is given by Dr. Frederick Peterson in the New York Medical 
Record of April i6, 1904. For reasons of economy, however, it 
is impossible for most hospitals to obtain separate structures, 
many being perforce content with a separate ward for consump- 
tives. Complete isolation, however, cannot be so obtained and in 
such cases the tent system should appeal with especial force. 
Several reports have been presented to this Association of the 
tent treatment inaugurated at the Manhattan State Hospital, 
New York City, by Dr. A. E. Macdonald, nearly four years ago. 
Having continued in successful operation since that time the tents 
have here provided complete isolation, while at the same time have 
been shown to possess value as a therapeutic measure. With the 
use of small tents, containing but three or four beds, secondary 
isolation can be secured, it being manifestly unjust to bring an 
incipient case in contact with an advanced one, although necessary 
to isolate both from the general hospital population. This econo- 
mical method of securing isolation while simultaneously securing 
hygienic surroundings, has since been adopted by various other 
hospitals, notably the Willard State Hospital of New York, the 
Rochester State Hospital of New York, the Central State Hospi- 
tal of Petersburg, Va., the Columbus State Hospital of Columbus, 
Ohio, and others. 

There are none to dispute with those eminent authorities — 
Brehmer, Dettweiler, Trudeau, and Knopf who agree that the 
basis of all treatment for tuberculosis must be hygienic and diete- 
tic. The climatic treatment has not proven worthy of its former 
reputation, a cheering fact to those who must treat the tuberculous 
insane oft-times in climates formerly supposed to be prohibitive 
of recovery. Several German authorities affirm that the treat- 
ment of pulmonary tuberculosis is possible wherever there is pure 
air, wherever appropriate food can be procured and wherever 
moderate graduated exercise can be instituted. It is not denied 
that certain climatic conditions are more favorable than others, 
but are not the essential features of treatment formerly supposed. 
While ideal conditions demand pure air free from dust and germs, 
unvarying temperature, low humidity and constant sun-light, yet 
remarkable results have been obtained when these conditions in 
no wise prevailed, but when a careful hygienic and dietetic treat- 



364 TUBERCULOSIS AMONG THE INSANE. 

ment was instituted. Nowhere has this fact been more fully 
demonstrated than at the Manhattan State Hospital, New York, 
since the institution of the tent treatment, for during a large 
part of the year climatic conditions are here the reverse of ideal. 
In searching for ideal conditions high altitudes were sought and 
recovery deemed impossible without a change of residence. It is, 
however, problematical whether the good so gained be not coun- 
ter-balanced by the cardiac strain induced by the rarified atmos- 
phere with the consequent disturbance of pulmonary circulation. 
At all events, it may be safely asserted that there are few climates 
which of themselves offer a bar to the successful treatment of 
tuberculosis. 

The medicinal treatment is symptomatic, the number of reme- 
dies suggested proving there is no specific, notwithstanding the 
assertion of the Italian scientist, Maragliano, that he has obtained 
a specific antitoxin. All medicinal treatment should be directed 
to the single purpose of promoting assimilation and constructive 
metabolism. It is of primary importance that the digestive tract 
be kept active for it has been truly said of this disease that a good 
stomach means a good prognosis. Care must, therefore, be exer- 
cised that suralimentation be not carried to an extreme, although 
it should also be remembered that a consumptive's appetite is 
no measure of guide as to his assimilative power. Indiscriminate 
forced feeding will, however, frequently produce anorexia, with 
deranged metabolism and even if there be some gain in weight it 
may not be indicative of the improvement supposed. While, of 
course, the specific indications of cough, haemoptysis, elevated tem- 
perature, night sweats, etc., must be treated as they are presented, 
still medicinal aid appears to be of the most decided benefit 
when employed to aid the digestive tract in caring for the increased 
amount of food demanded by the diseased organism and in rege- 
lating digestive disturbances. Some patients require rest, any 
marked elevation of temperature demanding bed treatment, while 
in such cases as show a beginning increase in weight, indicating 
increased assimilative power, regulated exercise should be in- 
stituted. 

The essential treatment, must, however, still remain pure air, 
good food and hygienic surroundings. Supply unlimited fresh 
air by whatsoever means, give a varied and increased diet, but 



C FLOYD HAVILAND. 365 

with meals moderate and frequent, provide improved hygienic 
conditions and the remainder of the treatment is subsidiary. 

With early diagnosis, with dietetic treatment and with such 
hygienic conditions best found in a constant outdoor life, it is 
certain that the majority of cases can be as successfully treated 
among the insane as the sane. 

But in all institutions prophylaxis is imperative and complete 
isolation must be secured. With the efforts now being constant- 
ly directed to this end, it is not rash to look forward to the day 
when the tuberculous insane will cease to be a burden of concern. 

DISCUSSION. 

Dr. Macdonald. — I do not think I have anything to add to the presen- 
tation made by my former assistant and which forms one of a series of 
four papers presented before this Association from year to year. What I 
wish to say is not in the nature of discussion. I rise to make an announce- 
ment that will, I think, be unwelcome news to you all. After four years 
of unquestionable success, the experiment of the tent treatment of the 
tuberculous insane at the Manhattan State Hospital East is to be aban- 
doned, it being determined by the State Commission in Lunacy that this 
work shall cease upon the first of June, next We are in hopes that they 
will reconsider their determination to allow the patients to remain only 
until the first of June. If, however, the present plans are carried out, the 
tent system will be abandoned and the patients will be sent away to other 
state hospitals where the outdoor treatment has not been adopted. 

It is a pleasure to me to hear from so many other hospitals in other 
localities that the system has been adopted and proven successful there; 
so that its arbitrary abandonment, if persisted in, in the State of its ini- 
tiation, cannot entirely suspend its practice. 



MEMORIAL NOTICES. 



GEORGE FREDERICK KEENE, M. D. 
By henry JONES, M. D. 

George Frederick Keene was bom in Whitman, Massachusetts, 
on October 22, 1853, his parents being Africa and Betsey (Turner) 
Keene. He came of an illustrious family, his maternal grand- 
mother Betsey Keene, being the daughter of Col. Amos Turner 
of Revolutionary renown, and his maternal grandfather, Daniel 
Keene, was a well-known member of the Society of Friends of 
Pembroke, Massachusetts. His grandparents on his father's side 
were also prime movers in the War of the Revolution, his grand- 
father fighting gallantly for liberty. 

He received his preliminary education in the schools of Whit- 
man, after his graduation at the high school entering Brown Uni- 
versity, from which he graduated in 1875. On leaving Brown he 
entered the Harvard Medical School, graduating in the class of 
1879, receiving the degree of A. M. at the same time from Brown. 
During his college course at Harvard he served for 18 months in 
the Boston City Hospital, receiving a diploma from that institu- 
tion in 1880. He also received a diploma from the Boston City 
Hospital, Medical Improvement Society, and became a member, 
this honor being conferred on him in recognition of his invention 
of a splint for Colles fracture. 

In May of the same year he commenced practice in Providence 
and was appointed to the dispensary district of the First and 
Tenth Wards. Shortly after this he was appointed out-patient 
surgeon to the Rhode Island Hospital and lecturer to the Hospital 
Training School for Nurses. He retained this position until his 
removal from Providence in 1886. 

On January i, 1884, he married Miss Frances B. Redmond, 
daughter of the Hon. Erastus Redmond of Ellsworth, Maine. 
Of this union two children were bom, George Frederick, Jr., and 



368 MEMORIAL NOTICES. 

Bessie Turner Keene, who, together with the widow, survive 
him. 

In 1884-85, during the illness of Prof. Chapin, Dr. Keene was 
engaged to lecture on physiology at Brown University, and he 
continued in that position until the professor recovered his health. 
In March, 1883, h^ was elected physician to the State Institutions 
at Cranston and in 1886 he was appointed a Resident Physician 
and Deputy Superintendent of the State Hospital for the Insane. 
He was later made Superintendent, which position he held at the 
time of his death. 

He was the author of a number of pamphlets relative to the 
practice of medicine, the most noted being " New Methods for 
Treatment of CoUes Fractures," " Present Evils of Insane Com- 
mitments," and " Mens Sana in Corpore Sano," " General Pare- 
sis," " Sanitation and Tuberculosis." 

He was a 32d degree Mason and a member of Mount Vernon 
Lodge No. 4 of Providence ; a member of the American Medical 
Association, the American Academy of Medicine, the American 
Medico-Psychological Association, the New York Medico-Legal 
Society, the Harvard Graduate Club, the Harvard Club of Rhode 
Island, the Providence Clinical Club, the Pomham and the West 
Side Qubs, the Providence and Rhode Island Medical Associa- 
tion, the Rhode Island Medico-Legal Society, the Beta Theta Pi 
fraternity and the Boston City Hospital Association. 

Dr. Keene was in his 526. year, and was considered by the 
medical profession and the bar of New England as one of the 
leading alienists in this part of the country. He had made a 
special and deep study of nervous troubles and mental diseases, 
and as an expert witness in cases involving questions of sanity 
he was sought. 

Dr. Keene accompanied the State Commission appointed by the 
Legislature to investigate sanatoriums for consumptives in the 
New England States at the time the plan for establishing a State 
sanatorium for consumptives in Rhode Island was started. His 
knowledge of tuberculosis made him a valuable member of such a 
commission as he had long fought the disease, and had written 
many articles on the subject. His paper "On the Municipal 
Responsibility in the Spread of Tuberculosis," which he read be- 
fore the conference of Charities and Corrections in 1899, attracted 



MEMORIAL NOTICES. 369 

wide-spread comment and attention. Under his advice and 
supervision the tuberculosis wards at the State Almshouse were 
erected, which are models of their kind. He was one of the first 
who advocated the use of tents for insane patients who had be- 
come infected with tuberculosis, a feature which has proven a 
great blessing to the patient suffering from this disease. 

Dr. Keene was the first Medical Superintendent of the State 
Hospital for the Insane in Rhode Island; of this honor he was 
extremely proud, and many times he referred to it — that it was 
the greatest honor that could have been conferred upon him. His 
love for the work in which he was engaged outweighed pecuniary 
considerations, for he could have gained greater financial reward 
in private practice had he sought it. His ambition was to put 
the State Hospital for the Insane on a level with other great in- 
stitutions of its kind in this country, and how he strove to achieve 
this end, those who were in close contact with him know. Those 
who are similarly engaged in the care of the mentally diseased 
fully realized his efforts, and as one noted alienist aptly states, 
" For many years he had been making bricks at Howard with in- 
sufficient straw, but despite all handicaps the quality and quantity 
of his work at the State Hospital will be his best and enduring 
monument." He had taken great pride in the building and 
equipping of a new congregate dining room, where the unfortu- 
nate could eat to sound of music and sight of flowers. His 
thought was always for their comfort and enjoyment. This work 
at the Hospital alone will forever be a monument to his memory. 
Not only was he the Superintendent of the Insane Hospital, but 
he was Physician in Chief to the Institutions at Howard, a posi- 
tion which he filled with the greatest credit to himself and pleas- 
ure to those with whom he came in contact. His services were 
cheerfully given to the poor, and those in prison, and his treat- 
ment of them was as scientific as if they occupied a higher station. 
A physician in the truest sense of the term, he encouraged and 
stimulated those about him to do their best in the profession, the 
practice of medicine being to him above all other considerations. 

As a teacher and clinician he was unexcelled ; his clinics with 
the staff were looked forward to with the greatest eagerness and 
pleasure ; a " bom diagnostician," he readily unravelled the mys- 
teries of perplexing cases, and no one who had ever heard his 

24 



370 UEUOmAL NOTICES. 

description of a case at the bedside or in his clinic, could ever for- 
get his concise and lucid explanation. 

By his untimely death his staff has lost a great teacher and 
wise counselor, the inmates of these institutions their kind friend 
and healer. His advice and guidance will be sadly missed. 

As a consultant Dr. Keene was called often, not only as a mental 
expert, but as a surgeon and physician, his knowledge of diseases 
making him a valuable ally at the bedside. 

Personally he was jovial and kind-hearted ; firm in his friend- 
ships, he drew many to him. Sincerity wa:s his motto and in his 
dealings with all this trait in his character was marked. He in- 
spired confidence and gained the respect of all with whom he had 
dealings, always trying to live his life according to an adage that 
he often repeated, " I want to so live that I deserve happiness 
whether I ever get it or not" And he did so live. Happiness 
came to him day by day in the doing of good to others. How 
much he was loved and respected by all was shown by the con- 
course at his funeral. The highest officials of the State were 
present, also former patients whose tears testified to their sorrow 
for the beloved Physician whose efforts in their behalf had re- 
stored to them Reason. Their floral offerings testified to tfie 
love they bore him; they assembled from near and far that they 
might take the last look and place upon his bier their last tokens 
of affection. The true physician, the firm friend, " we shall not 
look upon his like again ; " he lived respected and died regretted. 
The virtue of his deeds, however, will ever live ; his kindness to 
those broken in mind and body will not soon be forgotten ; they 
will long remain as a sweet and lasting remembrance. His name 
shall stand for what is progressive in medicine ; his qualities as a 
man and physician will always be remembered so long as Ae 
institutions in this State shall stand. 



DR. JAMES FRANCIS FERGUSON, 

Of " Falkibk." 

By WM. R DOLD, M. D. 

Jas. Francis Ferguson, M. D., for years a member of this Asso- 
ciation, a man popular with all, and well-loved by those who knew 
him intimately ; departed this life at his home in Central Valley, 
Orange county. New York, January 6, 1904. A year before that 
date, he suffered an attack of apoplexy and never recovered from 
its effects. 

Dr. Ferguson was a native of New York Qty, having been 
bom in the old President Monroe house, comer of Marion and 
Prince Streets, October 10, 1839. His parents were Scotch, and 
he had many characteristics of that people. In 1857 he became a 
private pupil of the celebrated Jas. R. Wood, M. D., and later, 
entered the Medical Department of the University of the City of 
New York, from which he graduated in 1861. He served on 
the Bellevue Hospital staff and also on the Charity Hospital staff, 
Blackwells Island. 

Upon the breaking out of the Civil War he offered his services 
to his native State and was commissioned an Assistant Surgeon 
in the 2nd New York State Militia. At the first battie of Bull 
Run, he was severely wounded in his left leg, from which injury 
he was lame the remainder of his Ufe. He was captured at that 
time and later was confined in Libby Prison, Richmond, Virginia. 
His devoted mother, a woman of great energy, succeeded, after 
much trouble, in having him paroled, and he returned home. In 
1862, having been exchanged, he became Major and Surgeon of 
the Second Duryee Zouaves. He served in Louisiana; was at 
the siege of Port Hudson, where he had charge of the field hos- 
pital, on the left of the line during that time. After the surrender 
of Port Hudson, he was ordered to New Orleans, remaining 
there for some time. He was brevetted Lieutenant Colonel of 



372 MSHORIAL NOTICES. 

the New York Volunteers, and was honorably discharged in 
March, 1864. 

His professional appointments were as follows: Attending 
Surgeon Bellevue Hospital, Out-door Dept, 1870-1871. Visiting 
Surgeon to the Charity Hospital, Blackwell's Island, 1872-1892. 
Visiting Physician to the Hospital for Nervous Diseases, 1886- 
1892, and Consulting Physician to the Charity (now Qty) Hos- 
pital) Blackwell's Island, New York City, since 1892. 

He was a member of the Society of Altmmi of Bellevue Hos- 
pital, The Medical Society of the County of New York, The 
New York Academy of Medicine, and The New York Neurologi- 
cal Society. 

Dr. Ferguson was a man of wealth and having become en- 
amored of that beautiful section of Orange County, New York, 
known as Central Valley, he determined to erect there a model 
sanitaritmi for nervous and mental diseases. This work he com- 
menced in 1888, and was engaged on it until attacked by fatal 
illness in 1903. He was his own architect and all the work on the 
different buildings of the sanitarium was carried on under his 
immediate supervision. He was a man of taste, and his work 
stands, a worthy monument, not only to this, but to the altruistic 
part of his nature, that induced him to do so much charitable 
work for those who could not afford to pay for care and treatment 
in such an institution. 

Ever devoted to the memory of his mother, he gave to the sani- 
tarium, the name of her native place in Scotland — Falkirk. 

During the time he conducted the institution, he had patients 
from many of the best families in this country, and I have been 
impressed by the fact that he had, to an unusual degree, the confi- 
dence and regard of his patrons. He was kind and thoughtful of 
those entrusted to his care ; constantly devising new means to add 
to their comfort and well-being. He was a man of charity, but 
few know to what extent he gave of his means. He disliked 
publicity and preferred to do good in a quiet way. His friends 
were many and when the day arrived for him to be laid at rest in 
the beautiful cemetery of Highland Mills, the number that fol- 
lowed his to his resting place was limited only by the number of 
convejrances that could be procured in that winter season, and 
gave testimony to the affection of those who knew him. 



MEMORIAL NOTICES. 373 

Dr. Ferguson was an enthusiastic Mason and in 1871-1872 was 
the High Priest of Kane Lodge, New York City. He attracted 
those who were associated with him and some of the best known 
men in New York were his devoted friends. By his death the 
Association lost a valuable member and the invalids who came 
under his care, an earnest worker in their behalf. 



DR. F. SAVARY PEARCE. 

By GEO. STOCKTON, M. D.. 
Superintendent Columbus State Hospital, Columbus, Ohio. 

Mr. President and Gentlemen of the American Medico- 
Psychological Association : 

I have been delegated to offer a few words in remembrance of 
a late valued member of this Association, Dr. F. Savary Pearce of 
Philadelphia, Pennsylvania. 

Dr. Pearce died at the home of his father in Steubenville, Ohio, 
on May 27, 1904. He had been applying himself to his work 
with unusual assiduity neglecting to give himself proper rest and 
relaxation; the consequence was a complete nervous collapse re- 
sulting in a short time in his death. I quote the following from 
the MedicO'Chirurgical Journal. 

In the death of Dr. F. Savary Pearce not only the Medico-Chirurgical 
College and the medical profession, but the whole world, suffered a loss 
which cannot be compensated, for Dr. Pearce fell a victim to over-zeal in 
the pursuit of a profession which he not only loved but honored. He was 
a tireless student and worker, and in his desire to benefit his fellow-beings 
he overtaxed his strength. Had he taken the rest from brain work which 
he was so ready to prescribe for others he would have probably been with 
us to-day and have lived many years, to bless those who sought his services. 

He never seemed to think he had any time or right to cease from his 
labors for mankind. While we mourn his loss we feel that his example 
will help many men to keep steadfast and earnest in the pursuit of their 
calling, who might otherwise have faltered and perhaps failed. 

There was no man in the profession who had achieved greater success 
in the special branch of their profession than Dr. Pearce; the hundreds 
whom he has helped to throw off the very troubles to which he at last 
succumbed himself will hold his memory dear and will regret that he 
could not have been persuaded in time to take the rest he so much needed 
It was truly a case of a life sacrificed to over-zeal in the following of a duty. 

Doctor F. Savary Pearce was educated in his native town, at- 
tending private and public schools, graduating in the Steubenville 
High School in 1886. 



MEMORIAL NOTICES. 375 

It is rather significant in view of the cause of his death, that the 
subject of his oration at the time he graduated was '* Work and 
Overwork." He also graduated from Duff's Business College in 
Pittsburgh^ Pennsylvania, in June, 1887. While still in attend- 
ance at the high school, he passed tiie competitive examination for 
admission to the United States Navy and received an order for 
admission to the same. His inclination, however, seemed to 
gravitate towards the medical profession, he resigned from the 
cadetship and returned to his native town, graduated in the high 
school and entered his father's office as a student of medicine. 

He obtained his medical degree from the University of Penn- 
sylvania May I, 1891. 

In a competitive examination he was the successful candidate, 
and entered upon his duties as a resident physician at the Presby- 
terian Hospital, which position he filled for one year; in May 
1892 he left the Presbyterian Hospital to accept the position of 
Interne at the Orthopedic Hospital and Infirmary for Nervous 
Diseases. It was at this hospital that he first became associated 
with Dr. S. Weir Mitchell, under whose direction his attention 
was particularly directed towards the study and investigation of 
mental and nervous diseases, to which subjects he henceforth 
gave particular and almost exclusive attention. 

During this time he became connected with the Medical Insti- 
tute of Philadelphia, quizzing on the subjects of Pathology and 
Physical Diagnosis. On December 8, 1896, he was elected by the 
Board of Trustees of the University of Pennsylvania as Instruc- 
tor in Physical Diagnosis, which position he held until 1901, when 
he resigned to accept the chair of Clinical Professor of Nervous 
and Mental Diseases on the faculty of the Medico-Chirurgical 
College of Philadelphia. 

He was at one time one of the '* Chiefs " of the St Agnes Hos- 
pital and at the time of his death held the position of neurologist 
to the Medico-Chirurgical College and Howard Hospitals. 

I will not take the time to enumerate all the different honors 
conferred on the doctor, but I think it timely to give a list of the 
principal organizations to which he belonged, as it shows the 
immense amount of time and energy he must have expended to 
keep in touch with him. Dr. Pearce was a member of the College 
of Physicians, Philadelphia, The Philadelphia Neurological So- 



376 MEMORIAL NOTICES. 

ciety. The Philadelphia Pediatric Society, The American Clima- 
tological Society, The Pennsylvania State Medical Society, an 
honorary member of the Eastern Ohio Medical Association, an 
active member of The Historical Society of Pennsylvania, a mem- 
ber of The Military Order of the Loyal Legion (he held this 
through his father, Brevet Lieutenant-Colonel Enoch Pearce, who 
was a surgeon on field duty during four years of the Civil War). 
Doctor Pearce was Chairman of his section on Neurology and 
Medical Jurisprudence of the American Medical Association, and 
was to have addressed the Association at their annual meeting at 
Atlantic City last June had he lived. 

About the time of his death he was invited to become a mem- 
ber of the Congress of Science and Art at the Columbian Exposi- 
tion at St. Louis. 

Dr. Pearce was a man of strong religious convictions. While 
not especially prominent in church matters, he is said to have had 
many warm admirers among the clergy of his home city. He 
was an honor to the profession in the conduct of his daily life, 
cheerful, careful of the feelings of others, and in every way a gen- 
tleman. His rector said of him, " I feel his death as a personal 
loss, the Church and the World cannot aiford to lose men so 
good and true and hard working as he was." 

The writer had the pleasure of meeting Dr. Pearce but twice ; 
I was then impressed by the aflFectionate and loving bearing of the 
deceased towards other members of his family, and how all in all 
they seemed to him and he to them. One of his close relatives 
pays him the following tribute: 

" He had a peculiar and beautiful devotion for his mother, and 
she ever recognized in him loving and thoughtful devotion, her 
tenderest love ever going out to and helping him on in his posi- 
tion and advancement; his success ever brought more success. 
Is it any wonder than thirteen days after his untimely death, fol- 
lowing the dreadful shock and irreconcilable disappointment, she 
should have died of a broken heart? " 

Dr. Enoch Pearce, the father of the deceased, is a descendant 
from the family of Franklin Pierce, President of the United 
States; he served for four years as a surgeon in the Civil War 
with distinction. At the present time he resides in Steubenville, 



MEMORIAL NOTICES. 377 

Ohio. Dr. Pearce the senior, graduated from the Jeflferson Medi- 
cal Collie, Philadelphia, Pennsylvania, in 1854, 

Dr. F. Savary Pearce was a prolific. writer. Most of his medical 
writings were on nervous and mental diseases and allied subjects; 
he also, however, contributed by his pen to poetry and romance. 

So far his works have never been properly classified or ar- 
ranged in chronological order. From September, 1896, to 
March, 1899, he wrote 49 medical articles and 9 literary works, 
consisting of poems and other writings ; in all about 132 original 
medical articles, besides many neurological studies and papers, 
some in colaboration with other writers. He was the author of 
20 articles during the last year of his life. He did quite a good 
deal of scientific microscopical work with Dr. S. Wier Mitchell ; 
he also was a co-worker with Dr. C. S. Curtin of Philadelphia in 
preparing a catalogue of the graduates of the University of Penn- 
sylvania. 

A short time before his death there appeared from his pen a 
very comprehensive work, entitled a Practical Treatise on Ner- 
vous Diseases for the Medical Student and General Practitioners. 

In closing I am going to take the liberty of quoting from the 
memoir of Dr. F. Savary Pearce, published in the Medico-Chir- 
urgical Journal for February, 1905. Written by James M. 
Anders, M. D., LL. D. 

" The personal side of Dr. Pearce was conspicuous, and his de- 
served popularity was due partly to an agreeable manner, but 
principally to his loving nature and gentleness and kindliness of 
heart. His personality was attractive, and even to persons, in- 
cluding physicians, who had not the privilege of an intimate ac- 
quaintance with him, but met him occasionally by chance. His 
Kfe should prove of inestimable value to the younger men of this 
and future generations as a pattern of many virtues on the one 
hand, and freedom from the commoner vices of his sex on the 
other. Although he departed this life prematurely, he left the 
memory of a spotless name, a high character, and a life full of 
benevolences, for the contemplation of all." 



DR. HENRY E. ALLISON. 
By ROBERT B. LAMB, M.D. 

Henry E. Allison was bom at Concord, New Hampshire, on 
December i, 1851. His early education was obtained at the pub- 
lic schools of Concord and at the Kimball Academy, Meridcn, 
New Hampshire, where he was graduated in 1871. Later in the 
same year he entered the classical department of Dartmouth Col- 
lege. Four well spent years saw him President of his class and 
an honor man on commencement day. 

His college course completed, he taught for a term and then 
commenced the study of medicine at the Dartmouth Medical 
College. In the spring of 1878 this school gave him his degree of 
M. D., and in August of the same year he became an Assistant 
Physician at the Willard Asylum at Ovid, New York. Dr. Alli- 
son remained at Willard nearly five years when he resigned and 
took up post-graduate study in New York City. Completing 
this study, he entered general practice at Waterloo, New York. 
In 1884 a vacancy occurred on the staff of the Willard Asylum. 
The board of trustees invited Dr. Allison to return to their ser- 
vice. He entered a competitive examination for the appointment, 
passed it with honor and was made First Assistant Physician at 
Willard. For five years he held this post, until July i, 1889, he 
was promoted to the Superintendency of the Asylum for Insane 
Criminals, then located at Auburn, New York, and the oldest 
institution of its kind in the world. 

In April, 1892, the ancient Auburn buildings were abandoned 
and the patients therefrom transferred to the new institution at 
Fishkill-on-Hudson, New York, now known as the Matteawan 
State Hospital, and of which Dr. Allison was the head until his 
death. It was in the upbuilding of this great institution that he 
gave the best years of his life. Doubtless the strain and worry 
incident thereto made possible the rapid inroad of serious disease 
which caused his death on November twelfth, last, after a visible 
illness of only three weeks. 



MEMORIAL NOTICES. 379 

It is quite needless for me to here dwell upon the pleasant ways 
and sound virtues of Dr. Allison. To those who knew him these 
are already known. To those who had not the rare privilege of 
his acquaintance, any wcx'ds that I might now say would not make 
clear the lovable nature of the man. I can only add that a more 
faithful, consistent, and conscientious worker could not be found ; 
one whose daily life stood as a constant example of that which 
was good, and which exercised its beneficent influence over those 
favored by its association. His natural ways were those of truth 
and kindness, and the lowest patient in his great institution — sick 
alike in mind and body — ^paid homage to his simple, rugged hon- 
esty and sincerity. 

His life's history is a record of true service. To the State, to 
his profession, to his friends, to his family, he gave the very 
best that was within him without thought of the cost to himself. 
Such living lessons have priceless influence. So long as men 
shall live, their lives and characters shall be moulded and shaped 
by the lives and characters of their fellows. May it here be said 
that knowledge of a career, such as is closed by the death of 
Dr. Allison, is a blessed heritage to us all. Blessed to the State, 
blessed to the profession of medicine, blessed to his friends and 
thrice blessed to the family made sorrowful by death, to whom 
this great Association tenders its most respectful sjrmpathy. 



DR. MERRICK BEMIS. 
By E. V. SCRIBNER, M. D. 

Dr. Merrick Bemis, for many years a member of this Associa- 
tion, died at his residence in Worcester, Massachusetts, on the 
third day of October, 1904. 

Dr. Bemis was bom in Sturbridge, Massachusetts, May 4, 1820. 
When he was a small child his parents removed to Charlton, later 
to Brookfield. He was brought up on a farm and enjoyed only 
such educational advantages as the ordinary country schools 
aflForded. Not content with this, however, by dint of personal 
effort he succeeded in completing a course at Dudley Academy. 
Teaching school to secure the funds he entered Amherst Acad- 
emy, intending to graduate from Amherst College. A severe 
illness of long duration compelled him to change his plans. For 
several years he taught school in Brookfield. Banning the 
study of medicine at twenty-two years of age, he soon went to 
Boston, remaining there for five years in the office of Dr. Wins- 
low Lewis. During the winter months he taught school to secure 
the money to prosecute his medical studies. He attended medical 
lectures at Pittsfield, Massachusetts, and at Castleton, Vermont, 
graduating from this latter institution in 1848. In November of 
this same year Dr. Bemis accepted a temporary service as assist- 
ant Physician in the State Lunatic Hospital at Worcester. Soon 
after he received a regular appointment upon the medical staflf 
of this institution, Doctor George Chandler being the Superin- 
tendent. He served in this position for eight years. Upon the 
resignation of Dr. Chandler in 1855, Dr. Bemis was elected to the 
position thus made vacant. The following eight months he de- 
voted to travel and study in Europe, taking charge of the hospital 
upon his return in the summer of 1856. For seventeen years he 
was Superintendent of the Worcester Hospital, resigning in 1872. 
During his administration he introduced many important changes 
in the methods of treating and caring for the insane, maintaining 
a high standard for his institution. During the latter part of his 
hospital service, Dr. Bemis purchased the property to which the 



MEMORIAL NOTICES. 38I 

Worcester Hospital was later removed, submitting plans for the 
erection of new buildings. In 1868 he again visited Europe, 
studying hospitals and their methods of treatment. After a full 
quarter century of continuous service in the State Hospital, Dr. 
Bemis resigned, establishing soon after, at Herbert Hall in Wor- 
cester, a private asylum for the care and treatment of women 
suffering f rc»n mental and nervous disease. 

This building which was now devoted to hospital purposes was 
originally erected in 1857 to serve as a young ladies' school. The 
property included some ten acres of land. Here Dr. Bemis con- 
ducted a successful private institution to the time of his death. 
During the last few years his son. Dr. John M. Bemis, was asso- 
ciated with him in his management In addition to the work of 
his private hospital Dr. Bemis had quite an extensive practice as 
insanity expert both in consultation and in the courts. 

Dr. Bemis served as Alderman and a member of the school 
board in 1861, 1862, and 1863. During the Civil War he was 
specially active in promoting the welfare of the soldiers and their 
families and took an active part in all matters of public concern. 
He was a member of the Horticultural Society, the Worcester 
Society of Antiquity, and the Natural History Society, being 
President of this last named Society at the time of his death. He 
has been a director of the Mechanics' National Bank. He was 
also a life member of the Pilgrim Society. He was an active 
member of the Massachusetts Medical Society, the American 
Medical Association, the New England Psychological Society and 
of the American Medico-Psychological Association. 

Dr. Bemis was one of the first American physicians to advocate 
cottage hospitals. In 1887 he was appointed as one of the State 
trustees of the Hospital Cottages for Children at Baldwinville, 
and served as President of the corporation. 

Dr. Bemis was possessed of a fine literary taste and accumu- 
lated a valuable library, the enjoyment of which did much to give 
pleasure and comfort to his declining years. 

Dr. Bemis married Caroline A. Gilmor, January i, 1856. She 
was the daughter of a Brookfield physician. One son was bom 
to them, John Merrick Bemis, a physician, member of the Ameri- 
can Medical Association and of the Massachusetts Medical 
Society. 



INDEX. 



Address, Annual, 123, 

Presidential, 87. 

Dr. D. R. Wallace, 81. 

Dr. L. L. Shropshire, 6a 

Hon. F. C. Davis, 59. 

Rev. H. T. Wilson, D. D., 57. 

Dr. F. E. Daniel, 53. 
Allison, Dr. Henry E., 378. 

Bemis, Dr. Merrick, 380. 

Broun, Dr. LeRoy, 263. 

Burgess, Dr. T. J. W., 53, 62, 64. 
68, 69. 70, 73, 74. 75, 76, 7^ 
79, 80, 82, 83, Ss, 87, 223, 306. 

By-Laws, 50. 

Camp, Dr. C. D., 209. 
Caples, Dr. B. M., 84. 
Cholaemia, Its Relation to Insan- 
ity, 225. 
Committee on Programme and 
Publication, 70, 74, 83. 
Nominating, Report, of, 64, 77, 
Auditing, Report of, 79. 
On Relations with American 
Congress of Physicians and 
Surgeons, 76, 80. 
To Purchase Memorial for Dr. 

H. M. Hurd, 75- 
To Discuss Dr. Punton's Paper, 
"Are the Insane Responsible 
for Criminal Acts ? " 
of Arrangements, Report of, 63. 
Congress, International Medical, 
76. 
of American Physicians and 
Surgeons, 76. 
Constitution, 45. 
Council, Report of, 70, 80. 
Crumbacker, Dr. W. P., 264. 



Daniel, Dr. F. E., 53. 

DaTis, Hon. F. C, 59. 

Dent, Dr. E. C, 68, 70, 71, 77, 80^ 

305. 
Dold, Dr. Wm. E., 371. 
Drug Addiction, Therapeutic and 

Medico-Legal Features of, 259. 

Epilepsy, as a Symptom, 251. 
Masked, 84. 

Flood, Dr. Everett, 251. 
Ferguson, Dr. J. F., 371. 

Geographical Distribution of Mem- 
bers and Institutions, 28. 

Gastrointestinal Tract, Relation to 
Mental Diseases, 307. 

Graves, Dr. M. L., 53, 57, 59, 60^ 
63,79. 

Hallucinations, A Case of Visual, 

etc, etc., 209. 
Haviland. Dr. C F., 355. 
HiU, Dr. C G., 69, 77, S3. 85, 181. 

192, 223, 331, 345. 
Hill,Dr. G.H.,84,304. 
Honorary Members, 44, 83. 
Huntingdon's Chorea, A Case oi, 

183. 
Hurd, Dr. A. W., 68, 192, 195. 
Hurd, Dr. H. M., 69, 72, 74, 75, «4» 

181. 193, 267, 304. 
Hutchings, Dr. R. H., 84, 265, 304. 

Institutions, Geographical Distri- 
bution of, 28. 

Insane Conditions, Surgery as a 
Relief for, 229. 

Insane, The, in Canada, 87. 

Insane, Tuberculosis Among, 355. 

Insanity, Prevention of, 217. 

383 



384 



INDEX. 



1 



Jones, Dr. H. A., 367. 
Journal of Insanity, Report of 
Editors, 72. 

Keene, Dr. G. R, 21^. 
Kemp, Dr. R. C, 307. 
Knapp, Dr. J. R., 333. 
KorsakofFs Psychosis, Report of 
Cases, 195. 

Lamb, Dr. R. B., 68, 84, 378. 

List of Members, 9. 

Liver, The, and its Relation to 
Nervous and Mental Dis- 
eases, 345. 

Members, List of, 9. 

Honorary, 44. 

Present at Meeting, 6$. 

New, 70, 7h 80. 
Macdonald, Dr. A. R, 69, 7S* 76, 

Melancholia, 133. 
Memorial Notices: — 

Dr. H. R Allison, 378. 

Dr. Merrick Bemis, 380. 

Dr. J. R Ferguson, 371. 

Dr. G. R Keene, 367. 

Dr. R S. Pearce, 374. 
Miller, Dr. H. W., 68, 183, I93» 

207. 
Mills, Dr. C. K, 209. 
Murphy, Dr. P. L., 7Zf 74. 83. 
Mysophobia, With Report of Case, 
171. 

Nominating Committee, 64, 77, 
Note, 51. 

Officers, iii, v. 
Election of, 78. 

Page, Dr. C. W., 74» 266. 
Palmer, Dr. H. L., 68, 80. 
Papers, Ownership of, 70. 



Pearce, Dr. R S., 374- 

Pilgrim, Dr. C. W., 77. 

Place for next Meeting, 8a 

Presidential Address, 87. 

Preston, Dr. R. J., 225. 

Proceedings, 53. 

Punton, Dr. John, 171, 192, a66^ 

305. 
Pure Food Congress, 83. 

Response to Addresses of Wel- 
come, 62. 

Resolution Extending Thanks» 
etc, 84. 

Robinson, Dr. J. R, 265. 

Rogers, Dr. J. G., 78. 

Rowe, Dr. J. T. W., 217. 

Scribner, Dr. R V., 380. 
Searcy, Dr. J. T., 78, 123. 
Shropshire, Dr. L. L., 60. 
Sprague, Dr. G. P., 259. 
Stiles, Mr. Wm. K, 70. 
Stockton, Dr. George, 374. 
Surgery for the Relief of Insane 

Conditions, 229. 
Surgery in the Manhattan State 

Hospital, West, 263. 
Surgery, Some Observations on 

Recent Cases, 333. 

Treasurer, Report of, 71. 
Tripartite Mentality, 123. 
Tuberculosis Among the Insane, 

355. 
Turner, Dr. J. S., 180. 

Visitors to Meeting, 67. 

Wade, Dr. J. P., 84. 
Wallace, Dr. D. R., 81. 

elected Honorary Member, 83. 
Wherry, Dr. J. W., 133. 
Wilson, Rev. H. T., 57. 
Witte, Dr. M. R, 229. 



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